US hospitals transferred fewer patients than usual to other acute-care facilities during caseload surges throughout the COVID-19 pandemic, which could have put some patients at risk, a National Institutes of Health (NIH)-led research team reports today in JAMA Network Open.
Outgoing transfers included those from an emergency department or hospital ward to another acute-care facility. Patients are commonly transferred to another facility during patient surges to provide adequate care.
The researchers analyzed data for adult patients at continuously reporting US hospitals in the PINC-AI Healthcare Database before the pandemic (January 2019 to February 2020) and during pandemic wave 1 (March to May 2020), wave 2 (June to September 2020), wave 3 (October 2020 to June 2021), Delta variant predominance (June to December 2021), and Omicron predominance (December 2021 to February 2022).
Of 681 hospitals, 30.1% were rural, 69.9% were urban, 52.9% were small (fewer than 200 beds), and 47.1% were large (more than 200 beds).
"Transferring patients to other hospitals because of inpatient saturation or need for higher levels of care was often challenging during the early waves of the COVID-19 pandemic," the study authors wrote. "Understanding how transfer patterns evolved over time and amid hospital overcrowding could inform future care delivery and load balancing efforts."
Weekly transfers remained low throughout pandemic
A total of 1.3 million patient transfers occurred during the study period, 32.7% of them from rural hospitals. Overall, 21.7% of hospitals experienced high-surge weeks during the pandemic, while 15.1% did so before the pandemic, and 14.5% did so in both periods. The peak average patient daily census for any week was 412.0 cases (interpreted as caseload being 412% of hospital capacity), which also occurred during Delta predominance.
Transferring patients to other hospitals because of inpatient saturation or need for higher levels of care was often challenging during the early waves of the COVID-19 pandemic.
Compared with before the pandemic (monthly range, 32,741 to 37,845 transfers), greater fluctuations in weekly transfers were observed throughout the pandemic (monthly range, 22,865 transfers in April 2020 to 38,961 in May 2021).
Average weekly outgoing transfers per hospital stayed lower than the prepandemic average of 12.1 transfers per week for most of the pandemic, ranging from 8.5 transfers per week during wave 1 to 11.9 per week during the Delta wave.
Despite increased COVID-19 transfers, hospital transfers for any indication declined during each national surge. Compared with the prepandemic baseline, outgoing acute care transfers at 99 high-caseload hospitals fell during wave 1 (−15.0%), returned to baseline in wave 2 (2.2%), and increased substantially in subsequent waves (19.8% in wave 3, 19.2% during Delta, and 15.4% amid Omicron).
At the most-strained hospitals, outgoing transfers rose 15.4% to 19.8% amid the third, Delta, and Omicron waves (compared with before the pandemic). The observed increases were seen mainly at small urban hospitals, where transfers peaked at 48.0% in wave 3.
Identifying transfer barriers
"Throughout the COVID-19 pandemic, study hospitals reported paradoxical decreases in overall patient transfers during each high-surge period," the researchers wrote. "Caseload-strained rural (vs urban) hospitals with fewer than 200 beds were unable to proportionally increase transfers."
The low rate of transfers amid the pandemic may have compromised patient care, they said.
Caseload-strained rural (vs urban) hospitals with fewer than 200 beds were unable to proportionally increase transfers.
"Decreased overall patient movement during the pandemic and the inability to increase transfers from small but overcrowded rural hospitals may indicate patient safety and access to care issues that warrant identifying and overcoming barriers to transfer patients for care or capacity during future surges," they wrote.
The researchers called for future survey, mixed-methods, and external validation studies to shed more light on relevant issues and establish coordination centers where they are needed most.
"The quality of and access to public health data and its reporting infrastructure must be improved to enable better real-time action so authorities are not flying blind during the next health crisis," they concluded. "Policies posing barriers to transfer must be identified and addressed urgently to maximally leverage load balancing to mitigate surge strain and save lives, particularly in high-risk regions."
