Check back often as we continue to post timely updates on COVID-19.
Early Release of our May Coronavirus articles.
COVER STORY: Hospitalists have had to thrown themselves into either the care of—or preparation for—patients with coronavirus, while managing unprecedented changes in workflow and schedule, patient interactions and stress levels. Stories from the front lines.
FEATURE ARTICLE: The struggle physicians face when deciding to isolate/quarantine from their families while treating COVID-19 patients.
Should you steer clear of your own family?
June 4, 2020
Survey #1: How physicians are treating covid
A new survey by Medical Economics looks at how the covid pandemic has affected physicians. The survey found that 52% of physicians have treated covid patients; 18% saw those patients in an office setting, 16% in the hospital, 19% via telehealth. Just under half of physicians (47%) say they haven’t treated any covid patients at all.
The survey found that 83% of physicians have increased their use of telehealth to treat covid. More than half of physicians (60%) say they don’t have adequate access to covid test kits, and only half think they have adequate PPE gear when treating covid patients.
Half of physicians say that they have patients who have experienced a health crisis or a deterioration in a chronic health problem that could have been prevented by routine health care. Nearly all (94%) say that some of their patients are foregoing routine and/or acute medical care because of the virus.
Survey #2: anxiety and underemployment in the age of covid
A survey by the healthcare staffing company CHG finds that covid is, not surprisingly, raising the levels of stress and burnout among physicians and PAs/NPs as it reduces their work hours and income.
Nearly three-quarters of physicians and PAs/NPs (72% ) report feeling slightly or significantly more general anxiety in their lives. Just over half (56%) are concerned that they’ll become infected themselves; 68% are worried that they’ll give the virus to a loved one.
A small number of respondents (7%) say they’ve been laid off; 6% say they’ve been furloughed. A much larger number (74%) say they’re working less because of the pandemic. Lower patient volumes are behind the reduction in work for 43% of respondents. The pause in elective care is behind fewer work hours for 26% of respondents.
Of those who were furloughed or laid off, 62% say they will file for unemployment, 57% plan to reduce expenses, and 52% say they will rely on savings. To supplement their income, about half of respondents (46%) are actively looking for new positions, 37% are working locum tenens, and 26% are finding work in telehealth.
How hospital volumes have been crushed by covid
While health care tries to come back to life as the covid pandemic shows signs of slowing, there are signs that hospitals continue to struggle.
A report by the firm Strata Decision Technology found that the number of patients who sought hospital care in March and April plummeted 55% compared to the same time frame during the previous year. And while some analysts had predicted that patient volumes might begin to pick up in May, data show that was probably not the case.
When comparing patient volume data from early April to early May, Strata found that daily ED visits were down by 23%, daily outpatient visits were down by 11%, and daily inpatient admissions were down by 8%.
Here’s a look at how individual specialties have seen their patient volumes affected by the pandemic. The following data compare patient volumes from March/April of 2020 to March/April of 2019.
- Primary knee replacements: -99%
- Lumbar/thoracic spinal fusions: -81%
- Primary hip replacements: -79%
- Diagnostic catheterizations: -65%
- Diagnostics: -60%
- Cardiology: -57%
- Breast health: -55%
- Percutaneous coronary interventions: -44%
- Cancer care: -37%
- Fracture repairs: -38%
June 1, 2020
Lockdowns cut infection rates by more than half
The stay-at-home orders issued in more than 40 states achieved their objective, slashing covid transmission by 58%. That’s according to a new study published in the American Journal of Infection Control. The authors tracked the number of confirmed cases before and after those orders took effect and found that the daily increase in community cases dropped from 12%—with the number of cases doubling every five to six days—to 5%. With a 5% daily increase, the number of covid cases instead doubled every 14 days.
Research letter: Start anticoagulants early
In a new research letter, French authors report that among 34 covid patients treated, 65% were found to have DVT on admission. Further, venous ultrasounds performed on those patients within 48 hours of ICU admission found that 79% had DVTs. Among those, 53% had bilateral thrombosis and 26% had proximal. “Despite anticoagulant prophylaxis,” the authors write in JAMA Network Open, “15% of our patients developed deep vein thrombosis only 2 days after ICU admission. Systematic anticoagulant therapy for all ICU patients with COVID-19 should be assessed.” In addition to starting anticoagulation promptly, researchers urge early detection.
New CMS waiver allows hospitals to offer SNF swing beds
One recurring problem during the pandemic: where to discharge covid patients when they no longer need hospital care but are too ill to go home. With many SNFs refusing to accept covid patients, a new CMS swing bed waiver should help. Issued last month, the waiver allows hospitals to offer patients long-term swing beds as long as patients meet criteria for SNF level of care. (The waiver does not apply to psychiatric or long-term care hospitals.) Those swing beds don’t need to be in a separate location, and hospitals must have a plan in place to discharge patients from swing beds as soon as practicable or when a SNF bed becomes available.
May 29, 2020
What will it take to bring patients back to the hospital?
Hospitals and health systems around the country are rolling out marketing efforts to convince patients it’s OK to access health care. Six of Southern California’s biggest health systems, for instance, have partnered to produce the BetterTogether.Health campaign. Using “Get Care When You Need It” as a tagline, the campaign is relying on a Web site and public service announcements with TV and radio spots, billboards, and ads in print, digital and social media. Also in California, a 150-bed community hospital is using targeted Facebook messaging to convince patients that it’s safe to come to its ED. One big part of that message: letting patients know the ED has been partitioned into separate sections for respiratory and non-respiratory patients. And in a new JAMA Internal Medicine perspective, a physician looks at how other services he is using—dry cleaners and tire and hardware stores—are building trust to convince customers to come back. The biggest challenge for hospitals, he writes, is getting a safety message out without scaring patients away. While photos of plexiglass shields at information stations will seem familiar, “published statements about the frequent testing of staff or their ritualistic gowning need careful thought, and perhaps some testing of their own.” A Kaiser Family Foundation poll found that almost half of respondents—48%—said they or a family member had delayed or postponed medical care due to the pandemic.
U.S. death toll climbs past 100,000
The U.S. on Wednesday passed this ghastly milestone: More than 100,000 Americans have now died of coronavirus in the last three months. According to the CDC, that death toll is out of close to 1.7 million cases, with more than 26% of reported cases among African-Americans. (African-Americans make up only 12% of the population.) The CDC further reports that close to 63,000 cases of covid infections are among health care workers, 294 of whom have died. However, those figures are probably under-counted because health care-personnel status was available in only 21% of total cases. Several states are seeing increases in the number of new cases and deaths including Alabama, Arkansas, California, North Carolina and Wisconsin
Start remdesivir before patients need to be intubated
The NIAID has finally released preliminary results of its much-publicized remdesivir trial. In that study, more than 1,000 patients were randomized to either remdesivir for 10 days or placebo, and those taking remdesivir had a shorter median time to recovery (11 vs. 15 days). The big takeaway: Results were significant only among patients receiving oxygen but not in those who were intubated, so use of the antiviral should begin before patients need mechanical ventilation. In a separate study, close to 400 patients with severe covid pneumonia who weren’t intubated were randomized to either five or 10 days of remdesivir, with the authors finding no significant difference in outcomes between the two groups. An editorial pointed out: Given the limited supplies of remdesivir, “priority should be given to a 5-day remdesivir regimen for patients at the early stages of severe disease” when they are on supplemental oxygen but not intubated.
Study doesn’t back theory of separate covid pneumonia phenotypes
Last month, a prominent Italian pulmonologist kicked off a big debate, suggesting in an editorial that there were two separate phenotypes of covid pneumonia, each requiring separate treatment. One presented like ARDS and benefited from standard respiratory therapy; the other was more akin to high-altitude pulmonary edema, and those patients could be harmed by standard ventilator protocols. But a new study in the Annals of the American Thoracic Society doesn’t back that concept. Instead, the authors found that the proposed characteristics of the two phenotypes weren’t mutually exclusive and that most patients showed features of both. “[T]he most reasonable approach for ICU care” for most covid patients, the authors concluded, is extrapolating data from ARDS.
Homegrown disinfection system sterilizes thousands of masks a day
An orthopedic surgeon working with several colleagues in his shop at home produced a prototype of a trellis that his health system—VCU Health in Richmond, Va.—is now using to hang and sterilize N95s with UV-C light. HealthLeaders reports that the builders originally used parts from home and tractor supply stores; once they finalized a design, machinists made the actual product. The system utilizes a UV-C light robot that was already being used to decontaminate patient rooms, and it is now sterilizing up to 12,000 N95s per day for reuse. VCU Health put together a decontamination facility on its campus that employs two dozen people. The cost: about $15,000, which doesn’t include the price of a UV-C light source. VCU Health has released a downloadable 28-page instruction manual for facilities to build their own.
May 27, 2020
Hospitals roll out the red carpet for visitors and patients
As the pandemic shows signs of waning, hospitals are beginning to welcome visitors so patients don’t have to recuperate—or die—alone. A MedPage Today article says that in New York state, 16 hospitals are taking part in a pilot project to allow visitors into the hospital. Visitors will be allowed onto units for a set amount of time and will have to wear PPE.
Hospitals are also working to make people who need care more comfortable coming to the hospital. A recent survey found that 40% of respondents planned to hold off on obtaining medical care for at least six months because of concerns about covid. A Healthcare Dive article looks at the strategies several health systems are using to encourage patients who need care to go to a hospital, from elective surgeries to mammograms and blood work. Strategies to make patients feel more comfortable include taking the temperature of patients upon arrival, providing face masks and other PPE, and procedures to keep patients socially distanced. CMS has also released guidelines for hospitals providing non-covid care.
Physician practices take steps toward re-opening
As the country tries to get back to business as normal, medical practices are taking steps toward opening up and seeing patients in-person again. A survey earlier this month by MGMA found that more than half of physicians across a range of specialties had already started seeing patients in person, and 29% said that most physicians were making on-site appointments. The survey found that many practices say they’re seeing only half of their pre-covid volumes, and many physicians are continuing to see patients via telehealth. In a second survey by the Primary Care Collaborative, more than half of primary care physicians think they’ll be overwhelmed by a backlog of health needs. MGMA has released a reopening checklist for medical practices.
A primer for billing telehealth services
Now that Medicare has announced that it will pay for telehealth visits conducted only via phone, and not just visits via video, do you know how to bill for those services? A Medscape article gives a list of the codes to use when billing for telehealth and some tips to avoid trouble. For example, Medicare don’t use the place of service 02 (telehealth), but use a tag indicating where the service would have been furnished if the visit was face-to-face.
May 22, 2020
Trends among New York City’s critically ill
Out of more than 1,100 covid patients admitted to two New York City hospitals in March and April, more than one in five—22%—became critically ill, and most of those patients (80%) needed to be ventilated for a median of 18 days. That’s according to a new prospective study published in The Lancet. By the end of April, 40% of critically ill patients had died, while another 37% were still hospitalized. Among critically ill patients, more than 80% had at least one chronic illness, with hypertension and diabetes being the most common, and 46% had obesity. Two-thirds of critically ill patients received vasopressors, 31% had renal replacement therapy and minority populations were disproportionately affected. Factors associated with in-hospital mortality were older age, chronic pulmonary disease, higher concentrations of interleukin-6 and higher D-dimers. In other clinical news, an international study of more than 96,000 hospitalized covid patients found that those given hydroxychloroquine had a significantly higher risk of death. Also, experts now warn that young adults are presenting with the same Kawasaki-like inflammatory syndrome seen in some children with covid. And a research team that uses cellphone data to track mobility and predict hotspots says that cities and states in the South that have been rapidly re-opening risk a wave of new cases within four weeks.
Great news on a potential vaccine? Not so fast
The company that announced good news this week related to its phase 1 vaccine trial saw its stock price soar. But STAT reports that vaccine experts had a very different take, pointing out that the company didn’t release enough study data to gauge how well the vaccine really performed. In the trial, 45 subjects received varying doses of the vaccine and all developed some antibodies. Eight developed neutralizing antibodies, but those patients were followed for only two weeks. Furthermore, while the company (Moderna) claimed those subjects’ antibody levels were similar to patients who’ve recovered from covid, it didn’t disclose those levels—and antibody levels in recovered patients can vary widely. The company says it plans to publish those data in a journal article.
