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Multicenter Study
. 2023 Apr 1;51(4):445-459.
doi: 10.1097/CCM.0000000000005802. Epub 2023 Feb 15.

Perceived Hospital Stress, Severe Acute Respiratory Syndrome Coronavirus 2 Activity, and Care Process Temporal Variance During the COVID-19 Pandemic

George L Anesi  1 , Adair Andrews  2 , He Julia Bai  3 , Pavan K Bhatraju  4 , David M Brett-Major  3   5 , M Jana Broadhurst  5   6 , Elizabeth Salvagio Campbell  7 , J Perren Cobb  8 , Martin Gonzalez  2 , Sonya Homami  4 , Cameron D Hypes  7   9 , Amy Irwin  10 , Christopher J Kratochvil  5 , Kelsey Krolikowski  11 , Vishakha K Kumar  2 , Douglas P Landsittel  12 , Richard A Lee  13 , Janice M Liebler  14 , Karen Lutrick  15 , Lucian T Marts  16 , Jarrod M Mosier  7   9 , Vikramjit Mukherjee  11 , Radu Postelnicu  11 , Valentina Rodina  17 , Leopoldo N Segal  11 , Jonathan E Sevransky  16   18 , Christine Spainhour  18 , Avantika Srivastava  19 , Timothy M Uyeki  20 , Mark M Wurfel  4 , David Wyles  10 , Laura Evans  4 ; Severe Acute Respiratory Infection-Preparedness (SARI-PREP) Study Group
Affiliations
Multicenter Study

Perceived Hospital Stress, Severe Acute Respiratory Syndrome Coronavirus 2 Activity, and Care Process Temporal Variance During the COVID-19 Pandemic

George L Anesi et al. Crit Care Med. .

Abstract

Objectives: The COVID-19 pandemic threatened standard hospital operations. We sought to understand how this stress was perceived and manifested within individual hospitals and in relation to local viral activity.

Design: Prospective weekly hospital stress survey, November 2020-June 2022.

Setting: Society of Critical Care Medicine's Discovery Severe Acute Respiratory Infection-Preparedness multicenter cohort study.

Subjects: Thirteen hospitals across seven U.S. health systems.

Interventions: None.

Measurements and main results: We analyzed 839 hospital-weeks of data over 85 pandemic weeks and five viral surges. Perceived overall hospital, ICU, and emergency department (ED) stress due to severe acute respiratory infection patients during the pandemic were reported by a mean of 43% ( sd , 36%), 32% (30%), and 14% (22%) of hospitals per week, respectively, and perceived care deviations in a mean of 36% (33%). Overall hospital stress was highly correlated with ICU stress (ρ = 0.82; p < 0.0001) but only moderately correlated with ED stress (ρ = 0.52; p < 0.0001). A county increase in 10 severe acute respiratory syndrome coronavirus 2 cases per 100,000 residents was associated with an increase in the odds of overall hospital, ICU, and ED stress by 9% (95% CI, 5-12%), 7% (3-10%), and 4% (2-6%), respectively. During the Delta variant surge, overall hospital stress persisted for a median of 11.5 weeks (interquartile range, 9-14 wk) after local case peak. ICU stress had a similar pattern of resolution (median 11 wk [6-14 wk] after local case peak; p = 0.59) while the resolution of ED stress (median 6 wk [5-6 wk] after local case peak; p = 0.003) was earlier. There was a similar but attenuated pattern during the Omicron BA.1 subvariant surge.

Conclusions: During the COVID-19 pandemic, perceived care deviations were common and potentially avoidable patient harm was rare. Perceived hospital stress persisted for weeks after surges peaked.

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Conflict of interest statement

Dr. Anesi received funding from the National Institutes of Health (NIH) (K23HL161353), UptoDate, and expert witness consulting. Drs. Anesi and Segal received support for article research from the NIH. Drs. Bhatraju’s, Brett-Major’s, Broadhurst’s, Cobb’s, Kratochvil’s, Kumar’s, Landsittel’s, Lieber’s, Lutrick’s, Sevransky’s, Wurfel’s, Wyles’, and Evans’, and Mr. Gonzalez’s institutions received funding from the Centers for Disease Control and Prevention (CDC) Foundation. Dr. Bhatraju received funding from the NIH (K23DK116967). Drs. Bhatraju, Cobb, Kratochvil, Landsittel, Rodina, Segal, and Evans received support for article research from the CDC Foundation. Dr. Cobb received funding from Akido Labs, BauHealth, and GibLib. Dr. Kumar received funding from Janssen R&D LLC and the Assistant Secretary for Planning and Evaluation Food and Drug Administration. Dr. Liebler received funding from Immunexpress. Dr. Sevransky’s institution received funding from Regeneron Pharmaceuticals, the Department of Health and Human Services, the Department of Defense, and Society of Critical Care Medicine. Dr. Uyeki disclosed government work. Dr. Wyles’ institution received funding from Gilead Sciences. Dr. Evans disclosed that she serves on the Council of the Society of Critical Care Medicine. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
Hospital stress and county severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases by pandemic week. The percentage of contributing study hospitals who reported overall hospital stress (red solid), ICU stress (green dotted), and emergency department (ED) stress (blue dashed) (left axis), and county SARS-CoV-2 cases per 100,000 residents for all study hospital counties (black solid; right axis) are plotted per pandemic week from November 2020 to June 2022. The SARS-CoV-2 variant/subvariant–dominated surges are noted in shaded colors. Stress percentages are based on complete case analyses. By visual inspection, overall hospital stress and ICU stress appear more closely related than either are to ED stress and at the end of surge periods, ED stress appears to abate earlier while hospital stress and ICU stress persist.
Figure 2.
Figure 2.
Among-hospital variation in hospital stress during the Omicron BA.1 subvariant surge. The adjusted percentage of weeks during the Omicron BA.1 subvariant surge that overall hospital, ICU, and emergency department (ED) stress were reported, adjusted for local county severe acute respiratory syndrome coronavirus 2 case counts per 100,000 residents, is plotted by study hospital (ranked by overall hospital stress proportion). Error bars represent 95% CIs. There is significant among-hospital variation in the frequency of adjusted overall hospital stress (red, range 11–94% of weeks), ICU stress (green, range 8–77% of weeks), and ED stress (red, range 3–71% of weeks) during this pandemic surge period.
Figure 3.
Figure 3.
Temporal relationships between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases and hospital stress. The black curve reports county SARS-CoV-2 cases per 100,000 residents among study site hospital counties. The start (circles) and end (square) of overall hospital stress (red), ICU stress (green), and emergency department (ED) stress (blue) are plotted such that the x-axis position represents the median weeks relative to the surge case peak and the y-axis position represents the median county SARS-CoV-2 cases per 100,000 residents at each stress start or end time point; error bars represent interquartile ranges (IQRs) for each axis. A, During the Delta variant surge, overall hospital, ICU, and ED stress began within a median of 1–2 wk of case peak, and stress persisted in the overall hospital, ICU, and ED for a median of 11.5 wk (IQR, 9–14 wk), 11 wk (IQR, 6–14 wk), and 6 wk (IQR, 5–6 wk) after county case peak, respectively. B, During the Omicron BA.1 subvariant surge, overall hospital, ICU, and ED stress started a median of 1–2 wk before county case peak, and stress persisted in the overall hospital, ICU, and ED for median of 6 wk (IQR, 5–6.5 wk), 5.5 wk (IQR, 4–6 wk), and 5 wk (IQR, 4–6 wk) after county case peak, respectively. ^Upper bound extends beyond figure range, see Table 3 for complete IQRs.
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