Month: December 2021

After an upswing during the Delta wave, the proportion of U.S. hospitals reporting critical staffing shortages had plateaued at about 19 percent. During the past three weeks, there is growing evidence that critical staffing shortages are again on the rise.

This post updates an earlier summary of trends in U.S. hospital staffing. During the Delta wave in the United States, the percentage of hospitals reporting critical staffing shortages rose from 12 to 19 percent. Even as hospital admission rates declined in October and November, the critical staffing percentage remained elevated at 19 percent. Over the past three weeks, as the Omicron variant has begun to spread, this percentage has increased to 21.4 percent.

Vaccine Mandates are Unlikely to be the Primary Cause.

Some have contended that vaccine mandates are contributing to the emerging shortage of healthcare workers. But there is little concrete evidence to back up this contention. While a small minority of healthcare employees have chosen to leave their jobs, the vast majority have opted for vaccine protection. At large healthcare systems like Houston Methodist, Truman Medical Centers/University Health in Kansas City, the North Carolina hospital system, Advocate Aurora Health in Chicago, Mount Sinai Health System in New York, St. Claire Regional Medical Center in Kentucky, and Henry Ford Health System in Detroit, less than 1 percent of employees have had to be let go.

The Labor Market for Skilled Nursing Care was Already Tight.

Still others have pointed to the increasing fees charged by traveling nurses and nurse staffing agencies to compensate for growing vacancies among nurse employees. The plain fact, however, is that the tight labor market for hospital-based nursing care predated the COVID-19 pandemic. Annual turnover among hospital-based registered nurses was already up to 15.9% in 2019 and increased to 18.7% in 2020.

It’s All About Pandemic Burnout.

Far and away the most critical determinant of rising staff shortages has been burnout and peritraumatic stress among healthcare workers, with more nurses leaving their employment as the pandemic drags on. While burnout among frontline healthcare workers has always been a serious problem, the percent of surveyed hospitals reporting 10% or more vacancies for RNs abruptly rose from 23.7% in 2019 to 31.8% in 2020 to 35.8% by early 2021.

The evidence of burnout among frontline workers is overwhelming not only in the U.S., but many other healthcare systems, including China during the initial Wuhan outbreak. The president of the American Nurses Association recently asked the U.S. Secretary of Health and Human Services to declare a national nursing shortage crisis. A national strategy to address healthcare worker burnout as been repeatedly urged.

We’re talking about continuous exposure to traumatic stress from extended hours, time away from family, near-continuous use of personal protective equipment, fear of personally contracting COVID-19, loss of patients with whom workers have become emotionally attached, and the rising frequency of medical errors as emergency rooms and ICUs fill up. We’re talking not only about ordinary job burnout, but also compassion burnout.

The anti-vaccination movement is driven in part by conspiracy theories that sow doubt about the integrity of medical professionals. Has the resulting loss of confidence caused some healthcare workers to experience a disconnect from their beliefs in the value of their work?

Stay Tuned.

We will continue to follow the aggregate U.S. hospital staffing situation as the Omicron wave plays out.

Daily admissions to Florida hospitals for confirmed adult and pediatric cases are now more than twice the count registered at a comparable point during last summer’s Delta wave.

We further update our comparison of the hospitalization curves for the Delta and Omicron waves in Florida. By day 15 from the initial appearance of each variant, statewide confirmed COVID-19 admissions among adults and children combined were running at about 250 per day. By day 29, however, Delta-wave admissions were 514, while Omicron-wave admissions have reached 1207. That’s more than twice the number of admissions registered at the same point during this past summer’s wave.

Omicron-Related Hospitalizations Now Doubling Every 6.75 Days

Log-linear regressions on the data points from days 10 to 29 now give doubling times of 20.6 days for Delta and 6.75 days for Omicron. (The 95% confidence interval for the Omicron doubling time is 6.02 – 7.69 days.) As we have repeatedly stressed, these early findings do not necessarily mean that the Omicron curve will reach the Delta peak of 2,360 statewide hospital admissions attained on August 17, 2021 (that is, day 68 from initial appearance).

Hospitalization Rates Matter.

Public officials and some commentators have noted that COVID-19 hospitalization rates are not rising nearly so fast as total case counts. The fact that hospitalization-to-case ratios are now lower than during the past summer’s wave has been highlighted as favorable news. With rapid home-based COVID-19 tests now in abundance, it is unclear what case counts reported by public health departments are supposed to represent.

We continue to focus here on severe disease and its impact on our already stressed healthcare system.

Technical Notes

As we’ve repeatedly noted, we do not have data on the variant underlying each hospital admission. Still, according to the most recent CDC report on state-specific variant proportions, 78.3% of recent SARS-CoV-2 samples sequenced in the U.S. region covering Florida were attributable to the Omicron variant.

We have estimated the initial appearance of the Delta variant as June 10, 2021. There are reports that the variant was in fact detected by late May. If we translated the time axis for Delta to the right, however, the Omicron-related hospitalization curve would be running even further ahead of its predecessor.

