Pandemic-Related Hospital Caseload Strain Attributes to Portion of COVID-19 Deaths

During the SARS-CoV-2 Delta variant wave, which led to a major increase in cases of COVID-19, there was a comparably detrimental relationship between COVID-19 caseload at hospitals of any type and survival, making up to 1 in 5 COVID-19 deaths attributable to hospital caseload, according to results published in Annals of Internal Medicine.¹

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Aside from the observable sickness and spread of the virus, the COVID-19 pandemic led to lasting effects in various other aspects of health care, including increases in burnout, exacerbation of existing staff shortages in hospitals, and a large increase in workforce turnover. Together, these factors result in caseload strain, which can lead to negative impacts on survival.¹

Hospitals across the United States differ in terms of the services they provide, their funding, and location. “These variations often translated into inequities under pandemic stress,” the investigators wrote, citing a study from Sarzynski et al that found many smaller and rural hospitals that rely on referral centers could not transfer patients. Problems transferring patients were found to be highest during high-caseload periods like the Delta wave.^1,2

The investigators aimed to investigate whether the quality of care at a certain type of hospital may be more resilient to caseload strain than another type. A retrospective cohort study was performed, analyzing whether hospitals’ care infrastructure influenced the COVID-19 volume-outcome relationships during the Delta surge, according to the investigators.¹

A total of 814 hospitals were included in the data set, with 620 (76.2%) having at least 1 intensive care unit (ICU). These consisted of 208 extracorporeal membrane oxygenation (ECMO)-capable, 216 multi-ICU, 36 large single-ICU, and 160 small single-ICU hospitals.¹

Throughout the analyzed study period, 50,752 (23%) patients were admitted to the ICU, and 27,474 (12%) received mechanical ventilation. Receiving mechanical ventilation on admission (day 0 to 1) was observed in 10,850 (4.9%) patients, 5.7% in ECMO-capable centers, 4.3% in multi-ICUs, 4.9% in large single-ICUs, and 2.7% in small single-ICUs. Furthermore, temporal variation in the caseload surge across hospitals was seen with higher distributions in August (range, 0.12 to 74.6) and September (range, 0.16 to 50.4).¹

Moving to a discussion of patient outcomes, 34,274 patients (15.3%) in the cohort with COVID-19 passed away or were discharged to hospice, according to the investigators. Crude mortality was higher during hospital-months surging above the 50th percentile compared with hospitals that did not surge. Importantly, adjusted marginal mortality risks did not differ across types of hospitals.¹

Previous trials examining the issue of hospital caseload have come to similar conclusions. One such trial, conducted by Kadri et al, suggested that nearly 1 in 4 COVID-19 deaths from March 2020 to August 2020 could be attributed to hospital caseload strain. Additionally, the current investigators supplemented Kadri et al’s findings by determining that the hospital overcrowding they had found has continued “well beyond the pandemic’s ‘learning curve.’”^1,3

In another critical discovery, caseload strain remained comparably detrimental to survival from COVID-19 no matter the type of hospital or their care infrastructure. This observation was continuously seen, even after patients who transferred in from other hospitals were excluded or when the analysis was constricted to those with present respiratory failure.¹

Overall, these findings indicate that avoiding surging caseload across hospitals can be indirectly lifesaving. By balancing the caseload, patients in smaller hospitals would be able to access better care and larger referral hospitals, the investigators discussed, writing, “In the future, a multipronged strategy will be necessary to more strategically utilize a finite resource of beds, transportation, and staff to leverage maximal benefits.”¹

REFERENCES

1. Neupane M, Warner S, Mancera A, et al. Association between hospital type and resilience during COVID-19 caseload stress: a retrospective cohort study. Ann Intern Med. 2024. doi:10.7326/M24-0869

2. Sarzynski SH, Mancera AG, Yek C, et al. Trends in patient transfers from overall and caseload-strained US hospitals during the COVID-19 pandemic. JAMA Netw Open. 2024;7(2):e2356174. doi:10.1001/jamanetworkopen.2023.56174

3. Kadri SS, Sun J, Lawandi A, et al. Association between caseload surge and COVID-19 survival in 558 US hospitals, March to August 2020. Ann Intern Med. 2021;174(9). doi:10.7326/M21-1213