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INTRODUCTION: To describe the epidemiology of Coronavirus Disease 2019 (COVID-19)-related critical illness at a diverse academic health system METHODS: We performed a single-health system, multihospital retrospective cohort study of patients with COVID- 19-related critical illness who were admitted to an intensive care unit (ICU) at any of five hospitals within the University of Pennsylvania Health System We report descriptive statistics for patient demographics, comorbidities, acute physiology parameters, receipt of ICU therapies, hospital outcomes, and survivorship Using multivariable linear and logistic regression, we evaluated trends over time in all-cause 28-day in-hospital mortality, the primary outcome, and in patient acuity, and we evaluated candidate prognostic risk factors for association with mortality RESULTS: 468 patients with COVID-19-related critical illness had a median age of 65 years (interquartile range [IQR] 54-74), were more likely male (57 7%), were more likely Black race (52 8%), and had a high co-morbidity burden (71 8% with ≥ 2 points on the Charlson Comorbidity Index) At least once during their hospitalization, 319 (68 2%) patients were treated with mechanical ventilation and 121 (25 9%) with vasopressors Outcomes were notable for 29 9% all-cause 28-day in-hospital mortality (37 0% among those who received mechanical ventilation and 14 8% among those who did not receive mechanical ventilation), 8-day (IQR 3-17) median ICU length of stay, 13-day (IQR 7-25) median hospital length of stay, and 10 8% all-cause 30-day readmission rate Mortality decreased over time from 43 5% (95% confidence interval 31 3%-53 8%) to 19 2% (11 6%- 26 7%) between the first and last 15-day periods in the fully adjusted model Risk factors at ICU admission prognostic for mortality included increasing age, peripheral vascular disease, low or high body mass index, abnormal mental status, hypoxemia, tachypnea, and thrombocytopenia CONCLUSIONS: Among patients with COVID-19-related critical illness admitted to the ICU at an academic health system in the U S , a finite set of patient-level factors were prognostic for mortality and mortality decreased over time

The question of who should direct the care of critically ill patients is both multifaceted and timely. Currently, only about 30% of critical care units in the United States are staffed by dedicated intensivists. This number is likely to increase as groups such as Leapfrog financially reward hospitals that have dedicated intensivists around the clock. The problem, however, is that the supply of intensivists by training is not projected to increase, whereas the demand for health care, by all accounts, will significantly increase in the near future. There is an increasing body of literature suggesting not only morbidity and mortality benefits but decreased length of stay and profound cost savings when a team directed by critical care physicians cares for patients in the intensive care unit. Despite this, many have argued that a consultant-based unit (so called open unit) is less alienating to a patient's primary care physician or surgeon and promotes continuity of care. In addition, although much of the literature has suggested purported benefit derived from a dedicated intensivist staffing model, little has been published regarding optimal intensivist/patient ratios. If dedicated critical care teams decrease complications in the intensive care unit, one may logically reason that as the intensivist/patient ratio decreases, morbidity or mortality, or both, might increase. This, however, has not yet been shown. This article will address many of these issues, discuss the history of critical care medicine in the United States, and review the pertinent literature. With the projected shortage of critical care-trained physicians and an increasingly aging population, it is imperative that health professionals evaluate this issue sooner rather than later.