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States like New York have started asking hospitals to distinguish between people who are admitted primarily for COVID-19 and those who came to the hospital for other reasons but also tested positive. These COVID-19 cases have come to be referred to by some as “incidental hospitalizations.”
The new data, which has revealed significant numbers of incidental infections, has fueled problematic and misleading claims on social media that the pandemic is overblown.
But not all incidental COVID-19 hospitalizations are the same. For some, infection is mild and their visit is unrelated to the virus. But others may be at the hospital to treat other health conditions that were caused or exacerbated by the virus.
All patients with COVID-19 require more resources, like personal protective equipment and isolated rooms, in a time when hospitals are trying to operate with severe staff shortages.
Soon after positive omicron COVID-19 cases exploded across the U.S., hospitalizations followed.
Many states are seeing their highest levels of COVID-19-related hospitalizations since the start of the pandemic nearly two years ago.
But unlike with earlier surges, new data show that large numbers of patients with COVID-19 are coming to the hospital for other reasons — something some are calling "incidental" cases.
Data New York released in early January revealed this dichotomy most starkly. The state shifted its reporting on COVID-19 hospitalizations and asked hospitals to distinguish between people who are admitted specifically for the virus and those who came to the hospital for other reasons but had it. As of Jan. 17, about 42% of COVID-19-positive patients in New York hospitals did not list COVID-19 as the reason for admission, according to state data. Hospitals in other states have started doing it, too.
This new data, however, has fueled problematic claims on social media that suggest it proves that hospitalization numbers are inflated and that the situation isn’t as dire as health officials are making it seem.
But those currently working in hospitals told us that the situation is far more complicated than those assertions suggest.
"I would invite them to take a look at conditions on the ground," said Dr. Jeremy Faust, an emergency room physician at Brigham and Women’s Hospital in Massachusetts. "At the end of the day, it doesn't matter if it’s incidental or not, what matters is that healthcare teams are stretched beyond their limits."
The premise fails to evaluate the whole picture and assumes all incidental cases are the same. All patients with COVID-19 — regardless of the severity of their infection — require more resources, like personal protective equipment and isolated rooms, in a time when hospitals are trying to operate with severe staff shortages.
Splitting patients up into these two categories — being hospitalized primarily for COVID-19 or with COVID-19 — might be useful for epidemiological data, doctors said, but not so much in showing what’s going on inside hospitals today. For some, the infection is mild and the purpose of their visit is unrelated to the virus. But others may be coming to the hospital to treat health conditions that were caused or exacerbated from contracting the virus. All are taking up beds.
PolitiFact consulted with medical experts and emergency room physicians to get clarity about the situation unfolding in U.S. hospitals amid the highly transmissible omicron variant. Here’s what we found out.
Higher case numbers.
Even with a more mild variant, the transmissibility of omicron has resulted in twice as many infections compared to previous variants. Those kinds of numbers are going to send higher numbers of people to the hospital eventually.
"The original strain was like hitting grand slams every once in a while and knocking someone out," Faust said. "With omicron, it’s single after single after single and pretty soon the bases are filled and runs are going to come in."
For example, in the first surges, a grandmother in a family of 10 might get the virus, but the other nine relatives might have been fine. With omicron, it’s much more possible for all 10 to get sick, experts said.
There are still many counties in the U.S. that don’t have adequate vaccination rates and, although omicron is a milder variant, it can still make unvaccinated adults ill and require hospitalization, said Dr. Monica Gandhi, an infectious disease specialist at the University of California, San Francisco.
"We are also not done with delta yet, as the CDC director reminds us, and hospitalizations and deaths are still being driven by this variant," Gandhi said in an email. "Even mild coronaviruses, adenoviruses, rhinoviruses and other viruses that cause upper respiratory tract symptoms can lead to hospitalizations in older frail adults in the wintertime, which is why COVID vaccination is so important."
This refers to when a patient is admitted to the hospital for something other than the virus, but tests positive for it when they arrive. Some of these are truly incidental — a patient broke their leg, got tested when they were being admitted and were found to be positive. They have no symptoms or mild symptoms and the virus is not related to why they’re at the hospital.
But many of these cases involve patients that had to go to the hospital to treat conditions that were exacerbated by a COVID-19 infection, health care workers said.
COVID-19 can affect multiple systems and often worsens even mild cases of other conditions. Before omicron emerged, health care providers found the most severe cases of COVID-19 attacked the lungs. And while omicron has so far been found to cause more upper respiratory illness than prior variants, COVID-19 infections can still cause a range of pro-inflammatory or vascular symptoms, including heart attacks, strokes or blood clots.
COVID-19 might not be the reason listed for admission, but the patient wouldn’t be there were it not for the virus.
Dr. Ashish Jha, dean of Brown University’s School of Public Health, gave an example of such a situation involving an 86-year-old patient with kidney disease.
"This 86-year-old had COVID a week ago with 2 days of fevers, sore throat," Jha wrote in a recent Twitter thread.
"Two days of fevers caused him to become dehydrated, go into acute kidney failure. His COVID is ‘better’ but he's in the hospital with kidney failure. Was he admitted for COVID? No. With COVID? Yes."