What impact will coronavirus have on physician compensation?
Physician compensation was enjoying modest gains this year—at least until the pandemic hit. The 2020 Medscape report on physician compensation found that average annual salaries rose between October 2019 and February 2020, with primary care physicians seeing a 2.5% boost and specialists a 1.5% gain. But now, the report notes, group and private practices and specialties that perform elective procedures are at serious risk due to the pandemic. Since March, patient volumes have fallen 60% and revenues dropped 55%, with 43,000 health care workers laid off in March. One bright note: The report points out that telemedicine volume has increased more than 200%.
Implementing evidence within days, not years
It can take a decade or more to translate research findings into clinical practice. But that’s all changed with coronavirus. A new Journal of Hospital Medicine perspective tells, according to its title, “An Implementation Story,” as physicians at Baystate Health decided to no longer pursue an early intubation strategy with covid patients. To produce a new respiratory pathway, one that featured high-flow nasal cannula or noninvasive ventilation instead of early intubation, the authors sought protocols from other institutions via social media, assembled all clinical stakeholders within their institution and reached consensus within 48 hours. (The protocol also endorses early “awake” proning, which was the focus of two new JAMA research letters here and here.) It was adopted immediately after aggressive distribution of and education about the new protocol, the authors report. “This endeavor,” they write, “highlights how the COVID-19 pandemic, for all its tragedy, may represent an important era for implementation science: a time when emerging literature from a variety of sources can be implemented in days rather than years.”
Not feeling all the “hero” talk?
In the latest episode in the covid podcast series produced by The Nocturnists, a group of clinicians reflects on the narratives being told around covid and each offers his or her own. The episode, “Insomnia,” includes audio diaries from a geriatrician distressed that she didn’t pick up on a diagnosis during a patient’s video visit and from a pediatric emergency physician in New York, struggling with loss that a colleague who died by suicide didn’t live to see “the hopeful part” of the pandemic’s arc “where people can imagine an end.” Several of the clinicians recorded—they also include two medical students, a hospitalist, an adult emergency physician and an ED nurse—touch on the “hero” and “soldier” metaphors so often used now for health care workers. “Nobody signed up for this,” one doctor says. “The metaphors of ‘war’ and ‘heroes’ and ‘fighting the good fight’—that’s not what medicine is. Nobody should be fighting this fight that was totally preventable.”
May 20, 2020
A look at medical training during the pandemic
How are residents and fellows dealing with the onslaught of covid during their training? An article from NPR talks to several physicians-in-training about the effects of the pandemic. Several note that the pandemic has them questioning everything they thought they knew about clinical medicine as they try to keep up with the effects of the virus on their patients. Others note that they are struggling with the emotional toll of seeing so much loss from the pandemic. One emergency medicine resident says he can’t forget talking to patients about to be put on ventilators about their chances for survival—and then listening as they talked to family members on the phone.
What specialties face the highest risk of covid?
New data show that it may not have been a coincidence that the Chinese doctor who died of covid after trying to warn the world about the coming pandemic was not an emergency medicine physician, but an ophthalmologist. A new preprint looking at infection rates among New York City resident physicians in March and April found that three specialties had the highest risk of contracting the virus: anesthesiology, emergency medicine and ophthalmology. A Medscape article says that risk factors for the three specialties are significantly higher than for other physicians. Researchers note that recent data show that the risk for ophthalmologists may be high because the virus can spread through the eyes.
How will academic careers be affected by covid?
Careers for young physicians looking to enter academic medicine may be derailed by the financial stress that is pummeling health care. A MedPage Today article says that academic institutions across the country have instituted hiring freezes, which may limit opportunities for residents hoping to enter academic medicine. While it appears that most existing fellowship offers are being honored, the terms of at least some of those arrangements have changed, with positions that were supposed to focus on teaching or research focusing instead more on clinical care. Analysts worry that the financial stress being felt in health care will hit next year’s residents even harder as they look for opportunities in academic medicine.
May 18, 2020
Which covid patients may become critically ill?
Researchers have published a validated Web-based tool to help calculate at admission whether covid patients will become critically ill. Using hospital records of close to 1,600 patients in China, the authors—writing in JAMA Internal Medicine—assessed more than 70 risk factors. They identified 10 variables associated with increased risk of critical illness, which was defined as needing ICU care or ventilation, or death: chest X-ray abnormality, age, hemoptysis, dyspnea, unconsciousness, number of comorbidities, cancer history, neutrophil-to-lymphocyte ratio, lactate dehydrogenase and direct bilirubin. In other news, Mayo Clinic and the Society of Critical Care Medicine have launched a dashboard with data on thousands of covid patients across more than 100 sites in eight countries. Data tracked include how long patients are being ventilated as well as ICU length of stay.
Here are the states that are the most vulnerable
The CDC has issued guidance on what schools and businesses should do to safely reopen. (The CDC originally proposed more strict draft guidelines.) But which states have the most vulnerable populations? A data analytics firm has ranked states according to more than two dozen medical and economic variables. Those variables include how big are states’ populations of elderly and/or patients with pre-existing medical conditions and of those who lack adequate housing or are living in poverty. According to the analysis, West Virginia is the most vulnerable state due to its large populations of elderly and of patients with chronic diseases, followed by Mississippi, Arkansas and Alabama.
Covid tests dogged by high rates of false negatives
A new study in Annals delivers this bad news: RT-PCR tests have virtually no value in diagnosing patients immediately after they are exposed to coronavirus, with patients continuing to have a high probability of false negatives for several days. Looking at seven previously published studies on both inpatients and outpatients, the authors found a 100% probability of false negatives on the day of exposure. That rate fell to 38% when symptoms began, which was typically four days later. Even three days after symptom onset—around day 8 from exposure—the false-negative rate was 20%. Key takeaways: Don’t rule out coronavirus based on RT-PCR test results alone, and consider waiting to test between one and three days after symptoms begin to minimize the odds of getting a false negative.
May 15, 2020
The next surge may be in noncovid care
While some states cautiously green-light the restart of some elective procedures, a new report suggests how much pent-up demand there may be for hospital services. Issued by a financial analytics firm, the report found that average inpatient census over a two-week period in March and April fell more than 54%. The drop-off was much steeper in specialties that had to halt elective procedures including a 74% reduction in orthopedic services and a 67% decrease in GI. But medical specialties also took an outsized hit with a 57% reduction in cardiology volume and a 37% decrease in cancer care. The report also found a 57% drop in care access for MIs and a 56% decline in stroke volumes. In a new commentary, two hospitalists warn about the coming surge in hospitals of noncovid care. And in new survey results from Premier, health care facilities weigh in with what they believe they need to resume full services: the ability to triple their testing capacity and screen all front-line workers, employees and patients coming for elective procedures.
Data on remdesivir is still MIA
While remdesivir has been the sole medication found to be of some benefit, many questions remain: Which covid patients should get it, and at what point during their illness? Hospitals report that there isn’t enough of the medication to go around. Moreover, clinicians have only an NIAID press release to go on and still don’t have the full study results they need to parse out which patients are more likely to benefit from the drug and at what dose. While distribution of the drug is being worked out, with state health agencies coordinating those efforts within states, individual hospitals trying to create their own remdesivir protocols may have to set up a lottery system to determine which patients get the drug. Clinicians are now calling for the release of full trial results.
Clinicians at risk for their own mental health crisis
During the pandemic, front-line workers have faced grueling days, prolonged stress and, for some, isolation for their families. Modern Healthcare reports that those conditions have been compounded by patient death rates running 10 times the usual number and clinicians being assigned to roles they don’t normally fill. According to experts, clinicians risk potential PTSD and burnout and hospitals need to address those mental health issues. Some hospitals are boosting in-house services and referrals and creating break rooms and outdoor spaces where clinicians can rest. New York’s Mount Sinai, where clinicians have treated thousands of covid patients, has launched a new center to look at the psychological impact of treating coronavirus on front-line workers with research, screening and treatment.
What will medical school look like?
More than three-fourths (77%) of medical schools say they plan to reopen by the end of July, while 15% intend to have students return by the end of this month. That’s according to results of an AAMC survey of more than 100 medical schools. But challenges remain including how much in-person teaching will be available. In areas with a high number of covid cases, for instance, attendings won’t have time to teach, and students will need to steer clear of patients to limit risk and conserve PPE. In mid-March, students were removed from direct patient care and continued with online learning. One interesting note: After postponing this spring’s MCATs, the AAMC plans to ramp up testing again, shortening the exam and offering multiple testing sessions per day to allow testers to maintain a safe distance. Usually, between 10,000 and 12,000 applicants sign up for the MCATs. But when the online scheduling system went live last week, it crashed—as 62,000 people tried to schedule an exam.
Investing in critical care: It makes sense, but it’s wrong
It stands to reason that the pandemic set off a frenzied effort to create more ICU beds and secure more ventilators. But the authors of a new Annals commentary argue that all that time, effort and money could have been better spent elsewhere—and would have produced better covid outcomes, including less mortality. Instead of investing in more “aggressive medical technology,” the writers say that time and money should instead go to resources that are even more scarce than ICU beds and ventilators: ward beds and healthy clinicians. Other resources to invest in to improve care include more widespread testing and contact tracing, PPE, improved public health measures, and training for more health care workers in palliative care communication techniques.
May 13, 2020
How are physicians on the front lines of covid care coping?
A series of recently published articles offers a look at how physicians are doing during the pandemic.
In a series of profiles published by FierceHealthcare, a Houston intensivist describes her experience treating covid patients. She talks about being surprised by how sick covid patients become, and how little clinicians still understand not only about the disease’s effects on patients, but its effects on health care providers.
Another article in the series profiles an ICU physician at Intermountain Healthcare in Utah who talks about her struggles to communicate with the family members—or lack thereof—of covid patients. One hospital went from 36 ICU beds to 150, in part by converting areas like boardrooms into units.
A Medscape article talks to seven clinicians preparing for a day on the front lines of covid care. They talk about their routines before and after their clinical shifts and their struggles to find the PPE that will protect them (and by extension, their families). As one New York emergency physician explained, he’s amazed by “how much of our lives feel under attack by this virus.”
Finally, there’s a somber look at clinicians who have died in the struggle to contain and treat covid. As an article published by Kaiser Health News notes, medical staff account for up to 20% of known coronavirus cases in some states. Its “Lost on the Frontline” series documents the lives of health care workers in the U.S. who have died of covid.
Getting back to “normal” with elective surgeries
As health systems look to return to “normal” after the covid pandemic, a number are starting by slowly bringing back elective surgeries. While orthopedic surgeons said in a recent survey that they expect surgical volumes to mostly rebound within the next three months, analysts predict that more of those surgeries will take place outside of the hospital. (The number of surgeries performed outside of hospitals is expected to rise from 12% to 20% in the next six months.)
Health system administrators, meanwhile, are not nearly as confident that patients will embrace surgery so soon. A report in FierceHealthcare says that patient hesitation to return for surgeries may delay a return to pre-covid volumes for 12 to 18 months. One administrator predicted that flu season in the fall will be a harsh reminder for many patients of the health risks that are still present.
A New York internist describes the changes his practice is making to bring high-risk patients who need to see a physician into the office. Those changes include streamlining the registration process to eliminate as many touchpoints as possible and reducing the amount of time patients spend in the office by allowing them to schedule follow-ups and referrals after they’ve left the office.
May 11, 2020
Roles for interferon, procalcitonin?
A new study in Lancet suggests there may be a role for interferon beta-1b in reducing covid transmission, symptoms and hospital stays. About 125 patients in Hong Kong were randomized to either triple therapy (interferon beta-1b, lopinavir–ritonavir and ribavirin) or lopinavir-ritonavir (controls). Those in the triple therapy cohort received interferon only if they presented within seven days of symptom onset. Patients in the triple therapy group had significantly shorter time to negative nasal swabs (7 vs. 12 days) as well as less time to symptom alleviation (4 vs. 8 days) and lower length of hospital stay (9 vs. 15 days). The lead author notes in a podcast that interferon may be the most important component of the triple therapy. In other news, the authors of recent CAP guidelines weigh in on treating covid-19 pneumonia. They write in Annals that they recommend the same antibiotics in covid pneumonia as in CAP and that procalcitonin may help limit antibiotic overuse.
