Check back often as we continue to post timely updates on COVID-19.
Its hurricane season and the pandemic is raging.
Planning for disasters that come in twos
August 7, 2020
States band together to boost antigen test production
While death rates in the U.S. are up to more than 1,000 per day, testing rates unfortunately are dropping. An AP analysis finds that testing rates have fallen 3.6% over the past two weeks, a decrease that experts say is due to patients’ frustration with having to wait to be tested and with not getting results for days or weeks. To boost test production, seven state governors this week announced a purchasing compact, the first of its kind. The states—Virginia, Louisiana, Massachusetts, Michigan, North Carolina, Ohio and Maryland—are working with the Rockefeller Foundation and negotiating with companies to produce 3.5 million rapid antigen tests, with results ready within 30 minutes. Each state would expect 500,000 tests; however, the governors say other states and cities may join them.
Is a civil war brewing over covid research?
Researchers have published preliminary data in a preprint on convalescent plasma, looking at 12 different studies. Those included three randomized trials, five matched control trials and four case study series. The data, which encompassed more than 800 patients, suggest a mortality benefit: Patients who received plasma had a 13% mortality rate vs. 25% for those with only standard treatment. The New York Times reports, however, that solid randomized data on plasma are hard to come by. That’s because clinicians’ enthusiasm to administer convalescent plasma has stymied research efforts to try to definitively find out if it really works. Doctors who want to give patients the therapy won’t enroll them in trials, worried that patients may get only placebo. And by the time clinical trials do get off the ground, outbreaks have passed so researchers have to scramble to enroll subjects in new hotspots. With several trials in the U.S. unfinished, the NIH is urging researchers to pool their data. An article in the New York Times Magazine points out that clinicians in many academic centers who use unproven therapies and off-label drugs with covid patients are facing off against their own researchers, who want to systematically build a body of evidence instead. That tension in some hospitals, according to the article, has “opened up a civil war.”
Cancer diagnoses drop sharply
Cancer diagnoses appear to be another victim of coronavirus, according to the authors of a research letter in JAMA Network Open. Researchers looked at weekly diagnostic numbers for six cancers, comparing figures from Quest Diagnostics last year to seven weeks this March and April. The weekly number of diagnoses was cut almost in half across all six cancer types, which included breast, colorectal, lung, gastric, pancreatic and esophageal. Breast cancer diagnoses took the biggest hit with a 51.8% decrease while the smallest decline was 24.7% for pancreatic cancer. The authors chalked those drops up to patients not being screened or ignoring symptoms while in lockdown. “The delay in diagnosis,” the authors write, “will likely lead to presentation at more advanced stages and poorer clinical outcomes.”
Surges expose the dangers of understaffing
Experts have identified many factors that cause covid mortality to spike including comorbidities and social determinants of health. Writing in Health Affairs, a New York City hospitalist points to what may be another critical factor: the chronic understaffing of hospital teams. The author works in a community hospital that, like others in that metropolitan area, was overwhelmed with covid patients this spring. As Healthcare Innovation reports, the writer believes the hospitals with “the least capacity for surge staffing” may eventually be linked to the highest number of excess deaths. The outbreak, he writes, was a great object lesson in how patient safety is jeopardized as patient-to-nurse ratios increase, particularly in the ICU. With covid patients, “patient-to-(respiratory) therapist ratios are just as vital.” In terms of staffing, the pandemic revealed the inequities of resources for safety net hospitals, a condition tolerated pre-covid. “The stress test of the pandemic made such stark inequities impossible to ignore.”
#MedRacism takes down an anti-affirmative action paper
Twitter’s #medbikini pushed back against a peer-reviewed paper by vascular surgeons, which criticized trainees for such social media behavior as posting pictures of wearing swimsuits, drinking alcohol, using profanity and engaging in political activism. The paper claimed such behavior was unprofessional, and the resulting pushback led to the paper’s retraction. Now, #MedRacism has taken on an article published earlier this year by the Journal of the American Heart Association and written by a director of an electrophysiology fellowship program. In what was styled a “white paper,” the author claims that affirmative action programs for blacks and Hispanics in cardiology programs have produced “poor performance” and “disengagement.” As comments snowballed on Twitter about racial and ethnic stereotypes, the publication first released an apology, then a retraction. With many commenters questioning how the author’s views affected his fellowship program, MedPage Today reported that the author had been relieved of that directorship.
August 5, 2020
Telehealth update: popular with patients, but will payment be permanent?
As many in health care wonder if telemedicine will continue the rapid growth it has experienced during the pandemic, there have been some encouraging signs in the news over the last week.
First, President Trump has proposed permanently extending certain telehealth policies that led to the rapid growth of telehealth during the pandemic. The proposal, which was announced with reforms to rural health payment that were part of an executive order, aims to make Medicare payment permanent for certain health providers. According to a report in Politico, a more comprehensive telehealth policy would have to come from Congress.
Data from a new survey find that about 90% of respondents who have had a telehealth visit are likely to schedule another one instead of an in-person visit. Those data probably have something to do with how safe patients feel in health care settings. The survey found that only 12% of respondents felt safe in emergency rooms and urgent care centers. By comparison, 42% felt safe in grocery stores and 37% felt safe in pharmacies.
Finally, new data find that telehealth visits accounted for nearly half of all primary care visits by Medicare patients in April. The report, which was released by an office of the HHS, found that both rural and urban areas saw an increase in use in both March and April, but it also found that rural areas saw a smaller increase in March and April as a proportion of all primary care visits than urban areas.
How the gender gap can cost $90,000 (in certain practices)
A new study from Harvard Medical School found that the more male physicians are in a practice, the lower the pay for female doctors.
In non-surgical private practices with the same number of men and women, men earn 12% more than women. When staffs are 90% male, men earn 20% more. A report in Forbes says that can come out to a gender gap of $90,000 or more. That gap gets even worse at surgical practices. At surgical practices with 90% or more of men, the gap grows to 27%, which can account for a difference of nearly $150,000.
August 3, 2020
Testing: Speed counts more than sensitivity
It’s time to rethink how the U.S. is doing testing, according to Harvard’s Ashish Jha, MD. In a commentary in Time, Dr. Jha writes that, “America’s testing infrastructure is collapsing”—due largely to the heavy reliance on PCR tests, which are both slow and expensive. He proposes instead using cheap antigen tests whereby everyone in the country would spit on a specially treated piece of paper every morning. Critics of such testing point to their less-than-perfect sensitivity of perhaps only 50%—a drawback that, Dr. Jha writes, would be countered by frequent testing and rapid results. Referring to a preprint on testing sensitivity, he writes that, “(S)peed matters much more than test sensitivity in controlling a pandemic.” Across the country, patients still wait more than a week for test results, a delay that renders those results and any possibility of contact tracing useless. One privileged group that gets answers in less than a day: NBA players and staff in Orlando. They are tested daily, with the NBA spending between $115,000 and $180,000 every day on tests that deliver results in less than 24 hours. The league last week announced that it will open a free testing site at an Orlando mall that would delivered results in less than 72 hours. Federal officials this weekend warned that the pandemic in the U.S. had entered a “new phase,” one that is “extraordinarily widespread” and now threatens outbreaks in the Midwest. To combat that growing spread, they recommended taking more extreme precautions including wearing masks in homes with multiple generations or vulnerable family members.
New hospital data collection so far falling short
Last month’s switch to having hospitals report their daily covid data to a private company contracted with HHS instead of to the CDC was supposed to streamline the collection process and make information more readily available. So far, that hasn’t panned out, according to sources quoted by NPR. While the CDC reported estimates three times a week based on the data it collected, officials in charge of the new collection method first said data would be updated several times a day, then daily and now weekly. According to the HHS Protect Public Data Hub, those data were last updated July 23. The hub data, sources say, reflect anomalies and inaccuracies. On Friday, the CDC director testified to a Congressional subcommittee that the switch in data collection methods—and the CDC wasn’t involved in making that final decision—was driven by the need to know where to distribute remdesivir.
