Share Patients, Not Ventilators: Lessons From an Academic Center With a Low Admission Rate of COVID-19 Patients.

To the Editor:

We still have a very poor understanding of the mechanisms driving the outcome of patients in acute respiratory failure, when dealing with limited critical care resources in face of sheer patient surges as has occurred during the current coronavirus disease 2019 (COVID-19) pandemic. In their paper recently published in CHEST (September 2020), Ramachandran et al called attention to the need for a coordinated nationwide strategy aiming at sharing ventilators between hospitals. There is, however, a paucity of evidence to support that the mortality rate has been influenced by limited access to ventilators or equipment in the United States. In addition, the benefit of increasing the number of accessible ventilators without the proper experienced “human power” or while treating mechanically ventilated patients outside the setting of well-organized ICU units, can certainly be challenged on several grounds. For instance, our institution—Milton S. Hershey Medical Center—underwent strategic expansion to increase the number of beds available by the early March. To our surprise, from March through May, 107 COVID-19 patients were admitted to our institution, with two fatalities (case fatality rate = 1.8%), considerably lower than the figures reported in the literature. Our community-based affiliate, St. Joseph’s Medical Center, simultaneously experienced a similar number of admissions (95 patients; Table 1 ) during the same 2-month period, but with a case fatality rate that reached 9.5% (χ2 = 5.65; P < .05). Fundamentally, the two hospitals differ in bed and thus personnel capacity, resulting in a much higher “burden ratio,” the ratio between the number of COVID-19 patients admitted and the overall number of beds (46.5% for St Joseph’s Medical Center vs 19.5% for Milton S. Hershey Medical Center). The experience described in the Northwell Health Hospitals in New York is highlighted by an extremely high burden ratio (124%), with a global mortality rate computed over 1 month only (March) at 9.7%. We, therefore, propose that our fortunate outcome is primarily attributable to a disproportionate excess of relative capacity and resources allocated to a low rate of admission of COVID-19 patients. This contention implies that limiting the number of COVID-19 patients below an individualized threshold should be associated with a reduction in the overall mortality rate.

Table 1

Identifying Institutional Burden

COVID-19 Cases and Hospital Capacities	PSHMCa	SJMCb	Northwell Health Hospitalsc
Admissions	107	95	5,700
Fatalities	2	9	553
Case fatality rate	0.018	0.095	0.097
Total beds	548	204	4584
“Burden” ratio (admissions/total beds)	0.195	0.465	1.243

COVID-19 = coronavirus disease 2019.

Milton. S. Hershey Medical Center (March 1-May 4).

St. Joseph’s Medical Center (March 1-May 4).

Northwell health system hospitals (March) abstracted from Richardson et al. Total beds of those hospitals compiled from northwell.edu.

The development of regional and national policies allowing for rapid, safe, and effective dispersal of patients between medical institutions that have experience and expertise in treating patients in acute respiratory failure, rather than increasing capacity to accommodate more patients in a given institution, could well represent the primary remedy to this burden/mortality relationship.