Q&A: 1 in 5 COVID-19 deaths due to strain of hospital overcrowding
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Key takeaways:
- Even as the pandemic waned, hospital overcrowding was responsible for one in five COVID-19 deaths, highlighting the importance of controlling surges.
- Healio spoke with Maniraj Neupane, MD, PhD, to learn more.
Hospital overcrowding accounted for roughly 20% of COVID-19 deaths even when vaccines and other therapeutics became available, highlighting the importance of managing case surges during public health crises, according to an expert.
Maniraj Neupane, MD, PhD, a critical care medicine specialist and pulmonologist at Prairie Center Internal Medicine & Nephrology, and colleagues recently published a retrospective cohort study in Annals of Internal Medicine in which they evaluated the effect of hospital overcrowding as cases surged during the COVID-19 pandemic.
In their analysis of 620 U.S. facilities, the researchers found that surging caseloads leading to overcrowding hurt all types of hospitals similarly, even those classified as highly advanced centers. They wrote that this finding is an important lesson from the pandemic, heightening the need to minimize surges in cases during future public health crises.
Healio spoke with Neupane to learn more about the study, the lessons that can be applied to the next pandemic and more.
Healio: Can you explain your rationale for conducting this research and why you feel it is important?
Neupane: Earlier on during the pandemic, our team at the NIH reported one in four COVID-19 deaths in U.S. hospitals were attributable to overcrowding. As the pandemic progressed and as the COVID-19 therapeutics and vaccines evolved, it was unclear whether the phenomenon that we saw during the early wave was due to lack of COVID-19 therapeutics or differences in health care infrastructure between hospitals. So, it was important to investigate if there are some hospital types that do better in taking care of critically ill respiratory failure patients when hospitals are operating in a public health crisis. This helps in preparing for effective care delivery during the next one.
Healio: Which hospital types struggled the most during the pandemic and which had the most success?
Neupane: We classified hospitals into four categories: large hospitals with extracorporeal membrane oxygenation (ECMO) capabilities, large hospitals with multiple specialized ICU types but no ECMO capabilities, large hospitals with a single ICU type and small hospitals (less than 200 beds) with single ICU type. This is not an exhaustive classification of hospital types, but we determined this was simple to understand and was guided by clinical logic based on the infrastructure needed to care for critically ill respiratory failure patients. We tested the performance of our classification system and depicted differences in care resources by hospital types. When we assessed longitudinally over 5 months of the Delta wave if some hospitals were more resilient than others when they were operating under overcrowded situations, we found that all hospital types were similarly affected when they were surging with COVID-19 patients. Indeed, we estimated one in five COVID-19 deaths in our cohort of 620 U.S. hospitals were due to overcrowding, even during the Delta wave of the pandemic when vaccines and COVID-19 therapeutics were available. All hospital types struggled — irrespective of their capabilities — to deliver optimal care during the pandemic when they were overcrowded with patients. This suggests we should prevent this from happening. When hospitals are strained due to overcrowding, it has been shown across multiple studies that patient care is affected adversely, and patient outcomes are worse. We likely captured this phenomenon occurring irrespective of hospitals’ capabilities and resources.
Healio: You wrote that the imbalances that strained hospitals during the pandemic have persisted beyond it. What factors contribute to these imbalances?
Neupane: Hospitals operate optimally when staff, stuff, space and systems — the 4 Ss — are balanced and compensate for each other. During the pandemic, all four of these were affected, and hospitals were strained because of the resulting imbalance. As the pandemic waned and routine care resumed, our hospitals continued to struggle with chronic staffing shortage, including nurses, physicians and other health care workforce. This shortage existed even before [COVID-19] and was exacerbated even further because of the pandemic. This has continued to create the imbalance between staffing, resources and the caseload of patients that hospitals are supposed to take care of every day now.
Healio: How can these discrepancies be overcome?
Neupane: First would be to recognize the problem that overcrowded hospitals could be detrimental for patient care. To prevent hospitals from being overcrowded, we should be able to easily measure and monitor their overcrowding status. Currently, there is no uniform way to monitor this. We are attempting to build a framework surrounding this that could be applicable in a multitude of settings. That will enable us to act in real time to offload overcrowded hospitals and distribute patient load across hospital types, including repatriation or back transfer of less acutely ill patients.
Healio: Are there any other lessons have we learned from the COVID-19 pandemic that we can apply to future crises?
Neupane: Several states in the U.S. implemented statewide medical operations coordination centers during the pandemic to enhance equitable access to care for needed patients during surges. This facilitated transfer of patients between hospitals and likely assisted in balancing loads across hospitals to some extent. Many of these medical operations coordination centers have been sunsetted as the pandemic waned. It is important to recognize the utility of those not only during future crises but also during routine times when caseload staff imbalances are a daily occurrence in many regions of the U.S.
Healio: Is there anything else you would like to add?
Neupane: Since the pandemic waned, several initiatives to collect routine data and assimilate them into health care dashboards have been paused, but we think it is important to continue collecting staffing and caseload numbers in health care dashboards and make them available to researchers and administrators to enable studies like ours to address this problem. Organizations like the Agency for Healthcare Research and Quality, the Administration for Strategic Preparedness and Response, the CDC and the CMS could potentially play significant roles toward this.