It’s also important to take these numbers lightly because hospitals vary in how they define "incidental", said Dr. Jeanne Noble, an associate professor of emergency medicine at the University of California, San Francisco.
"There is substantial variation in the proportion of COVID hospitalizations that are categorized as incidental — from 30% to 70% — because there is not an agreed upon definition for hospitalization ‘with COVID’ versus hospitalization ‘for COVID’."
Regardless if it’s an asymptomatic patient who happens to test positive, someone whose condition grew worse because of a COVID-19 infection, or a person who went to the hospital primarily for COVID-19 — all are taking up hospital beds and resources from hospitals that are already strapped, experts said.
Dr. Craig Spencer, an emergency room physician in New York City, recently wrote about this in an article for the New York Times. Although nearly all of his patients are experiencing milder illness compared to March 2020, they still take up the same amount of space, he said.
"Entering the hospital with the virus versus for the virus isn’t a relevant distinction if the hospital doesn’t have the beds or providers needed to care for its patients," he said.
Many incidental cases can pose a greater risk to health care workers and other patients because these people are coming into the hospitals at earlier, more contagious stages of the disease, said Faust, the physician at Brigham and Women’s Hospital.
"In the earlier waves, before delta and before the vaccine, most people were getting admitted for COVID pneumonia, which is a later finding and so people were less likely to be contagious," he said. "We’re admitting people earlier now who are likely more contagious and can get health care workers and fellow patients sick. It’s a bad combination. We don't want to see hospitals be a breeding ground for COVID."
Some hospitals likely collected this information before omicron came around, but the practice became more prevalent recently due to the sheer numbers of hospitalized people with COVID-19, experts told us.
"We did this throughout the pandemic but — since omicron is the most transmissible variant — and likely found in nasal passages of many individuals in the community, the issue of assigning hospitalizations correctly to ‘for COVID’ rather than ‘with COVID’ became more of an issue with omicron," Gandhi said.
This type of data collection can also help health and hospital officials track how the disease is behaving and then adjust practices and procedures.
"One of the reasons you want to track everything is that you want to learn from it," said Neysa Ernst, a nurse manager at Johns Hopkins Hospital in Maryland. "And the challenge is that everything is changing. I can tell you we are making decisions at our hospitals hour-by-hour, not day-by-day."
While the distinction of COVID-19 hospitalizations is important for the medical community to learn more about the state of the pandemic, it only goes so far.
Many so-called incidental cases were caused or worsened by the virus in the first place, and whether patients are coming to hospitals with or for COVID-19, they’re still being admitted in record numbers.
"I think people don't realize that just because we have yet to see apocalyptic scenes of people getting pulled off ventilators, that doesn't mean that capacity at this level isn’t extremely dangerous," Faust said.
"It’s known that when hospital capacity gets as high as it is in many regions, more patients die for all reasons — whether it’s because they don't get the care they need or they’re afraid to come into the hospital."
Outside the noise of incidental hospitalizations, many doctors — like Gandhi and Michael Daignault, a California emergency physician — are arguing for more detailed and uniform hospitalization metrics to be reported at the national level.
They propose that data on COVID-19 positive cases in hospitals should include whether it was incidental, primary or "nosocomial," meaning the patient wasn’t positive when they arrived but got infected during their hospital stay, and which patients required ICU care.
"Our call for more detailed hospital data isn’t just for the sake of having it," the doctors wrote in a recent article. "The efficacy of these approaches all hinge on accurate data; it informs our state and national pandemic responses and allows resources to be allocated accordingly."
Noble, the emergency medicine professor, agreed.
It would be helpful if federal health agencies provided hospitals with strict guidelines that were uniformly applied across the country, such as the percentage of patients hospitalized with COVID that require supplemental oxygen, she said.
"Noble said that would help health care providers "more accurately determine the number of COVID patients with significant respiratory illness who may indeed require our most finite resources: ventilators and ICU beds."
Facebook post, Jan. 10, 2022
Governor.NY.gov, Governor Hochul Updates New Yorkers on State's Progress Combating COVID-19, Jan. 17, 2022
Kaiser Health News, Incidental Cases and Staff Shortages Make Covid’s Next Act Tough for Hospitals, Jan. 13, 2022
Mercury News, COVID: How Bay Area hospitalizations compare to earlier in the pandemic, Jan. 6, 2022
Becker Hospital Review, Where people go wrong with 'incidental' COVID-19 hospitalizations, Jan. 10, 2022
The Atlantic, COVID-Hospitalization Numbers Are as Bad as They Look, Jan. 12, 2022
Twitter, Dr. Ashish Jha thread, Jan. 4, 2022
Email interview, Dr. Jeremy Faust, emergency physician at Brigham and Women’s Hospital, Jan. 13, 2022
Phone interview, Neysa Ernst, nurse manager at Johns Hopkins Hospital, Jan. 14, 2022
Email interview, Dr. Monica Gandhi, infectious disease specialist at the University of California, San Francisco, Jan. 14, 2022
Email interview, Dr. Jeanne Noble, associate professor of emergency medicine at the University of California, San Francisco, Jan. 14, 2022