key: cord-352234-utjne1ef
authors: Mendlovic, Joseph; Weiss, Gali; Da’as, Nael; Yinnon, Amos; Katz, David E.
title: Internal medicine patients admitted without COVID‐19 during the outbreak
date: 2020-08-11
journal: Int J Clin Pract
DOI: 10.1111/ijcp.13630
sha: 
doc_id: 352234
cord_uid: utjne1ef

BACKGROUND: The first case of COVID‐19 in Israel was reported on February 21, 2020. Shaare Zedek (SZ), a 1000‐bed tertiary care medical centre in Jerusalem, Israel, cared for a significant number of these patients. While attention focused on COVID‐19 patients, uninfected patients were admitted to decreasing numbers of available internal medicine (IM) beds as IM departments were converted to COVID‐19 isolation wards. As a result of the increase in COVID‐19 patients, closure of IM wards, re‐assignment of staff and dynamic changes in available community placement options, we investigated the impact of the outbreak on IM patient not admitted for COVID‐19. METHODS: We reviewed IM admissions during March 15‐April 30, 2020 for patients without COVID‐19. Characteristics assessed included number of admissions, age, length of stay, mortality rate, number of discharges, number discharged home and functional status of the patients. Data were compared with the previous 3 years (2017‐2019) during the same time period. RESULTS: During March 15‐April 30, 2020 there were 409 patients admitted to IM compared with a mean of 557 over the previous 3 years. Fewer patients were admitted to the ED and the IM wards during the outbreak. There was no significant difference between the two groups with regards to gender, in‐hospital mortality rate, number discharged, number discharged home and patient functional level. Patients admitted during the outbreak to IM were younger (74.85 vs 76.86 years) and had a mean shorter hospital length of stay (5.12 vs 7.63 days) compared with the previous 3 years. CONCLUSION: While the characteristics of patients admitted to IM during the outbreak were similar, hospital length of stay was significantly shorter. Internal management processes, as well as patient preferences may have contributed to this observation. An infectious disease outbreak may have a significant effect on uninfected admitted patients.

uninfected patients were admitted to decreasing numbers of available Internal Medicine (IM) beds. Pre-outbreak, SZ had four functioning IM departments. During the outbreak, the hospital developed five patient COVID-19 isolation wards and a dedicated Intensive Care Unit (ICU). There were fewer Emergency Department (ED) patients, but COVID-19 isolation wards filled up quickly. Staff had to be trained and deployed to work in these units. Many times, staff included subspecialist and non-IM tract interns. During the peak of the outbreak, two IM Departments were converted to COVID-19 isolation wards. As a result of the increase in COVID-19 patients, closure of IM wards, re-assignment of staff, and dynamic changes in available community placement options, we investigated the impact of the outbreak on IM patients not admitted for COVID-19.

We reviewed IM admissions during March 15-April 30, 2020 for patients without COVID-19. Characteristics assessed included number of admissions, age, length of stay, mortality rate, number of discharges and number discharged home. The term "outlier" was used to describe patients with longer hospital lengths of stay. For this analysis, we compare length of stay ≥10 days between the two groups. Data were compared with the previous 3 years (2017-2019) during the same time period. Functional status of the patients was approximated using the Norton scale. The Norton scale has traditionally been used to assess risk for pressure ulcers. 5 However, it is also a valid assessment tool for predicting hospitalisation length, complications during hospitalisation and in-hospital mortality in elderly patients admitted to an IM department. 6, 7 The scale consists of five questions addressing physical condition, mental condition, activity level, patient mobility, frequency and type of incontinence.

The score ranges from 5-20; less than 10 (very high risk), 10-14 (high risk), 15-18 (medium risk) and greater than 18 (low risk). Use of the scale is obligatory at SZ, and an assessment is conducted at the time of admission to the IM wards from the ED, and once a week thereafter. The last value during the admission was used for this analysis.

Descriptive statistics were utilised to assess characteristics of the study population. Association between categorical variables were tested using the Yates' chi-square. Comparison of quantitative variables in two independent groups were performed using the t test. 

