Effect of COVID-19 on Critical ICU Capacity in US Acute Care Hospitals
Authors: Tsai Thomas C. , Jacobson Benjamin H. , Jha Ashish K. 
Published: December 2020

AbstractImportanceThe current wave of COVID-19 infections has led to media reports of ICUs across the country reaching critical capacity. But the degree to which this has happened and community and institutional characteristics of hospitals where capacity limits have been reached is largely unknown.ObjectiveTo determine changes in intensive care capacity in US acute care hospitals between September and early December, 2020 and to identify whether hospitals serving more vulnerable populations were more likely to exceed critical-levels of ICU occupancy.Design, Setting, and ParticipantsRetrospective observational cohort of US acute care hospitals reporting to the US Department of Health and Human Services (HHS) from September 4, 2020 to December 3, 2020. Hospitals in this cohort were compared to all US acute care hospitals. Multivariate logistic regression was used to assess the relationship between community socioeconomic factors and hospital-structural features with a hospital reaching critical ICU capacity.ExposureCommunity-level socioeconomic status and hospital-structural featuresMain Outcomes and MeasuresOur primary outcome was reaching critical ICU capacity (>90%) for at least two weeks since September 4. Secondary outcomes included the weekly capacity and occupancy tabulated by state and by hospital referral region.Results1,791 hospitals had unsuppressed ICU capacity data in the HHS Protect dataset, with 45% of hospitals reaching critical ICU capacity for at least two weeks during the study period. Hospitals in the South (OR = 2.79, p<0.001), Midwest (OR = 1.76, p=0.01) and West (OR = 1.85, p<0.01) were more likely to reach critical capacity than those in the Northeast. For-profit hospitals (OR = 2.15, p<0.001), rural hospitals (OR = 1.40, p<0.05) and hospitals in areas of high uninsurance (OR = 1.94, p<0.001) were more likely to reach critical ICU capacity, while hospitals with more intensivists (OR = 0.92, p=0.044 and higher nurse-bed ratios (OR = 0.95, p=0.013) were less likely to reach critical capacity.Conclusions and RelevanceNearly half of U.S. hospitals reporting data to HHS Protect have reached critical capacity at some point since September. Those that are better resourced with staff were less likely to do so while for for-profit hospitals and those in poorer communities were more likely to reach capacity. Continued non-pharmacologic interventions are clearly needed to spread of the disease to ensure ICUs remain open for all patients needing critical care.Key PointsQuestionWith an increasing number of SARS-CoV2 infections, how has the burden on ICU capacity changed over the past three months and what community and institutional factors are associated with hospitals reaching critical capacity?Finding45% of US acute care hospitals have reached critical ICU capacity at some point over the past three months. Hospital located in areas with fewer insured people were more likely to reach critical ICU capacity. At an institutional level, for-profit hospitals, rural hospitals, and those that have less baseline staffing of intensivists and nurses were more likely to reach critical ICU capacity.MeaningThe COVID-19 pandemic appears to be disproportionately straining ICUs with fewer resources and staff, setting up a substantial risk to widen disparities in access to care for already underserved populations.