The calculations in the figure are derived from COVID-19 Reported Patient Impact and Hospital Capacity by State Timeseries, maintained by the U.S. Department of Health and Human Services. The daily counts represent the daily sums of two variables for all Florida hospitals combined:

• previous_day_admission_adult_covid_confirmed: Number of patients who were admitted to an adult inpatient bed on the previous calendar day who had confirmed COVID-19 at the time of admission in this state
• previous_day_admission_pediatric_covid_confirmed: Number of pediatric patients who were admitted to an inpatient bed, including NICU, PICU, newborn, and nursery, on the previous calendar day who had confirmed COVID-19 at the time of admission in this state

Some commentators have expressed a general concern that COVID-19 hospitalization counts include patients admitted for unrelated reasons who incidentally tested positive. Since confirmation of a COVID-19 diagnosis is made by PCR test results that are not immediately available at the time of admission, it is unlikely that the calculations in our figure above suffer from such a potential bias.

If hospitals were backdating COVID-19 diagnoses to the date of admission once they received one- or two-day delayed PCR results, we would detect significant backdating through comparison of serially posted databases.

But we don’t.

“A dire emergency is not the time to overturn decades of jurisprudence empowering federal agencies to act in the public interest.”

Opinion Column with Lawrence O. Gostin and Dorit Rubinstein Reiss, Washington Post, December 29, 2021

“The Supreme Court needs to uphold the president’s mandates without delay. Not doing so would be an affront to public health and the law.”

“Lower-court rulings that blocked the rules from taking effect were fundamentally flawed.”

“If the high court were to curb federal public health powers now, it could prove ruinous when the next crisis strikes.”

“The Supreme Court has a long history of upholding vaccination mandates, beginning with its seminal 1905 decision upholding smallpox vaccination and continuing with its 1944 ruling on the lawfulness of childhood vaccinations for school entry.”

The upswing in COVID-19 hospitalizations in Florida during the current Omicron wave continues to run well ahead of the Delta wave of last summer. Omicron-related hospitalizations are now doubling every 8 days.

We update our initial comparison of the hospitalization curves for the Delta and Omicron waves in Florida. By day 15 from the initial appearance of each variant, statewide confirmed COVID-19 admissions among adults and children combined were running at about 250 per day. By day 27, however, Delta-wave admissions were 450, while Omicron-wave admissions have reached 767.

Limitations

As we’ve already noted, we do not have data on the variant underlying each hospital admission. Still, according to CDC reports on variant proportions, 95.2% of COVID-19 cases in the region including Florida were attributable to Omicron by December 20, that is, day 20 on our timeline.

We have estimated the initial appearance of the Delta variance as June 10, 2021. There are reports that the variant was in fact detected by late May. If we translated the time axis for Delta to the right, however, the Omicron-related hospitalization curve would be running even further ahead of its predecessor.

Omicron-Related Hospitalizations So Far Doubling Every 8 Days

Log-linear regressions on the data points from days 10 to 27 give doubling times of 20.6 days for Delta and 7.8 days for Omicron. However, these early findings do not necessarily mean that the Omicron curve will reach the Delta peak of 2,360 statewide hospital admissions attained on August 17, 2021 (that is, day 68 from initial appearance).

We will continue to monitor Omicron-wave hospital admissions in Florida.

During the week ending December 17, emergency department visits for COVID-19 rose by 12.8%, while hospital admissions rose by 16.5%. There are now 6.2 hospital admissions per 100 ED visits for COVID-19. The evidence does not paint a reassuring picture of generally benign disease.

Following a Cohort of 250 High-Volume Hospitals

Numerous sources confirm that the incidence of newly diagnosed COVID-19 cases has been rising precipitously in the United States during the past three weeks. The more pressing issue, however, is the composition and severity of those cases.

To address this critical question, we are following a cohort of 250 high-volume hospitals located in 164 counties throughout the U.S. Our focus on a cohort of hospitals known to have treated large numbers of COVID-19 patients avoids problems of sampling variability and inconsistent reporting among smaller, lower-volume hospitals.

ED Visits for COVID-19 Increased by 12.8% During the Past Week.

For this 250-hospital cohort as a whole, we’ve relied on weekly reports from the U.S. Department of Health and Human Services to compute total emergency department visits for COVID-19 and total adult and pediatric hospital admissions for confirmed COVID-19. The admissions data exclude cases of patients who were admitted for other reasons and subsequently found to be infected.

In our 250 sentinel hospital cohort, Fig. 1 above shows that weekly ED visits for COVID-19 increased by 12.8% from 132,743 during the week ending December 10 to 149,798 during the week ending December 17, 2021. ED visits for COVID-19 are now approaching the peak of 158,150 reported for the week ending August 20 during the Delta wave.

Hospital Admissions for COVID-19 Have Risen to 6.2 per 100 ED Visits.

