Second victim experiences and moral injury as predictors of hospitalist burnout before and during the COVID-19 pandemic.

BACKGROUND: The increasing number of physicians leaving practice, especially hospitalists, has been well-documented. The most commonly examined factor associated with this exodus has been burnout. The COVID-19 pandemic has put a unique and unprecedented stress on hospitalists who have been at the front lines of patient care. Therefore, the investigation of burnout and its related factors in hospitalists is essential to preventing future physician shortages. OBJECTIVE: This study examined the relationship between burnout, second victim, and moral injury experiences before and during the COVID-19 pandemic among hospitalists. METHODS: Two anonymous cross-sectional surveys of hospitalists from a community hospital in the metropolitan Washington, DC area were conducted. One was conducted pre-COVID-19 (September-November 2019) and one was conducted during COVID-19 (July-August 2020). The surveys were sent to all full-time hospitalists via an online survey platform. A variety of areas were assessed including demographic (e.g., age, gender), work information (e.g., hours per week, years of experience), burnout, second victim experiences, well-being, and moral injury. RESULTS: Burnout rates among providers during these two time periods were similar. Second victim experiences remained prevalent in those who experienced burnout both pre and during COVID-19, but interestingly the prevalence increased in those without burnout during COVID-19. Moral injury was predictive of burnout during COVID-19. CONCLUSION: While there were some factors that predicted burnout that were similar both pre- and during-pandemic, moral injury was unique to predicting burnout during COVID-19. With burnout as a contributing factor to future physician shortages, it is imperative that predictive factors in a variety of different environments are well understood to prevent future shortages. Hospitalists may be an excellent barometer of these factors given their presence on the front line during the pandemic, and their experiences need to be further explored so that targeted interventions aimed at addressing those factors may be created.

The impact of variants and vaccination on the mortality and resource utilization of hospitalized patients with COVID-19.

BACKGROUND: COVID-19 outcomes among hospitalized patients may have changed due to new variants, therapies and vaccine availability. We assessed outcomes of adults hospitalized with COVID-19 from March 2020-February 2022. METHODS: Data were retrieved from electronic health medical records of adult COVID-19 patients hospitalized in a large community health system. Duration was split into March 2020-June 2021 (pre-Delta period), July-November 2021 (Delta period), and December 2021-February 2022 (Omicron period). RESULTS: Of included patients (n = 9582), 75% were admitted during pre-Delta, 9% during Delta, 16% during Omicron period. The COVID-positive inpatients were oldest during Omicron period but had lowest rates of COVID pneumonia and resource utilization (p < 0.0001); 46% were vaccinated during Delta and 61% during Omicron period (p < 0.0001). After adjustment for demographics and comorbidities, vaccination was associated with lower inpatient mortality (OR = 0.47 (0.34-0.65), p < 0.0001). The Omicron period was independently associated with lower risk of inpatient mortality (OR = 0.61 (0.45-0.82), p = 0.0010). Vaccination and Omicron period admission were also independently associated with lower healthcare resource utilization (p < 0.05). Magnitudes of associations varied between age groups with strongest protective effects seen in younger patients. CONCLUSION: Outcomes of COVID-19 inpatients were evolving throughout the pandemic and were affected by changing demographics, virus variants, and vaccination. KEY POINT: In this observational study of almost 10,000 patients hospitalized from March 2020-February 2022 with COVID-19, age and having multiple comorbidities remained consistent risk factors for mortality regardless of the variant. Vaccination was high in our hospitalized patients. Vaccination conveyed less severe illness and was associated with lower inpatient mortality.

Outcomes of hospitalized patients with COVID-19 during the course of the pandemic in a fully integrated health system.

