Characteristics of and Outcomes in COVID-19 Critical Care Patients in the Qassim Region, Saudi Arabia

Background and objective Characterizing the epidemiological features of coronavirus disease 2019 (COVID-19) is highly important for developing and implementing effective control measures against it. However, there is scarce data about the presenting features and outcomes in ICU patients with COVID-19 in the Kingdom of Saudi Arabia (KSA). In light of this, this study aimed to assess the characteristics of and outcomes in COVID-19 ICU patients in KSA in order to describe and identify the risks associated with morbidity and mortality among them. Methodology A retrospective, hospital-based study was conducted from March 2020 to October 2021, which involved the review of medical records of the patients admitted to the ICU at COVID-19 treatment centers. The demographic data, comorbidities, signs, and symptoms of the patients were collected, along with data on the need for ventilation, duration of ICU stay, and fatality rate. All data were analyzed and the associations between variables were evaluated. Results A total of 172 patients were included in the study, most of them males (n=97, 56.4%) and elderly (69.6 ±18.2 years). The majority were Saudi nationals (n=143, 83.1%). Regarding comorbidities accompanying COVID-19, about 95 (55.2%) patients had cardiac diseases while 85 (49.4%) had diabetes; 33.7% of the patients needed mechanical ventilation versus 40.7% who needed non-mechanical ventilation. Significant associations were found in terms of age, comorbidities, and mortality rate (90, 52.3%), especially with cardiac diseases (p=0.025), diabetes (p=0.009), and kidney diseases (p=0.003). Conclusion COVID-19 infection is associated with a wide range of characteristics and outcomes. Raising awareness about the risk factors associated with COVID-19 infection will improve clinical outcomes by ensuring correct resource allocations and implementation of appropriate preventive measures.


Introduction
In December 2019, an outbreak of severe acute respiratory syndrome (SARS) attributed to a new strain of coronavirus, specifically, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in the Wuhan region of China.This disease, which was eventually termed coronavirus disease 2019 (COVID-19), is characterized by a flu-like syndrome, with features such as fever, myalgia, cough, and gastrointestinal symptoms.Most cases are mild in nature, and some might be asymptomatic; however, approximately 15% of patients have a more severe presentation, and 5% experience a critical disease [1].In March 2020, COVID-19 was declared a global pandemic by the World Health Organization (WHO), and instances of the infection soon surpassed more than three million worldwide accompanied by expanding mortality rates [2].The first case of COVID-19 in the Kingdom of Saudi Arabia (KSA) was reported on March 2, 2020, and the peak of the pandemic was reported in June and July 2020, with 4,919 being the highest number of cases recorded in a single day: on June 18, 2020 [3].
Patients with SARS-CoV-2 pneumonia have a high mortality rate in the ICU, which exerts significant pressure on hospital intensive care resources [4].Because COVID-19 cases have increased exponentially around the world since the start of the pandemic, there is a need to document the temporal changes in patient characteristics over time, as well as the impact of real-world clinical practice on outcomes including ICU admissions, acute respiratory distress syndrome (ARDS)/respiratory failure, invasive mechanical ventilation (IMV), and all-cause mortality over time among patients with COVID-19 [5].Acute hypoxemic respiratory failure progressing to ARDS is the most common presentation of COVID-19 infection in the ICU [6].
COVID-19 infection's severity and outcome are determined by both the virus and the host's immune response.Several studies from China, Italy, Sweden, and the United States have linked the disease's poor prognosis with advanced age, male gender, and pre-existing chronic conditions such as high blood pressure, cardiovascular disease, and diabetes.Simultaneously, pediatric cases have been reported to have a milder clinical illness course [7].In Japan, an efficient healthcare system, with universal health insurance and the implementation of good personal hygiene practices such as the regular use of masks, as well as a very advanced level of medical practice and care, may have contributed to less severe outcomes related to COVID-19 in Japanese patients [8].
Given the high prevalence of hospitalization among COVID-19 patients in KSA, it is necessary to investigate if any distinct sociodemographic characteristics (e.g., age, sex) or medical factors [e.g., mandatory minute ventilation (MMV) usage, ICU admission] are linked with the increase in the morbidity and mortality risk in the country.Furthermore, the cost of hospitalization must be estimated [9].To handle the pandemic effectively and efficiently, it is critical to provide government officials and physicians with clear guidance regarding risk factors, mortality, and how to prioritize screening, testing, isolation, or quarantining of COVID-19 patients [9].In light of this, this study aimed to assess the characteristics of and outcomes in COVID-19 patients who developed critical illnesses requiring admission to ICU, with a view to describe and identify the risk factors associated with morbidity and mortality among them.

Study design and population
A retrospective, hospital-based cohort study was conducted at the King Fahad Specialist Hospital and Al-Rass General Hospital, Qassim Region, KSA, during the period from March 2020 to October 2021.It involved adult patients who were admitted to the hospital with severe COVID-19 infection requiring ICU admission.

Inclusion and exclusion criteria
Adult patients with confirmed diagnosis of COVID-19 who had severe symptoms requiring admission to ICU were included in the study.COVID-19 patients with mild or moderate symptoms requiring hospitalization but not ICU admission, patients aged less than 18 years, COVID-19 patients admitted to ICU for any other reason, and patients with incomplete data in their medical records were excluded.The sample size of our study was 172 patients.
Table 1 presents the demographic data, symptoms, and comorbidities among the study participants (n=172).