Palliative care: tough discussions, high demand
While cardiologists’ book of business has been cut in half since the start of the pandemic, one specialty is in high demand, at least in covid hotspots: palliative care. Kaiser Health News reports that palliative care has been transformed by the pandemic as patients and families are thrust into making quick decisions and as family meetings have been replaced by phone calls from the bedside or palliative care hotlines. The pandemic is spurring more widespread end-of-life-care planning discussions, with some hospitals now placing palliative care specialists in the ED for the first time to talk to coronavirus patients at high risk. But talk of hospitals perhaps rationing life-saving resources such as ventilators is worrying some patients, including cancer patients, who are revoking previous DNR orders</a> in case they catch coronavirus.
How is the virus mutating?
Preliminary results from a new research paper claim that the now-dominant strain of coronavirus has mutated and is now more contagious. That report, issued by scientists at the Los Alamos National Laboratory, notes that the mutated strain first appeared in Europe, and that patients with the now dominant strain are not more likely to need to be hospitalized. But other scientists and infectious diseases specialists have pushed back on those preprint results, saying there could be other reasons why a strain could reach dominance besides a mutation that makes it more infectious. In other news, researchers say that New York was the gateway for most of the infections in the U.S. Genetic samples indicate that more infections in the U.S. are linked to the line of virus associated with the New York outbreak—which arrived from Europe—than to the one in Washington state. Travel from the Seattle area has been associated with outbreaks in more than a dozen states.
May 8, 2020
Coronavirus is costing U.S. hospitals $50 billion a month
A new report from the American Hospital Association produces this price tag for how much coronavirus may cost U.S. hospitals: $200 billion, and that’s only for March through June. Calling covid-19 “the greatest financial crisis in history for hospitals and health systems,” the report estimated how much hospitals will spend to care for coronavirus patients and buy PPE as well as the impact of canceled elective procedures, postponed medical care, and the cost of additional staff services that some hospitals are paying for including child care and housing. Another report, this one from a data analytics company, estimates another steep cost of the crisis: The disruptions in U.S. health care caused by coronavirus may lead between April and June to the missed or delayed diagnoses of more than 80,000 cases of five common cancers.
Study: Therapeutic anticoagulation dosing may improve survival
Preliminary results on anticoagulation in patients with severe covid find mortality benefits with therapeutic, not prophylactic, dosing. In their observational study published by JACC, researchers analyzed the medical records of more than 2,700 patients treated over four weeks at one of Mount Sinai’s five hospitals in New York. Among patients not on ventilators, mortality was the same among patients receiving blood thinners and those who didn’t—but those on anticoagulation lived longer, a median of 21 days vs. 14. Mortality did improve among ventilated patients who were anticoagulated: 29% of patients receiving therapeutic dosing died vs. 63% of those who did not. Major bleeding rates were the same across both groups. The algorithm used called for prophylactic subcutaneous enoxaparin for covid patients on the floors, but full therapeutic dosing for those in the ICU. Based on its results, the health system has boosted dosing for patients outside the ICU, giving them intermediate doses. Guidelines from the International Society on Thrombosis and Haemostasis recommend prophylactic dosing. Mount Sinai is launching a randomized trial to test anticoagulation among 5,000 patients.
Who gets remdesivir?
Hospitals are criticizing the seemingly random way the federal government is distributing doses of remdesivir, the experimental drug that’s received emergency use authorization. STAT reports that about two dozen hospitals around the country have been selected to receive vials of the drug, while its manufacturer ramps up production. (Each vial can treat around 170 patients.) However, the decision-making process around those selections is unclear, and some of the hardest-hit hospitals aren’t receiving any. A watchdog group has also weighed in with what it considers a fair price for the drug: $4,460 for one treatment course. FiercePharma reports that the drug’s manufacturer wants to produce enough of the drug to treat 1 million patients by the end of the year.
Covid is linked to an inflammatory syndrome that’s striking children
Their numbers are small, and no children have died. But doctors in New York and the U.K. are sounding the alarm about what they’re calling pediatric multisystem inflammatory syndrome, which has been linked to covid-19. New York Times reports that children are presenting with symptoms that range from reddened tongues to enlarged coronary arteries similar to Kawasaki disease. Unlike most Kawasaki cases, however, some children with the emerging syndrome are in toxic shock. An alert from the New York City Health Department notes that 15 children ages 2 to 15 are in metro ICUs and asks clinicians to report any cases.
UPDATE: New York Gov. Andrew Cuomo on Friday announced that one child has died from the mysterious syndrome that’s linked to coronavirus. Throughout New York state, 73 children have been diagnosed with the syndrome.
Pushing back against “a global infodemic”
An open letter signed by 100 international public health experts and medical societies is making this demand of big tech companies: They need to stop profiting from viral misinformation and to fundamentally change how they share and promote false medical content. According to the letter, medical personnel now have to fight not only coronavirus but “a global infodemic” of false and dangerous cures and medical conspiracies; while medical misinformation has long been a problem on social media—think anti-vaxxers—it is increasingly promoting dangerous medicine, hurting the morale of health care workers and increasing costs. While some tech platforms have started to fact-check medical information, they need to go further, according to the letter, by detoxing the algorithms that determine what people see on their feeds, removing harmful information and blocking repeat offenders, and alerting users who have interacted with harmful misinformation.
May 6, 2020
Audio-only telehealth gets big boost from Medicare
One kink in the use of telemedicine services to care for patients safely—and to potentially bring in revenue for physician practices—may have been resolved. Medicare announced last week that it will increase payments for audio-only virtual visits from $14-$41 to about $46-$110.
Medicare recently began allowing physicians to bill for virtual visits at the same rate as in-person visits, but it was paying significantly less for audio-only visits. One recent survey found that 43% of physician practices said they’re using video for less than 20% of their visits, and 14% said they weren’t using video at all.
More than 100 physician groups recently urged Medicare to support audio-only visits, arguing that many older patients don’t have easy access to video conferencing technology.
Health care’s financial problems spread
The financial stress being felt by health care is accelerating, with hospitals around the country losing huge sums—and physicians feeling the pain. A HealthLeaders article reports that hospitals across the country (excluding New York and San Francisco) collectively are losing about $1.4 billion a day in lost revenue.
Patient volumes at these hospitals has dropped by over 50% since the beginning of March, with inpatient admissions down 30% and ED visits down 40%. The economic pain in medicine is so pervasive, in fact, that analysts say that it is a “driving force” behind the nation’s 4.8% drop in gross domestic product in the first quarter of 2020.
The pain being felt by hospitals and physician practices is also being felt by physicians, who report salary cuts of up to 50%. An article from MD Edge says that such moves may conflict with the terms of physicians’ contracts and offers advice on how to react when employers make unilateral changes to compensation.
May 4, 2020
Expect demand for remdesivir to spike
Given the modest benefits found in an NIH study of remdesivir, the FDA has issued an emergency use authorization for the antiviral. The New York Times reports that the temporary approval is only for covid patients with severe disease, although some clinicians believe the drug may be more effective if administered earlier in patients’ course of illness. Gilead Sciences, the drug’s manufacturer, plans to give away the first 1.5 million doses. That’s good news because clinicians worry that the drug isn’t widely available and that patient and family demands for it will now make that shortage worse.
ID society weighs in on N95s
The IDSA last week released new guidelines on N95 use and reuse, with this caveat: Because there are gaps in the evidence to support the recommendations, those will be updated as new evidence emerges. Moreover, the guidelines tailor recommendations to the availability of supplies with guidance on appropriate use according to conventional, contingency and crisis capacity standards. Among the eight recommendations: Clinicians in a conventional setting may use either a surgical mask, N95, or N99 or PAPR for routine patient care—or either a surgical mask or reprocessed respirator in a contingency or crisis setting. Also in a setting with contingency or crisis capacity: Clinicians should use a reprocessed N95, not a surgical mask, for procedures that generate aerosols, and they can add a face shield or surgical mask to an N95 for extended use. The society didn’t issue any recommendations for the use of shoe coverings or for the use of double vs. single gloves.
New round of CMS changes should boost testing, telehealth pay
The CMS has announced a new wave of regulatory changes, rolling back previous requirements to help increase telehealth payments, accelerate more widespread testing and boost bed capacity for hospitals. Hospitals now have more flexibility to create temporary beds, while the CMS is increasing its payment for telehealth visits, matching reimbursement for similar in-person outpatient care. That payment increase is retroactive to March 1. As for testing, patients no longer need a treating practitioner to order a test. Instead, tests can be ordered by any health care professional authorized by state law, and a written order is no longer needed for Medicare to pay for testing. Further, pharmacists can now team up with clinicians to help collect and assess test specimens, a move that should increase the number of drive-through test sites and allow pharmacy chains to begin to take a major role in testing. The CMS will also now pay for certain antibody and home tests.
May 1, 2020
Modest but real: Remdesivir may improve outcomes
The results haven’t been peer reviewed yet and the effect was only modest. But even Anthony Fauci, MD, said he was “optimistic” about the results of a government-funded trial on remdesivir. The randomized study tested the drug in more than 1,000 covid patients and found that those receiving remdesivir recovered four days faster than those given placebo (median recovery time: 11 vs. 15 days). While the remdesivir arm also showed a mortality benefit, it wasn’t statistically significant. This was the first U.S.-sponsored trial of the agent, although an earlier Chinese study on remdesivir found no benefit. However, the NIH trial enrolled more patients, and the Chinese study has been faulted for giving patients remdesivir later in the course of severe disease.
One in four health care workers at higher risk of poor outcomes
Due to age or chronic conditions, 26.6% of workers who provide direct patient care are at higher risk of poor coronavirus outcomes. That’s according to a new Annals study, which found that 3.7 million out of the nation’s 13.8 million health care workers are either older than age 64 or have chronic conditions like diabetes. Further, among those at high risk, 7.5% are uninsured, mainly among those working in nursing homes and home health. Among all health care workers doing direct patient care, about 29% have no paid sick leave, while 2.5% of hospital workers report family incomes below the poverty line. Researchers based their analysis on both CDC and census survey data.
How to manage pent-up demand for elective surgeries
With most elective surgeries now on hold, experts expect demand to surge once hospitals ramp up procedures once again. Before they do so, a new commentary argues, hospitals need to prioritize those upcoming surgeries, set strategies so their capacity won’t be overwhelmed, and come up with new approaches to surgical scheduling. Hospital leaders must balance the number of surgeries needed and the length of time those patients have been waiting for care against the availability of inpatient beds and PPE. They also need to realize that their traditional block scheduling for surgeries won’t be able to meet the demand. Instead, hospitals and surgeons should consider boosting their daily utilization, moving some procedures such as endoscopies out of surgical suites into procedure rooms, and expanding the hours of OR availability, perhaps into weekends.
“Shark Tank” initiative puts $1.5 billion up for grabs
The NIH this week announced an initiative designed to rapidly boost the development of at-home and point-of-care covid diagnostic tests. STAT reports that the challenge calls on scientists and inventors to develop diagnostic tests and compete for a portion of a $500 million pool; winners will be paired with manufacturers who can scale up production. Technologies will go through a four-phase, highly-competitive process to identify the best candidates. The goal is to make millions of easy-to-use tests available per week by the end of this summer. Experts around the country have pointed out that testing so far has been woefully inadequate. In an April report, an expert panel from Harvard called for the U.S. to conduct five million tests per day</a> by June, ramping up to 20 million per day by late July.
How are your kids?
Much is being written about how worried front-line health care workers are that they may infect their families. The Washington Post this week flipped that focus and interviewed children of doctors and nurses who are treating covid patients. Some of those children have been sent to live with relatives or friends, while others are living at home with parents who are self-isolating in basements or bedrooms or are working longer hours. All parents are struggling with how much to tell their children about the virus and their risk of contracting it. While the children featured in the article know their parents are doing something important, many are anxious or angry.
