Variation in COVID-19 disease severity at hospital admission over time and across hospitals A multi-institution cohort of Michigan hospitals

During the spring 2020 COVID-19 surge, hospitals in Southeast Michigan were overwhelmed, and hospital beds were limited. However, it is unknown whether threshold for hospital admission varied across hospitals or over time. Using a statewide registry, we performed a retrospective cohort study. We identified adult patients hospitalized with COVID-19 in Southeast Michigan (3/1/2020-6/1/2020). We classified disease severity on admission using the World Health Organization (WHO) ordinal scale. Our primary measure of interest was the proportion of patients admitted on room air. We also determined the proportion without acute organ dysfunction on admission or any point during hospitalization. We quantified variation across hospitals and over time by half-month epochs. Among 1315 hospitalizations across 22 hospitals, 57.3%(754/1,315) were admitted on room air, and 26.1% (343/1,315) remained on roomair for the duration of hospitalization. Across hospitals, the proportion ofCOVID-19 hospitalizations admitted on roomair varied from32.3% to 80.0%. Across half-month epochs, the proportion ranged from49.4% to 69.4%and nadired in early April 2020. Among patients admitted on roomair, 75.1%(566/754) had no acute organ dysfunction on admission, and 35.3%(266/754) never developed acute organ dysfunction at any point during hospitalization; there was marked variation in both proportions across hospitals. In-hospital mortality was 13.7% for patients admitted on room air vs 26.3% for patients requiring nasal cannula oxygen. Among patients hospitalized with COVID-19 during the spring 2020 surge in Southeast Michigan, more than half were on room air and a third had no acute organ dysfunction upon admission, but experienced high rates of disease progression and in-hospital mortality. Abbreviations: CQI = collaborative quality initiative, WHO = World Health Organization.