Niaz Ahmed Shaikh1, Saubia Fathima1, Aisha Siddique1, Lamis abufool1, Basma Demian1, Jehangir Mobushar1, Ranjana Pradeep1
1Department of Internal Medicine, Rashid Hospital, Dubai Health Authority, United Arab
Emirates (Correspondence: S. Fathima:
Abstract
Background: In the postpandemic era of 2022, we looked back at the early stages of the COVID-19 pandemic in 2020 and attempted to establish the challenges faced in hospitals at that time.
Aims: To identify the reasons for prolonged hospital stay after recovering from COVID-19.
Methods: This was a retrospective observational study in a tertiary hospital in Dubai from 1 April and 1 July 2020. It included 150 (18.75%) patients who fulfilled our definition of prolonged hospital stay.
Results: The mean duration of total hospital stay was 48.5 (9–272) days, with an interquartile range (IQR) of 22 days. The mean duration of extended stay was 27.5 (2–231) days, with an IQR of 17 days. The common reasons were mandatory isolation (n = 62, 28%), hospital-acquired infections (n = 37,17%), acute respiratory distress syndrome (n = 32, 15%), myopathy/neuropathy (n = 31, 14%), pulmonary fibrosis requiring oxygen supplementation (n = 31, 14%), and completion of COVID-19 treatment (n = 25, 12%).
Conclusion: We identified the factors that directly or indirectly contributed to the prolonged hospitalization of patients with COVID-19. To make optimal use of available resources, these issues should be addressed, in preparation for any subsequent pandemics.
Keywords: prolonged hospitalization, COVID-19, long COVID, length of stay, Dubai
Citation: Shaikh NA, Fathima S, Siddique A, Abufool L, Atef Demian BA, Mobushar JA, et al. Duration and etiology of extended hospitalization in patients recovered from COVID-19. East Mediterr Health J. 2023;29(x):xxx-xxx https://doi.org/10.26719/emhj/23.106 Received: 20/10/21, Accepted: 03/03/23
Copyright: © Authors; licensee World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction
Since the first case of COVID-19 was reported at the end of 2019 in Wuhan, China, > 661 million cases and > 6 million fatalities have been documented (1). The pandemic has presented the global economy with several major difficulties. The number of people needing hospitalization overstretched health care systems and the resources available, particularly in the early months of 2020. The necessary restrictions and lockdowns imposed a second burden on the global economy.
Although the novel SARS-CoV-2 primarily affects the respiratory system, there is much evidence that infection can involve multiple organ systems with various manifestations. Following apparent recovery, post-COVID complications may occur, such as acute and chronic long COVID syndrome (2, 3). These post-COVID-19 symptoms delay complete recovery and a return to full functionality (3, 4). Pulmonary fibrosis is a well-known consequence of acute respiratory distress syndrome and affects the life of survivors (5). Cardiovascular complications after recovery from COVID-19 have been reported, including hyperlipidaemia, heart failure, and glucose metabolism disorders (6–8). There is a high rate of complications in patients who require intensive care and intubation. The reported rate of cognitive impairments, including delirium, is between 30% and 80% (9). All these complications can contribute to delayed discharge. While hospitalization can be necessary and lifesaving, it comes with associated morbidity and costs that occur more commonly in the older population (9, 10).
Long COVID is gaining increasing attention; however, much of the research focus remains on the active stage of the infection. Only a few studies have explored the reasons for hospitalization after apparent recovery from COVID-19. Although many patients were released early, particularly later in the pandemic when the number of recommended days of isolation was reduced, a sizable percentage of patients needed to stay in hospital for an extended period (2). Guo et al. reported increased odds of prolonged hospital stay in women, and in patients with fever and chronic kidney or liver disease, increased creatinine levels, or bilateral pulmonary infiltration (11).
In the present study, we aimed to identify the reasons for the extended hospitalization after recovery from COVID-19 of some of the patients admitted to our institution. We hope that these data can be used to model bed demand for contingency planning as new variants of SARS-CoV-2 continue to emerge, and be a lesson in future pandemics.
Methods
Study design and participants
This was a retrospective observational study conducted in a government hospital in Dubai, United Arab Emirates (UAE). Rashid Hospital is a specialized tertiary care teaching hospital with a capacity of 786 beds. In the early stages of the pandemic, it was the largest centre among the few authorized for the treatment of COVID-19. Eight hundred patients with confirmed COVID-19 were admitted to the hospital from 1 April to 1 July 2020. Hospital policy at that time was that nasopharyngeal polymerase chain reaction (PCR) tests were repeated every 3 days for PCR-positive patients and every 24 hours for PCR-negative patients, until 2 consecutive negative readings were obtained. Patients were then considered fit for discharge (12, 13). Patients were also required to maintain 10–14 days of isolation after negative test results, as per interim guidance at the time (13, 14). Among the 800 patients admitted to hospital, 150 (18.75%) fulfilled the discharge criteria but remained in hospital and were studied in detail. Inclusion criteria were: patients who were diagnosed with COVID-19 on presentation, received treatment in accordance with the hospital protocol, and stayed in hospital for > 1 day after 2 consecutive negative PCR tests. Exclusion criteria were: patients who did not test positive on presentation and all patients who were discharged from the hospital within 1 day after 2 negative PCR tests.