April 28, 2020
The emerging toll of treating covid patients
If the world didn’t understand the trauma that can come from working in the middle of the covid pandemic, it’s starting to understand. Most recently was the news that a New York City ED physician who had treated covid patients and contracted the disease herself committed suicide. An NPR report on the topic found that half of Chinese health care workers who treated covid now suffer from depression, 44% have anxiety and one-third have insomnia. An article published by Annals of Internal Medicine offers strategies for group leaders and frontline physicians to care for themselves. As the authors point out, “This is a marathon, and endurance is essential.” Finally, a Philadelphia psychiatrist has launched a Facebook group and a physician free support line to help physicians on the front lines of coronavirus care. The COVID-19 Physicians Group features Facebook posts from physicians, and the hotline (888-409-0141) offers free confidential support from volunteer psychiatrists.
What happens to clinicians who speak up about PPE issues?
Physicians and nurses are continuing to speak up about PPE problems, and while some have been disciplined, others have won the battle to be able to speak up when they feel their health is being threatened. An Associated Press article details several instances in which physicians were given N95 masks, but not nurses. In several of those instances, nurses who spoke up and refused to work without N95 masks were fired or suspended.
But there are signs of progress. Several of the hospitals that fired a nurse who refused to work without an N95 masks say they are now providing them to all staff caring for covid patients, and one hospital that had suspended 10 nurses for refusing to work without N95 masks reinstated them and is now providing masks.
“Spot” the robot dog meets the Brigham’s covid unit
You’ve probably seen videos online of Boston Dynamics robot dogs doing difficult tasks like walking up steps. Now, you may see one its robot dogs walking down the halls of a hospital. “Spot” may have a robot body and legs, but its face is a tablet that displays the face of a treating physician. The robot gives physicians a safe way to talk to patients on covid wards. While that’s currently all the robot dog can do—it can’t take patients’ temperature, for example—Brigham and Women’s Hospital hopes the technology can offer even more help on covid wards. According to an article in Wired, patients have been receptive to seeing Spot.
April 27, 2020
Hospitals see a double-digit drop in non-covid cases
It’s a trend that can’t be explained just by the halt in elective procedures: Hospital census, except for covid patients, has plummeted since the pandemic began. Now, new data from Cigna indicate that hospitalizations for common acute problems have indeed gone down. The insurer looked at hospital utilization for seven conditions across the first three months of 2020. It found that hospitalizations for atrial fibrillation among its customers between February and March fell 35%, rates for TIAs dropped 31%, and those for seizures declined 28% and 24% for GI bleeds. Moreover, hospitalizations for aortic aneurysms decreased by 22%, acute appendicitis by 13% and ACS by 11%. Outpatient offices have been even more hard-hit, with a close to 60% decline seen in ambulatory visits in mid-March.
Stroke rates spike among young, middle-age patients
This week, interventional neurologists from New York’s Mount Sinai plan to publish a letter in NEJM about five of their covid patients, all of whom were under age 50 and all had suffered major strokes. Several other U.S. medical centers are publishing on the same phenomenon, according to the Washington Post, as many covid patients having strokes are experiencing LVOs, the deadliest type. With first responders in New York City picking up four times the typical number of patients who have died at home, physicians worry that some of them also suffered strokes. At Mount Sinai, the number of patients with LVOs doubled over the three-week covid surge, while the average age of stroke patients with covid was 15 years younger than of stroke patients who weren’t infected.
Free counseling is now available for front-line physicians
Doctors who need emotional and psychological support can access free counseling seven days a week. More than 600 psychiatrists have volunteered to staff the Physician Support Line (888-409-0141), a hotline that’s open from 8 a.m. to midnight Eastern time. Launched at the end of March, the free confidential hotline has since delivered more than 50 hours of counseling. When callers call in, they can be connected to either a volunteer psychiatrist or to a suicide prevention and disaster distress line. In HealthLeaders Media coverage, the hotline’s founder says the nature of the calls being received has changed from anxiety when the service was first launched to exhaustion as covid caseloads increase and distress as patients are dying. Clinicians don’t need to make an appointment.
April 24, 2020
NIH guidelines recommend against hydroxychloroquine
The NIH has released new coronavirus treatment guidelines that don’t recommend any specific antiviral treatment nor any drug for pre- or post-exposure prophylaxis. They do, however, recommend against using an hydroxychloroquine-azithromycin combination, citing QTc prolongations. (Non-peer reviewed results from the VA released this week indicate that hydroxychloroquine—both with and without azithromycin—didn’t lower covid patients’ risk of needing a ventilator.) The NIH guidelines also came out against using lopinavir/ritonavir or other HIV protease inhibitors and against interferons and Janus kinase inhibitors. Other therapies to steer clear of, according to the NIH: systemic corticosteroids for covid patients on ventilators who don’t have ARDS. As for ventilation, the NIH urges a phased approach to defer ventilator use as long as possible. That caution is also endorsed in a new international analysis, which states: “Severe pneumonia in COVID-19 differs in some important aspects from other causes of severe pneumonia or acute respiratory distress syndrome, and limiting the positive end-expiratory pressure level on the ventilator may be important.”
Congress approves more relief targeting hospitals, testing
Both the House and the Senate this week approved a new coronavirus relief package, this one adding up to about $484 billion. While the bulk of those funds ($310 billion) are earmarked for small business loans, $75 billion is designed for hospitals while $25 billion will support testing. As for the $100 billion for health care included in the first relief package approved last month, FierceHealthcare reports that $30 billion has already been distributed to providers. Of the remaining funds, another $20 billion will go to providers, $10 billion will go to hospitals in areas hit hard by outbreaks, $10 billion will go to rural hospitals, and $400 million will go to Indian Health Services hospitals and clinics. HHS also plans to distribute some funds to SNFs and providers that treat Medicaid patients. The rest will be reserved for more hotspot funding.
Want to restart elective procedures? Take it slow
What would it take to restart elective surgeries? The American College of Surgeons released 10 recommendations for what hospitals and health systems should consider before resuming procedures. No. 1 on that list is knowing your community’s covid prevalence, and hospitals should wait until their number of local covid cases has declined for at least two weeks; No. 2 is knowing your local testing availability. Part of that community awareness, the recommendations state, is setting a threshold of new covid cases that would trigger stopping elective surgeries again. Other recommendations include having a 30-day supply of PPE or a reliable supply chain; considering new sites for elective surgeries, including outpatient settings; and monitoring the stress and fatigue levels of front-line workers treating coronavirus patients. CMS guidance on resuming elective surgeries stresses taking a gradual approach to not threaten hospital capacity or personnel. As for re-starting local economies: Experts say that testing levels need to triple—to between 500,000 and 700,000 a day—to be able to identify and isolate infected patients before business can resume.
Visa constraints keep IMGs out of covid hotspots
While cities and states hard-hit by coronavirus want more health care workers, IMGs including hospitalists who might answer that call say they’re facing constraints. MedPage Today reports that as many as 15,000 IMGs around the country have visas that identify the specific hospital—and sometimes department—where they can work, with no ability to moonlight. Another 65,000 IMGs are living in this country but are not allowed to practice any form of medicine because they didn’t match to a U.S. residency program. Another challenge: Should IMGs become infected and no longer be able to work, they and their families could be deported. The ECFMG recommends easing visa restrictions to allow holders to work in hotspots and to give them and their families permanent waivers from deportation should IMG clinicians become sick.
The byzantine underbelly of PPE deals
It reads like a spy novel or a drug deal: In an NEJM letter titled “In Pursuit of PPE,” a physician executive from Massachusetts’ Baystate Health describes his foray into the bizarre world of trying to purchase PPE for his health system. Many of those deals, he writes, involve big money and many go south when his system is “outbid and outmuscled, sometimes by the federal government” In one convoluted arrangement, he and several members of his team flew to a small airport in the Midatlantic to inspect two semi-trailers—labeled as food service trucks—that contained Chinese face masks and N95s. Before the money could be transferred, FBI agents arrived and homeland security considered redirecting the shipment. The deal proceeded only after a member of Congress intervened. Then there’s this good-news, Philly-proud story: Forty employees of a factory in southeastern Pa. that produces polypropylene, a key ingredient in masks and gowns, just finished their “live-in,” spending 28 days living together in the factory without leaving and working 12-hour shifts around the clock.
April 22, 2020
PPE issues: a look at practical and ethical considerations
Shortages of PPE in health care are roiling providers and health care organizations. Physicians and nurses are being threatened for speaking up when they feel that they and their patients aren’t safe, and physicians worried about the health of themselves and their families are wondering how safe their PPE is keeping them.
A MedPageToday article offers tips on what clinicians can do when faced with shortages of PPE. The advice includes tips on how to extend the use of respirators and how to safely re-use them, along with strategies to decontaminate masks.
A medical ethicist addresses the question of whether clinicians are obligated to care for patients without adequate PPE. He concludes that while a certain amount of risk is inherent in the health care profession, health care workers don’t have an obligation to accept all risks. The comments at the end of the story pick up the debate, so make sure to check them out.
And a podcast by the show Freakonomics looks at the most fair and ethical ways to distribute ventilators. Panelists discuss problems with the first-come-first-served model of distributing ventilators, along with the question of whether health care workers should get special consideration when assigning ventilators to patients
Outpatient practices see financial problems ahead
For physician practices, the bad financial news just keeps on coming. With patient volumes down, many are furloughing or laying off staff. And many see bleak finances for the foreseeable future. Here’s a sampling of the latest surveys of physician practices:
• One-fifth of primary care practices say they could close within a month, and nearly half aren’t sure that they’ll have enough cash to keep their practices open. In the survey of 2,600 physicians, more than two-fifths have already had to lay off or furlough staff.
• In a survey by MGMA, practices report a 60% drop in patient volume and a 55% decrease in revenue since the pandemic began. About 75% of the survey’s 700-plus respondents employ less than 50 FTE physicians.
• In a survey of 160 practices in four states, respondents said that patient volumes are down 65% and will likely be down as much as 12% this time next year. Those practices predicted that by September, patient volumes will probably still be only 76% of normal.
A covid newsletter by—and for—physicians
A covid newsletter written for and by physicians is attempting to help give doctors an edge not only in staying up on new research, but in combatting the slew of information on the Internet about the coronavirus. The Fast Literature Assessment Review, known as FLARE, is produced by eight ICU physicians at Massachusetts General Hospital. According to an article in Wired, the newsletter sprang out of informal e-mail the physicians were exchanging with each other. Its mission is to give updates on the latest covid research and to debunk the newest unproven theories about the pandemic circulating on social media. Recent theories that were debunked included the idea that covid is similar to altitude sickness and the hype around chloroquine.
April 20, 2020
Health care workers converge on NYC
Utah’s Intermountain Healthcare has flown a team of about 100 physicians, nurses and specialists to New York City, while Cleveland Clinic is sending a 20-member team and medical centers in upstate New York are sending busloads. FierceHealthcare reports that the clinical staff from Intermountain who came to help staff New York City hospitals includes hospitalists and intensivists, as well as nurses, an internist, respiratory therapists and a pharmacist. They plan to remain in New York City until the end of this month, giving clinicians on the ground a break. One Intermountain critical care physician highlighted in the article notes that the census in her own ICU in Utah is down 50% and that she’s learning how to treat covid patients, should the surge hit her home hospital. She’s also seeing how clinicians can fill new roles, including a hospital tent for non-covid patients being staffed by second- and third-year family medicine residents.
The latest equipment shortage: dialysis machines
As many patients with severe covid suffer kidney failure, hospitals around the country are scrambling to locate not only enough dialysis machines and supplies but the trained nurses needed to provide the treatment. Nephrologists estimate that between 20% and 40% of covid patients in ICUs need emergency dialysis. According to the New York Times, a department chair from New York’s Mount Sinai Health System notes that the number of patients needing dialysis in her hospital has gone up three-fold. An article in Science details not only the kidney failure occurring with covid but also cardiac and neurological damage.
How many covid patients a day can your hospital manage?
A new, interactive online tool allows health systems and individual hospitals to estimate the maximum number of covid patients they can manage a day, given their acute and critical care resources. Canadian researchers writing in Annals put together model parameters from evolving international data. The tool calculates the maximum daily turnover, given patients’ average length of stay and average time on mechanical ventilation, with separate outputs for the manageable maximum number of acute care beds, critical care beds and ventilators.
