As Hospitals Fill Up, Some COVID-19 Patients Are Sent Home

Roxanne Nelson

December 03, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's  Coronavirus Resource Center.

Overall weekly hospitalizations are at their highest point in the pandemic for much of the nation. And healthcare facilities are becoming overwhelmed — to the point where some patients who may benefit from inpatient care are being sent home from the emergency department (ED), researchers and clinicians say.

"There is something funny happening with COVID hospitalizations," Ashish K. Jha, MD, MPH, a professor of Health Services, Policy, and Practice and dean of the School of Public Health at Brown University, Providence, Rhode Island, tweeted earlier this week. "Proportion of COVID [patients] getting hospitalized [is] falling. A lot."

His theory is that as hospitals fill up, the bar for admission is rising. "A patient who might have been admitted 4 weeks ago may get sent home now," he continued in the multi-tweet thread.

He notes that for months, one could reliably predict new hospitalizations from the 7-day rolling average. "By taking cases 7 days prior, multiplying by 3.5%. That is 3.5% (1 in 29) of those diagnosed today will be hospitalized about 7 days later."

Jha pointed out that there are many caveats to this formula, including that not all states report new hospitalizations (although his formula does take that into account). But according to his calculations, there should be more hospitalizations than what are being observed now, considering the jump in reported cases.

For example, on October 15, there were 53,000 new cases reported; thus, a week later, one would expect 1844 new hospitalizations. The actual number was 1855, which was quite close to the predicted amount.

Jump forward to November 1, and there were 80,000 new cases. Therefore on November 8, he wrote, there should have been 2804 new hospitalizations but instead there were 2604. "A little less. But fine," he said in the thread.

But on November 15, the new caseload had almost doubled, to 146,000, which should have led to 5111 new hospitalizations (using that 3.5% calculation). However, "there are only 3670," he wrote.

"Over much of September and October, you could look at cases today and predict that 3.5% of that number gets hospitalized 7 days later," he tweeted. "But in November, that number starts falling."

Jha concludes that the threshold for admission must be going up. Back in October, when plenty of beds were available, a patient infected with COVID-19 who was clinically borderline would most likely get admitted, but the situation has changed. By mid-November, with beds and staff in short supply, this same person will likely be sent home.

Rising Bar

Interviews and reports on social media suggest Jha is right: More patients are being sent home who would likely have been admitted a few weeks or months ago.

"Limited hospital capacity is making ER docs be more judicious with reserving hospitalization for those that need care that cannot be delivered at home," tweeted M. Kit Delgado, MD, in response to Jha's thread. "Fortunately, we've also developed more experience with who can be discharged and monitored at home," continued Delgado, assistant professor of emergency medicine at University of Pennsylvania Perelman School of Medicine, Philadelphia.

Delgado's team quantified some of that improvement in a recent study, he told Medscape Medical News.

"This knowledge may now lead to less precautionary hospitalizations," he said. "Also, increased use of admission to 'observation status,' which is appropriate for patients that do not require care beyond 24 hours — such as those who just need IV fluids for dehydration or a brief period of monitoring — do not get counted as hospitalizations."

And finally, the increased use of programs and technology to monitor patients at home, such as the use of telemedicine, pulse oximetry, and text messaging, has made home care safer. "Through better data, increased use of observation units, and increased services to monitor patients at home, there is less of a need to admit these patients to inpatient status if they don't need respiratory care, oxygen, steroids, COVID specific therapies, etc," Delgado pointed out.

But not everyone sees the shifts in admissions in such a benign way.

"In the Chicago hospital where I work, we're so inundated with sick patients, we're sending home elderly people with COVID-19 pneumonia who appear to be doing well, when we would have been hospitalizing them 6 months ago," Victoria Foxworth, RN, BSN, an ER nurse at the University of Chicago, Illinois, commented in response to a recent Medscape story on hospital capacity in the midwest.

"We're also seeing an uptick in patients with CVA, STEMI and surgical cases for appendicitis. Not every admission is for COVID. Where are the field hospitals now that were assembled at McCormick Place nine months ago?" she continued, referring to the Chicago convention center, the largest in North America.

Meanwhile, Sharon MacMillan, MD, a Massachusetts-based gynecologist and surgeon, tweeted that she agrees with Jha. "I'm doing house calls for the first time in a decade because they are sending home old, very sick patients with no safety net," she wrote. "One asked me, 'Did they send me home to die?' Sending O2 Sats 91% home! I now have a 'lending library' of pulse oximeters."

Jha's thread also resonated with Michael Metzler, MD, PhD, an emergency room doctor at Mercy St. Francis Hospital in Mountain View, Missouri.  "I can confirm to you, as an emergency room physician, that at least in southern Missouri we are sending home lots of people that we would never have sent home in the past, simply because it is impossible to get them admitted," Metzler tweeted.


Cases Surging, but Beds/Staff Limited

Early in the pandemic, there were frequent reports of tents and surge spaces being set up. But at this point, beds and space aren't the key problem for many institutions. "In our health system it's not so much a lack of beds, it's a lack of staff to meet the demand," Jill Jensen Chadwick, news director at the University of Kansas Health System, told Medscape Medical News.

Kansas has been hard hit, with 46% of hospitals across the state reporting staffing shortages this week, according to the Kansas City Star. Chadwick said that one of the facilities they work with, for example, has staff for 113 beds but are licensed for 207.

As a tertiary center, the University of Kansas Health System has been receiving patients from all over Kansas and neighboring states, as other facilities run out of beds and staff, Chadwick said. "I was told that one patient came from 400 miles away."

The hospital system reported today that the number of patients hospitalized with acute COVID-19 infections has dropped slightly to 89, from a record high of 100 yesterday; another 68 patients remain hospitalized because of COVID-19 but are past the acute infection phase.

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