Hospitals Reported That The COVID-19 Pandemic Has .
U.S. Department of Health and Human ServicesOffice of Inspector GeneralHospitals Reported That theCOVID-19 Pandemic HasSignificantly Strained HealthCare DeliveryResults of a National Pulse SurveyFebruary 22–26, 2021Christi A. GrimmPrincipal Deputy Inspector GeneralMarch 2021, OEI-09-21-00140
U.S. Department of Health and Human ServicesOffice of Inspector GeneralReport in BriefMarch 2021, OEI-09-21-00140Scope of the ReviewThis review provides a national snapshot,from the perspective of front-line hospitaladministrators, on how responding to theCOVID-19 pandemic has affected theircapacity to care for patients, staff, andcommunities. This is not a review of theHHS response to the COVID-19 pandemic.These hospital perspectives reflect a specificpoint in time—February 22–26, 2021—provided during a “pulse survey” (briefinterviews) that OIG conducted with320 hospitals nationwide. The timing wasnearly a year after the World HealthOrganization declared COVID-19 to be apandemic on March 11, 2020.First Pulse Survey—March 2020We conducted our first pulse survey ofchallenges that hospitals reported facing inresponse to COVID-19 during the earlyweeks of the pandemic. At that time,hospitals reported that they were largelyfocused on enhancing their capacity torespond to the pandemic. Hospitalsreported challenges such as significantshortages in personal protective equipment(PPE), ventilators, and other supplies asdemand increased across the country andaround the globe. Hospitals also spoke ofthe challenge of needing to rapidly expandfacility and staffing capacity. Finally,hospitals reported that, at the time, the lackof testing capability to detect whichpatients had COVID-19 negatively impactedhospital operations as they tried to preventoutbreaks among hospital patients andstaff.Since March 2020, the pandemic hascontinued to evolve. This snapshot from2021 provides HHS and otherdecisionmakers with updated informationon hospital perspectives. Specifically, thispulse survey offers hospital administrators’perspectives on the most significant strainsthat the response to COVID-19 has exertedon hospitals, as well as their perspectives onthe longer-term implications of thesestrains.Hospitals Reported That the COVID-19Pandemic Has Significantly Strained Health CareDeliveryKey TakeawaysIn February 2021, hospitals reported that operating in “survival mode” foran extended period of time has created new and different problems thanexperienced earlier in the pandemic and exacerbated longstandingchallenges in health care delivery, access, and health outcomes.Hospital-Reported Challenges. Hospitals described difficulty balancingthe complex and resource-intensive care needed for COVID-19 patients withefforts to resume routine hospital care. They reported that staffingshortages have affected patient care, and that exhaustion and trauma havetaken a toll on staff’s mental health. Administrators detailed challengesassociated with vaccine distribution efforts and concerns about vaccinehesitancy among staff and members of their communities. Hospitals alsoraised concerns that the pandemic has exacerbated existing disparities inaccess to care and health outcomes. Additionally, many hospitals reportedexperiencing financial instability because of increased expenses associatedwith responding to a pandemic and lower revenues from decreased use ofother hospital services. Hospitals indicated that many of the challengeswere more severe for rural hospitals.Addressing Hospital Challenges. Hospitals reported a range of strategiesto address their challenges and identified areas in which furthergovernment support could help as they continue responding to thepandemic. Broadly, the areas of government support included enhancingknowledge and guidance on the prevention and treatment of COVID-19,including safe means to discharge patients with COVID-19; helping to fillgaps in hospital staffing, especially for nurses and certain specialists;continuing financial relief, especially to increase care to rural andunderserved communities; and, encouraging widespread vaccinations toreduce the circulation of the virus.Looking Forward. Beyond the immediate needs in responding toCOVID-19, the pulse survey documents hospitals’ perspectives aboutlonger-term opportunities for improvement to address challenges thatexisted before, and were exacerbated by, the pandemic. These includereducing disparities in access to health care and in health outcomes;building and maintaining a more robust health care workforce; andstrengthening the resiliency of our health care system to respond topandemics and other public health emergencies and disasters.