April 17, 2020
Treating covid: Standard practices are out, improvisation is in
Now more than a month into treating this disease, doctors report that they’re tossing out standard medical practices and experimenting with the use of different drugs and treatment strategies. One new practice that has emerged: resisting early intubation for patients with oxygen saturation levels as low as in the 40s and opting instead to prone them or have them recline in chairs. The New York Times reports that some hospitals are proning patients—particularly those who are obese—on cut-out mattresses designed for pregnant women to ease their chest pressure. Doctors also note that proning doesn’t seem as effective in older patients. While experts complain about the lack of a centralized research strategy that could identify best practices, the NIH director is forming a partnership among pharmaceutical companies, government agencies both here and abroad, and academic centers. Very preliminary results from one center’s remdesivir trial are encouraging, although other studies on the drug have been inconclusive. Clinical trials are testing the effectiveness of tocilizumab, an immunosuppressive drug. And cardiac associations urge careful monitoring for arrhythmias when using hydroxychloroquine and azithromycin, a drug combo that’s being widely tested.
Three out of four infected health care workers are women
According to CDC data released this week, more than 9,000 health care workers in the U.S. have tested positive for coronavirus and 27 have died. Yet Kaiser Health News reports that commentators believe the true tally is actually far higher, and U.S. officials admit they have no system to provide a comprehensive count. The CDC data, which were based on a sample of only 16% of covid cases in the country, found that the vast majority—73%—of infected health care workers were female with a median age of 42. For a more accurate count, the CDC is studying hospitals in 14 states and reviewing infection surveillance and media reports. Meanwhile, a JAMA editorial proposes this bold response to the pandemic: Suspend the first year of medical school for the 20,000 incoming students slated to begin in July and enlist them instead in a national public health service program. After a month of training in infectious diseases epidemiology and control, those students would be deployed nationwide to help test, trace, track and isolate.
How many times can you decontaminate an N95?
A new study contends that disposable N95s may be safely decontaminated only a few times before their functional integrity starts going downhill. In research supported by the NIH, authors analyzed the efficacy of four common decontamination methods—UV, 70% ethanol, 70C heat and vaporized hydrogen peroxide—and assessed mask function after rounds of decontamination. They found that 70% ethanol degrades mask integrity within 30 minutes so shouldn’t be used. With dry heat, masks could safely be decontaminated two times, while UV and vaporized hydrogen peroxide could be used three times. The study, which wasn’t peer reviewed, was released on the medRxiv preprint server.
Physicians who need to recertify in 2020 get a reprieve
Doctors who are supposed to complete MOC requirements this year are getting a pass from the ABIM, at least through next year. In a letter from its president, the board announced that physicians will have through 2021 to complete any MOC requirements due this year, including assessments, point requirements or attestations, and that diplomates will not lose their certification. Further, doctors in their grace year will receive an additional year. Other boards, including the ABFM, are following suit, as is the American Board of Pediatrics. While the pediatric board hasn’t yet worked out the details of how it will ease deadlines and grant credits, its president said that pediatricians will get credit for the learning curve related to coronavirus and for that specialty’s “huge transformation in practice using telehealth.”
What’s it like to fight coronavirus? 100+ doctors weigh in
A family physician in New Jersey who has his own YouTube channel has posted a video with clips of more than 100 doctors talking about their experiences battling coronavirus. Known on social media as “Dr. Mike,” Mikhail Varshavski, DO, reached out to a wealth of colleagues, asking them what gives them hope, how they’ve been personally affected, what it means to be a doctor during a pandemic, and what about this disease and their efforts fighting it aren’t getting enough attention. Answers ranged from “How is one supposed to date at this point in time?” to maintaining a 30-minute decontamination routine when getting home and “remembering to stay flexible and lean into uncertainty.” Some hospitals are establishing covid wellness teams for their employees, staffing them with psychologists, social workers, hospital leaders and chaplains. And the ranks of the recovered in the U.S. are now at least 44,000, although—like every other figure related to the pandemic in this country—the actual count is believed to be far higher. Some have launched a Survivor Corps Facebook page to share their stories. While some fear being stigmatized for having been infected, many feel an urgent need to help by donating plasma.
April 13, 2020
Coronavirus exacts a terrible emotional toll
It’s not just the long hours and the fears of being infected. Doctors are reporting the high emotional burden of treating severe and dying covid patients who need to be kept isolated from their families. As it falls to doctors to make patients’ final calls to their kin, emergency physicians have rushed to get up to speed with palliative techniques and language, while other specialties—including psychiatrists—are training themselves in palliative care. A commentator who used to be in the military and leads programs in developing physician leadership has published “Ten Tips for a Crisis: Lessons from a Soldier” in the Journal of Hospital Medicine. Among his recommendations: find a battle buddy, get everyone in the fight, take time to huddle, and incorporate rest cycles and rotating teams.
Remdesivir: promising preliminary results
The study was very small and sponsored by industry, and it had no control arm. But researchers testing remdesivir report that more than two-thirds (68%) of 50-plus patients with severe covid who received up to 10 days of the therapy had a reduced need for oxygen support. Among the patients, 57% were intubated, 8% were receiving ECMO, and the rest had oxygen saturation levels of 94% or less. The majority (60%) had some adverse event including diarrhea, rash, and hypotension, as well as elevated hepatic enzymes and renal failure. Remdesivir is now available to hospitals and doctors through expanded access to compassionate use. While several randomized trials on remdesivir are now taking place, the authors write that “the outcomes observed in this compassionate-use program are the best currently available data.” In other news, two critical care doctors write that anxiety is leading clinicians treating patients with severe covid to ventilate and sedate patients too soon and to keep them on ventilators too long. Hospitals also now have to worry about shortages in sedatives for ventilated patients.
What should health care workers do if exposed?
According to the CDC, health care workers potentially exposed to coronavirus may continue to work, as long as they are asymptomatic and adhere to several safety practices. For one, workers who’ve been potentially exposed should continue to monitor their temperature, ideally before they come into the hospital. They should wear a face mask in the workplace at all times for at least 14 days after possible exposure, and remain six feet away from others. But here’s news on that famous six-foot distancing strategy: A CDC study that looked at covid contamination in air and surface samples in Wuhan found that coronavirus can travel up to 13 feet. (Further, one half of the soles on the shoes worn by ICU medical staff tested positive, potentially carrying covid throughout the hospital.) As for health care workers and patients who have recovered from covid, the FDA has released guidance on how to collect and use convalescent plasma.
April 10, 2020
WEEKLY ROUNDUP: “A really hard time”
As the U.S. death toll from coronavirus approached 2,000 a day several days this week, an influential model used to estimate hospital capacity and mortality came in with lower mortality predictions. While the number of hospitalizations in New York has flattened, the hospitalization and death rates among African-Americans and Latinos are, in the areas of the country where those data are being tracked, much higher than among whites. In Detroit, the Henry Ford Health System reports that more than 700 employees have tested positive. The CMS has already paid out close to $34 billion to providers in the form of advance or accelerated payments, with more relief payments to come. Genetic sequencing finds that the virus strain circulating in New York came from Europe, not Asia. And the director of an ICU in Brooklyn reports that as many as 80% of critically ill covid patients have kidney failure, a sign of very poor prognosis. “We’re still having a hard time trying to help everybody through it. A really hard time.”
HHS-watchdog report details hospital shortages
Severe equipment shortages, a lack of tests and a backlog of test results, confusing guidance from federal and state agencies, and a high emotional toll on staff: These are what hospitals are dealing with, according to a report issued this week by the HHS inspector general. Based on a telephone survey conducted March 23-27 of more than 300 hospitals, the report found widespread equipment shortages and hospitals struggling to maintain enough staff. In the report, ventilators were at the top of the list of equipment in short supply; in related news, New York’s Mount Sinai Health System has produced a clinical protocol to convert donated BiPAP machines into ventilators. And some critical care physicians are questioning the use of ventilators (or the early use of ventilators) in a subset of covid patients who, those doctors believe, may do better with noninvasive apnea devices or even nasal cannula.
What anticoagulation do covid patients need?
Thrombosis is increasingly emerging as a marker of severe coronavirus with physicians reporting not only respiratory failure but coagulopathy. Interim guidance from the International Society on Thrombosis and Haemostasis advises measuring D-dimer, prothrombin time, platelet counts and fibrinogin. The guidance also recommends using prophylactic doses of LMWH unless contraindicated in all hospitalized covid patients, including those not in the ICU. But some experts think prophylactic dosing may be too low, and some facilities are starting anticoagulation in covid patients with a D-dimer of more than 1,500 ng/mL and fibrinogen higher than 800 mg/mL. While some experts see advantages to using IV heparin in covid patients, other hospitals are instead choosing to use DOACs to limit the number of times nurses have to enter patients’ rooms.
Large staffing firms cut physician hours
There are signs that several of the larger physician staffing companies are feeling the financial effects of the COVID-19 pandemic. A ProPublica report published by HealthLeaders says that large firms are cutting back the hours of their ED doctors, anesthesiologists and other physicians. Revenue for these companies is dropping as people avoid hospitals for everything but the coronavirus, drying up visits to the ED and cancelling elective procedures. Analysts have complained that cutting ED coverage as hospitals brace for coronavirus could hurt patient care, but the companies insist that they are prepared for a surge in demand. The report comes on the heels of multiple reports of health care organizations furloughing workers.
What’s happened to all the heart attacks?
Hospitalists bracing for a coronavirus surge also report that their regular medical census is way down. In a New York Times article, famed Yale cardiologist Harlan Krumholz, MD, writes that hospitals, besides treating covid patients, are “eerily quiet.” The sharp drop in normal hospital volume can’t be explained by just the suspension of elective procedures; instead, heart attack and stroke patients aren’t showing up. According to an informal Twitter poll, almost half (45.4%) of responding cardiologists said their number of MI/ACS admissions during the pandemic has fallen between 40% and 60%. (Twenty-two percent reported a more than 60% reduction.) The most troubling explanation, Dr. Krumholz writes, is that patients who have symptoms are too afraid to come to a hospital and risk becoming infected. Or social distancing and the adoption of new activity and food behaviors may be reducing MI and stroke triggers. “As we fight coronavirus, we need to combat perceptions that everyone else must stay away from the hospital.”
April 8, 2020
What’s your duty to work when your PPE isn’t keeping you safe?
You’ve seen the stories of physicians and nurses who are being harassed, fined and fired over their refusal to work with PPE they think isn’t safe enough. Whether it’s nurses being outright fired for refusing to wear hospital-issued masks or physicians being left off the schedule because of similar concerns, health care workers are beginning to fight back against equipment that they say is inferior. That raises the question: Are physicians morally obligated to work in conditions in which their safety isn’t being protected? A New York Times article by a New York cardiologist explores whether physicians’ obligation to patient care overrides their obligations to their families. The author concludes that while most physicians will ultimately honor their professional obligation to care for patients, society must also honor its obligation to protect health care workers through measures like social distancing, the maintenance of public health infrastructure—and adequate safety gear. Finally, MedPage Today conducted a survey on the issue and allowed readers to leave comments on the topic.
The personal fallout of COVID-19 for doctors and nurses
• An article in FierceHealthcare quotes two physicians who describe watching patients suffer alone near the end of life because of quarantine conditions in hospitals.
• An article from KevinMD describes how a two-physician couple in New York City made the tough decision to send their daughter to live with her grandparents “for the foreseeable future” so they can fight the virus without fear of infecting her.
• Physicians and nurses who have had breaches in PPE while caring for patients who have tested positive for coronavirus are flocking to RVs, empty condos and whatever other accommodations they can find, all in an effort to protect their families.
A roundup of treatment tips from physicians via Twitter
A New Jersey hospitalist who had to intubate a young (and previously healthy) colleague talks about how he maintained his cool during a trying circumstance. A Michigan hospitalist who has cared for more than 100 COVID patients summarizes the patient presentations he’s seen. And a New Jersey ED physician remarks how patients with oxygen saturation as low as 75% can present with few if any symptoms. All of this comes courtesy of a review of physician Twitter posts from MedPage Today.