How are those back-to-school plans coming along?
A CDC report on a sleep-away camp gone wrong contains some bad news for children being able to go back to school in person. The camp, which was in session in Georgia for less than a week, required close to 600 campers and staff to provide documentation of negative testing; while staff were required to wear masks, the children—median age of 12—were not. More than three-quarters of campers and staff tested in just a few days (260) were positive. In related news, previous studies have suggested low transmissibility among children younger than age 10. But that wasn’t borne out in a research letter published online last week by JAMA Pediatrics. Researchers analyzed nasopharyngeal swabs collected in March and April around one Chicago tertiary pediatric medical center. They found that young children (age five and under) with mild to moderate covid had higher amounts of viral RNA in their nasopharynx than older children and adults. As for reopening college and universities, a study in JAMA Network Open concludes that campuses can safely reopen—if “strict behavioral interventions” can be maintained and students can be tested every two days.
July 31, 2020
What will it take to get the pandemic under control?
As the U.S. passes the 150,000 mark in coronavirus deaths, experts now say the country is in worse shape in terms of the pandemic than it was in March. How to bring it under control? That depends on the specific outbreak, according to interviews with 20 public health experts in the New York Times. Multiple epicenters have emerged, with outbreaks driven by different factors; some hotspots have been fueled by vacation travelers, while others are due to bars re-opening too soon or to residents refusing to wear masks. While some experts argue for a national lockdown, others say that stay-at-home orders should be issued only in communities that record more than 25 cases per 100,000 people. A report from the Johns Hopkins Center for Health Security calls for a national reset in pandemic response. Among the report’s suggested changes: issuing universal masking mandates, closing high-risk activities and settings in areas where hospitalizations are on the rise, and putting stay-at-home orders in place for at least two weeks in communities where health care systems are in (or approaching) crisis.
Intensivists are in short supply in more than a dozen states
There’s a shortage of testing supplies everywhere, and one-third of hospital pharmacies need more remdesivir. But a new report out of George Washington University highlights the increasing shortage of intensivists. That shortage is now severe in Arizona and Texas, according to the report, with more than 100% of the intensivists in those states already treating covid patients. Meanwhile, the supply of intensivists in 11 other states is strained, with less than 50% of them available to treat non-covid patients. Those states include Alabama, Arkansas, Florida, Idaho, Louisiana, Mississippi, Nevada, Oklahoma, South Carolina, Utah and Washington. To help manage shortages, the report notes that ICUs can employ surge-staffing models in which each intensivist, instead of caring for seven patients, treats 10. (Another surge staffing strategy: Have each critical care nurse treat three patients, not one.) But clinicians under such models run a greater risk of burnout. The SCCM has published a tiered staffing strategy to boost ICU staffing with non-ICU clinicians, including hospitalists.
Studies raise concerns of long-term cardiac damage
A new study out of Germany of relatively young covid patients (average age of 49) reports troubling results. On MRI scans taken more than two months after patients tested positive, the vast majority (78%) had abnormal cardiac findings, with the majority of them showing myocardial inflammation. Two-thirds of the patients studied had never been hospitalized, and the results were similar regardless of patients’ underlying conditions or covid severity. Another study, which looked at autopsy results, found high levels of virus in the hearts of almost two-thirds of the patients autopsied. Both studies were published in JAMA Cardiology. An editorial calls for more research to see if that high risk is confirmed. If it is, say the editorialists, the covid crisis may “shift to a new de novo incidence of heart failure and other chronic cardiovascular complications.”
First Medicare snapshot confirms racial, ethnic vulnerabilities
In the first of what the agency says will be monthly updates, the CMS has released data on the impact of coronavirus on Medicare beneficiaries. The analysis is based on claims and encounter data through June 20. Those data find a disproportionate burden of both infections and hospitalizations for black Americans, with African-Americans having 670 covid hospitalizations per 100,000 vs. 175 among white Americans. The second highest rate of hospitalizations is among American Indian/Alaskan Native Medicare populations with 505 hospitalizations per 100,000. Dual eligibles were also hospitalized at much higher rates as were patients with end-stage renal disease. In other CMS news, Medicare is implementing new procedure codes to identify the use of covid therapeutics remdesivir and convalescent plasma. The use of the new codes, according to the CMS, will allow the agency to track their use. The CMS will also now pay clinicians for counseling patients who test positive about the need for self-isolation.
The emotional stages of coronavirus
A New York hospitalist has detailed what he calls the “emotional evolution” that both covid patients and the clinicians treating them are going through. Patients, he writes in the New Yorker, often have a hard time accepting the debility they still feel weeks and months after they supposedly recover. As for physicians, the writer describes several stages of emotional response. First is excitement at treating such an unknown, along with fear about PPE shortages and anxiety over infecting family. But as sick patients overwhelm hospitals, clinicians start to feel detachment and disconnection. That desensitization can shift only if hospitals and clinicians can humanize the patients they’re treating, and he describes one New York ICU that asked family members to send in patient photos and bios to hang on IV poles. There’s also frustration with the misinformation that’s being passed around and with officials lifting restrictions too soon. “It reflects,” one of the author’s colleagues told him, “the ignorance and privilege of those who haven’t had to confront this suffering.”
July 29, 2020
Will independent practices survive the pandemic?
A new report says that more than half of independent physicians are worried about their future, stoking concerns about a coming wave of consolidation in health care.
The consulting firm McKinsey & Co. surveyed physicians before the pandemic and six weeks into it. Earlier this year, more than half of the respondents said they had no more than four weeks of cash on hand and were worried about going out of business because of covid. One-third of physicians in small, independent practices said that they thought working for a larger practice might provide them more benefits, and 26% said they were much more likely or somewhat more likely to consider partnering with a larger entity. About one-third were more likely to sell their practice, and 40% were more likely to consider employment.
An article in the New Yorker on the challenges outpatient practices are facing during the pandemic similarly questions whether many will be able to survive financially until the pandemic is gone. The author, an emergency medicine resident, talks about the challenges facing specialties like internal medicine, family medicine, pediatrics and ob/gyn because patient visits have dried up. The article points out that primary care was in crisis before the pandemic because of lackluster compensation and student loan debt, which has created a shortage of PCPs. But the pandemic has exacerbated many of those problems, and the author wonders whether doctor-patient relationships that have been severed because of the coronavirus will be able to be repaired once the pandemic is over.
Professionalism vs. sexism? Judging selfies of docs
Is it unprofessional for physicians to post on social media showing themselves with a drink in hand by the pool? An article in the Journal of Vascular Surgery–“Prevalence of unprofessional social media content among young vascular surgeons”—seems to think so. A team of three researchers condemned photos that featured “provocative posing in bikinis/swimwear” and “holding/consuming alcohol.” The article generated a fierce backlash that led to physicians around the world posting their best bikini pix. A CNN report that features pictures posted by male and female hospitalists says that the journal retracted the article and apologized. Critics say that the article targets images of women and highlights the problem of sexism in the field. The authors of the article are all men.
A look at physicians’ net worth
When it comes to the finances of physicians, the good news is that more than half are worth more than $1 million. The bad news is that physicians are seeing a 55% reduction in their revenues because of a 20-30% drop in patient volumes. That’s according to a new series of slideshows from Medscape, which drills down into the finances of different specialties. The slideshow for all physicians found that 19% of orthopedists have an average net worth of $5 million, compared to just 5% of internists. Medscape data find that the biggest sources of physician debt come from mortgages, car loans and medical school loans. Medscape has individualized slideshows for internists, family physicians, psychiatrists and cardiologists.
