Why ‘Transport to the Nearest Hospital’ Protocol Doesn’t Work in a Pandemic

"[Limited access to ICUs in low-income communities] increases the disparities between rich and poor," explains Genevieve Kanter, PhD, lead study author and an assistant professor of medicine, medical ethics, and health policy at the University of Pennsylvania. "These populations are being triply hit by COVID-19. First, they face higher infection rates because of the jobs that they tend to have, [they often] lack cars so they have to use public transportation, and their housing situations [aren't always ideal when it comes to the spread of COVID-19]. Second, once they contract the disease, their outcomes tend to be worse because there is a higher prevalence of underlying health conditions. And now, we’re documenting that these communities are hit a third time because, once they do need hospital care, they may not receive the care they need because their closest hospital doesn’t have the right facilities."

The report, published in the August issue of Health Affairs, found that 49 percent of the lowest-income communities had no ICU beds, while just 3 percent of the highest-income communities had no ICU beds.

"We found that there was a lot of variation across the country in the availability of ICU beds; the West and Midwest had the least availability," says Dr. Kanter. "When we look specifically at low-income communities with zero access to ICU beds, these tend to be in rural areas. So, given the way the pandemic is diffusing to rural areas, this is cause for concern."

Researchers looked at the most recent ICU bed capacity data for 4,518 short-term and critical access hospitals in the fifty states and Washington, D.C. They used the most recent data (2017 or 2018) from the Centers for Medicare and Medicaid Services’ Healthcare Provider Cost Reporting Information System. Researchers then used 2018 five-year American Community Survey estimates to obtain information on population, age distribution, racial distribution, population density, and median household income at the ZIP code level. Access to ICU services was defined as the number of ICU beds available per ten thousand inhabitants age fifty and older, the population at greatest risk for COIVD-19 hospitalizations.

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ICU access is critical for some COVID-19 patients. "COVID-19 affects the respiratory system, so patients have difficulty breathing and can’t get sufficient oxygen," says Dr. Kanter. "ICUs provide the ventilation or respiratory support they need for their bodies to continue to get oxygen." If you are admitted to a hospital without an ICU and find yourself needing intensive care, your case gets complicated, to say the least.

"Sometimes it can mean that you don’t get the care that you need—for example, the ventilator—and patients can die," says Dr. Kanter. "Sometimes patients can be transferred to a hospital that’s further away, but the other hospital has to be willing to receive new patients. As we note in our paper, COVID-19 patients can be very sick and [their care can be] very expensive, so other hospitals may be reluctant to receive them."

Because of this, the study authors recommend revisiting the protocol of taking patients to the nearest hospital. "The demand for COVID-19 and other care in low-income areas, whose residents are most adversely affected by SARS-CoV-2, is straining hospitals in low-income areas," the report reads. "Plans should be made for how and under what conditions patients can be transported to hospitals outside their immediate communities and how these transport protocols will be communicated to the public."

Additionally, the report says there needs to be more coordination of hospital transfers.

"Because there is little incentive for hospitals to volunteer to take on COVID-19 patients, we emphasize the need for higher-level—say, state-level—coordination of hospital transfers so that hospitals can share the load for these patients," says Dr. Kanter. "We also provide a list of communities most at risk [in the report] so that policymakers can monitor these areas and direct resources towards them as needed."

Lastly, the report states that emergency funds need to be directed toward hospitals lacking sufficient ICU resources, especially those caring for large older populations that are more likely to be hospitalized for COVID-19.

"As the COVID-19 pandemic progresses, coordinated policy responses are urgently needed to prevent preexisting socioeconomic disparities from exacerbating the harms already being done by COVID-19," the report reads.