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Observational Study
. 2021 Jul 1;49(7):1038-1048.
doi: 10.1097/CCM.0000000000005013.

Variation in Initial U.S. Hospital Responses to the Coronavirus Disease 2019 Pandemic

Kusum S Mathews  1   2 , Kevin P Seitz  3 , Kelly C Vranas  1   2   3   4   5   6   7   8   9   10   11   12   13   14   15 , Abhijit Duggal  7   8 , Thomas S Valley  1   2   3   4   5   6   7   8   9   10   11   12   13   14   15 , Bo Zhao  12 , Stephanie Gundel  13 , Michael O Harhay  14 , Steven Y Chang  15 , Catherine L Hough  5 ; National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury (PETAL) Clinical Trials Network
Affiliations
Observational Study

Variation in Initial U.S. Hospital Responses to the Coronavirus Disease 2019 Pandemic

Kusum S Mathews et al. Crit Care Med. .

Abstract

Objectives: The coronavirus disease 2019 pandemic has strained many healthcare systems. In response, U.S. hospitals altered their care delivery systems, but there are few data regarding specific structural changes. Understanding these changes is important to guide interpretation of outcomes and inform pandemic preparedness. We sought to characterize emergency responses across hospitals in the United States over time and in the context of local case rates early in the coronavirus disease 2019 pandemic.

Design: We surveyed hospitals from a national acute care trials group regarding operational and structural changes made in response to the coronavirus disease 2019 pandemic from January to August 2020. We collected prepandemic characteristics and changes to hospital system, space, staffing, and equipment during the pandemic. We compared the timing of these changes with county-level coronavirus disease 2019 case rates.

Setting and participants: U.S. hospitals participating in the Prevention and Early Treatment of Acute Lung Injury Network Coronavirus Disease 2019 Observational study. Site investigators at each hospital collected local data.

Interventions: None.

Measurements and main results: Forty-five sites participated (94% response rate). System-level changes (incident command activation and elective procedure cancellation) occurred at nearly all sites, preceding rises in local case rates. The peak inpatient census during the pandemic was greater than the prior hospital bed capacity in 57% of sites with notable regional variation. Nearly half (49%) expanded ward capacity, and 63% expanded ICU capacity, with nearly all bed expansion achieved through repurposing of clinical spaces. Two-thirds of sites adapted staffing to care for patients with coronavirus disease 2019, with 48% implementing tiered staffing models, 49% adding temporary physicians, nurses, or respiratory therapists, and 30% changing the ratios of physicians or nurses to patients.

Conclusions: The coronavirus disease 2019 pandemic prompted widespread system-level changes, but front-line clinical care varied widely according to specific hospital needs and infrastructure. Linking operational changes to care delivery processes is a necessary step to understand the impact of the coronavirus disease 2019 pandemic on patient outcomes.

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Conflict of interest statement

Dr. Mathews reports grants from National Institutes of Health (NIH)/National Heart Lung and Blood Institute (NHBLI) (K23HL130648) and serves on a steering committee of A Multi-Center, Adaptive, Randomized, Double-blind, Placebo-controlled Study to Assess the Efficacy and Safety of Gimsilumab in Subjects With Lung Injury or Acute Respiratory Distress Syndrome Secondary to COVID-19 (BREATHE) trial, funded by Roivant/Kinevant Sciences, outside of the submitted work. Dr. Vranas reports support from the Veterans Affairs Portland Health Care System, outside the submitted work. Dr. Harhay reports editorial positions at the American Thoracic Society and receiving grants from the NIH, outside the submitted work. Dr. Chang reported receiving personal fees from PureTech and LaJolla Pharmaceuticals, outside the submitted work. Dr. Hough reports grants from the NIH during the conduct of the study. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1:
Figure 1:. Choropleth map of surveyed hospital locations and county-level case rates of COVID-19 from March through August 2020.
This choropleth map illustrates spatial and temporal variation of weekly county-level COVID-19 cases rates (defined as the absolute number as a percentage of county population). Case rates from the third week of each month are shown in each panel.
Figure 2:
Figure 2:. Hospital operational changes from January to August 2020, matched with county-level COVID-19 case rates
Timing of hospital operational changes varied over the course of the first eight months of the pandemic, with regional variability. The red shading represents the rate of county-level COVID-19 cases per 1000 residents per week, matched to the county of each hospital. Overlying this heat map are six operational changes which show significant similarities across sites (e.g., elective procedure cancellation, [blue open circle]) and heterogeneity both pre-surge (e.g., incident command system activation, [orange solid circle]) and during the rise in cases (e.g., ICU expansion, [purple triangle]; tiered staffing models, [green solid square]; temporary staffing, [black open square]; alternative ventilator usage, [gray cross]). (Three hospitals had incomplete data for these changes).
Figure 3:
Figure 3:. Frequency of combinations of specific hospital operational changes across the PETAL Network between January-August 2020.
Hospitals across the PETAL Network implemented various combinations of operational changes. Steps included in this figure are limited to those implemented, not just planned at individual hospitals, including centralized triage systems, ICU and ward bed expansion, tiered staffing models, and alternative ventilator usage. The highest frequency of sites implemented only centralized triage processes. These changes are in addition to activation of an incident command center and elective procedure cancellation, which were in place at the majority of sites.
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