“Mayo Clinic is furloughing or reducing the hours of about 42 percent of its 70,000 employees across all of its campuses in an attempt to mitigate the financial losses from the COVID-19 pandemic…
“Approximately 30,000 staff from across all Mayo locations will receive reduced hours or some type of furlough, though the duration will vary depending on the work unit,” according to a statement on Wednesday from spokeswoman Ginger Plumbo.
As these will be furloughs, not layoffs, Mayo Clinic will continue to pay for the health care benefits for all of its employees while they are off work…
Doctors will not be furloughed, but will have a 10 percent wage reduction. Doctors who are senior managers will see reductions of 15 percent. Top executives are taking 20 percent reductions.
Some of Mayo Clinic’s medical departments are mostly quiet, so some doctors may be “redeployed where needed most,” according to Mayo.
Hospitals on the Rochester campus are operating at 35 to 40 percent capacity, and surgical volume is at 25 to 30 percent of the level that was expected. About 60 percent of Mayo Clinic’s business comes from elective procedures of the kind that are now on hold.
This is latest step in Mayo Clinic’s financial stabilization strategy to address an anticipated $3 billion loss due to the pandemic forcing a temporary halt in all elective procedures and average medical appointments.” (A)
“Elective surgery does not mean optional surgery. It simply means nonurgent, and what is truly nonurgent is not always so obvious. Gerard Doherty, the chair of the surgery department at Brigham and Women’s Hospital in Boston, which began postponing elective surgeries on Friday, says surgical procedures can fall into one of three categories. About 25 percent of the surgeries performed at his hospital can be delayed without much harm. These might include joint replacements and bariatric surgeries for weight loss. Another 25 percent are for life-threatening emergencies that need to be treated right away: perforated bowels, serious heart problems, bones that have broken through the skin…
All over the country, patients are finding their nonemergency surgical appointments canceled as hospitals prepare for a spike in coronavirus cases. Surgeries for early-stage cancer, joint replacements, epilepsy, and cataracts are all getting pushed back—to ration much-needed personal protective equipment, keep hospital beds open, and to shield patients from the virus. On Friday, the American College of Surgeons recommended that hospitals reschedule elective surgeries as needed. Hospitals in outbreak hot spots such as Seattle, New York, and Boston were the first to act, but more are likely to follow suit.
The last 50 percent are the tricky ones. These cases, Doherty says, have “some potential for harm to delay”; they might include cancer and problems in the blood vessels of the arms and legs. Brigham and Women’s is postponing some of these surgeries now on a case-by-case basis…
Canceling surgical appointments is also meant to limit the number of people circulating through hospitals. Surgeries like Kumm’s, which require a long hospital stay, during which visitors might be coming in and out, Ko said, may be particularly risky from the point of view of spreading the coronavirus. Hospitals around the country are also limiting patients to one adult visitor.” (B)
“In the same week that physicians at the University of California-San Francisco medical center were wiping down and reusing protective equipment like masks and gowns to conserve resources amid a surge of COVID-19 patients, 90 miles away teams of doctors at UC Davis Medical Center were fully suited up performing breast augmentations, hip replacements and other elective procedures that likely could have been postponed.
Across the nation, hospitals, nurses and physicians are sending out desperate pleas for donations of personal protective gear as supplies dwindle in the regions that have emerged as hot spots for the fast-spreading new coronavirus. The Centers for Medicare & Medicaid Services, the Surgeon General and the American College of Surgeons (ACS) have urged hospitals to curtail non-urgent elective procedures to preserve equipment. Washington state, Colorado, Massachusetts, Ohio, Kentucky, New York City and San Francisco have gone further, placing moratoriums on elective surgeries.
Still, in pockets of the country, some hospitals have continued to perform a range of elective procedures, spokespeople confirmed. In Pennsylvania, the University of Pittsburgh Medical Center is continuing to offer elective procedures on a case-by-case basis. In Indiana and Illinois, Franciscan Health will continue some elective surgeries, depending on the availability of protective equipment and the concentration of COVID-19 cases in the area. And in California, Nebraska, Nevada and Wyoming, Banner Health will continue to offer elective procedures in communities that haven’t yet reported cases of COVID-19.
The divergent responses underscore not only the disparities in supply stockpiles from hospital to hospital, but also a lack of coordination — even at a regional level — in getting equipment and medical care where it’s needed…
California offers a prime example of the disparate responses. The state has been an early epicenter for the new coronavirus, with more than 1,000 confirmed cases and nearly two dozen deaths. The San Francisco Bay Area has been hit particularly hard, and emergency room doctors at UCSF this week described dire shortages of personal protective equipment, or PPE. Sutter Health has shut down elective surgeries, as have most other University of California hospitals across the state.