Report in Brief continuedReport No. OEI-09-21-00140LimitationsThe hospitals’ front-line perspectivesprovide an important voice, among many,for HHS and other decisionmakers toconsider as they grapple with the challengespresented or worsened by the pandemic.However, it is the perspective of hospitaladministrators at a point in time,February 22–26, 2021. OIG has notindependently assessed the merits, costs, oreffectiveness of the strategies or areas forgovernment support identified by hospitals.As such, OIG is not endorsing thesuggestions made by the hospitaladministrators.Further, we recognize that HHS, Congress,and other government entities across theFederal, State, local, and Tribal levels aretaking substantial actions on a continualbasis to support hospitals in responding toCOVID-19. For example, the recentlypassed American Rescue Plan Act of2021 provides additional support andfunding that could help to address some ofthe challenges that hospitals identified.How OIG Did This ReviewThis report is based on a pulse survey conducted during February 22–26,2021, with hospital administrators from 320 hospitals across 45 States, theDistrict of Columbia, and Puerto Rico. Interviews focused on three keyquestions:1. What are your most difficult challenges in responding to the COVID-19pandemic right now, and what strategies have you been using toaddress the challenges?2. What are your organization’s greatest concerns going forward?3. How can government best support hospitals?Respondent hospitals included special pathogen centers, critical accesshospitals, and a range of hospitals nationwide of various sizes andcharacteristics. We spoke with representatives from 320 hospitals that werepart of our random sample of 397 hospitals, for an 81-percent rate ofcontact. (See Methodology on page 38 for additional information abouthow we conducted this pulse survey.)
HOSPITAL CHALLENGES: HIGHLIGHTSHealth Care DeliveryMeeting the Health Care Needs of COVID-19 PatientsHospitals emphasized the significant clinical challenges in treating COVID-19 patients, some of whom arevery ill, and patients with longer-term effects after recovering from acute illness. Hospitals also reporteddifficulty in balancing the care needed for COVID-19 patients with efforts to resume routine hospital careand challenges in discharging patients to post-acute settings during their recovery, which strained hospitalcapacity.Delays in Care Resulting in Patients With More Serious ConditionsHospitals reported that patients have delayed or forgone routine health care as a result of the COVID-19pandemic, which has led to worsening of patient conditions. Administrators predicted that widespreaddelayed care could result in higher hospitalization rates and need for more complex hospital care in thefuture.Increased Needs for Mental and Behavioral Health CareAdministrators voiced concern that the pandemic has led to greater mental and behavioral health needsamong patients. Administrators anticipated that the needs for mental and behavioral health services at theirhospitals would continue to grow and reported concern about meeting these needs.Worsening of Longstanding Challenges at Rural HospitalsRural hospitals reported particular difficulty responding to the COVID-19 pandemic and that the pandemichad worsened longstanding challenges in staffing, limited capacity, and finances. Hospitals explained thatstrategies employed by other hospitals, such as sharing clinicians across systems and providing telehealthservices, may not work for rural hospitals due to remote locations and lack of access to technology.Concerns about Exacerbation of Health Care DisparitiesHospitals raised concerns that the COVID-19 pandemic has exacerbated existing disparities in access to careand health outcomes.Benefits and Challenges of Expanded Telehealth UseHospitals reported that telehealth has become an important care delivery model during the COVID-19pandemic. Administrators also reported some challenges in delivering care with telehealth. Thesechallenges are that telehealth, by its very nature, cannot cover all aspects of health care delivery. They alsoreported that some patients, particularly those in underserved communities, do not have the devices orinternet access to conduct video calls.
