Check back often as we continue to post timely updates on COVID-19.
Don’t miss other important issues facing hospitalists. Battling the other epidemic: opioids
January 18, 2021
How health care is reaching out to vaccine-resistant workers
While there’s been a lot of attention paid to patients who don’t want to get a covid vaccine, health systems are also busy confronting the problem of workers who refuse to get vaccinated. Instead of forcing them to get the vaccine, some are trying to break through with reasoning. And when that approach doesn’t work, some health care facilities are resorting to bribes. A New York Times article says that to reach medical workers wary of getting a covid vaccine, some hospitals and long-term care centers are offering cash, extra time off and even Waffle House gift cards. The report says that in multiple cities, up to 30% of health care workers are not getting vaccinated. Some are worried about the newness of the vaccine; others cite a general lack of trust in the government.
When it comes to working with a different group of vaccine resisters—patients—an ID physician from Yale New Haven Health says that physicians need to try a multipronged approach. A HealthLeaders article offers four tips to help overcome patients’ objections to the covid vaccine that include casting the covid vaccine as part of a broader infection-prevention strategy and trying to understand patients’ values and goals to make a stronger case for getting the vaccine.
January 15, 2021
Surging covid cases force U.S. institutions to consider rationing care
In areas hard hit by the pandemic, health care institutions are beginning to raise the specter of rationing the care they provide covid patients. A ModernHealthcare report says that Arizona, which is facing one of the worst infection rates in the U.S., is nearing the day when its hospitals will have “triage officers” decide who gets treatment when there’s a shortage of staff, beds or ventilators. The leadership of five of the state’s biggest hospitals held a news conference to beg residents to mask up, socially distance and avoid large gatherings. The state has no mask mandate. In nearby Las Vegas, one hospital declared a disaster over the weekend after a covid surge left its ICU overflowing with patients. And in Atlanta, Grady Health System released a simple statement this week: “Grady is full.” For two weeks, the system’s daily count of covid patients has topped its peak numbers from the summer.
Are hospitals distributing the vaccine fairly? Critics cry foul
The sometimes-troubled rollout of the covid vaccine has some critics complaining that hospitals, which have been given tremendous authority in dispensing the vaccines, aren’t always doling the shots out fairly. A Kaiser Health News article says that in some hospitals, administrators and other workers who have no contact with patients have received the vaccine while patients and front-line staff have not. Other reports talk about the pressure that wealthy donors are placing on health care systems to jump the line. While the CDC and states have issued guidance on who should be vaccinated first, the report says those guidelines aren’t always followed. A New York Times report gives examples of healthy 20-somethings working in IT and research labs getting vaccinated before front-line workers and at-risk Americans. And a MedPage Today editorial says that hospitals need to stop “playing vaccine games” and show leadership in the often-absent lack of clear guidelines from states. The editorial says that when faced with issues like a surplus of vaccines, health systems are reluctant to go beyond the recommendations of their state and do the right thing (like ship those extra doses to a pharmacy with experience with vaccinations).
Which covid tests do doctors trust the most?
A new survey of 100 physicians in the U.S. and Europe found that most physicians (82%) trust the molecular (PCR) test to confirm active covid infections. When it comes to \ serology testing, by comparison, only 56% of physicians said they were confident in its accuracy and/or utility in confirming PCR results or identifying patients suspected of having a prior infection. The survey, which was conducted by the diagnostics company Oxford Immunotec Global PLC, asked physicians whether, when and how frequently they used four types of covid tests. More than 60% of respondents said they could use alternatives to serology and new tests to assess immunity and vaccine responses. Full results of the survey are available online. (Click on the link “December 2020, 100 Physicians Find raw data” on the bottom right side of the page.)
Federal government wins award for worst profiteering of 2020
This year’s Shkreli Awards find the federal government and Jared Kushner, President Trump’s son-in-law, at the top of the list of the worst examples of profiteering and dysfunction in health care. The awards are named after Martin Shkreli, the so-called “Pharma Bro” who earned public scorn—and jail time—for raising the price of an antiparasitic drug from $13.50 to $750 per pill. According to a MedPage Today report, Project Airbridge airlifted PPE from overseas, but instead of delivering the supplies to the neediest states, the PPE was given to six private medical supply companies to sell to the highest bidder. The Shkreli awards claim that action set in motion a bidding war among the states and blames the federal government and Kushner, who led Project Airbridge. Not only did the federal government end up outbidding states for PPE, but it seized PPE that states had managed to purchase on their own, exacerbating the shortage. A full list of all 10 Shkreli Awards for 2020 is online.