At UC Davis, in contrast, procedures have continued.
“I’ll be clear: There is no reason to cancel elective procedures at this time and doing so would be a disservice to our patients who, for many different reasons, require surgery or other scheduled procedures,” UC Davis Chief Medical Officer Dr. J. Douglas Kirk wrote in an email to employees earlier this week. “We currently have capacity and we have an outstanding supply chain and procurement team, so the UC Davis Medical Center is doing well on supplies, PPE and space utilization.” (C)
Some hospitals and surgery centers continue to conduct elective surgeries amid the COVID-19 crisis, defying federal requests and state bans seeking to stop the nonessential procedures even as essential medical supplies dwindle.
Medical staff members said the refusal to comply puts them and their families at risk as they are forced to reuse personal protection gear such as face masks. Some said the outsized influence of revenue-generating surgeons is a driving factor….
USA TODAY reported March 21 that hospitals, including UPMC and Virginia Hospital Center in Arlington, allowed some elective surgery. Surgeon General Jerome Adams wrote an op-ed for USA TODAY that day further urging physicians and hospitals to stop. VHC has apparently halted nonemergency procedures.
“As we are in the midst of a whole-of-government effort to fight COVID-19, we need all our health care workforce and more to meet the demands of this challenge,” Adams wrote. “Every non-urgent case takes precious staff time and energy, straining a workforce already going above and beyond in this fight.”
The American College of Surgeons cited the financial pressure in “ethical guidelines” it released.
“Health systems, and federal and state governments should begin developing comprehensive solutions to address the financial impact on hospitals, physicians, and other health care providers that result from canceled operations, so that these perceived financial risks do not influence some surgeons to continue to perform elective operations,” the guidelines say…
Facilities allowing nonemergency surgeries include Steward Health Care. The more than 30-hospital chain, which operates in states including Texas and Louisiana, said in a statement that it will “continue to support all scheduled surgeries and procedures, and we will leave the decision on whether it is appropriate to proceed now to our physicians and their patients.”
Steward said it is “committed to preserving access to scheduled procedure time for as long as possible.”…
Marty Makary, a Johns Hopkins University hospital surgeon and professor, said, “Any entirely elective procedure that uses valuable supplies at this critical time is short-sighted.”
“It is borderline unethical for any U.S. hospital to perform elective surgery if the operation can be delayed three or more months without any health consequences to the patient,” said Makary, author of “The Price We Pay: What Broke American Health Care – and How to Fix It.” (D)
“This week, ACS released guidelines for triaging elective surgery during the pandemic that include seven overarching principles:
1. Although some of the triaging guidelines include recommendations based on a low level of COVID-19 infections, coronavirus cases are expected to surge in the next few weeks and surgical teams are advised to prepare for much higher infection rates when triaging elective surgeries now.
2. Based on surgical judgment and resource availability, patients should get appropriate and timely surgical care.
3. Nonoperative management is advised when it is clinically appropriate for patients.
4. Surgical teams should consider waiting for COVID-19 test results for patients who may be infected.
5. With anticipated staffing shortages, emergency surgical procedures at night should be avoided.
6. Aerosol generating procedures such as intubation and electrocautery of blood increase healthcare worker risk for patients who test COVID-19 positive or are suspected of infection. If aerosol generating procedures are unavoidable, surgical staff should wear full personal protective equipment including an N95 mask or powered, air-purifying respirator designed for operating room use.
7. Although there is insufficient data to make a recommendation for open surgery vs. laparoscopy, surgical teams should pick an approach that reduces operating room time and increases safety for patients and healthcare workers.” (E)
“The ACS bulletin stated the following specific recommendations [11]:
Each hospital, health system, and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures until we have passed the predicted inflection point in the exposure graph and can be confident that our health care infrastructure can support a potentially rapid and overwhelming uptick in critical patient care needs.
Immediately minimize use of essential items needed to care for patients, including but not limited to, ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators. There are many asymptomatic patients who are, nevertheless, shedding virus and are unwittingly exposing other inpatients, outpatients, and health care providers to the risk of contracting COVID-19.” (F)
“What Cleveland Clinic says
The Clinic will determine, based on guidelines set by the Ohio Department of Health, which procedures are non-essential and ones where patients should expect delays.
“This change supports statewide efforts to conserve hospital beds, equipment and supplies while protecting healthcare workers in preparation for a potential surge of patients with COVID-19,” Cleveland Clinic spokeswoman Andrea Pacetti said.