During March 15-April 30, 2020 there were 409 patients admitted to IM compared with a mean of 557 over the previous 3 years (Table 1) . Fewer patients were admitted to the ED ( Figure 2 ) and the IM wards during this time. With regards to patient gender, in-hospital mortality rate, number discharged, number discharged home (ie, vs a healthcare facility) and the mean Norton score, there did not appear to be a significant difference between the two groups. In both groups, more than half of the patients were considered high or very high risk according to the Norton score, consistent with lower functional status for this study. Patients admitted during the outbreak to IM were younger and had shorter mean hospital stays by over 2 days, when compared with the previous 3 years. The median length of stay was the same, but the interquartile range was shortened by 1 day for the group of patients admitted during the outbreak. There were no difference between the two groups with regards to the number of patients admitted for ≥10 days.

This was an extremely dynamic period in Israel. A national shutdown severely limited movement, except for essential personnel and activities. During this period, the overall number of patients presenting to the Emergency Department (ED) was visibly less than the previous 3 years. While there were fewer patients admitted to IM via the ED, there were progressively fewer IM departments. During one of the peak days of the outbreak, the number of IM wards had been decreased from four to two. Additionally, a small 14-bed satellite unit was established to help decompress the IM wards. By this time, five isolation wards had been rapidly established, including an ICU ward for COVID-19 patients. Therefore, in comparison to the previous year, four IM wards had been replaced by two IM wards and five COVID-19 isolation wards ( Figure 3 ).

There are reports of hospitals having to shutdown wards and reallocate personnel and resources to be able to care for the influx of COVID-19 patients. 8 While no approach has been standard, there What's known • Hospitals in Israel had to adapt to the surge in COVID-19 patients, including training and deploying staff to work in newly formed COVID-19 isolation wards.

• While fewer numbers of patients were seen in the Emergency Department, non-COVID-19 patients continued to be admitted to a rapidly decreasing number of internal medicine beds at our institution.

• The COVID-19 outbreak was associated with changes in non-COVID-19 internal medicine patient characteristics and hospital length of stay.

• Research should focus on how outbreaks affect entire hospital populations and community resources.

will be a need to look back and assess individual site response to the pandemic, as well as to formulate a plan for the current effort and future healthcare epidemics.

Patients admitted to IM were significantly younger, as older patients may have been admitted to isolation wards, died at home or feared coming to the hospital, thinking it an epicentre of infection. 9 While not classically used for assessing the casemix of patients, the use of the Norton scale is obligatory for every IM admission at our facility and does describe many aspects of the patient's physical and mental attributes. More complex, albeit possibly harder to derive, metrics for assessing functional assessment do exist as well. 10 We observed a significantly decreased hospital length of stay, without an increase in mortality. After admitting the first infected patient, the hospital director established a team dedicated to overseeing patient flow from admission to discharge. This team was diagnosis (eg, admitting or discharge) was not assessed and might have differed between the two groups, possibly explaining the observed difference in hospital length of stay.

Physician staffing during this time period was a concern. Some IM residents and senior physicians were home in isolation, caring for children no longer at school during the day or retasked to COVID-19 isolation wards. We succeeded in maintaining IM staffing on the non-COVID-19 IM wards during this time and believe this helped allow us to maintain pre-outbreak mortality rates and numbers discharged. IM department teams were broken down into smaller groups and interaction between the groups was limited.

Conversations between different hospital groups were conducted via video conferencing. While the administration was actively engaged and promoted regular top-down and bottom-up communication, burn-out was a concern on the IM as well as the isolation wards. Proper planning allowed SZ to remain functional and even shorten IM patient length of stay. Further studies and research should address how outbreaks affect the entire hospital populations and surrounding community resources.

We confirm that all authors of this paper have fulfilled the conditions of the IJCP regarding contribution to the concept, design and drafting of the manuscript. In addition, all authors have passed final approval on the manuscript that is currently being submitted. We declare that the manuscript has not been submitted or accepted for publication elsewhere, and we are not aware of any manuscripts that are related to the one we submit. No conflicts of interests were declared by any of the authors regarding the content of this report.

David E. Katz https://orcid.org/0000-0002-4637-5145

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