January 14, 2021
More data on what covid looks like post-discharge
Several new studies provide data, giving a picture of what covid looks like after discharge. Chinese researchers have found that three-quarters of people hospitalized with covid are still reporting at least one symptom six months later. The study, which was published in The Lancet, found that the most common symptoms were fatigue or weakness (reported by 63% of patients). Sleep difficulties were reported by 26% of patients and anxiety or depression was reported by 23% of patients. Researchers examined nearly 2,500 patients discharged between January and May of 2020.
An Annals of Internal Medicine article published in November found that 40% of discharged covid patients had not returned to normal activity 60 days after discharge. Researchers found that out of 1,648 patients who were admitted to Michigan hospitals, 13% were treated in ICUs, 70% received supplemental oxygen and 24% died. After discharge, 7% died and 15% were readmitted. After 60 days after discharge, 20% had no follow-up, 33% had persistent symptoms, and 20% had new or worsening symptoms.
A preprint published by medRxiv found that six months after discharge, 37.4% of patients exhibited neurological abnormalities during a neurological exam. The most common were cognitive deficits (17.5%), hyposmia (15.7%) and postural tremor (13.8%). Overall, patients displayed “a wide array” of neurological symptoms including fatigue (34% of patients), memory/attention issues (31%) and sleep disorders (30%). Researchers said that patients who experienced these symptoms tended to have experienced more severe respiratory signs of covid while hospitalized.
Better news came from a study in Annals of American Thoracic Society. Researchers found that while there was fatigue and deconditioning in post-discharge covid patients, only a small number faced persistent lung problems in the months after leaving the hospital. A Medscape article says that in 4% of patients presenting for follow-up evaluations, repeated chest imaging found persistent infiltrate or atelectasis. Researchers concluded that clinically relevant fibrosis is an uncommon consequence of covid.
January 12, 2021
Will the U.S. have enough doses of the vaccine for a second shot?
As the country struggles to get covid vaccines into the arms of the most vulnerable Americans, the federal government will recommend that states give all doses of the vaccine they have immediately, and not worry about saving doses for a second shot. While 22 million doses of the vaccine have been shipped to the states, only about 9 million have been given to individuals to date, according to CDC data.
To speed up the delivery of the vaccine, the federal government will recommend that Americans over 65 and all Americans with pre-existing conditions should receive the vaccine as soon as possible. That changes the previous policy, which said that states should save a second dose for everyone who had received the first shot.
According to a New York Times report, second doses will be provided as vaccine manufacturers restock the government’s supplies. The announcement comes on the heels of President-elect Biden announcing that he would release all doses of the vaccine immediately after taking office.
There are concerns about administering all vaccines in stock without holding back doses for a second shot. A Medscape report quotes officials who are concerned that if future batches of vaccine fail quality control inspections, second shots for Americans could be delayed or missed altogether. The president elect’s transition team has said that it plans to boost production to make sure that second doses are available in time.
The President-elect has vowed that 100 million doses of the vaccine will be given in his first 100 days.
January 11, 2021
How covid testing and vaccines work with the variant strain
The emergence of a highly contagious strain of covid has policymakers and researchers scrambling to make sure that covid vaccines and covid tests would be effective in combatting the virus. There were two developments last week.
Vaccine effectiveness. New data show that the vaccine from Pfizer and BioNTech appears to be effective in combatting a variation on covid engineered by researchers. The study, which has not been peer-reviewed, found that in lab dishes, the vaccine was able to neutralize the variation of the virus. While this was not the same variation seen in South Africa and the UK, researchers said they were confident the vaccine would “highly likely” work against many variations. Officials with BioNTech said that if necessary, they could reconfigure the vaccine to target variations within six weeks.
Testing. The FDA last week said that mutations in covid can produce false negative results. While the risks were described as low, the FDA said three tests—TaqPath from Thermo Fisher, the handheld Accula test from Mesa Biotech and the Linea assay from Applied DNA Sciences—may be compromised by genetic variations in covid.
January 8, 2021
CDC: Reactions to the vaccine don’t outweigh the benefits
As government officials predict that the U.S. could soon give 1 million covid vaccines a day, there have been media reports detailing severe allergic reactions to various versions of the vaccine. This week, the CDC reported that while 29 Americans have developed anaphylaxis after getting either the Pfizer or Modern vaccine, it is not scaling back its recommendations about who should receive the vaccine. Senior officials say that the risk of morbidity and mortality from covid still outweighs the risks of adverse events from the vaccine. CDC officials have said, however, that patients who experience a reaction after the first dose of the vaccine should not receive a second dose. A report from FierceHealthcare says that the average time between receiving the vaccine and having a symptom of an allergic reaction was 13 minutes, and most patients saw symptoms within 15 minutes. Most patients who had a reaction had a documented history of allergic reactions to drugs, medical products, food and/or insect stings. The rate of reactions to covid vaccines is 11.1 cases per million vaccines given; for influenza, the rate is 1.3 cases per million doses.