The procedures that will move forward must be life-saving, preserve the function of organs or limbs, reduce the risk of metastasis or progression of a disease or reduce the risk of severe symptoms, according to the Clinic’s guidelines as well as MetroHealth and University Hospitals.
Examples of elective surgeries and other related procedures include,” deferrable bronchoscopy, deferrable upper and lower endoscopies, routine dental procedures, symptomatic problems which are stable, management of benign conditions, cosmetics, primary and revision joint therapy (non-infected), bariatric and elective hernia surgery, and urogynecology,” the Clinic says.
“We continue to adapt to this evolving situation, with the primary goal of keeping our patients and caregivers safe,” the Clinic said in a statement.” (G)
“Healthcare facilities should be able to begin performing elective procedures again if they follow certain protocols, according to guidelines released Sunday by the Centers for Medicare & Medicaid Services (CMS)…
“Every state and local official has to assess the situation on the ground,” she said. “They need to be able to screen patients and healthcare workers for the COVID virus, and we need to make sure that patients feel safe when they come in to seek healthcare services by showing they have the appropriate cleaning in place and that they observe social distancing inside the healthcare facilities.” Verma added that this will be a gradual process in which “healthcare systems across the country need to decide what services should be available. We want to make sure systems are reopening so they can stay open, and doing that in a very measured way.”
The new CMS guidelines specify that “non-COVID-19 care should be offered to patients as clinically appropriate and within a state, locality, or facility that has the resources to provide such care and the ability to quickly respond to a surge in COVID-19 cases, if necessary. Decisions should be consistent with public health information and in collaboration with state public health authorities.”
Once the facility has reopened to patients needing elective procedures, “evaluate the necessity of the care based on clinical needs,” the guidelines state. “Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary.”
As for getting the practice ready to accept patients, “Consider establishing Non-COVID Care (NCC) zones that would screen all patients for symptoms of COVID-19, including temperature checks. Staff would be routinely screened as would others who will work in the facility (physicians, nurses, housekeeping, delivery and all people who would enter the area),” according to the guidelines. “Sufficient resources should be available to the facility across phases of care, including PPE [personal protective equipment], healthy workforce, facilities, supplies, testing capacity, and post-acute care, without jeopardizing surge capacity.”
The guidelines also address PPE for patients and staff. “CMS recommends that healthcare providers and staff wear surgical facemasks at all times. Procedures on the mucous membranes including the respiratory tract, with a higher risk of aerosol transmission, should be done with great caution, and staff should utilize appropriate respiratory protection such as N95 masks and face shields. Patients should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks.” (H)
“Centers for Medicare & Medicaid Services (CMS) Recommendations, Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I
General Considerations
• In coordination with State and local public health officials, evaluate the incidence and trends for COVID-19 in the area where re-starting in-person care is being considered.
• Evaluate the necessity of the care based on clinical needs. Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary.
• Consider establishing Non-COVID Care (NCC) zones that would screen all patients for symptoms of COVID-19, including temperature checks. Staff would be routinely screened as would others who will work in the facility (physicians, nurses, housekeeping, delivery and all people who would enter the area).
• Sufficient resources should be available to the facility across phases of care, including PPE, healthy workforce, facilities, supplies, testing capacity, and post-acute care, without jeopardizing surge capacity.” (I)
1. KNOW YOUR COMMUNITY’S CORONAVIRUS STATISTICS. The maximum incubation period for the coronavirus is estimated at two weeks. There should be a decrease in incidence of COVID-19 cases for at least two weeks before elective surgery is resumed. Monitor local COVID-19 statistics such incidence of new cases to detect a resurgence of the virus. Consider setting a threshold for new cases of COVID-19 that would trigger putting elective surgeries on hold again.
2. KNOW AVAILABILITY OF COVID-19 TESTING AND CRAFT TESTING POLICIES.
Monitor local COVID-19 testing availability and lab result times.
Craft testing policies for patients such as pre-operative testing of patients scheduled for surgery.
Craft testing policies for healthcare workers such as screening and testing guidance.
With false negative test rates as high as 30%, consider establishing retesting policies for patients and healthcare workers.
With fever and lung complications possible in the postoperative period, consider establishing retesting guidelines for symptomatic patients.
3. PERSONAL PROTECTIVE EQUIPMENT.
Before elective surgery is resumed, there should be a stored inventory of PPE or a reliable supply chain for at least 30 days of operations.
PPE policies should be in place for COVID-19 positive patients, persons under investigation, and non-COVID-19 patients, including for high-risk procedures such as intubation.
Consider having all healthcare workers and staff wear appropriate PPE outside the operating room and having all patients wear cloth masks.
4. KNOW KEY HEALTHCARE FACILITY CAPACITIES.
A hospital’s available resources should include peri-anesthesia units, critical care, diagnostic imaging, and lab services.