July 27, 2020
Pooling tests delivers rapid results in low-risk patients
Need to conserve scarce testing supplies? Clinicians at a 171-bed community hospital in upper-state New York did just that by using a pooled testing strategy. Utilizing the Cepheid GenXpert system, they pooled nasopharyngeal samples from patients at low risk of covid into groups of three; over the course of three weeks, the hospital ran 530 tests using only 179 cartridges. Only four groups came back positive, requiring 11 more cartridges to be used. The pooled strategy, which was used for all patients who were admitted or placed under observation, saved two-thirds of the cartridges that would have been used for individual testing. Importantly, the authors note that they deployed the strategy when their community had an estimated positivity rate of between 1% and 2%. “If the rate of positive tests in our community rises,” they write, “the use of pooling may need to be limited or the pool size reduced.” In related news, Fierce Biotech reports that some states are seeing delays of days or weeks in test results, rendering testing basically useless. Those states are seeking out other lab partners besides the national commercial labs, which are overwhelmed.
Covid’s long-term effects
Clinicians now treating the long-term effects of covid are sounding this alarm: Some recovering covid patients will continue having persistent symptoms, perhaps indefinitely. An MMWR study of outpatients with mild covid found that 35% still reported persistent symptoms weeks after becoming infected, including patients ages 35 and younger with no underlying health conditions. And in an interview with New York magazine, the medical director of Mount Sinai’s Center for Post-COVID Care, which now treats about 300 patients, says the predominant persistent symptom is shortness of breath, due to long-term—or permanent—lung damage. Many patients also have chest pain and chest discomfort as well as neurological symptoms, and large numbers report anxiety, depression or PTSD. “I feel,” the medical director is quoted as saying, “like the population of this is going to be very large.” European countries that were hard-hit have since launched rehab services for recovering patients.
More than half of positive pregnant women are asymptomatic
A new report from the nation’s largest OB hospitalist provider makes a case for universal hospital covid testing, at least in labor and delivery units. The report, from Ob Hospitalist, looks at 10 weeks of patients across more than 160 hospitals. Among the 200 obstetric patients who presented and tested positive, 58% were asymptomatic. A study in The Lancet Child & Adolescent Health finds that 8% of women giving birth in three New York hospitals between March and May were positive. All the positive mothers practiced hand and skin hygiene and wore masks when holding their babies, most of whom roomed with their mothers in a closed isolette. Babies were tested for two weeks and followed up at one month via telemedicine—and none of them became infected. Among the mothers, 78% were breastfeeding at one week.
July 24, 2020
What data do we need?
With hospitals submitting daily covid data to HHS instead of the CDC, HHS this week unveiled its dashboard for hospital capacity data. Called the Coronavirus Data Hub, the dashboard reports on overall confirmed cases as well as inpatient and ICU bed utilization. According to MedPage Today, an HHS official claimed the new database was more robust, collecting data from 4,500 hospitals while the former CDC database included data from only 3,000. While that official said the data would be updated regularly, he didn’t say how often. A public health group led by a former head of the CDC is calling on states to collect standardized data to be able to mount an effective defense against the virus. The group is advocating for public data on 15 data points. In addition to per capita covid hospitalization rates and seven-day moving averages, the suggested indicators include the number of tests processed within 48 hours, per capita antigen and diagnostic testing rates, rates of confirmed and probable deaths, and infection rates among health care workers. “What gets measured,” the former CDC director was quoted in STAT as saying, “can get managed.”
One in six covid patients has a thrombotic event
In a new research letter published in JAMA, NYU Langone researchers report that about 16% of covid patients at their hospital in March and April had a thrombotic event including DVT, PE, MI or stroke. Among those patients, all-cause mortality was 43% vs. 21% for patients without thromboses. Most patients received low-dose prophylaxis. A well-known anticoagulant—heparin—is also in the news: Researchers writing in Antiviral Research report that heparin binds tightly to the virus, neutralizing it before it infects healthy cells. Until a vaccine is developed, the authors say, heparin could be inhaled as an early intervention among patients who test positive but don’t yet have symptoms. The research tested three heparin variants including one without anticoagulant properties.
Actual infection rates, fading immunity
With more than 4 million cases now in the U.S., the number of hospitalizations is matching the peak rate set in April, while the daily death toll this week passed 1,000 for at least two days for the first time since early June. As for how many Americans have actually been infected, a serosurvey of 16,000 people drawn from 10 sites around the country produced these estimates: The true infection rate in the U.S. is between six and 24 times the number of reported cases, based on antibodies. Writing in JAMA, the authors—who are CDC researchers—suggest that in seven of the 10 sites, actual infection rates are 10 times higher than reported. The analysis was based on blood samples collected routinely for inpatient monitoring and cholesterol screening, and the CDC has developed an interactive dashboard with data from the 10 sites. The results indicate very large numbers of patients with mild or asymptomatic infection. As for patients with mild infections, researchers writing in NEJM note that out of 34 patients recovering from mild cases, an assessment of their antibodies found a half-life of just over 70 days. According to the authors, “the results call for caution regarding antibody-based ‘immunity passports,’ herd immunity, and perhaps vaccine durability.”
Several vaccines about to move into phase 3 trials
This week brought more encouraging news about possible vaccines. One being developed by Oxford University and AstraZeneca produced an immune response among 1,000 patients enrolled in a phase 1-2 study, with interim results published in The Lancet. While researchers reported no serious side effects, 60% of subjects had mild or moderate side effects including headache, fever and injection site reactions. Chinese researchers also published results in The Lancet of a phase 2 trial in which their vaccine also induced neutralizing antibodies. Findings indicate, however, that the vaccine works better in patients under age 55. Meanwhile, the federal administration committed to paying Pfizer $1.95 billion if it delivers 100 million doses of a vaccine it’s developing with a German biotech by the end of this year. (Last week, results published by Moderna found that its vaccine candidate also produced an immune response.) USA Today reports that, after a call went out from the NIH for volunteers for vaccine and clinical trials, more than 138,000 Americans volunteered.
Beware your teens and tweens!
Among the many unknowns about coronavirus are these: How badly do children become infected, and are they major vectors of the virus? A study done in South Korea that looked at contact tracing for close to 60,000 patients found that children under age 10 transmit the disease much less frequently than adults. But that’s not the case for those ages 10 through 19; the tweens and teens may be spreading more virus than adults. Published in the CDC’s Emerging Infectious Diseases, the authors found that, overall, 12% of household contacts in homes with infected patients contracted the virus. However, that rate rose to 19% of household contacts in homes with patients ages 10-19, the highest rate among patients broken down by age. Households with covid patients under age 10, by contrast, had the lowest rate of transmission among household contacts: 5.3%. “We showed,” they wrote, “that household transmission of SARS-CoV-2 was high if the index patient was 10–19 years of age.”
July 20, 2020
Inpatient volumes bounce back
Hospitals saw their volumes begin to rebound in June although the volume of ED visits isn’t coming back as quickly. That’s according to an analysis from TransUnion Healthcare, an analytics company, which found that inpatient volumes in June were down only 8% from pre-covid benchmarks. That represents a 75% rebound from early April. The number of ED visits, however, was still 25% below pre-covid volumes, having recovered only about 50%. The bounce-back in ED visits for low-acuity diagnoses like ear pain has been even more sluggish—a possibly good trend, a company spokesperson pointed out, if patients with lower-acuity conditions are seeking out less acute care settings. Reuters reports, however, that areas of the country with growing outbreaks are again seeing patients pull back from hospital care, while Texas has again banned non-emergency procedures. An unpublished administration report identifies 18 states in the covid “red zone,” with more than 100 new cases per 100,000 people. The document suggests that those states should revert to more stringent measures.
What’s your post-acute care strategy for covid patients?
As pandemic hotspots shift to the South and West, one problem—in addition to ongoing PPE and testing shortages—keeps cropping up: Where to discharge covid patients once they no longer need hospital care? MedPage Today reports that Florida now has 11 post-acute facilities dedicated exclusively to covid patients, a network of about 750 beds. No national data exist on how many covid patients need rehab or SNF care after being hospitalized or how many require home-based post-acute treatment. So far, it doesn’t appear as if post-acute facilities have been overrun with covid patients, in part due to fewer patients getting elective procedures. Nursing-home advocates say that facilities accepting such patients need dedicated covid units and PPE. Further, figuring out discharge strategies has been made more difficult because of testing delays, with post-acute facilities refusing to admit patients without knowing their status. The CMS has announced that it plans to send point-of-care tests to 2,000 nursing home initially and eventually to all 15,000-plus facilities in the country.