Community-based docs shut out of the vaccine
Critics say that as hospitals are given broad discretion over who to vaccinate, PCPs and physicians who are unaffiliated with hospitals are being shut out of vaccine plans. That’s despite the fact that these physicians often see patients with covid before they present to the ED. According to the CDC, PCPs are supposed to be among the first in line for the covid vaccine, but a STAT article says that many physicians who practice independently are left relying on the goodwill of hospitals to be vaccinated. Sources report that some hospitals are vaccinating all their staff, including nonclinical personnel, before turning their attention to outpatient physicians. A report out of San Diego, for example, says that hospitals vaccinated staff including IT workers, billing staff and engineering employees before independent physicians in the community were considered for a vaccination. An official with a large health system told reporters that it simply can’t vaccinate physicians who aren’t affiliated with it. A FierceHealthcare report says that one recent survey found that only 23% of PCPs know where are they going to get the vaccine.
Number of hospitals at or near covid capacity grew by 90%
With more than 100,000 Americans hospitalized on most days recently, it’s probably no surprise that the number of hospitals at or near covid capacity grew by 90% between July and December. A study by the Epic Health Network found that by the middle of November—just before the Thanksgiving-fueled surge—the number of hospitals that reached 80%-100% capacity had doubled. The problem is worst at rural hospitals, which tend to have fewer ICU beds. U.S. hospitals have seen a 245% increase in the number of nurses caring for covid patients between September and December. One bright spot is that rural hospitals have seen a bigger expansion in their nursing staffs (46%) than metropolitan and suburban hospitals (24%).
How dangerous is the air in your hospital?
A review of studies looking at the air in hospitals has found that viable virus particles typically exist only close to patients. The authors say their review, which appeared in JAMA Network Open, shows that surgical masks are a safe precaution for staff working in most areas of hospitals, and that N95s can be saved for respiratory procedures where clinicians may be exposed to aerosols from patients. A Medscape article says that the review data make sense because covid patients are believed to shed higher quantities of infectious viruses shortly before and after symptoms begin. By the time they’re hospitalized, the thinking goes, these patients may be less contagious and have a smaller impact on the air in hospitals.
Job market: ED residents have trouble finding jobs
While hospitalists have encountered hard times in parts of the country, your colleagues in the ED may be having a significantly worse time. A Washington Post article describes one ED resident who can’t find a full-time job in his hometown of Houston and examines the career challenges other young ED physicians are facing. Besides a drop in patients going to the ED, staffing companies are losing contracts with financially stressed health systems and therefore cutting back on hiring physicians. Experts quoted in the Post article estimate that at least one-quarter of third-year ED residents are having trouble finding work. Many have had their contracts changed or had job offers rescinded altogether. An article in Slate tries to put the problem in perspective by comparing ED physicians, who it claims are functioning like members of the “gig economy” because so many work for third-party corporations and not hospitals, to people who deliver groceries.
December 23, 2020
Study halted on therapeutic anti-clot meds for severe disease
Giving therapeutic heparin dosing for prophylaxis to covid patients in the ICU may be unsafe, according to three international randomized trials. The strategy also appears to be futile in that ICU patients receiving therapeutic vs. prophylactic dosing showed no reduced need for organ support. The three trials, which are collaborating, halted enrollment in ICU patients. However, a press release from the University of Manitoba states that enrollment continues for hospitalized covid patients with moderate disease to compare outcomes between the two dosing strategies. The three trials are being funded by the NIH and its counterparts in Canada, the U.K., Australia and the European Union.
France fast-tracks citizenship for health care workers, others
About 700 front-line immigrant workers in France who were potentially exposed to coronavirus through their jobs are now receiving expedited reviews for citizenship. The New York Times reports that those include not only health care workers, but those in child care, social workers, garbage collectors, cashiers and housekeepers. France has seen its number of naturalized citizens decrease in the last few years, and citizenship applications get routinely bogged down in paperwork. The government first initiated the fast-track program in September; this week, it announced that 700 workers were being included.
December 22, 2020
More infectious? Or are people more reckless?
British researchers and politicians are sounding the alarm about a new virus variant making the rounds in the U.K. that, officials say, is substantially more contagious. The same news is coming out of South Africa where a similar variant has apparently been the cause of most new cases there since mid-November. According to the New York Times, scientists expect the virus to continue to mutate, particularly as more potential hosts stave it off through vaccination and immunity. While British officials say the new variant is 70% more transmissible, some experts remain to be convinced, saying that finding hasn’t been confirmed in the lab and that the rise in new cases may be driven more by human behavior. Experts also say that the current mutations are not substantial enough to affect the efficacy of current covid vaccines. So far, STAT reports, the mutations don’t appear to make infected patients more sick. European countries are already suspending air travel to and from the U.K.