Within our 250-hospital cohort, admissions for COVID-19 have been rising somewhat faster than ED visits. While ED visits rose by 12.8% during the most recent week, hospital admissions rose by 16.5%. As shown in Fig. 2 above, hospital admissions now stand at 6.2 per 100 ED visits. While admissions per 100 ED visits are continuing to rise, Fig. 2 shows that this indicator remains below its peak of 9.9 attained during the week ending August 13.

What Do These Results Imply About Omicron-Related Case Severity ?

Tracking hospital admissions per 100 ED visits is obviously a more informative means of assessing Omicron-related case severity than comparing current admission rates to historical controls. Virtually all patients admitted with COVID-19 pneumonia and other acute complications come through the hospital’s emergency department.

Patients who present to the ED with COVID-19 symptoms are a self-triaged population. The symptoms motivating them to seek emergency care now may have changed from those bringing them to the ED last summer. Criteria for admitting patients may also have changed, especially if hospital resources are more constrained, as we have recently reported.

Still, the data in Figs. 1 and 2 hardly communicate the reassuring picture of a generally benign disease. To be sure, the current rate of 6.2 admissions per 100 ED visits is still about 27 percent below the peak of 9.9 during the Delta wave. Only time will tell, however, how high this indicator will continue to rise.

And as many observers have already pointed out, the sheer volume of new cases may be enough to bring our healthcare system to its knees.

Sentinel Hospital Cohort

The upswing in COVID-19 hospitalizations in Florida during the current Omicron wave is so far running ahead of the Delta wave of last summer.

By day 15 from the initial appearance of each variant, statewide confirmed COVID-19 admissions among adults and children combined were running at about 250 per day. By day 24, however, Delta-wave admissions were 311, while Omicron-wave admissions had reached 527.

Limitations

We do not have data on the variant underlying each hospital admission. Still, according to CDC reports on variant proportions, 95.2% of COVID-19 cases in the region including Florida were attributable to Omicron by December 20, that is, day 20 on our timeline.

We have estimated the initial appearance of the Delta variance as June 10, 2021. There are reports that the variant was in fact detected by late May. If we translated the time axis for Delta to the right, however, the Omicron-related hospitalization curve would be running even further ahead of its predecessor.

Still, the mere fact that Omicron-related admissions now exceed Delta-related admissions does not mean that the Omicron curve will reach the Delta peak of 2,360 statewide hospital admissions attained on August 17, 2021 (that is, day 68 from initial appearance).

Stay Tuned.

We will continue to monitor Omicron-wave hospital admissions in Florida.

After an upswing during the Delta wave, the proportion of U.S. hospitals reporting critical staffing shortages had plateaued at about 19 percent. During the past two weeks, there are signs that critical staffing shortages may once again be on the rise.

During the Delta wave in the United States, the percentage of hospitals reporting critical staffing shortages rose from 12 to 19 percent. Even as hospital admission rates declined in October and November, the critical staffing percentage remained elevated at 19 percent. During the past two weeks, as the Omicron variant has begun to spread, this percentage has increased to 19.8 and 20.5 percent, respectively.

Vaccine Mandates are Unlikely to be the Primary Cause.

Some have contended that vaccine mandates are contributing to the emerging shortage of healthcare workers. But there is little concrete evidence to back up this contention. While a small minority of healthcare employees have chosen to leave their jobs, the vast majority have opted for vaccine protection. At large healthcare systems like Houston Methodist, Truman Medical Centers/University Health in Kansas City, the North Carolina hospital system, Advocate Aurora Health in Chicago, Mount Sinai Health System in New York, St. Claire Regional Medical Center in Kentucky, and Henry Ford Health System in Detroit, less than 1 percent of employees had to be let go.

The Labor Market for Skilled Nursing Care was Already Tight.

Still others have pointed to the increasing fees charged by traveling nurses and nurse staffing agencies to compensate for growing vacancies among nurse employees. The plain fact, however, is that the tight labor market for hospital-based nursing care predated the COVID-19 pandemic. Annual turnover among hospital-based registered nurses was already up to 15.9% in 2019 and increased to 18.7% in 2020.

It’s All About Pandemic Burnout.

Far and away the most critical determinant of rising staff shortages has been burnout, with more nurses leaving their employment as the pandemic drags out. While burnout among frontline healthcare workers has always been a serious problem, the percent of surveyed hospitals reporting 10% or more vacancies for RNs abruptly rose from 23.7% in 2019 to 31.8% in 2020 to 35.8% by early 2021. The evidence of burnout among frontline workers is overwhelming not only in the U.S., but other healthcare systems, including China during the initial Wuhan outbreak.

Stay Tuned.

We will continue to follow the aggregate U.S. hospital staffing situation as the Omicron wave plays out.

Continuing to follow our cohort of 250 sentinel hospitals, we track aggregate weekly admissions for COVID-19 per 100 emergency department visits.

The peak of 9.88 COVID-19 admissions per 100 ED visits for the week ending 8/13/21 occurred during the Delta wave in the United States. Admissions per 100 ED visits reached a minimum of 4.47 during the week ending 11/5. The most recent data for the week ending 12/10 show the rate at 6.03 admissions per 100 ED visits.