Some patients go in for COVID-19, others are infected alongside another issue. In hospitals, those lines blur

Inside a busy intensive care unit in Toronto’s east end, Dr. Martin Betts often sees patients grappling with a double diagnosis: a serious health issue coupled with — or caused by — COVID-19.

As chief of critical care for the Scarborough Health Network, Betts has treated several patients with diabetic ketoacidosis, a build-up of acids in the blood that’s a life-threatening complication of diabetes, which can be triggered by viral infections.

Other people have been admitted for heart inflammation, heart attacks and even cardiac arrest caused by a SARS-CoV-2 infection — yet COVID-19 is often listed as a secondary diagnosis, a situation Betts describes as “misleading.”

“Incidental COVID patients actually have potentially a longer length of stay, and higher mortality … they actually should be considered a bigger burden on the system than being described as incidental cases,” he said.

“I think that’s a story that really needs to be told.”

‘For’ versus ‘with’

As an Omicron-drive surge keeps sending more COVID-19 patients into hospitals, some jurisdictions — including Ontario earlier this month, following the lead of various U.S. hospitals — are breaking down hospital data differently.

They’re now distinguishing between people admitted directly for COVID-19 and those admitted for other health issues who also test positive, since the variant is infecting such a wide assortment of patients.

In other words, you’re either in hospital for COVID-19, or with COVID-19.

The data distinction might make it easier to brush off incidental infections, downplay the pressure on hospitals, or assume the crisis phase of this pandemic has already passed.

But Betts and other clinicians say the reality on the ground is more complicated, and those binary buckets don’t capture all the nuances of patient experiences and care in a system under strain during a pandemic. 

More than a ‘bit player’

“I think the impression in the community is that these COVID infections really aren’t much, that it’s just a sort of bit player in this patient’s illness,” Betts said. “That’s not the case.”

In recent weeks, sky-high infection rates began muddying COVID-19 data in a few ways. Record-breaking case spikes proved too tough to track, and many areas of the country have scaled back testing, leaving Canada in the dark about just how many people are getting infected each day.

At the same time, this variant is operating differently, often causing less severe illness than its predecessor, Delta. That’s partly thanks to Omicron’s vast array of mutations, and partly because millions of Canadians are now largely protected from dire health impacts, thanks to vaccinations.

That means while unprecedented numbers of people became infected in mere weeks, many aren’t presenting in hospitals with classic COVID-19 pneumonia, but rather a wider array of symptoms, or while coping with another health issue.

Betts says breaking down hospitalized patients between those admitted for COVID-19 and those infected after being admitted with another condition, can be helpful for planning health-system capacity, given the specialized care and treatments required for patients who have full-blown COVID-19.

“But to me,” he said, “that’s the end of it.”

Poorer outcomes for infected patients

Many patients who test positive while in hospital for another issue wind up having poorer outcomes than those who aren’t battling a coronavirus infection, Betts said. 

Multiple studies from various countries suggest higher death rates for patients being treated for hip fractures who also tested positive for the coronavirus, compared to those who tested negative, for instance. Having a coronavirus infection also makes it riskier to get various types of surgery, and increases the odds that someone who’s pregnant will have a preterm delivery, stillbirth, or other complications.

Then, of course, there’s the ripple effect on the health and well-being of people who aren’t infected with COVID-19 at all, including thousands of cancelled and delayed surgeries.

Hospitals under pressure

During a recent media briefing to highlight the pressure felt by Hamilton hospitals, Dr. Zain Chagla, co-medical director of infection control for St. Joseph’s Healthcare Hamilton, explained how the current surge of Omicron admissions is putting strain on the health-care system as a whole, regardless of how patients are classified. 

Such a high number of infected patients admitted all at once means people are having “repeated exposures,” he said. Even negative test results can’t completely rule out an infection, which can then spark virus transmission within hospitals. 

And it’s really more like three buckets of patients that hospital teams are seeing, Chagla added: people who are seriously ill with classic COVID-19 pneumonia, those who are battling another major health issue alongside a COVID-19 infection and those who have cases that are truly incidental, like someone testing positive after being admitted for a scheduled procedure.

“The hospital pressures are fairly similar across all three of those,” he said.

More COVID-19 patients of any sort inside a hospital is a logistical struggle, echoed Dr. Joe Vipond, an emergency physician in Calgary.

“Even if you are inadvertently diagnosed with COVID when you’re coming into the hospital with another issue, it still makes things hard,” he said. “You can’t just throw a COVID-positive patient into a four-bedroom room.”

Weeks of impact from ‘massive’ Omicron surge 

Dr. Alex Wong, an infectious diseases specialist in Regina, said the pressure-cooker situation facing many Canadian hospitals in the weeks ahead is largely COVID-19-related, regardless of how jurisdictions break down the data.

“Massive surges cannot just be explained by persons being hospitalized for other reasons who are ‘incidentally’ found to have COVID,” he said.

“It’s going to be this perfect storm of lack of staff, plus lack of beds, plus a huge surge of patients, that’s going to really put the system on edge.”

Federal modelling released on Friday suggested Omicron infections will spike hospital admissions in the coming weeks, with “several weeks of very intense activity expected to come.”

At that briefing, public health officials discussed the shift in many jurisdictions to reporting patients with COVID-19 and incidental infections, with Chief Public Health Officer Dr. Teresa Tam noting the breakdown will prove useful to studying the impact of this latest variant.

“But for the hospitals themselves, they are pretty full, and hospitals have always been very stretched during the winter months in any case,” she said. 

“So it really doesn’t help at all having a massive Omicron surge.”