Consider new sites for elective surgery such as hospital spaces that were converted for COVID-19 care, including outpatient departments.
OR schedules should be set to accommodate a spike of electives surgeries such as performing procedures at night or on weekends.
Make sure there is sufficient capacity for preoperative, intraoperative, postoperative, and post-acute care.
5. SUPPLIES CAPACITY.
Ensure there are adequate levels of surgical supplies and equipment such as implants and anesthesia-sedation medications.
Ensure a supply chain is in place for traditional or new vendors.
Conduct an inventory of existing supplies and check expiration dates.
There should be adequate cleaning supplies, particularly for areas where care is provided to COVID-19 patients and persons under investigation.
6. HEALTHCARE WORKER STAFFING.
There should be adequate multidisciplinary staffing for routine and expanded hours.
Assess coordination of key staff members, including surgeons, anesthesiologists, nurses, and housekeeping.
Have contingencies in place for staff members who test positive for the coronavirus.
Assess the level of stress and fatigue among healthcare workers who have been providing frontline care during surges of COVID-19 patients.
Consider mitigation efforts for workforce shortages such as enlisting retired surgeons to work as first assistants.
7. CREATE GOVERNANCE COMMITTEE.
A governance committee can make real-time decisions for several pivotal issues, including PPE, pandemic assessment, patient backlog, and safety and quality.
The governance committee should be multidisciplinary, including surgeons, anesthesiologists, and nurses.
At least during the elective surgery ramp-up period, the governance committee should meet daily.
8. PATIENT COMMUNICATION.
Consider creating a multidisciplinary committee to manage patient communication.
There are several crucial patient communication topics, including procedure prioritization, coronavirus testing policies, PPE use, and advance directives.
9. PRIORITIZATION OF SURGERY.
Key stakeholders such as surgeons, anesthesiologists, and nurses should participate in ramp-up planning, including the collaborative formation of principles and frameworks for surgery prioritization.
The prioritization process should be adjustable to local, regional, and national epidemiological trends and changes in COVID-19 care. The prioritization process should also take a facility’s resources, priorities, and patient needs into account.
he prioritization process, principles, and framework should be transparent to hospitals, healthcare workers, and the public. The benefits of transparency include reducing ethical dilemmas.
There are multiple considerations in developing the prioritization process, including a list of canceled and delayed procedures, a strategy for phased opening of ORs, PPE availability, and issues related to increased OR volume.
10. ENSURE SAFETY AND HIGH VALUE IN ALL FIVE PHASES OF SURGICAL CARE.
Optimal care in the preoperative phase includes considering the use of telehealth.
Optimal care in the immediate preoperative phase features reviewing surgery, anesthesia, and nursing checklists for possible revisions related to COVID-19 positive patients and other considerations.
Optimal care in the intraoperative phase includes guidelines for staff during intubation.
Optimal care in the postoperative phase includes adherence to standardized care protocols.
Optimal care in the post discharge phase includes post-acute care facility availability and safety. (J)
“Ohio’s doctors and surgeons have one week to tell the governor what steps they would take to protect patients and conserve personal protective equipment if he were to lift the ban on elective surgeries.
Gov. Mike DeWine said he talked for about two hours Wednesday with medical professionals worried about patients who can’t get help because of the state’s restriction. He told the group to give him a plan that would still minimize the use of personal protective equipment…
Ohio Health Director Dr. Amy Acton halted nonessential surgeries and medical procedures during the coronavirus crisis on March 18. The concern was not that medical personnel and facilities were unsafe, but that regular use might deplete the state’s supply of protective gear, and surgical centers might be needed to house COVID-19 patients.
Neither of those things has happened, said Rep. Nino Vitale, R-Urbana. That’s why he and a growing number of other state legislators want the restrictions on health care providers lifted as soon as possible.
“It is the No. 1 call to our offices — even above ‘I can’t get through to the unemployment number,’” Vitale said.
Dr. Thomas Kramer, a gastroenterologist at the Taylor Station Surgical Center on the Far East Side, said he and many of his colleagues think they should be able to get back to work immediately.
Kramer said he doesn’t doubt the seriousness of the virus but thinks it’s clear that Ohio has avoided a worst-case scenario. The center, he said, has enough personal protective equipment from its usual shipments to operate as normal.
“It’s not making a lot of sense to us as physicians and nurses as things are improving,” Kramer said. “If we’ve got enough equipment, and we’re doing the things they want us to do, and people need the health care … then when are we going to be doing this again?”