The study was conducted after approval by the Ethics Committee of the hospital.
Data collection
Electronic medical records were used to collect data regarding patient demographic information, duration of hospitalization, treatment received, and details of hospital stay including medical complications. The data were gathered in an Excel sheet. The reasons for prolonged hospital stay were categorized into 4 groups: (1) related to complications of COVID-19 infection and/or medication; (2) complications related to hospitalization; (3) pre-existing condition or a condition unrelated to COVID-19: and (4) other reasons including isolation and repatriation.
Statistical analysis
Continuous measurements were reported as mean and standard deviation, and categorical variables were reported as numbers and percentages.
Results
Patient characteristics
The mean age of the 150 patients was 47.7 (19–76) years (Table 1). There were 136 (90.6%) male and 14 (9.4%) female patients. Seventy (46.6%) patients had no comorbidities, 46 (30.6%) had only 1, 22 (14.6%) had 2, and 12 (8%) had 3. Fifty-four (36.6%) patients had diabetes mellitus, 43 (28.6%) had hypertension, and 29 (26.8%) had other comorbidities.
Hospitalization
The mean total hospital stay for the 150 patients was 28.5 (9–272) days, with an interquartile range (IQR) of 22 days (Table 1). The mean extended hospital stay after 2 consecutive negative PCR results until discharge was 11.5 (2–231) days, with an IQR of 17 days. Sixty-four (42.6%) patients were admitted to the intensive care unit; most of whom were COVID-19 positive at that time and tested negative later. Twenty-six (17.3%) patients who stayed in hospital after testing negative for COVID-19 died.
We grouped the reasons for prolonged hospitalization into the following 4 categories (Table 1). (1) Complications/treatment of COVID-19 (n = 89, 59.3%). Most of these patients had severe COVID pneumonia with multiorgan dysfunction. They required a longer time to recover from the illness and its complications. Common reasons noted were acute respiratory distress syndrome requiring intubation and subsequent tracheostomy (n = 32). Other reasons were: difficulty in decannulation of the tracheostomy tube, and pneumothorax (n = 3); post-COVID lung fibrosis requiring supplemental oxygen support (n = 31); venous thromboembolism with hemodynamically compromising pulmonary embolism (n = 2); bleeding from mucosal surfaces as well as external and internal hematomas (n = 4); and drug-induced acute kidney injury (n = 14) and liver dysfunction (n = 2). (2) Complications related to hospitalization (n = 52, 34.6%). Hospital-acquired infections such as secondary bacterial pneumonia, urine infection, catheter and tracheostomy site infections, and bed sores contributed to prolonged stay in many patients. Many patients were affected by neuropathy and myopathy that required prolonged physiotherapy. (3) Pre-existing conditions or conditions unrelated to COVID-19 (n = 18, 12%). The common causes in this category were uncontrolled diabetes, heart failure, acute kidney injury, seizures, ischaemic and haemorrhagic stroke, and upper gastrointestinal bleeding. Four patients had pulmonary tuberculosis, 2 were treated for intracerebral haemorrhage, and 1 for cervical fracture. (4) Other reasons, including isolation issues related to discharge, repatriation, and logistics (n = 70, 46.6%). This category included patients that were unable to arrange isolation at home or needed to be repatriated to their home country. One patient extended her stay because her newborn baby needed hospital care.
Discussion
A single symptomatic case of COVID-19 is predicted to have a median direct medical cost of $3045 in the United States of America for the course of the infection (15). Back in 2005, it was estimated that each hospital stay in the UAE cost $223.26 per day. Since then, the cost has grown dramatically (10). Our study focused on identifying the reasons for prolonged hospital stay after recovering from COVID-19. Understanding these reasons would reduce the length of time spent in hospital and the associated costs.