April 6, 2020
New York “regionalizes” hospitals in the state
With more than 120,000 covid cases in the state, the 200 hospitals in New York are effectively no longer functioning independently. Instead, state officials have announced that facilities will operate as one state-wide hospital system, sharing supplies, staff and covid patients. Vox reports that the top priority in the state plan is to move doctors and nurses from less affected hospitals upstate to New York City. Patients and resources will also be shared across hospitals throughout the state under the management of the state health department. In hard-hit parts of Europe, covid patients are likewise being transferred out of overwhelmed hospitals via high-speed rail and military planes to facilities with more capacity. New York City’s mayor has called for a national enlistment program for physicians and nurses to be able to deploy medical personnel to covid hotspots around the country. And New York-Presbyterian last week announced that it will pay all front-line staff a $1,250 bonus if they worked at a hospital campus or outpatient site in the system for a week in March providing care or care support to coronavirus patients.
Remdesivir: Docs, hospitals now have expanded access
The manufacturer of remdesivir has announced that it is expanding and streamlining access for hospitals and physicians to the experimental treatment. Remdesivir, an antiviral developed to treat Ebola that isn’t approved by the FDA, is a potential covid treatment that’s been rushed into multiple clinical trials. Its manufacturer Gilead Sciences has now taken the drug’s limited compassionate use program—which will remain in effect for individual pregnant women and children—and is allowing hospitals and doctors to apply for emergency use for multiple covid patients with severe illness at one time. Under its compassionate use program, Gilead has supplied the drug to more than 1,700 patients but has been overwhelmed by individual applications. The company has also ramped up manufacturing and produced 1.5 million doses, enough to treat more than 140,000 patients.
Doing intubations “right next to the nuclear reactor”
For those who haven’t yet treated—or had to intubate—a coronavirus patient, an “as told to” article by a Chicago anesthesiologist is a sobering reminder of how risky treating these patients can be. Cory Deburghgraeve, MD, is an anesthesiologist at the University of Illinois at Chicago who typically spends his workdays doing epidurals and C-sections for women having babies. Now, his full-time job is intubating covid patients in the ICU 14 hours a day, six nights a week. Dr. Deburghgraeve is one of two physicians—one who covers days while he covers nights—who volunteered to be the dedicated providers doing intubations to limit their colleagues’ exposure. While he has asthma, he says he was moved to volunteer because he’s in his early 30s and doesn’t have children. Most covid patients he’s intubated, he reports, are 50 years old or younger and in severe respiratory distress, with oxygen levels as low as 70. When patients’ airway is exposed, which he describes as being “right next to the nuclear reactor,” he sees significant swelling in the upper airway. The ICU has had some successes; one younger patient weaned from a vent was discharged home. But he writes that patients who would typically be on a vent only a few days are staying on for two or three weeks.
April 3, 2020
One million-plus cases worldwide and counting
This morning’s U.S. tally: 245,601 cases, 6,058 deaths. While models cited this week by the administration estimate a death toll in the U.S. between 100,000 and 200,000, epidemiologists question those predictions, saying it’s not clear what those models are based on. A new JAMA perspective provides a framework for rationing ventilators and ICU beds. Organizations are setting up exchanges to allow hospitals to trade supplies. The AMA has issued guidance for retired clinicians coming back to work, given their age-related risk. Recommendations include keeping them away from direct patient care and instead exploring telehealth, filling administrative roles, and doing online teaching or mentoring for medical schools. Data indicate that tests (even if available) may have only a 70% sensitivity, with even lower sensitivity among asymptomatic patients.
What do hospitals need?
What does a surge in covid patients mean for medical supplies? Survey results released this week by Premier indicate what extreme supply demands look like: Covid surges lead to a 17-fold burn rate for N95s, a more than eight-fold in face shields, six-fold for swabs, five-fold for surgical gowns and more than three-fold for surgical masks. Average survey respondents had about three weeks’ worth of N95s on hand. But those with active covid patients had only a three-day supply, and one in four (23%) were going through more than 100 N95s a day. The FDA has approved a machine that can clean 80,000 surgical masks and N95s per day with vaporized hydrogen peroxide. Another machine being marketed claims it can disinfect 500 N95s an hour using UV light. And contradicting some hospital policies, the Joint Commission this week said it supports clinicians bringing protective gear from home to use at work, with evidence suggesting benefits from using personally-owned respirators and masks.
You made the cover of The New Yorker
Tributes to front-line hospital workers have poured in from editorial pages and publications. This week’s New Yorker cover, titled “Bedtime,” shows a gowned-gloved-masked worker in a crowded hospital hallway bidding goodnight to two young children, while a Mike Luckovich cartoon for the Atlanta Journal-Constitution shows doctors, nurses, scientists and first responders in the seminal Iwo Jima pose planting the American flag. One bright note: When New York’s governor sent out a call for reinforcements for his state’s hospitals, 82,000 volunteered for a reserve medical force of recent retirees and health care workers who can leave other jobs. And some humor: GomerBlog points out that a coronavirus vaccine should be ready by 2021 for anti-vaxxers to completely reject and protest against. “At press time, officials noted conspiracy theories about the not-yet-developed vaccine containing mercury were spreading on Twitter.”
April 2, 2020
Why are U.S. masks being sold to foreign buyers?
A Forbes journalist has filed this harrowing news: The U.S. continues to allow medical supplies in this country to be purchased by foreign buyers and shipped overseas. Last week, the author reports, he spent 10 hours listening in on frenzied phone calls between brokers selling N95 masks and potential purchasers from state governments and hospital systems. At day’s end, about 280 million N95s that were warehoused in the U.S. had been sold—that day—to foreign buyers and were about to be exported, while U.S. purchasers were able to secure virtually none of them. The federal administration has at least halted overseas shipments of PPE from the stockpile maintained by the U.S. Agency for International Development, after realizing that two deliveries from that stockpile were being sent to Thailand. News outlets yesterday reported that the U.S. emergency stockpile maintained by the federal government and now being distributed by FEMA is nearly depleted.
One in four infected patients may be asymptomatic
CDC officials are now saying that as many as 25% of patients infected with covid may be completely asymptomatic, a data point leading many officials to consider recommending the use of face masks—for everyone. Such a recommendation, however, would causes a run on face masks just when health care workers are in increasingly dire need. Among passengers on the Diamond Princess cruise ship, 18% of infected patients never developed symptoms, while investigators in Hong Kong have reported that between 20% and 40% of transmissions in China occurred from patients before they developed symptoms. Studies also show that infected patients are most contagious one to three days before any symptoms appear.
Is there a clinical role for immune survivors?
While convalescent plasma is being tested as a possible treatment for serious illness, the issue of potential immunity among surviving covid patients raises this question: Could providers who contract the virus and recover be an important clinical workforce? That’s touched on in an IDSA blog entry written by ID physician and pandemic expert Daniel Lucey, MD, MPH. Dr. Lucey points to many unknowns, including: Are survivors truly immune, and how accurate are antibody tests? How would such tests be developed and distributed, and by whom, and would clinicians need verification of being antibody-positive? “I would be reluctant, or at least very slow initially,” Dr. Lucey wrote, “to recommend that frontline workers who are antibody-positive against the SARS-CoV-2 virus should not wear COVID-19 personal protective equipment.”
April 1, 2020
Hospitalists issue some hard-won guidance
The hospitalists with EvergreenHealth in Kirkland, Wash., have the distinction of treating many of the first covid patients in this country infected through community transmission. As their number of critically ill patients climbed, the clinicians and administration there rapidly worked to create flexible staffing, new ways to cohort patients and negative pressure rooms out of general floors. The physicians were also learning about the disease course as patients developed ARDS, ground-glass opacities, and persistent fevers, and presented with elevated CRP and D-dimers. They also learned to use early intubation—not bridging—once patients’ need for supplemental oxygen start to increase. The EvergreenHealth hospitalists have put their lessons learned into a nine-page PDF of protocols and best practices.
NY wants you! (So does California)
New York’s governor Andrew Cuomo this week issued this plea to health care workers nationwide: “Please come help us in New York.” To try to manage the deepening crisis in New York City and throughout the state, the governor is asking one million health care workers around the country to volunteer their services in New York now. California’s governor Gavin Newsom is also appealing to retired health care workers and those now in training to come join the new California Health Corps. To facilitate that appeal and to help staff the emergency hospitals being built in that state, Gov. Newsom signed an executive order waiving health care staffing ratios. The state is also waiving some licensing and certification requirements.
Doctors be warned: Watch what you say about COVID-19, PPE
A report from Bloomberg says that hospitals are threatening to fire health care workers who talk too much about their working conditions in the age of COVID-19. The report says that a nurse in Chicago was fired after telling a colleague via e-mail that she wanted a more protective mask. And another report from Modern Healthcare says that an ED physician in Washington state claims he was fired after criticizing his hospital’s handling of the coronavirus. A Medscape report notes that hospitals are muzzling physician complaints, particularly when it comes to a lack of personal protective equipment. Hospitals are also forcing physicians to remove online posts and face retribution for speaking out.
Don’t bother bringing your own N95 to work
Talking about issues with PPE isn’t the only fire-able offense. Clinicians who bring their own protective gear to work are discovering trouble. A Medscape report says that physicians at a northern California hospital say they’ve been warned they can be fired for bringing their own N95 mask to work, and that they need a note from her physician to even consider wearing the mask. A Modern Healthcare report says that one nurse who was fired for bringing her own N95 mask to work is suing her employer for more than $50,000 for lost wages and emotional damages. Some hospitals worry that the gear will scare patients.
Competing interests: clinician safety vs. PPE supplies
PPE tops the list of concerns of physicians on the front lines of the COVID-19 outbreak. That includes the head of hospital medicine at Stanford, who talks about her hospital’s efforts to treat coronavirus patients in an article on Medscape, Hospitalist Neera K. Ahuja, MD, talks with noted physician-author Abraham Verghese, MD, about everything from the changing definition of who qualifies for COVID testing to adjusting physician staffing levels to meeting the growing pandemic. Dr. Ahuja says that one of her more difficult moments occurred when a faculty member explained that she wanted to wear a mask everywhere in the hospital, not just while treating patients. Dr. Ahuja says that the conversation illustrates the competing mandates of keeping clinicians safe while simultaneously preserving PPE supplies.
March 31, 2020
The new normal: Experts predict between 100K-200K U.S. dead
Federal experts today plan to release the statistical models they’re using to come up with stunning predictions of expected dead in the U.S.: between 100,000 and 200,000. The New York Times reports that the death toll in the U.S. today surpassed 3,100, with the U.S. having the highest number of confirmed cases in the world: more than 160,000. (With testing so sparse and delayed, many cases remain undetected.) Virus expert Anthony Fauci, MD, discussed those estimates over the weekend, saying he expects the number of cases in the U.S. to eventually be in the millions. Better news: With close to 250 million Americans in 29 states now ordered to stay at home, data on daily fever readings (a tell-tale covid symptom) around the country show a decline.
CMS waives more regulations to boost hospital capacity
The CMS yesterday announced a host of temporary waivers of regulations, all to allow hospitals to quickly ramp up capacity and expand the number of health care workers. Hospitals may now, for instance, contract with ambulatory surgery centers to provide hospital services including trauma surgeries and cancer procedures. Non-hospital buildings and spaces—including hotels and dormitories—may now be used for patient care and quarantine, and ambulances may now transport patients to a wide range of outpatient locations including urgent care centers and physician offices. As for boosting the workforce, the CMS is now allowing hospitals to hire private practice providers, and it is waiving requirements that CRNAs must be supervised by physicians. Hospitals also now have a blanket waiver to provide benefits to staff including meals, laundry service and day care.
Is using hydroxychloroquine “a rush to judgment”?
The FDA has given an emergency green-light to using the anti-malarial hydroxychloroquine to treat covid patients. While the agency acknowledged that the therapy is unproven in coronavirus, it said that deriving any benefit in treating serious covid cases risk may be worth the risk. Experts warn that use of the drug could affect heart rhythms among patients taking certain drugs or those with heart problems, and long-term use is associated with retinopathy. Researchers writing in Annals cautioned against using the drug without further investigation, writing that doing so would be “a rush to judgment” that could endanger supplies for approved uses among patients with lupus and rheumatoid arthritis.