Residents ensnared in H1-B ban
The guidance seemed clear: The federal proclamation issued at the end of June barring most immigrant workers on H1-B visas notes that doctors involved in the care of covid patients are exempt. But ProPublica now reports that despite that guidance, hundreds of first-year residents from other countries weren’t able to secure visas in time to start their training this month and many teaching hospitals are now short-staffed. Consulates around the world have been slow to implement the guidance, and residents are left waiting for approvals from the departments of State and Homeland Security. As of last week, some consulates began approving visas, and a State Department Web site spelled out the exemption for covid-related health care workers and researchers.
July 13, 2020
U.S. covid death rate is again on the rise
Driven by deaths in the South and the West, the coronavirus death rate in the U.S. is rising once again. That reverses a trend that’s lasted for months in which the number of daily deaths from covid has fallen. According to an analysis from Associated Press, the seven-day rolling average for deaths per day hit 664 last Friday, up from 578 two weeks ago. Driving up those averages are covid deaths in California, Texas, Florida, Arizona, Illinois, New Jersey and South Carolina. While researchers now expect the number of deaths to rise for weeks, they believe the death rate will stop short of where it was this spring as a result of more widespread testing, mask-wearing and social distancing. Florida on Sunday scored the highest number of infections reported on a single day in any state: 15,300. That’s 3,000 more cases than were reported on any day in New York in April.
Study: Remdesivir may slash covid mortality
It’s once again medical news by press release, with actual data not yet published or peer-reviewed. But Gilead Sciences, the manufacturer of remdesivir, has announced that in a new trial of more than 1,100 patients, the antiviral was associated with a 62% lower risk of mortality. According to the announcement, the mortality rate for patients who received remdesivir was 7.6% at day 14 vs. 12.5% for patients not given the drug. Further, 74% of those on remdesivir recovered by day 14 vs. 59% of those given standard care. News coverage indicates that black patients did especially well on the treatment, while those under 65 did better on remdesivir than those 65 and older. More benefit was also seen in patients who weren’t intubated. Earlier this year, remdesivir was linked to faster time to recovery for covid patients.
Will home-schooling ever end?
As the debate over whether schools can safely open again in the fall is raging, Johns Hopkins has issued resources for reopening schools. Perhaps some encouraging news: A study published in Pediatrics suggests that children aren’t major spreaders of the infection. Looking at household contacts of 40 children infected with covid in Switzerland in March and April, researchers found that 79% of those homes had at least one adult with suspected or confirmed covid before a child exhibited symptoms. In only 8% of households was a child suspected of being the index case. An accompanying editorial argues that “serious consideration should be paid toward strategies that allow schools to remain open, even during periods of COVID-19 spread,” to minimize the developmental and social disadvantages to children of remaining out of school. The American Academy of Pediatrics has issued a statement with this clarification: While being in school benefits children, “Science should drive decision-making.”
July 10, 2020
Testing crisis: Deja vu all over again
With the U.S. passing the 3 million mark in covid cases this week, many cities and states are struggling with the same dilemma that crippled hotspots in the pandemic’s early days: a lack of testing capacity. The New York Times reports that the U.S. performed three times as many tests in June as in April. Still, one testing site in New Orleans recently ran out of tests five minutes after it opened for the day, while patients in Phoenix are waiting in their cars for eight hours to be tested. Other cities are again restricting testing to only those patients with symptoms. In addition to skyrocketing demand, officials also point to scarce testing supplies and lab backlogs as reasons for the lack of capacity. The HHS plans to open surge testing sites in three outbreak locations: Jacksonville, Fla., Baton Rouge, La., and Edinburg, Texas. Each site is designed to remain in its location between five and 12 days and to test 5,000 samples per day. As for accurate point-of-care testing that would allow patients to test themselves at home and have results in minutes, companies are working furiously. While some of the products being designed would test sputum or identify coronavirus proteins, they are all in early stages and won’t be marketed for months. One proposed solution is a pooling strategy that would combine multiple samples and test them as a group. And Atul Gawande, MD, is co-author of an HBR article on assurance testing that proposes a network of online testing marketplaces.
Coronavirus and racial inequity
The most comprehensive look yet at the first 1.5 million covid cases in the U.S. indicates that Black and Latino patients have been disproportionately affected across the country, not just in large cities. Latinos and African-Americans are three times as likely to become infected as whites in the U.S., and close to twice as likely to die. Native Americans were also much more likely to be infected than whites, as were Asian Americans, although not to as great a degree. As for the reasons behind the disparities, experts say that both Blacks and Latinos tend to have front-line jobs that can’t be done at home, take public transportation, or live in crowded or multigenerational homes. The data were released by the CDC after the New York Times filed a FOIA lawsuit for the information.
Concern grows about neurological symptoms
A study in JAMA Neurology of covid patients in two New York academic centers finds that their stroke rate was eight times greater than among patients with the flu: 1.6% vs. 0.2%. U.K. neurologists writing in Brain published details of more than 40 coronavirus patients, some of whom had only mild symptoms, who ended up with acute disseminated encephalomyelitis, nerve damage, stroke or temporary brain dysfunction. The BBC reports that a University of Pittsburgh neurologist is coordinating scientists across 17 countries who are using brain scans to monitor neurologic conditions among covid patients. According to that researcher, neurological injuries caused by the virus may “result in much greater overall disability, and possibly more death” than lung problems. And while typical covid presentations in the hospital include pneumonia, ARDS or a flu-like illness, a write-up in BMJ Postgraduate Medical Journal details emerging atypical presentations when respiratory symptoms may not be apparent. Those include silent hypoxemia; delirium; cardiovascular, GI, and hepatic symptoms; and neurologic features including encephalitis. Given that range of symptoms, the authors write, it’s important to not miss other diagnoses in patients who aren’t infected with coronavirus.
What should you stockpile?
A new survey finds that virtually all hospitals are stockpiling supplies of critical medications in preparation for covid surges this summer and fall. Health care improvement company Premier surveyed its members in June and found that 88% were building their supplies of sedatives, neuromuscular blockers and controlled substances. Among respondents, 51% reported having a safety stock that could last a month while 25% were planning to stock a two-month supply. More than 80% were also stockpiling agents for rapid intubation, while 75% were stocking vasopressors. To handle covid comorbidities and complications, hospitals are also building their supplies of inhalers and IV syringes.
The pandemic’s hit on women researchers
Research into coronavirus may be exploding, but women in medical research aren’t making the kind of gains their male colleagues are. One study, for instance, that looked at published covid papers found that lead authorships by women researchers fell 23% compared to the same publications last year. Further, an analysis in Nature of preprints also found that authorship by women researchers during the pandemic has fallen compared to that of men. Experts suspect the disparity may be driven by the need for parents—specifically mothers—to take on more child care. To ensure that women academicians aren’t penalized for a research slowdown, STAT reports that Harvard Medical School and Massachusetts General Hospital have temporarily stopped the clock for tenure-track researchers and established video presentation options for women researchers to present their work.
July 8, 2020
Is telehealth fizzling out as the pandemic rages on?
While telehealth services were booming in the early days of the covid pandemic, there are signs that interest in telemedicine may be waning. Here’s a look at recent coverage of telemedicine’s adoption:
Fewer patient visits?
While many industry experts predicted that the embrace of telemedicine seen during the pandemic would continue once covid had subsided, there are signs that the use of telemedicine has already started to decline. An article in STAT says that during the week of June 14, telemedicine was used for 8% of the number of visits that would have occurred before the pandemic. In April, the number was nearly 14%.The article says that the decline in telemedicine visits could be due to difficulties getting patients—particularly the elderly—to use technology and a lack of technical resources in smaller groups. The report notes that groups with 100-plus providers shifted almost 16% of their pre-pandemic volumes to telemedicine, compared to 8% for groups with five or fewer clinicians.
