The odds of a patient hospitalized with COVID-19 dying were higher in hospitals that were hit with the largest surges of patients during the pandemic, a study published in the Journal of Hospital Medicine found.
Researchers from the University of California, San Francisco (UCSF) teamed with care coordination software company Careport Health to look at how hospital-level factors, such as surges of patients, impacted patient outcomes.
As it turned out, there was a clear difference.
Looking at data from 117 hospitals across the U.S. from spring 2020, the researchers found about 21% of patients admitted to the hospital for COVID-19 died. But when controlling for other factors, the mortality rate was one-third higher among hospitals where the COVID-19 burden was greatest.
"Clearly, we usually think of volume as correlating with better outcomes because people have better processes and more experience," Brian Block, M.D., assistant professor of medicine at UCSF and lead author, told Fierce Healthcare. "In this case, I think we were showing that excess volumes beyond what people could accommodate puts a strain that starts impacting outcomes."
Block, a pulmonary care physician in San Francisco, said the idea for the study came after hearing about the experiences his colleagues in New York were having as surges of COVID-19 patients flooded their ICUs.
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"Our experiences were just totally different. We had all the staff we needed, everyone was in a room that was appropriate to take care of them, we could deliver our standard high quality of care we give patients with severe respiratory failure," Block told Fierce Healthcare. "My friends who were back on the East Coast were describing situations of working with staff who were not used to taking care of patients with respiratory failure, sometimes not even internal medicine doctors, they were working with respiratory therapists and nurses that weren’t necessarily practicing in their normal care setting either so they were taking care of patients on different floors or with different types of illness."
Even when it came to equipment, the doctors in New York said they had to make due at times with the use of ventilators that were only intended to be used for transportation purposes—such as for a trip for a CT scan—but were instead being repurposed for ongoing treatment of respiratory failure, he said.
The fact the data did indicate excess mortality makes the case for the early messaging of the importance of "flattening the curve," said Lissy Hu, M.D., CEO and founder of CarePort Health and a co-author on the research.
“This study really has shown, through data from a lot of hospitals, that there is a real impact to flattening the curve and making sure hospitals aren’t overburdened," Hu said.
Their work adds to a growing body of research that found poorer outcomes in hospitals hit heaviest by surges across the world. For instance, in January, Veterans Administration (VA) researchers published a study in the Journal of the American Medical Association that linked ICU demand with mortality rates during the COVID-19 pandemic in VA hospitals.
Researchers in Israel and the U.K. have had similar findings.
Broader implications
Block and Hu said the findings have broader implications for the question of if—and how—hospitals should change their preparation for the possibility of a future pandemic.
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“If we were to step back a little bit and think about the larger trend in healthcare and what has happened over the last decade, is a lot of hospitals have closed. There’s a broad shift toward home-based and community-based care versus the hospital level of care,” Hu said. “I think this is one of the potential risks of that shift that has occurred. When events like this occur when there is a sudden need for ICU hospital resources, you do run the risk of your hospital being overburdened, and potentially that leading to inferior outcomes for patients."
One of the notable storylines of the pandemic was the state of the supply chain of equipment like ventilators, medications or personal protective equipment and the impact fluctuations could have on patient care.
But less attention was paid to the strains on healthcare workforce and the impact that could have. That will be a crucial problem to solve, Block said.
“Hospitals were able to work heroically to try to take care of patients. I definitely don’t want to detract from the enormous efforts that colleagues put in across the country to take care of patients, many of them working incredible hours, under strain, around other people who were sick, not seeing their family, worried for their own personal safety, losing colleagues. People really rose to the occasion here," Block said. "But the question is, ‘How much do we want to continue to ask them to rise?'”