Hospitals develop, deploy their own covid tests
Some good news: More hospitals and academic centers report that they’ve now developed the ability to test covid patients in-house, cutting down on crippling testing delays. While reagent shortages continue to threaten that capability, FierceHealthcare reports that the lab at New York’s Montefiore Medical Center is now running hundreds of tests a day, while the test developed at Baltimore’s Johns Hopkins Hospital is being used for 1,000 daily tests. The stimulus package that Congress passed last week requires insurers to cover the cost of tests developed by hospitals, and the CMS is now asking hospitals to report their daily testing data along with their daily supply needs and bed capacity. JAMA livestream contains more news on managing covid patients.
March 30, 2020
When 911 is overwhelmed
Coronavirus calls are overwhelming the 911 call system in New York City. While EMS in that city typically fields 4,000 calls a day, that number has now risen to more than 7,000. The outsized volume has left paramedics making on-the-spot decisions about who is well enough to stay in place and who needs to be taken to one of the city’s hospitals, with EMS rationing protective gear. Over the past several weeks, the nature of the calls has also changed from reporting fever or respiratory distress to cardiac arrest and organ failure. New York’s governor on Sunday reported that more than 76,000 retired health care workers have now volunteered to work in New York hospitals. And New Yorkers are taking to their balconies and open windows at 7 p.m. to cheer for health care workers and first responders.
How bad is the PPE shortage?
Pretty dire, according to survey results released by APIC. In an online survey of U.S. facilities, the infection control association learned that close to half—48%—are either already or almost out of respirators. Close to half (49%) reported they don’t have enough face shields, and nearly one-third (31%) don’t have enough masks. Even hand sanitizer is in short supply with 25% of facilities saying they are almost out. APIC called on the federal government to help alleviate those shortages, while Science News reports that “carpenters, clothing companies and local sewing circles are stepping up to help.” JAMA put out a call for creative ideas in how to conserve PPE and has received scores of responses.
CMS waives its (loathed) three-day SNF rule
The CMS this month announced that it is waiving its three-day rule for covering SNF care for Medicare beneficiaries, part of the agency’s emergency efforts to make regulations more flexible and allow hospitals to more effectively discharge patients. Inpatients who need SNF care no longer need to first be hospitalized for at least three days. Other changes: The CMS is renewing SNF coverage for some Medicare patients who have exhausted those benefits. It is also waiving its requirement that critical access hospitals can have only 25 beds and that patients’ length of stay much be limited to only 96 hours.
March 27, 2020
U.S.A.: We’re No. 1
The U.S. yesterday surpassed China as the nation with the highest number of confirmed cases. This morning’s Johns Hopkins’ stats: 85,996 cases in the U.S., 542,788 cases worldwide, 24,361 deaths worldwide. The House today may vote on the largest economic relief bill in U.S. history, one that would give hospitals $100 billion to offset the costs of treating covid patients. Early trials on the efficacy of lopinavir-ritonavir and hydroxychloroquine to treat hospitalized covid patients found neither to be effective. Research on patients hospitalized with coronavirus in Wuhan finds that 20% had cardiac injury, making those patients more likely to need noninvasive and invasive ventilation and have much higher mortality. The FDA is allowing clinicians to use alternative respiratory devices, and it has given the green-light to convalescent plasma from covid patients who have recovered as an investigational treatment for those with severe disease. Pediatric hospitals are resisting taking adult patients from other facilities, saying doing so wouldn’t be safe. Instead, they urge hospitals that treat adults and are at capacity to send all pediatric patients to children’s hospitals. An NEJM perspective outlines what the government can do to help alleviate PPE shortages. And hospitals are now debating whether to institute universal do-not-resuscitate orders for coronavirus patients, citing infection-control concerns and the shortage of PPE.
How to stretch ICU staffing
ICUs should switch to a model of tiered staffing that integrates experienced critical care clinicians with others repurposed from other hospital departments. That’s according to pandemic recommendations issued by the SCCM. The suggested model gives a physician who has critical care experience oversight over four teams, with each team managing 24 beds. Further, each team should consist of four staffing tiers. An experienced ICU APC or a reassigned non-ICU physician should be the first tier, while the second tier would consist of both experienced and reassigned physicians, APCs, respiratory therapists, CRNAs and CAAs; personnel in that second tier would concentrate on ventilation. Experienced ICU nurses would make up the third tier and reassigned non-ICU nurses would be in the fourth. To make such staffing possible, the SCCM issued the following recommendations: limit elective surgeries to free up beds, staff and ventilators; train reassigned staff; combine those who have ICU experience with those who don’t; and practice public health measures to minimize transmission. The SCCM also points out that 48% of U.S. hospitals have no intensivists on staff.
Teaching hospitals face visa moratorium
With the State Department putting a temporary halt to issuing visas, the visas of more than 4,000 foreign physicians are now up in the air. Those doctors, most of whom are waiting for J-1 visas, are slated to begin their residencies in U.S. teaching hospitals in July. Earlier this month, the state department sent out guidance to sponsors including the ECFMG to either cancel their programs or postpone their start dates. Among the more than 7,000 IMGs placed in residency programs in last week’s Match, more than 3,000 are already U.S. citizens.
Staffing strategies: All hands on deck
What types of staffing strategies do you need when more than 50% of all your admissions are coronavirus patients? That’s the situation Northwell Health, the largest system in the greater metro New York area with 15 hospitals, now finds itself in. Those hospitals are also dealing with this reality: Between 25% and 35% of those admitted patients need ICU-level care.
Joshua Case, MD, is medical director of Northwell’s hospital medicine program. In an SHM Webinar, Dr. Case discussed the tactics his hospitalist programs are using to increase provider capacity:
• Reach out to outpatient physicians. Talk to the physicians in your community, whether or not they still have hospital privileges, to have them come into the hospital and treat low-acuity patients. Be sure to devise some quick computer training as well as emergency credentialing so onboarding isn’t held up by red tape.
• Bring back the “-ists.” Hospitalists have typically taken on specialists’ admissions to allow those physicians to focus on outpatient procedures and visits. Now that those outpatient options are shut down, give back admissions with those primary diagnoses to the specialists. Pulmonologists, meanwhile, and anesthesiologists can be enlisted to run vents.
Partner any outpatient clinicians who are unfamiliar with the hospital with early-year residents or NPs/PAs. In academic settings, think about how to deploy third-year residents and fellows.
• Figure out who shouldn’t come in. Hospitalists who have been exposed may be in quarantine while they wait for test results. Others—including those who are pregnant or immunocompromised—should likewise work offsite. Have those doctors take cross coverage at night, freeing up the onsite physicians. If your hospital has telemedicine, staff those services with offsite physicians as well.
For hospitals that don’t yet have a big COVID population, some physicians who shouldn’t work with coronavirus patients may still be able to come in and treat other patients
But at Northwell’s sites, “there’s no such thing any longer as a non-COVID unit,” Dr. Case said. If coronavirus patients are still only a minority of admissions, let physicians decide who wants to staff those teams or units.
“Physicians now have a tremendous amount of anxiety,” Dr. Case said.
Instead of work clothes and white coats, clinicians are wearing scrubs. The health system is exploring how to provide onsite showers as well as scrub services so doctors can clean up before they come go and have their work clothes laundered without taking them home.
In the presentation, Dr. Case was joined by Romil Chadha, MD, interim director of the hospital medicine division at the University of Kentucky. That entire state, Dr. Chada pointed out, has only 160 COVID-positive patients, so it is weeks away from being in the same situation as the hospitals in New York.
But the academic center has made essential plans including for child care. “We need child care for between 1,500 and 2,000 children a day,” said Dr. Chadha. Local YMCAs have stepped up to provide that care, while medical students have also volunteered. All the staff—doctors as well as nurses, pharmacists and social workers—are sharing their child-care resources.
Dr. Chadha also noted the tremendous number of volunteer offers that he and his colleagues have received. He mentioned one vascular surgeon—now sidelined—who wanted to know what he could do to help, fi out the hospitalists.
“He said he hadn’t placed a vent in 10 years, but he was willing to do so,” he said. “I’ve been floored by the response.”
Dr. Case agreed. “The only answer to give people is ‘yes,’ ” he said. ” ‘I will find something for you.’ ”
What the stimulus bill could mean for hospitals
The Senate this week approved a $2 trillion economic stimulus bill that, if it becomes law, would deliver $130 billion to hospitals and community heath centers.
Hospitals would receive $100 billion to help offset the costs of treating COVID patients and to make up for lost revenue from suspended surgeries and procedures. That’s good news, given reports that hospitals—because of too low reimbursement rates—might lose an average of $2,800 per COVID patient and have to initiate layoffs within several months.
The bill also includes $16 billion for medical supplies, $11 billion to develop vaccines and diagnostic tests, $250 million to boost hospital capacity, and $275 million to expand capacity for rural hospitals. In addition, $200 million is earmarked for promoting telehealth. The House is expected to vote on the bill this week.
PPE: How to extend the use of N95s
In a new SHM Webinar, Joshua Case, MD, medical director of hospital medicine for Northwell Health in New York, discussed how health care personnel in his system—which is at the epicenter of the epidemic in this country—are extending the use of N95s appropriately and safely.
For one, hospitalists don’t need to use N95s all the time they’re in the hospital or with low-risk patients. Instead, all personnel wear surgical masks in the hospital all the time, as do all suspected or confirmed COVID patients when they’re not alone.
To extend N95 use with high-risk patients, Dr. Case said it’s OK to use the same N95 to go from patient to patient. (For added protection, personnel also put surgical masks over their N95s.) Between patients, perform hand hygiene, remove the gown and gloves you used with one patient, and don a new gown and gloves.
As for reuse, N95s can be stored in a paper bag or “breathable” plastic. How long can an individual N95 be used altogether? According to manufacturer recommendations, there is no specific time limit to N95 use, and the same mask can be used until it’s worn, dirty, damaged or tough to breathe in. In his system, Dr. Case said, they’re using N95s for up to a total of about 100 hours.
That is absolutely not the case when doing aerosolizing procedures such as intubations; in such cases, N95s must be thrown away. To limit the number of such procedures, the health system is no longer doing nebulizer treatments or BiPAP/CPAP. Obtaining a nasopharyngeal swab is not considered an aerosolizing procedure.
As for donning PPE, “use the buddy system,” said Dr. Case. “Have someone else check your equipment as you’re putting it on.” And even if patients are crashing, “always put your equipment on first. It’s like those airplane safety videos that tell you to put on your own oxygen mask before trying to help others.”
Other tips: To limit your exposure, limit your time with COVID patients and visit them only once a day. Take advantage of technology—any telehealth robots or in-room video cameras or tablets, even in-room telephones—for additional communication with patients.
As for making sure your N95 fits properly: Kiss the beards goodbye. “If you have facial hair,” said Dr. Case, “you need to shave.”
Survey finds PCP practices already reeling from COVID-19
A mid-March survey of more than 500 PCPs in 48 states finds that just over half of respondents were already saying that they face a lack of personal protective equipment (PPE); nearly half also reported that they had inadequate testing capabilities. About one-fifth (21%) of respondents reported that the pandemic was already having a “severe impact” on their groups, while 30% said the strain of the pandemic on their practice was “close to severe.” An article in FierceHealthcare says the survey found that physicians are dealing with staff illnesses and a flood of questions via the phone and e-mail. Practices are also reeling from the financial impact of cancelling face-to-face patient appointments and replacing them with lower-paying tele-visits. In related news, a survey of Chinese physicians who treated coronavirus patients found high rates of depression, anxiety, insomnia and distress.
Are these hospital hacks safe or not?
As hospital-based doctors brace for the impact of COVID-19, some have started coming up with workarounds to shortages of supplies. Baby monitors are being rigged to help keep clinicians from having to enter the rooms of infected patients in an effort to preserve personal protective equipment, for example, and physicians are looking at ways to share ventilators among more than one patient. But as an article in Medscape warns, not all hacks are necessarily safe. For a look at other hacks (and a review of the safety of at least one of them), see the article in Medscape.
March 24, 2020
Moving care from the hospital to the community
In a new NEJM perspective, Italian doctors a hospital in Bergamo—the epicenter of the outbreak in Italy where, the physicians write, they are “far beyond the tipping point”—argue that a new model of care must be devised to effectively fight the outbreak. Instead of patient-centered care that revolves around hospitals, community-centered models need to move much more treatment and surveillance out into the community.
What would such a model look like? One that relies on a comprehensive network of home care, mobile clinics, telemedicine, and the delivery of early oxygen, pulse oximeters, and nutrition to the homes of patients with only mild illness or those who are recovering.