Some payers scaling back coverage
A report in Becker’s Hospital Review says that some payers are scaling back their telehealth coverage. Blue Cross Blue Shield of Texas, for example, is scaling back its expanded telehealth coverage at the end of August, and Aetna began charging patients co-pays and cost-sharing for telehealth visits in early June. The report notes that some Arizona insurers had begun to decrease telehealth coverage, but as hospital ICUs in the state have filled with covid patients, they have restored telehealth coverage.
Promise vs. reality
An article in last month’s New Yorker notes that while telehealth has the potential to improve patient care, it can be a tough sell with physicians, even those in rural areas who don’t have a lot of resources and could see a boost from the technology. The article notes that one problem is that patients who are old and poor lack the technology needed to take advantage of telehealth services. The article also looks at reimbursement issues that have slowed the adoption of telemedicine.
Fraud in telehealth
Finally, another report from Becker’s says that Medicare administrator Seema Verma noted in an interview with Business Insider that the CMS is investigating fraudulent charges for telehealth services. She noted that some providers are billing for “more visits than are humanly possible in a day.”
July 6, 2020
Researchers: It’s airborne
Close to 250 scientists from more than 30 countries have signed onto an open letter to the WHO that they plan to publish this week. Their goal: to have the WHO revise its recommendations to acknowledge that coronavirus is airborne, based on evidence described in the letter. To date, the WHO has maintained that the virus is transmitted via droplets, and it continues to state that health care workers not involved in aerosol-generating procedures are protected with only surgical masks. However, the open letter argues that the virus is airborne and can linger indoors, particularly in tight quarters with poor ventilation. As a result, people should wear masks indoors, even when they’re socially distanced, and health care workers need N95 respirators. The authors of a recent Annals opinion piece made a similar case: “Use of N95 respirators to protect HCWs should not merely be a preference or a recommendation based on availability. The data indicate that it should be the standard for all inpatient COVID-19 management.”
Remdesivir’s new price tag
Remdesivir’s manufacturer last week outlined the drug’s new pricing policy, announcing that a treatment course in hospitals would cost $3,120 for covid patients with private insurance and $2,340 for patients insured by the government. The company, Gilead Sciences, also announced that almost the entire supply of the drug through September—more than 500,000 courses—will be sold in the U.S. Advocacy groups pushed back, saying the price was too high for a drug that has so far failed to improve covid mortality, while public health officials slammed the lack of better access to the drug worldwide. The California-based company, which up to now has donated the drug, defended the sales policy, noting that case numbers are surging in the U.S. The HHS says the drug is being shipped to states with record-high cases including Arizona, California, Florida and Texas. And the authors of a JAMA viewpoint propose a lottery among states to ensure fair distribution of remdesivir, so long as the lottery is paired with registries of clinical outcomes.
Chaotic research efforts make the case for large studies
More than 1,000 clinical trials targeting covid treatment and prevention have been launched since this January. But a new STAT analysis finds that much of those efforts are chaotic and wasting valuable resources. According to the analysis, many studies are too small with no controls, and they target too few potential treatments. One out of six of those trials, for instance, was designed to test antimalarials, which have since proved to be ineffective. Experts are calling for greater research collaboration worldwide and for a national clinical trial agenda in the U.S. As for other problems getting covid research off the ground, New York’s Northwell Health is a case in point. The pandemic came and went in the greater New York area before the investigators of many of the health system’s studies could enroll enough patients. That’s a problem with covid-related research even in medical centers that sweep aside internal hurdles related to oversight and regulations.
July 1, 2020
The outlook for post-covid finances in health care is grim
As the covid pandemic continues to rage in parts of the country, estimates of the economic damage are pouring in, and the news is bad. Newest data estimate that U.S. hospitals stand to lose more than $300 billion in 2020 as a result of the pandemic. Primary care practices, by comparison, stand to lose about $67,000 per physician in revenue.
A report from the American Hospital Association says that hospitals have seen declines in their inpatient volumes of 19.5% and health systems have seen declines of 34.5%. Many hospitals don’t expect volumes to return to pre-pandemic levels until 2021 at the earliest.
A Health Affairs study says that primary care practices in the U.S. will lose just over $15 billion. Researchers emphasize that number could go higher if quarantine conditions are extended or renewed, and if reimbursement rates for telemedicine revert to pre-pandemic levels.
Finally, a report from the AMGA says that more than 40% of health systems say it will take a year for their revenues to reach pre-pandemic levels. One-fifth of health systems surveyed and nearly 40% of medical groups reported drops in revenue of more than 50%.
How is covid affecting physicians’ personal finances?
While much attention has been paid to the financial havoc covid is causing large health systems and medical practices, the pandemic is also affecting physicians’ personal finances. According to a Medscape report, primary care compensation at the beginning of 2020 averaged $243,000 and specialist compensation was $346,000. But experts in the report said that some of their physician clients have reported drops in income of 50% and had stopped saving for retirement to cover basic expenses, which are outlined in the report. A report in Fierce Healthcare says one piece of good news is that because about half of physicians surveyed said they had a net worth of between $1 million and $5 million, they have some resources to get through financial hard times.
June 29, 2020
Who’s at high risk, and what’s the real number of U.S. cases?
Two global milestones passed this weekend: More than a half-million people have died of covid worldwide, and there are now 10 million confirmed cases. Here in the U.S., an analysis of antibody tests suggests that the actual covid infection rate in this country is more than 10 times greater than what’s been reported. That’s according to the CDC, which is partnering with commercial labs to test blood samples. The current analysis is based on serology samples taken between late March and early May in six states. The CDC has also broadened its list of people at high risk for developing severe disease. Instead of pegging high risk to age, the new guidance emphasizes the risk younger patients run from underlying health conditions including having a BMI of 30 or more or diabetes. Given the number of states struggling with record hospitalization numbers, the HHS secretary this weekend warned that “the window is closing for us to take action and get this under control.”
Mayo Clinic plans to restore staff pay, end furloughs
Mayo Clinic last week announced that it was calling back furloughed staff and restoring the pay cuts it had enacted earlier this year to manage falling revenue. The health system, which is based in Rochester, Minn., had cut the hours or pay of more than 40% of its 70,000-plus employees; while physicians weren’t furloughed, they did receive a 10% pay cut. The furloughs and pay cuts were originally designed to last through this year, but they will now end mid-July. That’s thanks to a better-than-expected return of clinical practice and research as outpatient, surgical and procedural volumes continue to rise. The only pay cuts that will remain in effect for those for senior leadership.
MIT launches new preprint review
The amount of covid research has exploded, as have the non-peer-reviewed results of many of those trials. To vet the findings being published on servers like bioRxiv and medRxiv, MIT and UC Berkeley have teamed up to launch a new open access journal. Rapid Reviews Covid 19 plans to publish reviews of preprint findings to weed out misinformation and bad methodology as well as highlight important new research. The project, which has received a $350,000 grant, will tap 1,600 potential reviewers.
June 26, 2020
SXSW surge, unmet demands for testing and steroid shortages
Given climbing case numbers in Texas, the state’s governor this week halted elective procedures in four counties. Texas and Arizona are two of the hardest hit among 29 states where caseloads are on the rise, while more than a dozen public laboratories nationwide say they are struggling to meet testing demand. That problem is particularly acute in Arizona where, the New York Times reports, testing bottlenecks remain the same as they were several months ago, with labs not having enough machines or trained personnel. While national testing capacity has reached a half million per day, that doesn’t help cities and states with outbreaks that need to sharply increase testing capacity. STAT reports that hospitals now have a shortage of several injectable forms of dexamethasone, the steroid found in preliminary results to lower covid mortality. After those results were announced June 16, hospital orders for the low-cost drug rose more than 600% in three days, while the rate of orders being filled for it fell by half.
