Hospital referrals, exclusions from hospital care, and deaths among long-term care residents in the Community of Madrid during the March-April 2020 COVID-19 epidemic period: A multivariate time series analysis

Abstract

Background: From March 6 to April 7, 2020 the Community of Madrid (CoM), Spain, issued interventions in response to the COVID-19 epidemic, including hospital referral triage protocols for long-term care facility (LTCF) residents (March 18–25). Those with moderate to severe physical disability and/or cognitive impairment were excluded from hospital referral. This research assesses changes in the association between daily hospital referrals and the deaths of LTCF residents attributable to the triage protocols. Methods: Daily hospital referrals and all-cause mortality from January to June 2020 among LTCF residents were obtained. Statistically significant changes in LTCF resident hospital referrals, and daily deaths in-hospital and in-LTCF were identified when testing for breaks and regimes in the time series. Multivariate time series analyses were conducted to test changes in the associations between LTCF resident hospital referrals with in-hospital and in-LTCF daily deaths as well as with daily deaths in the CoM population aged 65 + at the time triage protocols were implemented. Results: Among LTCF residents, hospital referrals declined sharply from March 6 to March 23, 2020. Increases in daily deaths at LTCFs occurred from March 7 to April 1 followed by a decrease reaching pre-epidemic levels after April 28. The daily ratio of in-hospital deaths to in-LTCF deaths reached its lowest values from March 8 to April 13, 2020. The four versions of the triage protocol, published from March 18 to March 25 had no impact on further changes in the association of hospital referrals with daily deaths of LTCF residents in-hospital or in-LTCF. Daily deaths in the CoM population aged 65 + were the main driver of daily deaths of LTCF residents. Conclusions: During March-April 2020, while hospital referrals decreased because of CoM governmental interventions, daily deaths of LTCF residents within LTCFs increased. Increases in hospital ICU bed occupancy and non-ICU bed occupancy by non-residents of LTCF suggest that the CoM government chose to protect hospitals from collapse by restricting hospital referrals from LTCFs without concurrently implementing crisis standards of care within LTCFs. CoM triage protocols sanctioned the already existing restrictions on hospital referrals of LTCF residents set by the CoM government.