Without those robust outpatient resources, the authors argue, hospitals such as their own—which they call “highly contaminated”—as well as medical transport and health care personnel will remain vectors of infection. “The more medicalized and centralized the society, the more widespread the virus.”
March 23, 2020
NY guv to hospitals: Expand capacity now
New York governor Andrew Cuomo this weekend outlined an aggressive emergency agenda to expand hospital capacity in his state. That state, he said in a Sunday briefing, had about 15 times more confirmed cases than any other.
While New York currently has 53,000 hospital beds, more than twice that number—110,000—are needed. To that end, he asked hospitals to devise plans to double their number of beds, and he mandated them developing plans to increase bed capacity by 50%. He also ordered suspending elective surgeries in the state as of Wednesday, discussed repurposing now-empty hotels and school dormitories to take care of patients, and said he was waiving all state regulations on licensed beds.
In the same briefing, the governor asked the Army Corps of Engineers to immediately begin building four temporary hospitals in the greater New York metropolitan area. He also asked FEMA to set up four field hospitals in Manhattan’s Jacob K. Javits Convention Center, each with a capacity of 250 beds.
As for stats on COVID-19: According to Gov. Cuomo, 13% of confirmed cases in the state have needed to be hospitalized.
And speaking of New York: CBS News on Friday reported that 1,000 retired health care workers in New York City volunteered over the course of 24 hours to come back to work.
What worked in Asia?
In a New Yorker article, Atul Gawande, MD, reports on how health care workers in some Asian countries treated COVID-19 patients while keeping themselves infection-free. The article holds out hope of preserving critically important equipment like N95s.
All health care workers in Hong Kong and Singapore wore surgical masks and gloves, practiced hand hygiene, and disinfected all surfaces between consults. Patients with tell-tale symptoms, known contact or a travel history were treated in separate clinics and wards. Doctors stayed six feet away from patients (except during exams) and from each other. N95s were used only for procedures, like intubations, that involved aerosols.
Each country also defined “close contact.” In Hong Kong, that meant spending 15 minutes at a distance of less than six feet without a surgical mask. (The definition was 30 minutes in Singapore.) When clinicians were exposed to suspected or positive patients within six feet for less than 15 minutes but more than two, they could stay on the job wearing a surgical mask and checking their temperature twice daily. Those with only brief contact monitored themselves for symptoms.
“Extraordinary precautions,” Dr. Gawande writes, “don’t seem to be required to stop it,” adding that hospital workers in those Asian countries were able to stay infection-free without strict quarantine policies.
March 20, 2020
“At war with no ammo”: tests, vents, swabs and PPE
This morning’s Johns Hopkins COVID-19 stats: 14,250 U.S. cases, 246,275 cases worldwide, 10,038 deaths worldwide. To address the shortage of doctors, the HHS this week announced that physicians will be able to practice across state lines.
Some health systems are figuring out a role for retired clinicians and medical students. While coronavirus testing is still in very short supply, some providers are suspending testing drive-thrus due to limited test supplies, including swabs, and to conserve tests for critically ill patients. Other systems have decided to preserve tests for high-risk patients and for health care workers.
To shore up hospitals’ stock of protective gear, the CMS this week recommended delaying all elective surgeries and non-essential medical and surgical procedures. Some innovative hospitals are building simpler ventilators themselves.
Car companies offered to begin manufacturing respirators, while the department of defense this week said it will release 2,000 ventilators and five million masks to federal agencies. An ED physician in Detroit demonstrates how to modify a ventilator to accommodate two to four patients at a time. A California surgeon, with only a limited supply of respirator masks in the OR, had this description: “We’re at war with no ammo.” More than 600,000 health care workers have signed onto a letter asking the government, industry, media and general population to help immediately with supplies
Different predictions: How bad will it get?
Among many models released this week predicting possible pandemic outcomes, none contained good news. One model given a great deal of credibility was issued by Britain’s Imperial College. It predicted 2.2 million deaths in the U.S. if no containment or mitigation strategies were pursued, with aggressive mitigation measures cutting that mortality in half.
A Harvard analysis looked at several scenarios, weighing different infection rates across different timelines in the U.S. to gauge where—and how soon—hospitals could run out of beds. A health care analysis company this week also released its model of projected ICU bed shortages, breaking those down by state. According to those predictions, Seattle will hit its ICU capacity at the end of this month, with New York filling its ICU beds in the first week of April. Specialty hospitals, including Cancer Treatment Centers of America, and ambulatory surgery centers are offering to accept acute and critical care patients if hospitals are overwhelmed. The New York Times has compiled a list of bed shortages around the US.
How long does COVID-19 survive in air, on surfaces?
Experimental findings released this week indicate how long the coronavirus can survive in the air and on surfaces, results that have key implications for health care workers. Aerosolized virus (droplets smaller than 5 micrometers) can stay suspended in the air for a half hour before falling onto surfaces.
Such aerosols could infect clinicians who don’t have proper protections while intubating sick patients. Aerosolized virus and droplets could also land on protective equipment and be released into the air when that equipment is being removed. (In their experiments, researchers found that virus remained viable in aerosols for three hours.)
On surfaces, the virus can live the longest on both stainless steel and plastic—for 72 hours, although the amount of viable virus decreases over that time. The virus survives only four hours on copper and up to 24 hours on cardboard.
March 20, 2020
Analysis: Young adults aren’t immune
It’s been known for months that coronavirus is particularly dangerous for elderly patients, and a new CDC analysis of COVID-19 patients in the U.S. between Feb. 12 and March 16 bears that out. But the analysis also finds that the majority of coronavirus patients hospitalized in the U.S. so far—55%—were under age 65, with 20% between the ages of 20 and 44. (Eighteen percent were ages 45–54 and 17% were ages 55–64.) As for ICU admissions, 7% were among patients 85 or older, 46% among ages 65–84 years, 36% among ages 45–64 years and 12% among adults 20–44 years. Twenty percent of the deaths in the U.S. included in the analysis were among patients age 64 or younger.
March 13, 2020
Where are the tests?
With the World Health Organization this week announcing that coronavirus is now a global pandemic, Johns Hopkins yesterday reports that there are more than 127,800 cases worldwide and more than 4,700 deaths. The number of confirmed cases in the U.S. stands at 1,323—a figure assumed to be under-reported, given crippling delays in testing and in test shortages. Testing reports this week indicate that the U.S. has administered five tests per million people vs. 3,692 per million in South Korea.
The Cleveland Clinic announced yesterday that it had started testing for coronavirus in-house, one of perhaps only a dozen institutions in the country that can do so. Other labs in the U.S. worry about supply shortages, while doctors in Italy have <a href=>received guidelines on how to ration ICU beds and ventilators. An article in Annals details how hospitals should prepare to handle rising volumes and protect health care workers.
Hospitals race to get telemedicine up and running
With coronavirus bearing down, the Wall Street Journal reports that hospitals are scrambling to build—or expand—their telemedicine capacity as a potential tool for testing and monitoring COVID-19 patients. Part of what’s driving that rush is the need to allow nonclinical staff to work offsite. In addition to rising demand for telehealth vendors and software upgrades, some hospitals—including New York’s Mount Sinai—are developing coronavirus dashboards in their EHRs so that doctors and nurses can access all patient information related to screening, labs and images in one place. The $8.3 billion coronavirus relief legislation passed last week waives longstanding Medicare restrictions on paying for telemedicine, but challenges remain.
March 6, 2020
States of emergency
With California, Maryland and Washington declaring a state of emergency, coronavirus has now caused 12 deaths with more than 200 confirmed cases in the U.S., and infections reported in 18 states. Internationally, there are nearly 100,000 cases and more than 3,300 deaths, with Johns Hopkins reporting that more than 53,600 patients have recovered from the virus. Both the House and Senate this week passed $8.3 billion in emergency coronavirus aid, with funds earmarked for state and local health departments and for telehealth services for Medicare beneficiaries, among other items.
An online survey done this week of 6,500 nurses found that only 29% reported that their hospitals had a plan to isolate potential coronavirus cases and only 44% had been given guidance on how to manage the virus. Only 30% felt their hospitals had enough protective gear for health care workers. The FDA has approved a policy allowing some labs to create and use their own coronavirus tests; the UW Medicine lab in Seattle, for instance, which covers the UW medical school and hospitals, is now processing 100 coronavirus tests a day, with the capacity to do up to 4,000 a day.
February 28, 2020
First case of community transmission
This week, the CDC reports 60 coronavirus cases in the U.S., 45 of whom were repatriated from either China or a cruise ship docked in Japan. The CDC also suspects that one patient in California may be the first case of community transmission in this country. Coronavirus has now spread to 47 countries outside China, with major outbreaks in South Korea, Italy and Iran. A CDC director this week urged Americans to prepare for a potential outbreak and noted that the CDC will send out modified versions of its faulty virus test kits to state and local governments and commercial labs.
Axios reports that the FDA is maintaining a list of about 150 drugs that might experience shortages if the outbreak worsens in China, a major supplier of raw pharmaceutical ingredients. Meanwhile, researchers are testing HIV medications against the virus as well as an experimental infusion first tested against Ebola, and Emory University plans to begin a trial on a nucleoside analog developed to treat flu. A JAMA infographic breaks down the numbers for COVID-19 and this year’s moderately severe flu season.
February 21, 2020
Panel warns hospitals to have a plan
With the disease toll in China standing at about 75,000 confirmed cases and 2,100 deaths, a new analysis finds that the novel coronavirus is more contagious than the viruses that cause MERS and SARS. Meanwhile, an expert panel at this week’s Society of Critical Care Medicine meeting warned hospitals to prepare now for a possible influx of COVID-19 patients by having a plan to identify and isolate patients as well as to collect and report data on cases.
Experts worry that in the event of an outbreak here, hospitals may run short of ECMO machines and ventilators. Analysts this week also warned that the current outbreak could disrupt the U.S. medical supply chain, which relies on products and components from China. The CDC has begun monitoring some patients with flu-like symptoms for COVID-19 in New York, Los Angeles, San Francisco, Chicago and Seattle. The CDC also released this reality check: This season, the flu has caused 250,000 hospitalizations in the U.S. and 14,000 deaths.
February 14, 2020
Cases in the United States
The CDC announced yesterday that it has confirmed the 15th coronavirus case in the U.S. That patient has been under quarantine in Texas since arriving on a flight from China earlier this month. Meanwhile, China revised up its number of coronavirus cases by 20,000 as the result of new diagnostic criteria that don’t rely on lab tests, according to the Washington Post. The new case total there is more than 63,000, with more than 1,300 deaths reported. That puts the coronavirus death toll higher than that of the 2003 SARS pandemic, although the CDC notes that the mortality rate associated with the novel coronavirus is less than that of SARS: 2% vs. 10%.
While the new virus’ mortality rate may be lower, experts believe it’s more easily transmitted. Researchers are optimistic that they may have a vaccine against the novel coronavirus by this fall. The virus has been given at least two official names: severe acute respiratory syndrome coronavirus 2 and COVID-19.
January 31, 2020
WHO declares coronavirus a global public health emergency
The World Health Organization yesterday declared that the coronavirus outbreak that originated in China is now a global emergency, with more than 8,000 cases reported worldwide. While most of those cases are in China, the virus has spread to many other countries including the U.S. The declaration escalates global response to the disease but leaves it up to individual countries to decide what protective measures to take, including whether to close their borders or screen airport passengers. As of Thursday, officials had confirmed the sixth case of coronavirus in the U.S., the first case in this country of clear human-to-human transmission.
January 24, 2020
The CDC has confirmed that a patient in Washington state is being treated for the 2019-nCoV coronavirus that broke out in China last month, making him the first patient in the U.S. with that diagnosis. The man had recently traveled to Wuhan province, the site of the outbreak in China where at least 17 deaths from the pneumonia-like disease have been reported.
While the CDC announced this week that it would begin screening passengers returning from Wuhan at several U.S. airports, Chinese authorities have since imposed travel restrictions on Wuhan and surrounding municipalities, covering about 25 million people. Cases have been detected around China as well as in Thailand, Japan, South Korea, Singapore and Vietnam, in addition to the U.S.