ACP recommends N95s for all covid care
Guidance on masks and respirators from national and international agencies has been controversial: While the WHO says N95s should be used only during aerosolizing procedures with covid patients, the CDC recommends using N95s for all covid care—unless supplies are limited. The ACP has now weighed in with what it calls “practice points,” looking at the effectiveness of N95s vs. surgical masks vs. cloth masks. Among its recommendations: All health care personnel in close contact with suspected or confirmed covid should use N95s, while all suspected or confirmed covid patients in health care settings should wear surgical masks. (All staff, patients and visitors not in close contact with covid patients should also wear surgical masks.) As for cloth masks, they are “not considered PPE in health care settings,” and they shouldn’t be used. The guidance defines “close contact” as being within six feet of a covid patient or handling secretions from such patients. As for extended use and re-use, the guidance says there is no available evidence. But based on nonclinical outcomes, extended N95 use is preferable to re-use.
To manage ICU capacity, think state-wide, not local
When it comes to factors that can drive up covid mortality in hotspots, the authors of a Harvard Business Review piece propose this one: overcrowding of individual ICUs. Both Germany and Italy had similar infection rates, they write, but the mortality rate in Germany was 4.7% vs. 14.5% in Italy. While there were many reasons for that disparity, one was the ability in Germany to tamp down individual ICU capacity. German hospitals were able to easily transfer critically ill patients out of crowded ICUs, thanks to a national ICU bed registry that tracks available critical care beds and ventilators and allows doctors to relocate ICU patients quickly. Trying to boost ICU capacity in individual hospitals may only increase mortality, the authors argue, as overload leads to higher provider fatigue and infections among health care workers. Instead of trying to manage individual ICU capacity, hospitals should adopt a pan-regional or pan-state management strategy instead.
Health care workers, others, exempt from new H1-B restrictions
The Trump administration this week made headlines for restricting temporary work visas. A new executive order, which took effect earlier this week and remains active through the end of the year, suspends new H-1 and H-2B, L-1, J and other visas for more than 500,000 skilled and seasonal workers. Exempt from that executive order, however, are health care workers, while other broad exemptions apply to agricultural and food industry workers. The visa suspension also does not affect the status of visa-holders already in the country. The rationale given was to protect jobs lost due to the pandemic. Earlier this year, the administration called a temporary halt to issuing new green cards.
Foundations suspend fundraisers—and research suffers
Many nonprofit foundations and disease societies are being challenged by funding shortfalls. That’s because the charity fundraisers they depend on—silent auctions, mini-marathons and galas—have dried up due to covid. Not only is foundation staff being laid off, but research grants from those nonprofits are being postponed or even canceled. That’s bad news for junior researchers who often score their first grant from a disease society or foundation. According to a source in Science, such “training wheel grants”—while they make up only 5% of national research funding—often go to young researchers for small, high-risk pilots. Scoring such support enables researchers to then go on and attract much larger, government-funded grants.
June 22, 2020
WHO reports record numbers of new daily cases
This weekend, the WHO announced the largest single-day jump in the number of covid case worldwide: more than 183,000, with Brazil setting a record for the country with the most new cases in a single day (55,000). Seven states also set records over the weekend for new daily-case numbers. Health experts say that’s not just a factor of more testing but that hospitalizations are on the rise in Arizona, Texas, Florida, and North and South Carolina. As the pandemic reaches rural areas, concerns grow about financially-strapped rural hospitals. And the Boston Globe reports that statewide data show the disproportionate burden of disease among Hispanics and black Americans. While Hispanics make up only 12% of the population in Massachusetts, they account for close to 30% of all cases, while black Americans’ positive rate in the state is more than 14% although they represent only 7% of the population.
Need to sterilize masks? Steer clear of chlorine dioxide
University of Oklahoma researchers compared mask sterilization via either hydrogen peroxide vapor or chlorine dioxide on three different types of masks: N95s, KN95s and surgical masks. Their findings: Hydrogen peroxide vapor was better than chlorine dioxide, which was found to compromise masks’ filtration efficiency. With chlorine dioxide, MedPage Today reports, the filtration efficiency of both KN95s and surgical masks fell below 50% for particles of 300 nm; with vaporized hydrogen peroxide, that efficiency remained above 95% for both N95s and KN95s. (Surgical mask efficiency was reduced after being sterilized with hydrogen peroxide vapor.) While the research looked at filtration efficiency according to aerosol particle size, the study did not look at the effects of multiple rounds of sterilization.
Antibodies may fade quickly, at least in asymptomatic patients
Do recovering patients have immunity going forward? And if they do, for how long? A letter published in Nature Medicine may provide some clues. Chinese researchers looked at the clinical features and immune responses of 37 asymptomatic patients, comparing them to an equal number of people not infected. They found that antibodies may last only two or three months—although that may not mean that patients can be re-infected. According to the New York Times, the research also found that asymptomatic patients shed virus longer than those with symptoms. A preprint article published in Nature suggests that even low antibody levels may prevent re-infection.
June 19, 2020
Racial disparities, bias and activism
Calling African-American mortality from covid “a sentinel event,” editorialists in the Journal of the American College of Cardiology write that covid’s disproportionate toll among black Americans highlights “deep-rooted U.S. health care failures.” Specific disparities exist for African-Americans in cardiovascular disease and social determinants of health, both predictors of covid infection and mortality. An NEJM piece notes that many of the decision-making tools, algorithms and formulas used in medicine end up denying black patients needed care. The consequences of adjusting lab values for kidney function according to race, for instance, gives blacks better filtration rates than whites, kicking some black patients off transplant lists. And a growing number of clinicians are taking part in direct advocacy against police brutality and racial disparities, with more than 10,000 health care workers marching in downtown Seattle for Black Lives Matter. But while the national ranks of those participating in #whitecoatsforblacklives have swelled, activism may still be uncomfortable for some in a profession taught to keep silent about political and social beliefs.
Lessons learned: How NYC’s public system managed the surge
As covid cases spike in the Sunbelt and western U.S., an analysis in Health Affairs describes how New York City’s public health system (NYC Health + Hospitals, with 11 hospitals and three field hospitals) managed the crisis there this spring. One key component: increasing ICU beds, and at its apex, the health system—which had 300 ICU beds—was treating more than 1,000 ICU patients. “Primary” ICU spaces were those that already had ICU equipment, while “flex” spaces were added in PACUs, ORs and procedural areas. The most seriously ill patients were treated in the primary spaces. As for boosting ICU staff, the system used a tiered model, with experienced staff leading those who were redeployed. The EDs also had to be extensively managed, with text-message campaigns and open public letters urging patients with mild symptoms to not come to an ED. The health system also partnered with the city’s 911 call center to set up telehealth assessments of patient symptoms. Another Health Affairs commentary describes how NYC Health + Hospitals trained 20,000 staff including close to 9,000 nurses on covid content within two months.
Dexamethasone results: Proceed with caution
In the wake of this week’s announcement that low-cost dexamethasone cut mortality in covid patients who need respiratory support, Britain’s National Health Service approved use of the steroid in all ventilated covid patients. But some experts are urging caution, pointing out that researchers in the dexamethasone trial released only a summary of their data and that those data have yet to be peer-reviewed. They also note that other optimistic studies related to covid therapies have ultimately been shot down. “(A)fter all the retractions and walk backs,” wrote Atul Gawande, MD, on Twitter, “it is unacceptable to tout study results by press release without releasing the paper.” Given the enthusiasm the preliminary results have received, the WHO clarified that the therapy is to be used only for patients with severe covid who need oxygen or ventilation, not for mild cases or for prophylaxis.