Discussion
The COVID-19 pandemic has rapidly evolved across the world.The demographic distribution and temporal trends in adverse clinical outcomes associated with the condition, such as ICU admissions, ARDS/respiratory failure, IMV, and all-cause mortality, must be understood on a global scale [4].In this cross-sectional study, we reviewed the medical records of 172 adult patients to assess the clinical characteristics and outcomes of COVID-19 ICU patients in the Qassim Region, Saudi Arabia.Our study findings showed that the patients were mostly male (n=97, 56.4%), with a mean age of 63.6 ±20 years.A similar result was observed in another study where COVID-19 was most commonly found in adult male patients aged 34-59 years [11].Another study involving 22 COVID-19 ICU patients reported a median age of 54.5 years, and 16 (72.7%) of the patients were males.Also, all of them had at least one comorbidity [12].
This study reported the clinical characteristics of and outcomes in patients who needed mechanical/nonmechanical ventilation; 58 (33.7%) patients needed mechanical (invasive) ventilation and 31 (32.0%) of them were males.Most of them had a heart disease (n=36, 37.9%).Of note, 70 (40.7%)patients in our study needed non-mechanical (noninvasive) ventilation; most of them were female (n=35, 46.7%) and had a heart disease (n=40, 42.1%).According to a recent study, non-survivors used interventional invasive mechanical ventilation at a much higher rate than survivors (83% vs. 31%, p=0.001) [7].Among survivors, the period of mechanical ventilation was significantly shorter (6.3 vs. 12.2 days) with 270 (31.5%) patients requiring it throughout their hospital stay [7].Another study found a lower mortality rate than our study and documented survivors who underwent prolonged mechanical ventilation for more than three weeks [8].In a Canadian study, among patients admitted to the ICU for COVID-19, about two-thirds received invasive mechanical ventilation and one-quarter died [15].
The results of our study showed that COVID-19 has a more unfavorable impact on elderly patients with comorbid diseases.Most of the patients who died (n=90, 52.3%) were elderly (mean age: 69.6 ±18.2 years, p<0.001), suggesting elevated risk throughout the course of the disease among older patients.These results are in accordance with findings from other prior studies.Elderly patients had a higher prevalence of preexisting comorbidities, which could have negatively affected patients' ability to fight against infections [16].
In addition, Takahashi et al. [14] found that declined T-cell response is associated with advanced age, which could lead to lower efficacy in viral clearance and a higher likelihood of inflammatory cytokine storm, resulting in poor health outcomes.
In our study, most of the patients who had a long hospital stay had immune diseases (mean number of days: 28.5 +31.8, p=0.048), and kidney diseases (mean number of days: 17.1 ±12.8, p=0.010), while patients with obesity (10.6 ±10.5 days) and cancer (6.1 ±5.9 days) had the shortest duration of hospital stay.The findings of another study revealed a longer hospital stay, longer time in the ICU, a higher probability of ICU admission, and a more urgent need for mechanical ventilation among patients with more chronic conditions compared to other groups [12].
Several limitations should be taken into consideration when interpreting the results of this study.We employed a retrospective, short-term study design; a prospective research design would have given us greater insight into the outcomes of severe COVID-19 infections admitted to the ICU.The study was also limited by its relatively small sample size.

Conclusions
COVID-19 infection is associated with a wide range of characteristics and outcomes.Based on our findings, most of the COVID-19 ICU patients were elderly males with multiple comorbidities, mainly diabetes, cardiac diseases, and obesity.A significant association was found between certain comorbidities and death rates in our patients, as well as between specific comorbidities and the duration of hospital stay.Raising awareness about risk factors of COVID-19 infection will improve the clinical outcomes among patients by ensuring timely and correct resource allocations as well as the implementation of appropriate preventive measures.Further studies are required to validate our findings.

TABLE 1 : Demographic data along with symptoms and comorbid diseases among the study participants (n=172)
SD: standard deviation

Table 2
needed noninvasive ventilation.Moreover, most of the patients who needed invasive ventilation were males (n=31, 32,0%), Saudi nationals (n=51, 35.7%), and had a mean age of 65.8 ±19.9 years.Also, most had three to four comorbidities (n=24, 35.8%).No significant association was found between the variables.Most of the patients who needed noninvasive ventilation were females (n=35, 46.7%), of non-Saudi nationality (n=12, 41.4%), and had a mean age of 61.6 ±21 years.Most of them had three to four comorbid diseases (n=30, 44.8%).The mean number of diseases was 2.8 ±1.6.No significant association was found between the variables.

TABLE 2 : Association between patient demographics, comorbid diseases, and the need for invasive or noninvasive ventilation (n=172)
SD: standard deviation

TABLE 3 : Association between the patient demographics, comorbid diseases, and mortality rate (n=172)
SD: standard deviation

Table 4
presents the association between comorbid diseases and the duration of hospital stay among the patients.Patients with immune disorders and kidney diseases had the most prolonged hospital stay (28.5 ±31.8 and 17.1 ±12.8 days respectively) and this association was significant (p=0.048 and 0.010 respectively), while patients with obesity (10.6 ±10.5 days) and cancer (6.1 ±5.9 days) had the shortest duration of hospital stay.

TABLE 4 : Association between comorbid diseases and the duration of hospital stay among the patients (n=172)
SD: standard deviation