Orthopedic surgeon Ian Thompson told the task force that he has patients who probably will need additional surgeries or face worse outcomes because they aren’t getting physical therapy. One female patient got worse because her knee-replacement surgery was put on hold.
“Her knee gave out, and she fell and broke her hip and is now in the hospital,” Thompson said.
A pediatric dentist from Minster in northwestern Ohio said he’s worried about his patients’ teeth shifting because devices such as braces and retainers require frequent checkups.
“The longer that treatment gets delayed, there will be teeth moving in directions unsupervised,” Dr. Phil Slonkosky said. “That’s definitely going to cause some problems.”
DeWine and Acton are the ones with the authority to lift the restriction on nonessential medical care. They’ve been in contact with groups such as the Ohio Hospital Association as well as state legislators.
“I think common sense is going to prevail here,” said Rep. Derek Merrin, R-Monclova. “I expect for there to be a reversal here shortly.”
Merrin acknowledged that short of changing the laws that give Acton the authority to issue such orders, there isn’t a lot that legislators can do to force her hand regarding doctors’ offices and surgical centers. He said hopes that the governor and his team will trust Ohio’s medical professionals to keep their patients and employees safe.
“Health decisions need to be between the physician and the patient … We do not need the state government micromanaging what kind of procedures people will get,” Merrin said. “State government has no role in telling someone if they are going to have a hip replacement or not.”” (K)
“Virginia Governor Ralph Northam is extending several orders he announced earlier in the COVID-19 pandemic, including postponements of elective surgeries and the closure of DMV offices.
Northam announced in a statement on Thursday that the current ban on elective surgeries, which was set to expire on Friday, April 24, is being extended by one week to May 1..
Just a few hours before the governor’s announcement on Thursday, the Virginia Hospital & Healthcare Association sent a public letter to the governor urging his administration to let the elective surgery postponement order expire, saying that hospitals have the capacity to handle both the procedures and COVID-19 cases.
But the governor said the ban on elective surgeries will continue until State Health Commissioner M. Norman Oliver, MD, MA can “evaluate, in conjunction with hospitals and other medical facilities, how to safely ease restrictions on non-essential medical procedures, and the availability of personal protective equipment.”
The VHHA said that Virginia hospitals have already established a framework (which you can review here), for re-opening the health care delivery system in a responsible manner consistent with the Open Up America Again Guidance document recently issued by the White House.
“My top priority is protecting public health, and that includes ensuring that our frontline medical staff have the equipment they need to stay safe as they treat Virginians who are sick,” said Governor Northam. “We have increased our supply of PPE, but before we allow elective surgeries to resume, we must first be assured that the doctors, nurses, and medical staff who are fighting this virus or conducting emergency surgeries have the necessary supplies. We are working with medical facilities on plans to ensure that we can resume elective surgeries safely and responsibly.”
The public health emergency order, Order of Public Health Emergency Two, does not apply to any procedure if the delay would cause harm to a patient. The order also does not apply to outpatient visits in hospital-based clinics, family planning services, or emergency needs.
But the VHHA says the continued postponement of the procedures puts patients with chronic conditions at risk and keeps medical workers furloughed.
Hospitals continue to treat emergency patients and perform essential surgeries, and Northam says “Virginians should feel safe going to hospitals if they are experiencing a medical emergency, such as a heart attack.”” (L)
The American Hospital Association published a road map to resuming elective surgeries on April 17, alongside the American College of Surgeons, American Society of Anesthesiologists and the Association of periOperative Registered Nurses.
The road map details principles and considerations for health care professionals to take into account as they start integrating more elective procedures back into their schedules. Some of the principles include timing for reopening elective surgeries, COVID-19 testing within facilities, adequate Personal Protection Equipment (PPE) supplies, conservation policies for PPE and case prioritization and scheduling…
Resumption of elective surgeries is a part of President Donald Trump’s “Reopening America” plan. “We’re encouraging states around the country to restart elective surgery wherever possible even on a county by county basis,” Vice President Mike Pence said Friday, speaking at Trump’s signing of a $484 billion coronavirus relief package.
As states gauge whether to allow elective surgeries, surgeons and hospitals face the difficult task of balancing patients’ needs with safety and equipment requirements. Postponing elective surgeries has also allowed hospitals to conserve personal protective equipment (PPE) and hospital beds for care involving COVID-19 patients.
“Coronavirus is highly infectious, and if there’s a procedure that would bring people together, just like in a restaurant or an airplane, then avoiding it if it can be avoided is the best practice,” Dr. David Hoyt, executive director of the American College of Surgeons, told NBC News. “You have to balance that with patients that need surgery, but the urgency of it can be triaged, and that’s what was done.”