BACKGROUND: Given the rapid spread of COVID-19 and its associated morbidity and mortality, healthcare providers throughout the world have been forced to constantly update and change their care delivery models. OBJECTIVE: To assess the outcomes of COVID-19 hospitalized patients during the course of the pandemic in a well-integrated health system. METHODS: The study used data from the electronic health medical records to assess trends in clinical profile and outcomes of hospitalized adult COVID-19 patients hospitalized in our 5-hospital health system from March 2020-May 2021 (n = 6865). Integration of the health system began in February 2020 and was fully actualized by March 30, 2020. RESULTS: Mortality decreased from 15% during first peak (March-May 2020; the rate includes 19% in March-April and 10% in May 2020) to 6% in summer-fall 2020, increased to 13% during the second peak (November 2020-January 2021), and dropped to 7% during the decline period (February-May 2021) (p<0.01). Resource utilization followed a similar pattern including a decrease in ICU use from 35% (first peak) to 16% (decline period), mechanical ventilation from 16% (first peak, including 45% in March 2020) to 9-11% in subsequent periods (p<0.01). Independent predictors of inpatient mortality across multiple study periods included older age, male sex, higher multi-morbidity scores, morbid obesity, and indicators of severe illness on admission such as oxygen saturation ≤90% and high qSOFA score (all p<0.05). However, admission during the first peak remained independently associated with increased mortality even after adjustment for patient-related factors: odds ratio = 1.8 (1.4-2.4) (p<0.0001). CONCLUSIONS: The creation of a fully integrated health system allowed us to dynamically respond to the everchanging COVID-19 landscape. In this context, despite the increasing patient acuity, our mortality and resource utilization rates have improved during the pandemic.

Service line care delivery model for COVID-19 patient-centric care.

OBJECTIVES: The COVID-19 pandemic has caused hospitals around the world to quickly develop not only strategies to treat patients but also methods to protect health care and frontline workers. STUDY DESIGN: Descriptive study. METHODS: We outlined the steps and processes that we took to respond to the challenges presented by the COVID-19 pandemic while continuing to provide our routine acute care services to our community. RESULTS: These steps and processes included establishing teams focused on maintaining an adequate supply of personal protection equipment, cross-training staff, developing disaster-based triage for the emergency department, creating quality improvement teams geared toward updating care based on the most current literature, developing COVID-19-based units, creating COVID-19-specific teams of providers, maximizing use of our electronic health record system to allocate beds, and providing adequate practitioner coverage by creating a computer-based dashboard that indicated the need for health care practitioners. These processes led to seamless and integrated care for all patients with COVID-19 across our health system and resulted in a reduction in mortality from a high of 20% during the first peak (March and April 2020) to 6% during the plateau period (June-October 2020) to 12% during the second peak (November and December 2020). CONCLUSIONS: The detailed processes put in place will help hospital systems meet the continuing challenges not only of COVID-19 but also beyond COVID-19 when other unique public health crises may present themselves.

Neutralizing Monoclonal Antibody Treatment Reduces Hospitalization for Mild and Moderate Coronavirus Disease 2019 (COVID-19): A Real-World Experience.

BACKGROUND: Neutralizing monoclonal antibody (NmAb) treatments have received Emergency Use Authorization to treat patients with mild or moderate COVID-19 infection. To date, no real- world data on the efficacy of NmAbs have been reported from clinical practice. We assessed the impact of NmAb treatment given in the outpatient clinical practice setting on hospital utilization. METHODS: Electronic medical records were used to identify adult COVID-19 patients who received NmAbs (bamlanivimab [BAM] or casirivimab and imdevimab [REGN-COV2]) and historic COVID-19 controls. Post-index hospitalization rates were compared. RESULTS: 707 confirmed COVID-19 patients received NmAbs and 1709 historic COVID-19 controls were included; 553 (78%) received BAM, 154 (22%) received REGN-COV2. Patients receiving NmAb infusion had significantly lower hospitalization rates (5.8% vs 11.4%, P < .0001), shorter length of stay if hospitalized (mean, 5.2 vs 7.4 days; P = .02), and fewer ED visits within 30 days post-index (8.1% vs 12.3%, P = .003) than controls. Hospitalization-free survival was significantly longer in NmAb patients compared with controls (P < .0001). There was a trend towards a lower hospitalization rate among patients who received NmAbs within 2-4 days after symptom onset. In multivariate analysis, having received an NmAb transfusion was independently associated with a lower risk of hospitalization after adjustment for age, sex, race, BMI, and referral source (adjusted HR [95% CI], .54 [0.38-0.79]; P = .0012). Overall mortality was not different between the 2 groups. CONCLUSIONS: NmAb treatment reduced hospital utilization, especially when received within a few days of symptom onset. Further study is needed to validate these findings.