StaffingStaff Burnout and TraumaHospitals reported that increased hours and responsibilities, along with other stressors caused by theCOVID-19 pandemic, resulted in staff being exhausted, mentally fatigued, and sometimesexperiencing possible post-traumatic stress disorder (PTSD). Several hospitals reported thatwitnessing COVID-19-related deaths especially weighed on staffs’ mental health.Staffing Shortages Due to High Turnover and CompetitionMany hospitals reported that they were experiencing concerning staff shortages, particularly among nurses,raising concerns for hospitals about patient safety and quality of care. Hospitals also expressed concernsabout the future of the health care workforce as the recruitment pool for nurses and other health careworkers has continued to shrink.VaccinationsDiversion of Limited Resources to Vaccine EffortsAlthough hospitals viewed their vaccination efforts as a positive step toward pandemic recovery, severalhospitals noted that these efforts come at a cost—further stretching limited clinical staff and straininghospital finances. Hospitals reported that differences in government guidance on vaccine eligibility made itmore complicated for them to determine who is eligible, requiring additional effort for hospitals.Vaccine Hesitancy Among Hospital Staff and the CommunitySome hospitals reported that some staff and members of the community were hesitant to take theCOVID-19 vaccine or declined to get vaccinated due in part to safety concerns. Hospitals reported thatsome staff distrusted the rapid vaccine development and approval process and had concerns that thevaccines may not be effective or may pose risks.Ensuring Vaccination Access for Rural and Other Underserved PopulationsHospitals reported that vaccinating rural communities presented unique challenges that made it difficult toensure vaccination access for residents. Hospitals also reported needing to take extra steps to ensure accessto vaccinations for some senior and low-income populations, such as those who do not have internet accessor the technology skills to navigate online scheduling.FinancesFinancial Instability From Higher Costs and Lower RevenuesMany hospitals reported concerns about their financial stability as the COVID-19 pandemic hadincreased costs and decreased revenues. They explained that their higher costs were associated withpatient care, staffing, PPE, and COVID-19 testing and vaccinations; lower revenues stemmed fromfewer routine and elective services and reimbursement rates that, according to the hospitals, did notkeep up with increasing costs of care for some COVID-19 patients.
TABLE OF CONTENTSHOSPITAL LOCATION AND OCCUPANCY1FINDINGS2Health Care Delivery2Hospitals reported significant challenges in meeting the needs of COVID-19 patients anduncertainty about future COVID-19 caseloadsHospitals reported that the pandemic led to delayed care and feared that an erosion of trustin hospital safety would continue to keep patients from seeking needed careHospitals expressed concern about meeting the increased need for mental and behavioralhealth care that has emerged as an outgrowth of the pandemicRural hospitals reported that longstanding operational challenges have worsened during thepandemicHospital administrators raised concerns that the COVID-19 pandemic has worsened existingdisparities in access to care and health outcomesHospitals reported the adoption and use of telehealth was beneficial and a change they wantto retain despite some challengesStaffing9Hospitals reported that increased workloads and the stress of treating seriously ill and dyingCOVID-19 patients have led to staff burnout and, in some cases, traumaHospitals reported that high turnover and competition for medical staff have created staffingshortages that in some cases affect patient careVaccinations12Hospitals reported that vaccination efforts were positive steps toward pandemic recovery butexacerbated challenges with clinical staff shortages and hospital financesDifferences in government guidelines regarding vaccine eligibility and prioritization createdchallenges for hospitalsHospitals reported that some hospital staff and members of the community were hesitant toget vaccinatedHospitals reported challenges in ensuring access to vaccinations for rural, senior, andlow-income populationsHospitals reported frustration with the unpredictable and insufficient supply of vaccinesSuppliesHospitals reported difficulty maintaining a steady supply of affordable, high-quality PPE16
Finances17Hospitals reported that their operational costs have risen dramatically while their revenueshave declined, threatening their financial stabilityHospitals expressed uncertainty about rules on repayment of prior Federal loansADDRESSING HOSPITAL CHALLENGES20Hospitals reported implementing strategies to address challenges and described areas in whichnew and continued government support would be helpfulEnhancing knowledge and guidance on the prevention and treatment of COVID-19Providing support to increase care to underserved communitiesAddressing hospital staffing needs and helping to support current staffDeveloping education campaigns regarding vaccines and other public health issuesProviding ongoing support on financial issuesLeading a coordinated emergency responseLOOKING FORWARD25Addressing Urgent and Systemic Challenges Exacerbated by the COVID-19 PandemicSELECTED HOSPITAL STRATEGIES26BACKGROUND28GLOSSARY OF KEY TERMS34METHODOLOGY38APPENDIX: CHARACTERISTICS OF RESPONDING HOSPITALS AND THEIRCOMMUNITIES41ACKNOWLEDGMENTS AND CONTACT45ABOUT THE OFFICE OF INSPECTOR GENERAL46ENDNOTES47
