How Hospitals Have Reduced Lengths of Stay and Deaths From Covid

Just as outcomes are becoming more patient specific, so are treatments. Better understanding of how the virus attacks the body and more best practices are reducing hospital stays and mortality. 

But patient age and gender as well as hospital staffing, expertise, equipment and medicine availability are all affecting survival rates. JL

Melanie Evans reports in the Wall Street Journal:

New tools and a better understanding of how Covid-19 attacks the body are helping to improve medical outcomes. The median length of stay for hospitalized Covid-19 patients was six days in September, down from seven in April. For all Covid-19 patients, survival increased 28% between April and September. (But) there are many possible reasons besides better medical care for reduced hospital stays, including patients’ ages and medical histories, how early in their illness they were hospitalized and each hospital’s capacity and resources.

U.S. hospitals say they are facing the pandemic’s largest surge armed with treatment improvements that allow them to save lives, care for more patients and accelerate the recovery of coronavirus sufferers.

HCA Healthcare Inc., one of the nation’s largest hospital chains with 186 hospitals, has more intensive-care capacity as the sickest patients recover more quickly. At the Mayo Clinic’s hospital in Rochester, Minn., coronavirus patients now stay a median of five days, half as long as in March. The time Covid-19 patients spend at Advocate Aurora Health’s 26 Midwestern hospitals has fallen 25% on average since May.

The shift could be a result of several factors and more study is needed, said doctors and researchers. But the results are consistent with anecdotal reports from doctors saying that new tools and a better understanding of how Covid-19 attacks the body are helping to improve medical outcomes.

Even so, surges again threaten to overwhelm hospitals, according to hospital executives and public health experts. Covid-19 patients flooding into hospitals have set national records each of the last nine days, reaching 79,410 Wednesday.

Many hospitals across the country are again scrambling to add more beds and cancelling nonessential surgery to make room for coronavirus patients. Staffing shortages are compounding the strain, limiting the number of patients hospitals can safely accept.

“There are not a lot of beds available in Minnesota right now,” said Dan Brown, who oversees intensive care for Mayo Clinic hospitals in the Midwest, Florida and Arizona. Minnesota was not as hard-hit as other states in the spring. “Thank goodness we have seen the gains and we’ve learned what we’ve learned. If this had happened early on we would have been in a worse mess,” he said.

Research on hospital outcomes during the pandemic is limited; studies that meet rigorous scientific standards take time. One recently published study suggests that better care has improved survival. An internal analysis by HCA Healthcare found similar results; the data is more real-time but has not been formally studied.

The study, published in the Journal of Hospital Medicine, found that death rates for Covid-19 hospital patients dropped between March and August at three New York hospitals. The rate fell to 7.6% from 25.6% after researchers took into account the fact that patients in the summer were younger and healthier than the spring.

Better medical care is one possible reason for the survival boost, said Leora Horwitz, a physician at NYU Langone Health in New York and an author of the study.

Another potential cause: New York hospitals were overrun in the spring but not the summer. Surges can strain hospitals and lead to worse outcomes, Dr. Horwitz said.Several factors influence how long Covid-19 patients remain hospitalized, including their age and underlying health, doctors and hospital executives said, but treatment has also improved with new therapies identified by months of intense research and experience with the novel virus.

“We have more tools and treatments for this disease, and that is likely factoring into the shorter hospital stays for our Covid patients,” said Advocate Aurora Chief Medical Officer Gary Stuck.

HCA Healthcare can now care for more critically ill patients after adopting algorithms in June that appear to speed recovery and improve survival, its executives said.

The company began using computers across its hospitals that month to scan medical records of ventilated Covid-19 patients and alerts doctors to possible treatment options, a technology it named NATE C-ARDS.

“For patients with similar lung injury at the time of ventilation, the introduction of NATE C-ARDS resulted in greater adherence to best practice protocols, in turn resulting in decreased mortality and shorter length of stay on ventilators,” said  Jonathan Perlin, the company’s chief medical officer.

The company didn’t provide specific figures for the group of patients in its analysis.

For all Covid-19 patients, survival increased 28% between April and September across HCA Healthcare’s hospitals, Dr. Perlin said.

For coronavirus patients on ventilators, the time they needed breathing support dropped an average of four days during the same period across the hospitals, he said. Fewer HCA patients were put on ventilators in later months, and those who did were older and sicker, he said.

To generate the computer alerts, HCA experts scoured research on proning, a maneuver in which hospital staffers roll patients on their stomachs to relieve pressure on the lungs, and optimal pressure settings for ventilators, Dr. Perlin said. Ventilation brings its own risks, including lung injury from poorly managed settings.

Medical teams in HCA intensive-care units review the alerts throughout the day. One alert identifies patients who may benefit from proning. Two others notify doctors when ventilators may need adjustment to prevent further lung damage.

Michael Nottidge, who oversees the intensive care doctors at HCA’s TriStar Centennial Medical Center in Nashville, Tenn., regularly scans alerts and calls doctors about patients flagged red for “opportunities to optimize.”

Doctors sometimes have good reason to dispute the red flag, he said, but other times find the alert can bring attention to patients whose condition has incrementally changed.

Even with those gains, TriStar Centennial Medical Center, one of Tennessee’s largest hospitals, and other Nashville-area hospitals have grown more crowded, he said. “We’re all just bracing for the next wave,” he added.

Research prior to the pandemic shows the benefits from closely following recommendations for when to prone patients, how to manage ventilators and steps to wean patients off ventilators as soon as possible, said Corey Hardin, an associate professor of medicine at Harvard Medical School, who studies the acute respiratory distress syndrome seen in Covid-19 patients.

More widespread adoption of those previously known treatments for severe respiratory problems has improved care for coronavirus patients, Dr. Hardin said.

Other data point to Covid-19 patients spending less time in the hospital.

The median length of stay for hospitalized Covid-19 patients was six days in September, down from seven in April, according to the Epic Health Research Network, which analyzes medical-record data from customers of software company Epic Systems Corp. The data are based on 132,384 patients across 518 hospitals in 27 states.

The result was statistically significant, a measure used to test that the changes are not a result of random chance.

“Even a decrease of a single day is significant,” said Nichole Quick, a physician who works on clinical informatics for the company.

Still, researchers caution that the data don’t tell a straightforward story. There are many possible reasons besides better medical care for reduced hospital stays, including patients’ ages and medical histories, how early in their illness they were hospitalized and each hospital’s capacity and resources.

Patients ages 19 to 34, for example, accounted for more Covid-19 hospitalizations in September than in April, as the percentage of patients ages 55 to 64 and 85 and older declined, the Epic Health Research Network analysis found. Younger patients, who typically are at lower risk from the virus, spent less time in the hospital, the data show.