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Patient age, comorbidity burden, and disease severity at presentation are the major factors associated with surviving COVID-19. Hospital-level factors including ICU occupancy may confer additional risk to individual patients, particularly at times of maximal stress on healthcare systems. The interaction of patient- and hospital-level factors over time during pandemic disease remains an area of active exploration.To determine the impact of patient and hospital risk factors during episodic surges, characterize severity distribution between waves, and evaluate patient-level impact of ICU capacity on COVID-19 survivorship.Retrospective cohort study.Four acute care hospitals within an integrated healthcare network in San Diego, California.All patients (18+ y.o.) admitted with a positive PCR test for SARS-CoV-2 or ICD-10 code for COVID-19 from March 1, 2020 through June 30, 2021.Patient survivorship and length of stay.Six thousand eight hundred fifty-one patients were evaluated in this large cohort series. Patient level factors associated with mortality included: severity at admission (WHO Clinical Progression Score [WCPS]), age, gender, BMI, marital status, language preference, Elixhauser score, elevated laboratory (d-dimer, ferritin, LDH) or lower absolute lymphocyte count. When adjusting for patient age alone, survivorship during surges was also inversely associated with ICU occupancy, though this correlation was not present when adjusted for patient-level factors.Patient age, comorbidity burden, and severity at the time of presentation are the major factors associated with surviving COVID-19. Hospital-level factors including ICU occupancy may confer additional risk to individual patients, particularly at times of maximal stress on healthcare systems.