Covid-19: 1-in-4 U.S. Hospital Deaths Linked to Caseload Surges

Roughly 1-in-4 Covid-19 deaths in U.S. hospitals during the early months of the Covid-19 pandemic may have been attributable to strains on facilities and staffers due to surging caseloads, according to findings from a retrospective study of data from more than 550 hospitals conducted by researchers from the National Institutes of Health.

After risk adjustment, patients cared for in hospitals with the highest surges of Covid-19 patients had death rates that were twice as high as those cared for in hospitals that were not experiencing surges, with hospital strain due to Covid-19 responsible for an estimated 6,000 deaths.

Although baseline inpatient Covid-19 survival improved during the March through August 2020 study period, after adjusting for changing case and treatment patterns and other factors, the risk for death due to surging Covid-19 caseloads was found to increase in the latter months of the study.

The findings, published online July 5 in Annals of Internal Medicine, suggest that “prioritizing staffing, inventory and logistical support” in the early months of the surge could have significantly reduced mortality, wrote researcher Sameer Kadri, MD, of the National Institutes of Health Clinical Center, Bethesda, Maryland, and colleagues.

“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,” they wrote. “Preemptive engagement of relief health care (’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.”

The retrospective cohort study included data on 144,116 patients hospitalized for Covid-19 at 558 U.S. hospitals between March and August of 2020, with discharges or death occurring by October of that year.

Researchers developed a surge index specific to Covid-19 to measure hospital strain associated with Covid-19-patient numbers in relation to baseline bed capacity. Larger, urban hospitals were overrepresented in the analysis.

Clusters of hospitals with very high surge indices were seen in the Northeastern U.S. in April and in the South and Western U.S. in July of 2020.

The analysis also revealed:

• Forty-nine hospitals entered the 99th percentile of surge index between March and May 2020, and 20 hospitals entered this category between June and August.
• Within the 99th percentile category between March and May, Hispanic patients represented 18% of cases and 16% of deaths; this increased to 65% of cases and 71% of deaths between June and August.
• Corticosteroid use increased after May in all surge and severity strata, with greater use among the highest surge indices. Nearly three quarters of patients received hydroxychloroquine in March, but use decreased sharply and stayed near zero in June through August.
• Rates of ICU admission and intubation decreased over the study period.
• Crude mortality decreased in the early months of the study period, but this decline appeared to plateau among patients admitted to hospitals between June and August, during which time higher surge indices showed higher crude mortality.

The researchers estimated that of the total 25,344 deaths attributed to Covid-19 at the hospitals, a total of 5,868 (95% CI, 3,584-8171) were “potentially attributable to hospital caseload surge.”

They also noted that their findings may not be generalizable to all U.S. hospitals due to limitations, such as the possibility of residual confounding.

In an editorial published with the study, Vineet Chopra, MD, of the University of Michigan, Ann Arbor, called for a unified, regional approach to managing patients hospitalized with Covid-19 moving forward to prevent “the deleterious effects of future surges on patients.”

Chopra noted that since regional Covid-19 surges tend to affect multiple hospitals, “the current approach, which largely consists of ’every hospital for itself’ must be changed.”

“Instead, we need a coordinated, regional approach to absorb the shock of rapid increases in Covid-19 volume. State health departments, payers, professional societies, and hospital associations are well positioned to lead this dialogue,” Chopra wrote.

He applauded a Michigan initiative designed to improve patient care, which had input from multiple stakeholders, including 40 hospitals systems.

“By collecting and analyzing granular hospital data during waves of the pandemic, sharing knowledge, and hosting weekly webinars at the height of the Michigan surge, the Mi-COVID19 initiative served as an amalgam for clinicians and hospital leaders across the state to tackle important questions ranging from therapeutic strategies and excess antibiotic use to provider wellness and long-term outcomes of Covid-19 survivors,” Chopra wrote.

He also warned that “it is all but certain that future surges, if managed using our current paradigm, will not only harm patients but also weaken the strength and resolve of our most precious resource: our people.”

“Simply put, we owe it not only to our patients but also to our providers to come together when Covid-19 strikes. Kadri and colleagues’ findings serve as powerful motivation to move away from the status quo.”

1. Roughly 1-in-4 Covid-19 deaths in U.S. hospitals during the early months of the Covid-19 pandemic may have been attributable to strains on facilities and staffers due to surging caseloads, NIH researchers found.

2. After risk adjustment, patients cared for in hospitals with the highest surges of Covid-19 patients had death rates that were twice as high as those cared for in hospitals that were not experiencing surges.

Salynn Boyles, Contributing Writer, BreakingMED™

Cat ID: 926

Topic ID: 79,926,728,932,933,926,928,934