So you got the vaccine. Can your life return to normal?
If you’re among the few who’ve already received a dose of vaccine, you’re not fully vaccinated until you get the second dose in a couple of weeks. At that time, your risk of becoming infected should be significantly lower—but it’s not zero, so you will have to continue to wear masks, physically distance, and avoid large get-togethers and travel. Several questions about the vaccine and those who receive it remain, including: Can you spread virus to others, and how long does immunity last? The New York Times reports that in a survey of epidemiologists, fewer than one-third said their behavior will change after they’re vaccinated. Instead, they intend to take the same precautions they are taking already—until about 70% of the country has received the vaccine. Once you and those you want to socialize are all vaccinated, it should be easier to gather together, even indoors.
December 21, 2020
States start receiving the Moderna vaccine
With the FDA issuing an EUA late last week, the Massachusetts biotech Moderna is now shipping out vaccine, with its first vaccinations taking place today. The Washington Post reports that a combined total of about 7.9 million doses of both the Moderna and Pfizer vaccines are shipping this week. But states have reported a sharp—and unexplained—drop in the number of Pfizer vaccine doses they had expected to receive this week. The drug manufacturer pushed back against the administration’s claims that the delays were due to production problems. Instead, the company said, it had millions of doses warehoused and waiting for shipping instructions from the government. Last week, Pfizer shipped 2.9 million doses. The CDC reportedly told states that the number of Pfizer doses being shipped this week was being cut by 40%.
“First in the room! Back of the line!”
Stanford University last week issued an apology for a botched vaccination rollout that prioritized stay-at-home faculty over front-line residents. As originally drawn up, the university’s allocation policy for its first 5,000 doses was leaving out all but a handful or two of residents and fellows, many of whom work with covid patients, while vaccinating faculty not involved in direct care and some administrators. That sparked a demonstration at the hospital and a commitment from the university to correct the botched allocation. NPR reports that the stand-off was due to an algorithm that prioritized allocation by recipients’ age and the units they work; because of their young age and not having a set assignment, residents dropped to the bottom of the list.
December 18, 2020
Ten-day “heightened risk” post-discharge
Hospitalized covid patients face a higher risk of readmissions and death within the first 10 days post-discharge than matched non-covid patients. That’s the conclusion of research that looked at data on close to 2,200 index covid hospitalizations in 132 VA hospitals. Researchers measured those patients’ readmission and death rates for up to 60 days and compared them to patients hospitalized with either non-covid pneumonia or heart failure. Within 60 days of discharge, 19.9% of covid patients were readmitted while 9.1% had died. Compared to patients with non-covid pneumonia or heart failure, covid survivors had lower overall rates of 60-day readmissions and deaths. But that was not the case within the first 10 days when rates for both readmissions and deaths for covid patients were higher. The findings, the authors write, suggest “a period of heightened risk of clinical deterioration.” The authors also note that focusing exclusively on inpatient death tolls “may substantially underestimate burdens of COVID-19.”
Covid: what science gained and lost
Scientists this year produced more than 74,000 covid-related papers, with one-third of researchers in the U.S., Canada and Europe reporting that they had suspended their previous work and pivoted to covid research. An article in The Atlantic compares the efforts of the scientific community around covid to the Manhattan Project and the Apollo program—and finds that covid beats them both in terms of focused scientific attention. But while much of the coverage in the U.S. targeted the political failures in covid response, many scientific missteps have been made. Some successes: fast-forming alliances, freely accessible preprints, an extraordinary and apparently successful race to find vaccines. Some low points: shoddy studies with sometimes misleading results, trials launched in haste with too small samples, women’s research hours falling more than men’s, and covid’s single focus leaving other topics neglected. “At its best, science is a self-correcting march toward greater knowledge for the betterment of humanity,” the author writes. “At its worst, it is a self-interested pursuit of greater prestige at the cost of truth and rigor.”
Nurses get the superhero treatment, plus a worthy cause
A health system has teamed up with Marvel to illustrate the true stories of nurse “superheroes.” Medpage Today reports that the Pittsburgh-based Allegheny Health Network wanted to thank its nurses. The health system worked with Marvel to create a comic, “The Vitals: True Nurse Stories,” with three stories of eight hospital nurses caring for covid patients. While they don’t wear capes or suffer genetic mutations, they do go above and beyond, and the health system has distributed thousands of copies of the comic throughout Pittsburgh schools. And Michael Osterholm, PhD, who heads up the University of Minnesota’s Center for Infectious Disease Research and Policy, worked with a local charity council and foundation to launch the Frontline Families Fund, which is collecting donations for families of health care workers who have died in the pandemic. Since its launch in mid-November, the fund has raised close to $750,000, with donations going to direct grants and scholarships.