Some surgeons have also shared concerns about performing elective surgeries on asymptomatic COVID-19 patients, fearful that patient mortality and ICU rates can increase significantly for those with unknown infection at the time of surgery.
Hospitals that resume elective surgeries need to be mindful of maintaining beds and equipment in case there are an uptick of sick patients, Hoyt said. “I think people need to ramp up at some rates, not just do it all overnight.”
Most hospitals have come up with systems to assess the urgency of elective surgeries for their patients…
The University of Chicago hospital published a scoring system this month to aid surgeons in making decisions about elective surgeries. The “Medically Necessary Time-Sensitive (MeNTS) Prioritization” system allows surgeons to assess elective surgeries systematically — evaluating risks for both patients and personnel.
“While these numbers are not meant to be strict cutoffs, as far as if it’s above some number, then you can’t do it and below it, you can, that sort of thing, it at least provides guidance,” Dr. Vivek N. Prachand, professor of surgery and chief quality officer for surgery at University of Chicago, said.
Prachand said that this will provide some guidance and then the threshold of whether to do the surgery can be decided, “not only the score, but the availability of the resources and personnel in the hospital itself, depending on where it’s located, not only geographically but where it’s located along the COVID curve.”.. (M)
“Hospitals are preparing for elective surgeries, which were put on hold because of COVID-19. This comes after Governor Greg Abbott made the announcement Friday to allow the procedures again across Texas.
Doctor Richard Peterson, with the Long School of Medicine at UT Health San Antonio, said the move to allow elective surgeries will be methodically planned.
“Most of the facilities are looking to resume elective surgeries kind of starting next week and it’s going to be a gradual ramp-up,” said Peterson said.
Peterson, who also practices at University Hospital, Foundation Surgical Hospital of San Antonio and CHRISTUS Santa Rosa Health System, said patients undergoing elective surgery are often vulnerable.
“What we don’t want to do is put a patient who isn’t sick, at risk for getting sick, especially with this virus,” Peterson said, “So we are taking extra preventative steps.”
Peterson said because non-emergent surgeries are backed up, there will be a re-introduction process.
“We are going to be careful about how much we are scheduling so we don’t overload and use up all of that protective personal protective equipment,” Peterson told us.
Peterson also said doctors will test every elective surgery patient for COVID-19.
“I think that’s kind of a new change, to ensure that we’re definitely making sure the patients aren’t infected prior to surgery,” Peterson said…
In a statement, Methodist Healthcare’s President and CEO, Allen Harrison, said staff there will follow similar guidelines.
As we continue to monitor the dynamic shifts of the COVID-19 pandemic, Methodist Healthcare has begun to thoughtfully re-introduce elective procedures and surgeries following Governor Abbott’s updated Executive Order on Friday, April 17. Elective procedures are not the equivalent of “optional” procedures that can be delayed indefinitely. Elective procedures are those that can be scheduled. These procedures have been classified within tiers of urgency and acuity, allowing us to prioritize services as we take a measured approach to this transition. While continuing to abide by all state regulations, patients and physicians will see continued, and in some cases enhanced, screening, testing, universal masking and patient cohorting, patient flow procedures, as well as infection prevention protocols in our facilities. As an added precaution, we will conduct universal COVID-19 testing for all elective surgery patients prior to their procedure and will continue with a “no visitor” policy per Health and Human Services guidance.” (N)
“Amid the ongoing COVID-19 pandemic, Governor Andrew M. Cuomo today announced elective outpatient treatments can resume in counties and hospitals without significant risk of COVID-19 surge in the near term. Hospitals will be able to resume performing elective outpatient treatments on April 28, 2020 if the hospital capacity is over 25 percent for the county and if there have been fewer than 10 new hospitalizations of COVID-19 patients in the county over the past 10 days. If a hospital is located in a county eligible to resume elective outpatient treatments, but that hospital has a capacity under 25 percent or has had more than 10 new hospitalizations in the past 10 days, that hospital is not eligible to resume elective surgeries. If a county or hospital that has resumed elective surgery experiences a decrease in hospital capacity below the 25 percent threshold or an increase of 10 or more new hospitalizations of COVID-19 patients, elective surgeries must cease. Further, patients must test negative for COVID-19 prior to any elective outpatient treatment. The State Department of Health will issue guidance on resuming elective surgeries.
Restrictions on elective surgery will remain in place in Bronx, Queens, Rockland, Nassau, Clinton, Yates, Westchester, Albany, Richmond, Schuyler, Kings, Suffolk, New York, Dutchess, Sullivan, Ulster, Erie, Orange and Rensselaer Counties as the state continues to monitor the rate of new COVID-19 infections in the region.