Patients in our hospital were treated for COVID-19 in accordance with the UAE national guidelines in force at that time. Several of the drugs used in this study to treat COVID-19 infection are known to cause adverse effects. For example, lopinavir/ritonavir and favipiravir may cause liver enzyme abnormalities (17, 18), low-molecular-weight heparin may cause anaemia and haemorrhage (19), and tocilizumab increases the risk of secondary infections (20). All of these adverse effects can contribute to prolonged hospital stay and postponed discharge. In our study, 4 patients experienced bleeding complications, including 1 large subcutaneous hematoma that caused a significant drop in haemoglobin that required blood transfusion. The bleeding events were related to anticoagulation therapy. Two patients developed liver injury that was likely related to COVID-19 infection or medication. Hepatotoxic drugs such as lopinavir/ritonavir were withdrawn from these patients, and their liver functions improved during recovery from infection. COVID-19 is known to induce acute kidney injury with complex pathophysiology (21). Fourteen patients in our study developed acute kidney injury, but almost all of them recovered during the course of the infection, and none required dialysis. A few simple steps might help reduce these complications; for example, identifying patients at high risk for bleeding before beginning anticoagulation, such as those with a high HAS-BLED score, and those receiving concurrent antiplatelet agents. A careful review of medication to reduce multiple hepatotoxic or nephrotoxic drugs and decrease drug interactions would also reduce adverse effects. It should be emphasized that the most recent WHO guidelines state that anticoagulation is not necessary for these patients, thus lowering the risk of bleeding and, consequently, hospitalization (22).
Comorbidities are known to complicate and lengthen hospital stays in many conditions. They were particularly important for patients with COVID-19 because they had an impact on the standard of care, especially in the early phases of the pandemic, when health services were not well equipped to handle such a large number of hospitalizations. To minimize the exposure of staff to infection, most patients only received minimum essential care. For example, a patient with a stroke and COVID-19 did not receive the same physiotherapy and support compared with a stroke patient without COVID-19. Some comorbidities increase complications in COVID-19. Most of our patients with prolonged stay had comorbidities, including diabetes mellitus and hypertension. Diabetes and metabolic syndrome are proinflammatory and prothrombotic states that play an important role in the complications of COVID-19 (23). Diabetes alters the immune response and inhibits both the innate and adaptive immune responses (24). There is a positive association between blood glucose levels and length of stay in hospital (7). Diabetes is an independent risk factor for hospital-acquired pneumonia, thus complicating COVID-19 cases (25). Closer and more vigilant monitoring of patients could reduce some of these complications.
The average length of stay in our study was 48 days, which was longer than that reported in other studies. Rees et al. reported that length of stay for COVID-19 patients ranged from < 1 week to nearly 2 months, and the typical length of stay in intensive care was 1–3 weeks (26). In a few cases, the identified cause of extended stay was incidental, that is, unrelated to COVID-19; however there were significant consequences that required further investigation. Examples included haemorrhagic stroke in 2 patients and cervical spine fracture in another. COVID-19 indirectly affected the quality of care required due to patient isolation and the difficulty of scheduling interventions such as computed tomography or echocardiography because of the need for postprocedural sterilization. Three of our patients were worked up for pulmonary tuberculosis coinfection. Two patients developed acute exacerbation of heart failure and needed further care, thus extending hospitalization.
Older patients are more likely to develop complications such as immobilization, dehydration, malnutrition, nosocomial infections, and bed sores (27). Early physiotherapy with nutritional support could perhaps reduce these complications. Thirty-seven (17%) of our patients developed hospital-acquired infection and required treatment with intravenous antibiotics. This could have been prevented with regular monitoring and removal of unnecessary lines and urinary catheters that were missed due to increased patient load and fear of infection. Probably, shorter mandatory isolation periods would improve care because it would enable patients to be shifted to appropriate wards and facilities.
Expatriates account for the majority of residents and a large percentage of patients in the UAE (28). Most of the expatriate patients were workers who lived in the country without their families and had no support after hospital discharge; therefore, they had to be repatriated to their home country instead of regular discharge from the hospital. Nine (6%) of our patients had to be repatriated. The repatriation process was prolonged by lockdown and suspension of international flights as measures to control the pandemic. At the beginning of the pandemic lack of rehabilitation and isolation facilities also contributed to the problem of prolonged hospitalization.
Conclusion
We confirmed that COVID-19 alone might not have been the main cause of protracted hospitalization, but these patients had a variety of other contributory factors. The most common reasons for prolonged hospitalization were: completion of isolation period for patients who could not isolate at home; hospital-acquired infections requiring prolonged treatment; severe infection causing acute respiratory distress syndrome requiring intensive care; myopathy/neuropathy requiring rehabilitation; and pulmonary fibrosis requiring oxygen supplementation. Optimal management of resources has been a major challenge during the COVID-19 pandemic, thus understanding the causes and effects of prolonged hospitalization is essential. If these complications and issues can be identified, anticipated, and addressed early on, then patients can be discharged earlier, thus reducing the burden on health care systems. Improved infection control practices could be implemented to help prevent catastrophic hospital-acquired infections, and a reduction in the patient isolation period could allow important investigations to be arranged sooner. After establishing the causes of prolonged hospitalization, hospital management could plan appropriate bed and personnel allocation and logistical assistance ahead of any unanticipated future pandemics.
Table1. Patient characteristics
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