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BackgroundA COVID-19 hospital guideline was implemented across all acute hospitals in Wales in March 2020, and data was collected across the first 3 Waves of the pandemic. We aimed to observe trends in mortality with a focus on ward-based outcomes. MethodsRetrospective case-note review of data for adults admitted to hospital with community acquired COVID-19 between March 2020 and December 2021 Results5887 cases were analysed. Overall mortality from COVID-19 fell from 31.5% in Wave 1 to 22.6% in Wave 2 to 18.8% in Wave 3 (p<0.01). Ward mortality for patients on oxygen fell from 34.6% in Wave 1 to 19.5% in Wave 2 (p<0.01) to 14.3% in Wave 3 (p=0.03). For those managed with CPAP/HFNO on wards, the mortality reduced from 58.9% in Wave 1 to 45.6% in Wave 2 (p=0.05) and further to 42.6% in Wave 3 (p=0.03). The mortality for patients managed with CPAP/HFNO on ICU reduced from 43.8% in Wave 1 to 24.7% in Wave 2 (p=0.12) and further to 20.4% in Wave 3 (p=0.03). Patients receiving CPAP/HFNO on the wards were on average 11 years older and more co-morbid than those on ICU. In Wave 3, 77% of hospital admissions with COVID-19 were unvaccinated with mortality rates of 20.5% compared to 4.8% mortality in those who had received three vaccines (p<0.01). ConclusionsThere were successive reductions in mortality in inpatients over the 3 Waves reflecting new treatments and better management of complications. The impact of vaccines on outcomes of hospitalised patients was notable in Wave 3. Key Messages What is the key question?What are the outcomes from COVID-19 pneumonitis managed on respiratory wards and how have they changed over successive waves of the pandemic? What is the bottom line?Significant improvements in mortality over time were noted in patients requiring oxygen, CPAP or HFNO. Patients managed with these modalities in ICU had lower mortality rates than those on wards, but they were younger and less co-morbid. In wave 3 patients were largely unvaccinated with higher mortality rates than those who were fully vaccinated. Why read on?This is a national study including all acute hospitals in Wales over three waves of the pandemic from March 2020 to December 2021. It is the first paper to demonstrate at a national level the outcomes of ward management of COVID pneumonitis over successive waves.
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ObjectivesTo define the burden of nosocomial (hospital-acquired) novel pandemic coronavirus (covid-19) infection among adults hospitalised across Wales. DesignRetrospective observational study of adult patients with polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection between 1st March - 1st July 2020 with a recorded hospital admission within the subsequent 31 days. Outcomes were collected up to 20th November using a standardised online data collection tool. SettingService evaluation performed across 18 secondary or tertiary care hospitals. Participants4112 admissions with a positive SARS-CoV-2 PCR result between 1st March to 1st July 2020 were screened. Anonymised data from 2518 participants were returned, representing over 60% of adults hospitalised across the nation of Wales. Main outcome measuresThe prevalence and outcomes (death, discharge) for nosocomial covid-19, assessed across of a range of possible case definitions. ResultsInpatient mortality rates for nosocomial covid-19 ranged from 38% to 42% and remained consistently higher than participants with community-acquired infection (31% to 35%) across a range of case definitions. Participants with nosocomial-acquired infection were an older, frailer, and multi-morbid population than those with community-acquired infection. Based on the Public Health Wales case definition, 50% of participants had been admitted for 30 days prior to diagnostic testing. ConclusionsThis represents the largest assessment of clinical outcomes for patients with nosocomial covid-19 in the UK to date. These findings suggest that inpatient mortality rates from nosocomial-infection are likely higher than previously reported, emphasizing the importance of infection control measures, and supports prioritisation of vaccination for covid-19 negative admissions and trials of post-exposure prophylaxis in inpatient cohorts. Trial registrationThis project was approved and sponsored by the Welsh Government, as part of a national audit and quality improvement scheme for patients hospitalised covid-19 across Wales. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSWe searched PubMed and ISI Web of Science up until 31-December-2020 for studies reporting on patient outcomes following hospital-acquired infection due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We identified a range of case-definitions for hospital-acquired infection, based on timing of diagnostic testing 5 to 15 days following admission. The largest and only multi-centre study concluded individuals with nosocomial infection are at a lower risk of death from SARS-CoV-2 than those infected in the community, however, was performed early in the pandemic and utilised a conservative definition of nosocomial infection. What this study addsOur multi-centre observational study represents the largest assessment of clinical outcomes for patients with nosocomial covid-19 in the UK to date, and suggests the burden of nosocomial SARS-CoV-2 infection has been underestimated. Nosocomial-infection occurred in older, frailer, and multi-morbid individuals, and was consistently associated with greater inpatient mortality than amongst those who were infected in the community across a spectrum of case-definitions. Our findings support implementation of enhanced infection control measures to reduce this burden during future waves, especially given the recent emergence of novel viral variants with enhanced transmissibility. Furthermore, roughly half of the patients meeting the Public Health Wales definition of definite nosocomial SARS-CoV-2 infection had been admitted for 30 days prior to diagnosis, highlighting a potential window of opportunity for inpatient pre-exposure and/or post-exposure prophylaxis.