December 17, 2020
Baricitinib-remdesivir combo speeds up recovery
While a randomized trial of more than 1,000 hospitalized covid patients didn’t
post blockbuster results, the findings were still positive and promising. Writing in NEJM, the authors note that adding the antiinflammatory baricitinib to remdesivir (vs. placebo plus remdesivir) produced slightly faster median recovery times: seven vs. eight days. Shorter recovery was especially marked with combination therapy in patients on high-flow oxygen or non-invasive ventilation: 10 vs. 18 days. Use of the therapeutic combo was also linked to better clinical status and fewer adverse events. Another plus: Baricitinib, which is approved for treating rheumatoid arthritis, is an oral drug with few drug-drug interactions that is already being used in more than 70 countries. The FDA has already issued an EUA for the combo therapy, and the NIH’s treatment guidelines panel has weighed in. Among its recommendations: Panel members don't find enough data to recommend either for or against using baricitinib with remdesivir in hospitalized patients where corticosteroids can be used. But in rare cases when corticosteroids can’t be used, the panel recommends the combination therapy in hospitalized, nonintubated covid patients who need supplemental oxygen. However, baricitinib should not be used to treat covid without remdesivir, except in clinical trials.
December 16, 2020
First vaccinations begin (updated Dec. 17)
The FDA last Friday issued an EUA for the Pfizer vaccine, with the first doses shipped earlier this week and delivered to hospitals and nursing homes. The FDA’s advisory panel is meeting Thursday to decide whether to recommend authorizing use of the Moderna vaccine as well. The FDA also released data on the Moderna candidate, indicating that it achieved 95% efficacy in enrollees age 18-64, 86% efficacy in those age 85 and older, and 100% efficacy against severe disease. In interim guidance, the CDC notes that patients with acute covid should wait until they’ve recovered to be vaccinated. Further, pregnant or immunocompromised patients may still be vaccinated if they don’t have other contraindications, while patients with a history of anaphylaxis should be observed for 30 minutes after vaccination and those with a history of allergic reactions should be observed 15 minutes. One health care worker in Alaska had a severe reaction to the vaccine and was hospitalized overnight. According to the Washington Post, the worker had no history of
allergic reactions.As scientists explain in a Huffpost article, the vaccines were developed so quickly because funding—usually a huge hurdle—was abundant and the testing and manufacturing phases overlapped to save time. Also, development was a global effort and the research didn’t start from scratch, as some vaccine development took place during earlier SARS and MERS outbreaks. Vaccine developers could also use early research about mRNA vaccines; both the Pfizer and Moderna vaccines are mRNA vaccines. Much of the pioneering research on mRNA vaccines was done by Katalin Kariko, PhD, an Hungarian immigrant whose 40-year research career included being fired, demoted and passed over for grants.
December 11, 2020
FDA committee green-lights Pfizer-BioNTech vaccine
FDA advisors yesterday endorsed the use of the Pfizer-BioNTech vaccine, paving the way for the FDA to issue an emergency use authorization within hours or days. CNBC this week reported that the government plans to distribute 2.9 million doses of the vaccine as soon as the FDA authorizes its use. In related news, state health departments are leaving it up to individual hospitals to figure out how, when and who among their workforce to vaccinate first. A Business Insider article provides details on how four large health systems—Intermountain, Northwell Health, McLaren Health Care in Michigan and Yale New Haven Health—plan to vaccinate staff. Some will stagger vaccinations within departments in case some doctors and nurses are out with side effects, which can include headache and fatigue. Others wanted to let clinicians themselves decide who to be vaccinated first; they have scrapped that approach because initial vaccine supplies will be limited. Instead, most health systems will prioritize those on the front lines with covid patients, including workers in environmental services. While some hospitals intend to vaccinate their own staff, McLaren will partner with Walgreens. Vaccine candidates from both Pfizer and Moderna are getting close to an EUA from the FDA, although Pfizer may not be able to provide more than 100 million doses—enough to vaccinate 50 million people—before next summer.