Governor Cuomo also announced the state will take a regional approach to reopening and will make decisions on which counties and regions to open and when to open them based on the facts and data specific to that area. Lieutenant Governor Kathy Hochul will coordinate Western New York’s public health and reopening strategy, and former Lieutenant Governor Robert Duffy will volunteer as a special advisor to coordinate the Finger Lakes’ public health and reopening strategy.
It is essential that we continue to support hospitals and health care workers in all regions to ensure they have both capacity and supplies to treat COVID patients because this virus is by no means defeated.
“As New York continues to flatten the curve of new COVID-19 infections, we are now ready to lift the restrictions on elective surgeries in regions where hospital capacity and the rate of new infections do not present a significant risk of a surge in new positive cases,” Governor Cuomo said. “It is essential that we continue to support hospitals and health care workers in all regions to ensure they have both capacity and supplies to treat COVID patients because this virus is by no means defeated.”” (O)
“Despite a directive from the governor of Pennsylvania, the state’s biggest hospital system is preparing to ramp up elective surgical procedures — the goal being to reach pre-shutdown surgical capacity within six weeks.
The Post-Gazette has obtained documentation showing that UPMC is gearing up for the move that makes it the only health care system in the region to do so.
A letter to UPMC surgeons dated April 15 from hospital leadership offers guidance to surgeons on how to justify doing such procedures, recommending the use of terms such as “urgent,” “cancer,” “unstable” and “relief from suffering” in reports.
“We have NOT said no to a surgery that the surgeon and patient feels should proceed,” according to the April 15 letter, which was obtained by the Post-Gazette.
UPMC employees told the Post-Gazette in March that they were upset over risks to staff and patient health, and the use of resources that might be needed as the virus spread.
The Pittsburgh-based health system’s push to return to pre-COVID-19 levels of elective surgery comes despite a ban on elective medical procedures issued by the Pennsylvania governor in March, a ban that the state health department said is still in effect.
But a spokesman for the health system, which operates 40 hospitals, said Monday that UPMC believes it can do elective procedures safely and noted that new guidance from the Centers for Medicare and Medicaid Services emphasized flexibility to “allow facilities to provide care for patients needing non-emergent health care.”
If successful, UPMC, which reported $20.6 billion in revenue for 2019, would be among the first health systems in Pennsylvania to restore elective operations.
UPMC was behind other Pittsburgh-area health systems in winding down non-emergency procedures after Gov. Wolf’s March 19 directive, continuing to do them after Allegheny Health Network, Excela Health, Heritage Valley Health System, St. Clair and Washington Health System said they had stopped.
At Allegheny Health Network, the surgical shutdown continues for elective procedures.
“At AHN, we continue to closely monitor the progression of the COVID-19 pandemic in western PA while also communicating regularly with local and state health officials about the safest and most responsible approaches to patient care at this time,” spokesman Dan Laurent said in a statement. “We are preparing appropriately for an organized, phased-in return to normal surgical operations in the coming weeks and will strictly follow CDC and CMS guidelines in order to ensure the safety and well-being of our patients and caregivers when we do.”
To return to pre-shutdown surgical capacity, UPMC is counting on technology that received emergency clearance from the Food and Drug Administration on March 29, which allows COVID-19-contaminated face masks to be sterilized for reuse by doctors and nurses up to 20 times.
Typically, the malleable polyester masks are discarded after wearing once or twice, but nationwide shortages of the protective gear have been reported…
More than 1,300 UPMC employees were briefed on the plans Thursday, where the partnership with Battelle was described as key to the restoration of the non-emergency surgery caseload at UPMC.
On Friday, Gov. Wolf provided a broad outline for reopening the state, but without a timeline or benchmarks that would guide his decision. On Monday, the governor went further, easing restrictions on online car sales and allowing the restart of construction projects statewide May 8. But he stopped well short of ending mitigation efforts.
The Wolf administration does “not feel that today is the day that hospitals should resume these services,” state Department of Health spokesman Nate Wardle said Thursday. “We must take a slow, iterative process as we ease back on our mitigation efforts and not move too quickly.”
He declined to elaborate when contacted Monday. Health officials have warned that ending mitigation efforts too soon could bring a rebound of the disease.
Citing CMS guidance that was issued Sunday, UPMC spokesman Paul Wood said on Monday that the time was right to begin doing elective procedures.
“In the current environment, with proper protection and precautions, we believe that we can soon begin to treat patients who postponed needed treatments and procedures,” he said in a statement.
His comments echoed the new CMS guidance.
“At this time, many areas have a low, or relatively low and stable, incidence of COVID-19 and that it is important to be flexible and allow facilities to provide care for patients needing non-emergent, non-COVID-19 health care,” CMS said. “In addition, as states and localities begin to stabilize, it is important to restart care that is currently being postponed.”