What recovery can look like for the sickest patients
In New York City, the fight against covid has switched from the ICU to recovery units where the sickest covid patients, many of whom were intubated for weeks, re-learn how to walk and to eat. Sources quoted by the New York Times say the PTSD symptoms seen in many critically ill patients seem magnified among those recovering from coronavirus as those patients stay longer in ICUs and lose more muscle. MedPage Today notes that no algorithms have been released targeting post-covid care. New York’s Mount Sinai has organized a Center for Post-COVID Care to follow up on thousands of covid patients. In the three weeks that center has been operating, 80% of the patients treated there needed a pulmonology referral while 50% needed cardiology, between 20% and 30% were referred to neurology, and many received a psychiatric referral.
Patient satisfaction becomes soaring patient appreciation
It’s unprecedented, according to the CEO and CMO of Press Ganey. In a piece in the Harvard Business Review, they write that they are used to seeing patient satisfaction scores for overall care inch up by 1% a year. Yet in just one month—this February to March—survey scores for overall care from more than 238,000 hospitalized patients rose 1.6% nationwide. That jump was eclipsed by increases in covid hotspots: a 4.3% one-month increase in Washington state and a 13.2% spike in New York. As for how surveyed patients rated physician skills, those rose 2.4% nationally, but 2.8% in Washington and 10.4% in New York, with similar hikes seen for nursing ratings, overall courtesy and responsiveness. “This is,” they write, “the survey version of their banging on pots every night.”
June 16, 2020
Study: Low-cost steroid cuts covid mortality
U.K. researchers today announced the findings of their 6,000-patient RECOVERY trial: Dexamethasone reduced deaths by one-third in ventilated covid patients and by one-fifth in those receiving supplemental oxygen. According to a statement from the study’s chief investigators, more than 2,100 patients were randomized to dexamethasone 6 mg once daily (either PO or IV) for 10 days. More than 4,300 other patients who were randomized to the control arm received only usual care. Among patients receiving usual care, 28-day mortality was 41% among ventilated patients, 25% among those requiring oxygen and 13% among those with no respiratory intervention. Among patients in the dexamethasone arm, however, researchers say that one death was prevented for every eight ventilated patients and for every 25 patients requiring oxygen alone. The study found no benefit to the therapy among patients who didn’t need respiratory support. Saying that the drug was the first found to cut covid mortality, the authors—who are working to publish full details—wrote: “The survival benefit is clear and large in those patients who are sick enough to require oxygen treatment, so dexamethasone should now become standard of care in these patients.”
FDA yanks emergency use for hydroxychloroquine
The FDA this week withdrew its emergency use order for hydroxychloroquine and chloroquine, saying the drugs were not proving effective against covid and highlighting what the agency called “serious side effects,” including cardiac adverse events. According to a top FDA official, the withdrawal was based on recent science. The FDA this week also cautioned against using hydroxychloroquine in combination with remdesivir, saying that using both could reduce remdesivir’s antiviral activity. A list of frequently asked questions from the FDA states that the agency does not recommend treating hospitalized covid patients with hydroxychloroquine outside of a clinical trial.
Childrens’ risk of infection is only half that of adults’
A new letter published in Nature Research delivers this reassuring news: Children and teenagers are only half as likely to become infected with covid as those age 20 or older. Further, even when children and teenagers do become infected, they don’t develop clinical disease or develop only mild symptoms. The authors surveyed populations in six nations. They note that among patients ages 10 to 19, only 21% develop symptoms vs. 69% of those over age 70. According to Washington Post coverage, the findings have big implications not only for re-opening schools this fall but for developing countries that have very young populations. Previous studies from China have found that children are as likely as adults to become infected.
June 12, 2020
Some states see spikes in covid hospitalizations
With all states in some phase of reopening, the number of covid cases in the U.S. has now surpassed 2 million. While 21 states have reported increases in their number of covid cases since Memorial Day, nine states are seeing their number of covid hospitalizations rise: Texas, California, Arizona, Arkansas, North and South Carolina, Oregon, Mississippi, and Utah. As hospitalizations continue to mount in Arizona, Banner Health has sounded the alarm, pointing out that half the hospitalized cases in that state are in Banner hospitals. If that trend continues, according to a health system statement, the hospitals will need to surge up to 125% bed capacity. Two preprint studies in Nature Research quantify the impact of lockdowns in different countries. The authors of one of those studies estimate that the shutdown in the U.S. prevented 60 million infections and 285 million in China, while the other preprint finds that lockdown measures in Europe may have saved more than 3 million lives.
Which respirators shouldn’t you reuse?
The FDA this week released a list of respirators it says shouldn’t be decontaminated and reused. On that list: N95s manufactured in China—banned because of issues around quality control—as well as any respirators with exhalation tubes. According to the agency, hospitals should use decontamination systems only on non-cellulose-compatible N95 respirators. The announcement reverses in part the FDA’s emergency authorizations issued earlier this year that OKed decontaminating single-use masks and respirators. HealthLeaders Media reports that the Massachusetts Nurses Association, citing safety concerns, had petitioned for the right to refuse to wear decontaminated masks and respirators. And the Pennsylvania health department has now ordered all hospitals in the state to replace any soiled or damaged respirators on request, as well as require universal masking. Responding to complaints about PPE voiced by one of Pennsylvania’s largest nursing unions, the state now requires hospitals to provide respirators to any staff providing direct care to covid patients.
Health system launches acute ventilator recovery units
Because covid patients who are ventilated for more than a week need physical therapy, a New York health system has come up with this solution: acute ventilator recovery units. Northwell Health has now launched two such units, each costing about $1 million to equip. Those units are being staffed by hospitalists, pulmonologists, respiratory and physical therapists, and nurses. Patients in the units are being weaned off ventilators while receiving physical therapy. The two units, which together have 27 beds, are intended to bridge care between the ICU and acute rehab facilities. Patients transferred to the unit must have a tracheostomy, be hemodynamically stable and be able to participate in physical therapy.
Preventing your own mental health crisis
Writing in Annals, two palliative care physicians applaud the types of resources—employee assistance programs, debriefings and counseling—that institutions have set up to address the trauma front-line clinicians are experiencing treating covid. But those approaches aren’t enough, they write, sharing what they call “a foundational set of principles” to help clinicians cope. Those include “looking past the illness” by spending a few minutes on the phone with a family member to learn something “humanizing” about the patient; fostering community, not self-isolation, to build resilience; promoting vulnerability, the opposite of all the “super-hero” characterizations; and establishing boundaries and limitations, making sure clinicians have scheduled time off that they use.
Black clinicians navigate two pandemics
The intersection of the coronavirus pandemic, with its catastrophic burden on black Americans, and the grief caused by the latest round of racist murders makes this “a time of deep sorrow for Black people.” So writes Kimberly Manning, MD, a hospitalist at Atlanta’s Grady Hospital and Emory’s associate vice chair of diversity, equity and inclusion. In a Journal of Hospital Medicine perspective, Dr. Manning describes the texts and e-mails she’s received from colleagues who realize that she, along with all African-Americans, continue to face a “far more destructive pandemic,” even as coronavirus ravages black communities. Her advice: listen more than talk, extend timely support, don’t expect the grieving to guide you in how to help and “remember that support is a verb.” The Nocturnists is handing over the mic, launching a new audio documentary series called Black Voices in Healthcare. The series host has issued an open call to black health care workers to participate.
June 10, 2020
New data show mixed picture of physicians’ finances
A new survey finds that while physicians in several major specialties have experienced drops in compensation over the past year, about one-third still say their practices are financially stronger than they were five years ago.
Data from the most recent Medical Economics survey of physicians paints a mixed picture of physicians’ compensation and finances. The survey found that in terms of compensation, specialties like internal medicine, family medicine and pediatrics all experienced declines in their incomes from 2018 to 2019. Internists reported an average income of $243,000, family physicians reported an average of $241,000, and pediatrics reported an average of $231,000.
When asked to compare the financial state of their practice five years ago, 31% of respondents said things were better, 34% said things are about the same and 35% said things were worse.