Outsized risks for health workers
A study from the U.K. puts in stark relief the risk of severe covid that health care workers run. Writing in BMJ Occupational & Environmental Medicine, the authors looked at severe covid risk by occupation and found that health care workers’ risk is more than seven times greater than non-essential workers. Overall, the risk of essential workers is 1.6 times that of non-essential workers, while those providing child or elder care run 2.5 times the risk of non-essential workers and those in transport run 2.2 times the risk. The study also found substantial racial disparities in the risk of severe covid, with non-white essential workers having 2.4 times the risk of white essential workers. In better news: Most employees with Advocate Aurora Health in the Midwest will find extra cash in their next paycheck. In a video message, the health system CEO said that employees would share $66 million in bonuses in recognition of their “remarkable work, commitment and sacrifices throughout the unprecedented year of 2020.” With the tiered bonuses, administrative and corporate personnel will each receive $500, those providing onsite support to clinical staff will receive $800 and direct patient-care providers will each be given $1,300. Bonuses will go to close to 69,000 employees, about 90% of the health system’s staff.
A (mostly) slow flu season, fewer hospital-acquired infections
New data indicate that flu activity in November was low compared to last year, with some exceptions. The data, from Walgreens, looked at patterns in antiviral medications being ordered in stores. Flu activity was highest in Nevada and Mississippi and had taken hold of some communities particularly in Texas and parts of the South and Midwest. In other news, the CDC reports that hospitals last year made progress in tamping down hospital-acquired infections. The report found that the incidence of bloodstream infections in hospitals fell 7%, while hospitals had 8% fewer hospital-acquired UTIs (ICUs saw a 12% decrease) and 18% fewer cases of C. diff. The report did find a 2% increase in ventilator-association infections and no significant change in surgical site infections or those caused by MRSA.
How speaking up (and out) can hurt clinicians
Recent news highlights the dangers of clinicians going public about ignoring pandemic rules and restrictions. At the same time, other health workers find themselves in trouble for speaking out against what they see as unsafe practices in their hospitals. One Oregon family physician who bragged at a post-election rally that he and his office staff refuse to wear masks has had his license suspended. Oregon state law requires providers to wear face masks in health care settings. Meanwhile, a nurse—also in Oregon—who posted a video on social media saying she rarely wears a mask, travels often and allows her kids to have play dates has reached an agreement with her employer to no longer work there. But at the other end of the safety spectrum: A nurse who was fired after raising concerns about the scrubs that nurses have to wear at a hospital in St. Paul, Minn., may find his license on the line. When the hospital told nurses to wear and launder their own scrubs, the nurse instead wore hospital-issued (and washed) scrubs and filed an OSHA complaint, alleging the policy was unsafe. According to MedPage Today, he was fired for violating the hospital’s dress code, and he then sued the hospital for whistleblower retaliation and wrongful termination. Now the state’s nursing licensing board is investigating his conduct, putting his license at stake—while a union steward at the hospital says that nurses are still required to wear and clean their own scrubs.
December 10, 2020
A single day death record, and ICUs are filling up
Wednesday’s death toll in the U.S.—3,123—exceeded the number of
lives lost on 9/11 and at Pearl Harbor, and was the single highest death count in
the country since the pandemic began. The New York Times released an interactive map that allows you to gauge the capacity left at an ICU near you. The accompanying article points out that one-third of Americans last week lived near hospitals with fewer than 15% of their ICU beds available, while one in 10 lived in areas where remaining ICU capacity was down to 5%. Both the map and article were based on facility-level data on hospitalized covid patients that the federal government released for the first time. Who’s fueling the explosive spread? Less than one in five people. An Axios-Ipsos index finds that 18% of the population is driving most of the out-of-home, indoor activity that’s behind many transmissions. During a week, members of this group spend at least one hour in three or more indoor settings including bars and restaurants, gyms, places of worship, entertainment centers, and other people’s homes. Only 44% of those people report wearing a mask at all times—and group members are more likely to be under age 55, male and Republican.
December 9, 2020
Finally. a national plan?
The CDC last week released what the New York Times called “a battle plan,” spelling out 10 public health measures that, with the current high levels of transmission, are now essential nationwide. In its starkest language yet, the agency noted that rising case numbers call for a uniform national approach. While all 10 recommendations have been issued before, it was the first time the CDC had issued a summary of it guidance. Along with universal mask use (including on mass transportation), the agency advised physical distancing and limited contacts; avoiding nonessential indoor spaces and crowded outdoor ones; increased testing, diagnosis and isolation; prompt investigation and contact tracing; safeguarding high-risk populations; protecting essential workers, including providing adequate PPE; postponing travel; increased ventilation and enhanced hand hygiene; and achieving widespread vaccine availability. The guidance also gave top priority to keeping K-12 schools open, recommending that schools be the last to close and the first to re-open. In-door restaurant dining was flagged as “particularly high-risk,” and the agency recommends that all exercise be done outdoors. In other news, the incoming administration is nominating Rochelle Walensky, MD, MPH, chief of infectious diseases at Massachusetts General Hospital and Brigham and Women’s Hospital, to run the CDC.
