- New insights show the precise impact of COVID-19 surges on hospital clinical operations.
- Hospitals can stay a step ahead of a disease outbreak by learning from the experiences of hospitals in regions where the disease recently has surged.
- Public-health policymaking should consider strategies for triaging and diversion to alleviate operational stress on hospitals.
Hospitals should be ready to implement processes to better manage “strain” during future surges of COVID-19 or other disease outbreaks, says an expert in critical care medicine.
Testifying recently during a Senate committee hearing, David Janz, MD, director of medical critical care services with University Medical Center in New Orleans, said mitigating strain on hospital capacity will be crucial in the response to any disease surge.
“How does a hospital manage mass-casualty incidents, or how do we care for critically ill adults when intensive care units are full? Hospital strain occurs much earlier than the nightmare scenario of running out of ventilators,” Janz said July 27 during a Senate Health, Education, Labor & Pensions (HELP) Committee hearing on COVID-19 lessons for the healthcare and public health sectors. “Even more worrisome, hospital strain is associated with worse patient outcomes.”
A recently published study backs up Janz’s point, quantifying the relationship between surges in COVID-19 cases at hospitals and mortality rates during the early months of the pandemic.
In March-August 2020, spanning approximately the first six months of the pandemic, 23.2% of COVID-19 deaths were “potentially attributable to hospitals strained by surging caseload,” researchers with the National Institutes of Health concluded in the Annals of Internal Medicine.
High case numbers may thwart advances in treatments
For each month in the study, the researchers stratified 558 hospitals in a national database according to COVID-19 caseload relative to pre-pandemic bed capacity. Caseloads were weighted based on variables related to severity, such as number of cases for which invasive ventilation was required.
The researchers then examined whether there was an association between a hospital’s caseload and COVID-19 patients’ risk-adjusted odds ratio of in-hospital mortality or discharge to hospice.
COVID-19 mortality decreased across hospitals during the five-month study period. However, compared with hospitals in the lower half of the “surge index,” those in the upper half had a risk-adjusted mortality odds ratio of at least 1.11. The odds ratio increased to 1.42 for hospitals in the 90th percentile, 1.59 for hospitals in the 95th percentile and 2 for those in the 99th percentile.
The statistical relationship between case surge and mortality was stronger in June, July and August 2020 compared with March, April and May “despite greater corticosteroid use and more judicious intubation during later and higher-surging months,” the researchers wrote.
Getting out in front of strain
In March 2020, University Medical Center “responded to the soon-to-come strain by scaling critical care services for COVID-19, adding personnel such as nurses and physicians, giving them evidence-based patient care tools that allowed them to provide high-value critical care to a large number of patients,” Janz said.
The hospital anticipated the challenges that awaited by examining data from hospitals in the Lombardy region of Italy, where rates of COVID-19 positive tests had been similar to what New Orleans was just starting to experience. The operational responses of the Italian hospitals also offered lessons.
“An early description from this region — not just of what illness coronavirus causes, but how large numbers of patients with this disease impact a healthcare system — was critical to our preparation,” Janz said.
Having learned by studying the experiences of hospitals in Italy, University Medical Center dispersed its own insights about managing strain via webinars conducted by state and federal health authorities. Such sessions should be hallmarks of future responses as well, Janz said.
“The ability for us and others to share these operational successes … was vital to smaller, more resource-limited hospitals, to aid them during times of current and future strain,” he said.
He noted that some of the standards of care and best practices relayed during the sessions were implemented on a large scale nationally within weeks. “It was very quick,” he said.
Strategies to relieve high caseloads
Although their study did not establish causation, the NIH researchers said the findings are strong enough to “suggest potential value in prioritizing staffing, inventory and logistical support early, especially to select hospitals approaching concerning surge index thresholds. Doing so might prepare these hospitals to better manage patients with COVID-19 in the event of even greater and more prolonged surges.”
New approaches to triaging and diversion may also be warranted.
“Our data raise the question of whether there may be a role for earlier diversion of patients with COVID-19 from emergency departments of hospitals experiencing surges,” the researchers wrote. “Preemptive engagement of relief healthcare (‘shock absorber’) facilities is already occurring. Medical operations coordination cells are enabling these triage efforts to cross state lines, especially when neighboring hospitals are also experiencing surges.
“However, the risks and benefits of transporting patients with COVID-19 must be carefully studied and calibrated to individual hospitals’ capacity, infrastructure and resources.”
What’s certain is that establishing solutions should be a priority.
“Strain will continue to affect hospitals in various ways in the future," Janz said, "and successful responses to strain may avoid poor patient outcomes.”