HOSPITAL LOCATION AND OCCUPANCYExhibit 1: The 320 responding hospitals were located in 45 States, the District of Columbia,and Puerto Rico.Source: OIG analysis of 320 responding hospitals using the address listed for their provider number, March 2021.Exhibit 2: Some responding hospitals were operating at an over 90-percent adult inpatientoccupancy and/or an over 90-percent adult intensive care unit (ICU) occupancy.132228333745423656402032195Inpatient Occupancy81431233111ICU OccupancySource: OIG analysis of HHS Protect data for February 17, 2021.Note: For adult inpatient occupancy, the total equals 316 responding hospitals because not all hospitals reported data in HHS Protect. Foradult ICU occupancy, the total equals 230 because we excluded 86 hospitals that reported not having any ICU beds.Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health CareOEI-09-21-00140Hospital Location and Occupancy 1
FINDINGSHEALTH CARE DELIVERYHospitals reported significant challenges in meeting the needsof COVID-19 patients and uncertainty about future COVID-19caseloadsHospitals are at the forefront of health care delivery during the COVID-19 pandemic,and hospital administrators described the strain the pandemic has placed on patientcare. In some cases, hospitals reported that underlying problems with health caredelivery were exacerbated, such as challenges providing care for underserved patientsand challenges for rural hospitals with limited resources.The volume of COVID-19 patients and the complexity of theirimmediate and long-term needs significantly strained patientcare and hospital operationsHospitals reported being overwhelmed by the volume of patients, especially duringsurges in COVID-19 infections. They explained that this put a severe strain on theirbed capacity. Some hospitals reported that they operated at over 100-percentcapacity during surges, and high occupancy continues for some hospitals. At the timeof our survey, 40 responding hospitals had over 90-percent inpatient occupancy and56 had over 90 percent of their ICU beds occupied. (See the Appendix on page 41 formore information about the capacity and other characteristics of respondinghospitals.) One urban hospital, with a nearly full ICU the week before our survey,reported that it would do only urgent surgeries and discharged patients to theirhomes for recovery because of a shortage of recovery areas in the hospital.Hospitals emphasized the great clinical challenges in treating COVID-19 patients,particularly those with severe illness and comorbidities. Hospital clinicians have hadto keep up with emerging treatment protocols, often without sufficient specialty staff,such as infectious disease specialists, pulmonologists, respiratory therapists, andclinical nurses trained in treating COVID-19.COVID-19 patients with longer-term effects will also need complex specialty care.Hospitals reported seeing patients with serious post-COVID conditions, such aspulmonary issues, pneumonia, heart problems, and blood clots. One hospitaldescribed “a tsunami of people going forward” who they predicted would experiencelong-term effects from COVID-19.Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health CareOEI-09-21-00140Findings 2
Administrators reported challenges in balancing the complex and resource-intensivecare needed for COVID-19 patients with efforts to resume routine hospital care.Hospitals reported having difficulty integrating COVID-19 care into normaloperations, chiefly because of concerns about infection control. As hospitalsreopened more services for patients after the early months of the pandemic, such asresuming elective surgeries, they experienced increased challenges in keepinginfected COVID-19 patients separated from non-infected patients. Complicating thisfurther, hospitals explained that a new patient’s COVID-19 positivity status may not beimmediately known.Hospitals reported challenges in discharging COVID-19 patientsduring their recovery, which affected available bed spacethroughout the hospitalHospitals reported difficulty in discharging COVID-19 patients following the acutestage of their illness, resulting in longer hospital stays. Administrators reportedchallenges in transferring patients to post-acute facilities such as nursing homes,rehabilitation hospitals, and hospice facilities. According to administrators, somepost-acute facilities were either unwilling or unable to accept patients because thefacilities were concerned about potential COVID-19 infections. Others did not havebed capacity or staff to care for the patients.“We have patients in the acute-care setting that really donot belong here in terms of what they need clinically butcan’t move on because there is not an available option.”- Hospital administratorAdministrators reported that delays in discharge affected available bed spacethroughout the hospital and had other downstream effects. For example, hospitalsreported that patient opportunities for specialized post-acute care (e.g., rehabilitation)were delayed. Hospitals also reported that longer stays created bottlenecksthroughout hospitals, including in ICUs and emergency departments. As an example,one hospital reported that 13 of its 17 emergency treatment rooms were occupied byCOVID-19 patients waiting to be admitted to the hospital.Uncertainty about future COVID-1
Benefits and Challenges of Expanded Telehealth Use Hospitals reported that telehealth has become an important care delivery model during the COVID-19 pandemic. Administrators also reported some challenges in delivering care with telehealth. These challenges are that telehealth, by its very
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