The impact of the COVID-19 pandemic on longitudinal trends of surgical mortality and inpatient quality of care in Ontario, Canada.

The study used administrative hospital records and did not measure care processes, so it cannot attribute changes to staffing, agency use, overtime, visitation restrictions or specific nursing practices. Adjustment for age, sex, comorbidity and neighbourhood characteristics may not fully account for the possibility that patients admitted during the pandemic were sicker or had more advanced disease. For SARS-CoV-2-positive admissions, reverse causality is possible: a harm event could lead to a longer stay and later infection, or infection could lead to more harm. Some indicators have imperfect accuracy or limited history, including delirium coding and restraint data, which were only introduced in April 2018. There are no benchmarks for many indicators, so it is difficult to tell whether an event is avoidable or unavoidable. Some increases may reflect better reporting or changing definitions over time rather than a true rise in incidence. Pressure injury was limited to acute inpatients and likely underestimates the wider burden in other settings. The results may not generalise to other jurisdictions.

No specific funding was used. The authors declared no conflicts of interest. The work used data compiled by CIHI and ICES, and was produced with support from the Ontario Ministry of Health; the views expressed are the authors' and not necessarily those of CIHI, ICES or the Ministry.

Do not conclude that nursing care caused these harms or that quality fell across the board. Many indicators were unchanged or improved, and the study did not measure care processes, so it cannot link the trends to staffing, agency nurses, overtime or visitation policies.