Hospitals make plans to vaccinate staff
A CDC committee has recommended that health care workers be the first to receive vaccine. But state health departments are leaving it up to individual hospitals to figure out how, when and who among their workforce to vaccinate first. In a Business Insider article, representatives from four big health systems—Intermountain, Northwell Health, McLaren Health Care in Michigan and Yale New Haven Health—shared some of their strategies to vaccinate staff. Some plan to stagger vaccinations within departments in case some doctors and nurses are out with side effects, which can include headache and fatigue. Others wanted to let clinicians themselves decide who wanted to be vaccinated first, but have scrapped that approac because initial vaccine supplies will be limited. Instead, most health systems are prioritizing those on the front lines with covid patients, including workers in environmental services. While some hospitals intend to vaccinate their own staff, McLaren will partner with Walgreen’s throughout the state. Vaccine candidates from both Pfizer and Moderna are getting close to an EUA from the FDA, although Pfizer may not be able to provide more than 100 million doses—enough to vaccinate 50 million people—before <a href=https://www.washingtonpost.com/health/2020/12/07/pfizer-vaccine-doses-trump/>next summer</a>.
December 7, 2020
You became infected. Should you get vaccinated?
For the thousands of health care workers who’ve already been infected with covid, should they be vaccinated when a vaccine becomes available? Clinicians are falling on different sides of that debate, according to MedPage Today. Some who’ve recovered believe they’ve developed some immunity and think that scarce vaccine resources should instead go to others who’ve never been exposed. But others point to the fact that long-term immunity is still an open question and that no one knows how long antibodies may persist. That camp believes they should be included in the first wave to receive vaccine to avoid becoming re-infected and perhaps taking the virus home to their families. Still others hold that, while clinicians who’ve recovered should eventually be vaccinated sooner rather than later, they may want to hold off until colleagues who have never been infected receive the vaccine first. That raises another question: Given how many people remain asymptomatic after being infected, should people first be tested for antibodies before being vaccinated?
Remdesivir: shrinking indications?
The NIH last week revised its guidelines on the use of remdesivir, further contracting the drug’s indications. In updated guidance on therapeutic management, the NIH no longer recommends remdesivir with dexamethasone for hospitalized covid patients who need either intubation or ECMO. Instead, dexamathasone alone is now recommended for those such patients. The NIH does recommend using remdesivir in hospitalized patients who need minimal supplemental oxygen, and a combination of remdesivir and dexamethasone for those requiring increasing amounts of supplemental oxygen. As for hospitalized patients not on supplemental oxygen, NIH maintains there is insufficient evidence either for or against using remdesivir. The WHO last week published interim results of a trial it sponsored, one that concluded that remdesivir—as well as hydroxychloroquine, lopinavir and interferon regimens—don’t improve hospitalized patients’ overall mortality, length of stay or need for ventilation. But editorialists have pushed back against that conclusion, noting that the WHO trial was conducted across more than 400 hospitals in 30 countries. While launching the trial was “a remarkable achievement,” they wrote, the research was conducted “in settings with varied and evolving standards of care, capacity to administer treatment, and treatment options.” The editorial also points out that other studies have found that remdesivir helps speed recover, and the authors believe the drug’s role in treating hospitalized patients is still being determined.
December 5, 2020
Former hospitalist named surgeon general—again
Vivek Murthy, MD, MBA, a former hospitalist at Boston’s Brigham and Women’s Hospital who served as the nation’s surgeon general from 2014 to 2017, has been named the surgeon general in the incoming administration. But Dr. Murthy is also being given “a broader portfolio,” according to Politico, one that will include being the top medical expert of the incoming administration’s covid response as well as its public face. As surgeon general, Dr. Murthy is expected to devote himself to the pandemic response in the coming year. Once the immediate crisis has abated, he will likely focus on substance abuse, mental health and health care disparities. Dr. Murthy currently serves as co-chair of the president-elect’s covid advisory board.
December 4, 2020
No good inpatient news in 2021 physician fee schedule
The CMS this week finalized the Medicare physician fee schedule, boosting payments for outpatient E/M visits starting in 2021. However, the final rule also busted down the conversion factor from $36.09 to $32.41, a move panned by several medical societies. (The final rule also made permanent the expansion of several telehealth services.) In response, the president of SHM this week sent a letter to several members of the House of Representatives, voicing strong support for their bipartisan bill (H.R. 8702). If passed, that bill would hold providers harmless for two years from pay cuts due to budget neutrality adjustments to the physician fee schedule. Otherwise, the letter states, those adjustments will translate to hospitalists seeing an 8% drop in their Medicare fee-for-service revenue.
