Full ICUs amid COVID surges could lead to thousands of extra deaths

A modeling study today in Morbidity and Mortality Weekly Report estimates that 12,000 more people die 2 weeks after US hospitals reach 75% adult intensive care unit (ICU) occupancy amid COVID-19 pandemic surges, a figure that rises to 80,000 when ICUs are full—which is the case now in many hospitals in multiple US states.

Researchers from the US Department of Homeland Security's Cybersecurity & Infrastructure Security Agency COVID Task Force evaluated the relationship between overwhelmed hospitals and excess deaths from Jul 4, 2020, to Jul 10, 2021. The end of the study period included the emergence and eventual dominance of the more transmissible Delta (B1617.2) variant.

The Centers for Disease Control and Prevention (CDC) provided data on excess all-cause deaths, and the Department of Health and Human Services (HHS) provided hospitalization data. Excess deaths were estimated as the difference between observed and expected deaths over specific periods.

Effects felt up to 6 weeks later

Over the study period, excess deaths rose as ICU bed occupancy increased 2, 4, and 6 weeks after surges. A model based on data on all-cause excess deaths predicted that 75% ICU bed occupancy was tied to another 12,000 deaths (95% confidence interval [CI], 8,623 to 17,294) 2 weeks later, with more deaths at 4 and 6 weeks.

When all ICU beds nationwide are full, 80,000 excess deaths can be expected (95% CI, 53,576 to 132,765).

The study authors noted that emergency department crowding, high ICU occupancy, and ambulance diversion were reported to lead to poor patient outcomes (eg, medical errors, low quality of care, treatment delays, increased deaths) even before the pandemic.

"During 2020, the impact of these effects, which included potentially avoidable excess deaths, fell more heavily on working-aged adults from marginalized communities who experience poor access to health care outside pandemic conditions," they wrote.

"Racial and ethnic subgroups experienced disproportionately higher percentage increases in deaths, with the most pronounced effect among the Hispanic/Latino communities who represent an estimated 21% of the essential critical infrastructure workforce."

US ICU occupancy topped 75% for at least 12 weeks

The researchers noted that, as of Oct 25, 2021, HHS data showed that ICU occupancy capacity in US adult ICUs nationwide has surpassed 75% for at least 12 weeks. "This means that the United States continues to experience the high and sustained levels of hospital strain that, according to the model's results, are associated with significant subsequent increases in excess deaths," they said.

The findings, they said, indicate the importance of preventing COVID-19 infections and hospitalizations. "State, local, tribal, and territorial leaders could evaluate ways to reduce strain on public health and health care infrastructures, including implementing interventions to reduce overall disease prevalence such as vaccination and other prevention strategies, as well as ways to expand or enhance capacity during times of high disease prevalence."

While COVID-19–driven ICU bed occupancy is not a direct cause of excess deaths, the researchers said it indicates "broader issues that can contribute to excess deaths, such as curtailed services, stressed operations, and public reluctance to seek services." They call for research assessing the cascading effects of pandemic-related healthcare system dysfunction.

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