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      Access to Intensive Care Unit Care for Elderly Patients with COVID-19 in Portugal Translated title: Acesso a cuidados de UCI para doentes idosos com COVID-19 em Portugal


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          The overstretched intensive care unit (ICU) capacity during the 2019 coronavirus disease (COVID-19) pandemic generated a debate about age being an important criterion for triaging patients with COVID-19 for ICU admission [1, 2]. In Portugal, as of April 30, 2020, there have been 24,987 cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection (6,136 [24.5%] patients aged ≥70 years) and 1,007 individuals have died from COVID-19 (878 [87.2%] patients aged ≥70 years) [3, 4]. This was a multicenter retrospective cohort using data retrieved from the ICU databases. For comparisons between variables, we used χ2 or Fisher exact tests (SPSS V20; IBM Corp., North Castle, NY, USA). As of April 30, in 6 hospitals in Lisbon (catchment area of 1.2 million people), 95 (4.8% of a total of 1,988 cases) patients with COVID-19 pneumonia (nasal/pharynx swab or respiratory secretions with positive SARS-CoV2 by real-time polymerase chain reaction) were admitted to the ICU, with 39 (41.1%) patients aged ≥70 years. Overall, 94 (98.9%) patients required invasive mechanical ventilation (IMV). Among those aged ≥70 years, 38 (97.4%) patients required IMV and only 1 (2.6%) patient was managed solely with a high-flow nasal cannula. Overall, the mean (±SD) sequential organ failure assessment (SOFA) score on ICU admission was 7 (±3), and 16 (16.8%) patients did not survive the ICU stay. Four ICU (70.5% of the 95 patients included) were using the Clinical Frailty Scale to help triage patients with COVID-19 for ICU admission, with those having >6 points being generally declined for ICU care [5]. In 5 (12.8%) patients aged ≥70 years, do-not-resuscitate decisions were established during the ICU stay. In this cohort, patients aged ≥70 years were twice more likely to be admitted to the ICU than others (Table 1; RR = 2.14; 95% CI 1.44–3.18). Moreover, patients aged ≥70 years had access to IMV (RR = 0.97; 95% CI 0.93–1.03) and mean SOFA scores similar to those of others (8 vs. 7; RR = 1.38; 95% CI 0.47–4.07). However, patients aged ≥70 years were 6 times more likely to die in the ICU than others (RR = 6.22; 95% CI 1.90–20.39). Alternatively, of every 4 patients aged ≥70 years admitted to the ICU, 1 derived a survival benefit from ICU care (number needed to treat: 4; 95% CI 2–8). Our findings suggest that chronological age was not a limitative criterion for ICU admission in patients with COVID-19. More likely, clinicians pondered factors such as the number and severity of comorbidities, the presence and severity of frailty, and the number and severity of acute organ dysfunctions [5]. The following limitations warrant consideration. First, the COVID-19 incidence decreased a few weeks following the lockdown imposed by the Portuguese government on March 18 (from a peak of 1,516 cases on April 10 to 368 cases on April 30) [3]. Second, the peak ICU bed occupancy rate occurred on April 6 (60.1% of the total national capacity) [4]. Finally, data on comorbidities and patients declined for ICU admission were not captured and thus we could not weigh for those potential confounders. In conclusion, access to ICU care for elderly patients with COVID-19 may be preserved during the pandemic, especially if there is no strained ICU capacity. While patients aged ≥70 years may incur in a higher mortality, those selected by ICU clinicians may benefit from ICU care. Statement of Ethics Informed consent was waived due to the observational nature of this study. Conflicts of Interest Statement The authors have no conflict of interests to declare. Funding Sources The authors have no funding sources to declare. Author Contributions F.S.C., A.B., I.B., A.R., G.D., A.C.A., and R.P. collected the data. F.S.C. analyzed and interpreted the data. F.S.C. and A.B. drafted this paper. All of the authors read and approved the final version of this work.

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          Most cited references5

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          Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy

          In December 2019, a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) emerged in China and has spread globally, creating a pandemic. Information about the clinical characteristics of infected patients who require intensive care is limited.
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            Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State

            This case series describes the clinical presentation, characteristics, and outcomes of patients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit at a public hospital in Washington State in February 2020, including initial reports of cardiomyopathy in one-third of the patients.
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              The variability of critical care bed numbers in Europe.

              To quantify the numbers of critical care beds in Europe and to understand the differences in these numbers between countries when corrected for population size and gross domestic product. Prospective data collection of critical care bed numbers for each country in Europe from July 2010 to July 2011. Sources were identified in each country that could provide data on numbers of critical care beds (intensive care and intermediate care). These data were then cross-referenced with data from international databases describing population size and age, gross domestic product (GDP), expenditure on healthcare and numbers of acute care beds. We identified 2,068,892 acute care beds and 73,585 (2.8 %) critical care beds. Due to the heterogeneous descriptions of these beds in the individual countries it was not possible to discriminate between intensive care and intermediate care in most cases. On average there were 11.5 critical care beds per 100,000 head of population, with marked differences between countries (Germany 29.2, Portugal 4.2). The numbers of critical care beds per country corrected for population size were positively correlated with GDP (r(2) = 0.16, p = 0.05), numbers of acute care beds corrected for population (r(2) = 0.12, p = 0.05) and the percentage of acute care beds designated as critical care (r(2) = 0.59, p < 0.0001). They were not correlated with the proportion of GDP expended on healthcare. Critical care bed numbers vary considerably between countries in Europe. Better understanding of these numbers should facilitate improved planning for critical care capacity and utilization in the future.

                Author and article information

                Portuguese Journal of Public Health
                S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.com )
                15 December 2020
                : 38
                : 2
                : 1-3
                [1 ] aIntensive Care Unit, Curry Cabral Hospital, Lisbon, Portugal
                [2 ] bIntensive Care Unit, Dr. José de Almeida Hospital, Cascais, Portugal
                [3 ] cIntensive Care Unit, Dr. Manoel Constâncio Hospital, Abrantes, Portugal
                [4 ] dIntensive Care Unit, Dr. Fernando Fonseca Hospital, Amadora, Portugal
                [5 ] eIntensive Care Unit, São Bernardo Hospital, Setúbal, Portugal
                [6 ] fNeuro-intensive and Trauma Care Unit, São José Hospital, Lisbon, Portugal
                [7 ] gMedical Urgency Unit, São José Hospital, Lisbon, Portugal
                Author notes
                *Filipe S. Cardoso, Intensive Care Unit, Curry Cabral Hospital, R Beneficiência N8, PT–1050-099 Lisbon (Portugal), filipe_sousacardoso@ 123456hotmail.com

                Filipe S. Cardoso and André Borges contributed equally.

                Copyright © 2020 by S. Karger AG, Basel

                This article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND). Usage and distribution for commercial purposes as well as any distribution of modified material requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                : 25 June 2020
                : 20 August 2020
                : 2020
                Page count
                Tables: 1, References: 5, Pages: 3

                covid-19,access to healthcare,elderly,portugal,acesso a cuidados de saúde,idosos


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