Doctors, nurses appeal to state leaders
As daily hospitalization and death rates continue to break records, overwhelmed health care workers are appealing directly to state governors to take further actions to contain the virus. In Connecticut, a letter that physicians sent to the governor garnered close to 700 online signatures. That letter asked him to close gyms and indoor dining and to ban public gatherings. In response, the Washington Post reports, the governor met virtually with several of those physicians to hear their concerns. In Mississippi, however, the governor rejected a call from four leaders of health systems and medical associations in the state to re-impose a statewide mask mandate. Instead, the governor increased the number of counties in the state that have mask mandates, to 54 out of a total of 82 counties. Doctors in Tennessee have likewise appealed to their governor to put a statewide mask order in place, while physicians in Missouri have started a similar petition.
December 2, 2020
CDC advisory panel: You’re 1a (updated Dec. 4)
With more than 100,000 Americans now hospitalized for covid, a federal advisory panel this week recommended that health care workers—all 21 million—be the first in the country to receive a vaccine when one becomes available. Also at the front of the line in what the CDC is calling phase 1a of vaccine distribution: about 3 million residents of long term care facilities, a population with more than 100,000 deaths. The recommendations came in a 13-to-1 vote from the CDC’s Advisory Committee on Immunization Practices, an expert panel that helps the CDC determine how to distribute vaccine doses. The FDA may issue EUAs for vaccines next week, with the first doses available this month. Operation Warp Speed, the federal vaccine initiative, plans to vaccinate 100 million Americans, including all health care workers and high-risk patients. According to a preprint model, prioritizing health care workers and high-risk patients and vaccinating 40% of the U.S. population could decrease hospitalizations by 85% and deaths by 88%. But will being vaccinated be mandatory in hospitals? According to a write-up from the Philadelphia Inquirer, the answer is “probably not,” given that these vaccines won’t be fully licensed. Spokespeople from local health systems in Philadelphia noted that being vaccinated, at least initially, will be voluntary, while a New Jersey health department poll found that about one-third of doctors surveyed didn’t want to be part of the first round of vaccinations.
CDC revises its guidance on quarantine (updated Dec. 4)
The CDC this week recommended a shorter time for quarantine, a move that public health officials hope will encourage more exposed patients to actually stay home. While the CDC still advises a 14-day quarantine as the safest course, the revised guidance holds that exposed individuals who don’t develop symptoms need to quarantine only 10 days, while those who also test negative should stay in quarantine only seven days. The revisions come after a meta-analysis in The Lancet found that, while viral shedding may last weeks or even months, no live virus is shed longer than nine days. According to that analysis, covid patients are the most infectious from two days before symptom onset to five days later, while older patients tend to shed live virus for nine days. Another finding: Asymptomatic patients have the same viral loads as those experiencing symptoms, but they can clear those loads faster. The authors write, “These findings indicate that, in clinical practice, repeat testing might not be indicated to deem patients no longer infectious. Duration of infectiousness and subsequent isolation timelines could reflect viral load dynamics and could be counted from symptom onset for 10 days in non-severe cases.”
Olfactory mucosa may be the gateway for brain infections
Neurologists still aren’t sure if coronavirus can invade the brain directly. New findings based on more than 30 autopsies suggest that such an invasion may be happening via olfactory mucosa. Publishing in Nature Neuroscience, German researchers took images of intact virus in patients’ nasopharynx, perhaps entering the central nervous system by “exploiting the close proximity.” The authors noted that their results apply to only patients with severe disease. They also added this: “As we were able to detect SARS-CoV-2 RNA in some individuals in CNS regions that have no direct connection to the olfactory mucosa, such as the cerebellum, there may be other mechanisms or routes of viral entry into the CNS, possibly in addition to or in combination with axonal transport.”
December 1, 2020
Hospital staffing becomes “a national bidding war
It’s a staffing problem that hospitals are struggling with: an exodus of nurses being lured away to other facilities or to traveling-nurse agencies by lucrative incentives. An article from Kaiser Health News describes what its authors call “a national bidding war,” as nurses—especially those who feel they’re not adequately protected against covid in their hospitals—easily find higher-paying opportunities elsewhere. The article quotes one nurse who quit a full-time job in suburban Denver hospital where PPE was reused until it fell apart; as a traveling nurse, she saw her salary jump from $800 a week to $5,200, with a contract that guaranteed adequate PPE. Job postings, particularly for slots in Plains and Rocky Mountain states looking for ICU nurses, are offering up to $10,000 a week. Rural and urban safety-net hospitals can’t begin to afford such salaries and have the most to lose.
Today’s Hospitalist has been reporting on covid-19 since January 2020. Click here for earlier updates.