Physicians who said their practices were better off financially said factors included seeing more patients, pay-for-performance incentives and renegotiating contracts with payers. Physicians who said their practices were in worse shape blamed more time spent on uncompensated tasks and lower reimbursement from commercial payers and higher overhead.
A slideshow has more details on compensation trends by specialty, type of practice, size of practice and more.
Advocacy group aims to protect physicians who speak up about PPE
A new group has formed to protect the rights of health care professionals who voice concerns they have about PPE and other issues surrounding the covid pandemic.
There have been numerous reports during the pandemic of health care workers being fired or disciplined for complaining about the state of their PPE gear. The new group, Beacon, will try to protect the rights of health care professionals who speak out about PPE and other covid-related issues.
Beacon published a letter on social media urging hospitals to respect medical professionals who “research, write and speak” about PPE. Beacon is asking physicians and health care professionals to sign a petition demanding fair and safe treatment of physicians and nurses when it comes to discussing covid-related issues like PPE.
The group intends to help health care professionals who face retaliation by helping them get their jobs back, retain a severance package or get compensation for unfair treatment.
Physician social media ratings fall way behind lawyer ratings
A new report says that lawyers are 44% more likely than physicians to receive a five-star review on the social media platform Yelp. Put another way, lawyers are 72% less likely than a doctor to receive a one-star review.
The report, published by the health care marketing firm Vanguard, found that the average Yelp rating for a doctor is 3.5 stars compared to an average rating of 4.2 for lawyers.
An article in Physicians Practice says that a study of 35,000 physician reviews found that while 96% of unhappy patients were satisfied with the quality of care, they were unhappy with non-care issues like wait times in the office and hold times on the phone. The article looks at strategies medical practices can take to address patients’ issues with those aspects of care to boost their ratings on social media sites like Yelp.
June 8, 2020
Problems arise with recycled N95s
Given mask shortages in hit-hard facilities, many hospitals have adopted protocols to extend the use of N95s and/or re-use them after storage or cleaning. But in a new research letter, UCSF researchers outline problems they uncovered with extended use and reuse. Looking at N95s worn by 68 clinicians in their ED, the authors found a high level of fit failure (71%) among duckbill N95s compared to 28% for dome-shaped masks. Among those wearing dome-shaped masks, fit failure was linked to a higher number of shifts worn, more frequent donning and doffing, and increased hours worn. “Health systems should closely evaluate N95 fit during extended use or reuse,” the authors write, “and limit duckbill mask use if alternatives are available.”
Roundup: asymptomatic patients, neurologic symptoms
As cities and states loosen stay-at-home orders, a new Annals review makes the case for substantially broadening testing to include asymptomatic patients. Data suggest that almost half (40% to 45%) of all infections are caused by asymptomatic carriers who may transmit virus to others for more than 14 days. Given the constraints with diagnostic testing, the authors call for innovative surveillance tactics including crowdsourcing data from wearables and monitoring sewage. In other news, more than half—57%—of all covid patients admitted to two hospitals in Spain had neurologic symptoms. The retrospective observational study, which was published in Neurology, looked at data on more than 800 patients. The authors found that while neurologic symptoms were present in all covid stages including recovery, stroke and inflammatory diseases appeared in late stages. One in five patients hospitalized was found to have disordered consciousness. And in addition to age and underlying conditions, genetics may play a key role in determining who develops only mild symptoms vs. severe disease. A preprint study, for instance, links having type A blood to a 50% greater risk of needing oxygen or ventilation. Other genes may regulate immune response and trigger an overreaction.
Hospitals continue to bleed jobs
Very mixed news on health care jobs in May: It was the second straight month of negative job growth for hospitals, although dentists and outpatient offices saw the return of more than 300,000 positions. Hospitals, however, reported losing 27,000 jobs last month, which came in the wake of 127,000 jobs lost in April. And while hospitals have received billions in federal relief funds designed to tide them over, a New York Times analysis finds that many of the large health systems receiving relief funds have billions of dollars in cash reserves. Many of those same systems have also cut workers’ pay while continuing to award big bonuses to top executives.
June 5, 2020
What protests may mean for transmission
The protests against racial injustice going on across America may also fuel a surge in coronavirus cases, experts say. While many protesters can’t social distance and some don’t wear masks, the fact that they are shouting and chanting is increasing the odds of passing the virus from person to person, while fires and tear gas may also increase risk. An IDSA spokesperson noted that clinicians may want to include questions about taking part in a protest when screening possible covid patients and to “enlarge the differential” to see if patients might have inhaled tear gas or were near fires. Many hospital and medical groups, including the AMA, the American Hospital Association and the American Nurses Association, have said that police brutality is a public health issue and that racism and inequitable access to care are also driving the pandemic’s disproportionate impact on African-Americans. Across the country, while some states are seeing reduced caseloads, hospitalizations continue to rise in other states including Wisconsin and Minnesota.
Some good news (maybe) for convalescent plasma
Convalescent plasma comes up short in a new study in terms of improving outcomes for patients with either severe or life-threatening covid—but the authors did note “a signal of possible clinical benefit” among those with severe disease. Chinese researchers randomized about 100 patients to either convalescent plasma plus standard therapy or standard therapy alone. Overall, they found no significant differences between the two groups in terms of less time to clinical improvement within 28 days or in mortality or time to discharge. (Patients with severe disease included those in respiratory distress, while the group with life-threatening disease included those with organ failure or intubation.) But an editorial points out that the study was underpowered and that it makes sense that the therapy would be more effective among patients who aren’t intubated. The findings, the editorialists write, “provide an important signal of possible benefit in the subgroup of severely ill patients and suggests that high titer antibody against SARS-CoV-2 may have antiviral efficacy.” In related news, “60 Minutes” this week highlighted convalescent plasma research being done at New Jersey’s Hackensack University Medical Center in which plasma donors are being handpicked. About 20% of donors have the strongest antibody response, and researchers are testing outcomes among covid patients treated with plasma from those donors.
Covid studies are challenged, then retracted
Two well-publicized covid studies have now been retracted after a host of clinicians, researchers and statisticians penned open letters to the study authors, asking to see the data their findings were based upon. One of the studies, which appeared in The Lancet, found increased mortality risk among covid patients taking hydroxychloroquine and chloroquine, findings that led the WHO to suspend a hydroxychloroquine trial. The open letter to the authors called for independent validation of the results and pointed out research inconsistencies. (The WHO has since resumed its research.) The second trial was published in NEJM, and it reported not finding a link between ACE inhibitors/ARBs and in-hospital covid mortality. The letter targeting that study questioned the reliability of the data used. Both studies relied on the same database, and both had several of the same authors. The authors this week retracted their findings, saying that the company that compiled and analyzed the data used in both studies—Surgisphere—was not cooperating with an independent review.
CMS extends more flexibility to alternative-payment models
Throwing a lifeline to hospitals and health systems struggling with coronavirus, the administration this week outlined changes to its value-based payment model programs. Among those, as reported by FierceHealthcare: The CMS will delay the start of its direct contracting model next year and extend its Next-Gen ACO model through the end of next year. It’s also allowing participants in the BPCI Advanced program to eliminate either upside or downside risk, and it is removing the downside risk for the joint replacement comprehensive care model for all episodes through the covid emergency period. A professional association of ACOs praised the changes, saying the new options would protect ACOs from pandemic-related losses.
A primer to help keep patients—and clinicians—safe
How can clinicians in covid hotspots keep themselves and their patients safe while they deal with unprecedented demand and stress? A new AHRQ primer delves into team factors that can boost safety while treating covid patients. The authors note that fatigue and burnout as well as time constraints and the stress of dealing with new teams can all lead to misdiagnoses and adverse events. Recommendations to help reduce those risks include rapid team formation by using huddles, debriefings and checklists. And because so many new work processes have been introduced to treat covid, attention must be paid to identify “potential failure points” where mistakes are more easily made. The primer also recommends using simulation to help teams prepare and prominent signage for equipment locations, hand hygiene and PPE reminders, and restricted areas.
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.