In a conference call with more than 1,300 employees Thursday, UPMC officials said non-emergency operations would be ramped by 10% this week after a case-by-case review, which will include COVID-19 testing of the patient two days before the procedure, according to the person who participated in the briefing but was not at liberty to speak publicly about it. Back surgery for chronic pain and hernia repair are examples of the operations that could start to be scheduled.” (P)
“New Hyde Park, N.Y.-based Northwell Health is giving front-line staff responding to the COVID-19 pandemic a $2,500 lump-sum payment and a week of paid time off.
Physicians, nurses, respiratory therapists and others involved in direct patient care are eligible for the bonus and PTO as are housekeepers, environmental services workers and others. The health system said about 45,000 workers are eligible for the payments and supplemental PTO.” (Q)
PART 1. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”
PART 2. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”
PART3. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)
PART 4. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….
PART 5. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”
POST 6. Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””
PART 7. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.
PART 8. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”
PART 9. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”
Part 10. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.
PART 11. CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”
Part 12. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”
Part 13. CORONAVIRUS. March 14, 2020. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”
PART 14. CORONAVIRUS. March 17, 2020. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”
PART 15. CORONAVIRUS. March 22, 2020. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.
PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT
PART 17. April 2, 2020. CORONAVIRUS. Florida allows churches to continue holding services. Gun stores deemed “essential.” “New York’s private and public hospitals unite to manage patient load and share resources.
PART 18. April 9, 2020. CORONAVIRUS. “The federal government’s emergency stockpile of personal protective equipment (PPE) is depleted, and states will not be receiving any more shipments, administration staff told a House panel.
PART 19. April 13, 2020 CORONOAVIRUS. “…overlooked in the United States’ halting mobilization against the novel coronavirus: the personal aides, hospice attendants, nurses and occupational or physical therapists who deliver medical or support services to patients in their homes.”
POST 22. April 29, 2020. CORONAVIRUS. ..the “ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries[JM1] ….”
“President Trump on Saturday cited “positive signs” in the fight against the coronavirus pandemic, claiming that he inherited “broken junk” from the prior administration but has since turned the U.S. into the “king of ventilators.”” (A)
“Just about a month ago, people stricken with the new coronavirus started to arrive in unending ranks at hospitals in the New York metropolitan area, forming the white-hot center of the pandemic in the United States.
Now, doctors in the region have started sharing on medical grapevines what it has been like to re-engineer, on the fly, their health care systems, their practice of medicine, their personal lives.
Medicine routinely remakes itself, generation by generation. For the disease that drives this pandemic, certain ironclad emergency medical practices have dissolved almost overnight.
The biggest change: Instead of quickly sedating people who had shockingly low levels of oxygen and then putting them on mechanical ventilators, many doctors are now keeping patients conscious, having them roll over in bed, recline in chairs and continue to breathe on their own — with additional oxygen — for as long as possible.
The idea is to get them off their backs and thereby make more lung available. A number of doctors are even trying patients on a special massage mattress designed for pregnant women because it has cutouts that ease the load on the belly and chest.
Other doctors are rejiggering CPAP breathing machines, normally used to help people with sleep apnea, or they have hacked together valves and filters. For some critically ill patients, a ventilator may be the only real hope.” (B)
“Even as hospitals and governors raise the alarm about a shortage of ventilators, some critical care physicians are questioning the widespread use of the breathing machines for Covid-19 patients, saying that large numbers of patients could instead be treated with less intensive respiratory support.
If the iconoclasts are right, putting coronavirus patients on ventilators could be of little benefit to many and even harmful to some.
What’s driving this reassessment is a baffling observation about Covid-19: Many patients have blood oxygen levels so low they should be dead. But they’re not gasping for air, their hearts aren’t racing, and their brains show no signs of blinking off from lack of oxygen.
What is making critical care physicians suspect that blood levels of oxygen, which for decades have driven decisions about breathing support for patients with pneumonia and acute respiratory distress, might be misleading them about how to care for those with Covid-19. In particular, more and more are concerned about the use of intubation and mechanical ventilators. They argue that more patients could receive simpler, noninvasive respiratory support, such as the breathing masks used in sleep apnea, at least to start with and maybe for the duration of the illness.
“I think we may indeed be able to support a subset of these patients” with less invasive breathing support, said Sohan Japa, an internal medicine physician at Boston’s Brigham and Women’s Hospital. “I think we have to be more nuanced about who we intubate.”..
An oxygen saturation rate below 93% (normal is 95% to 100%) has long been taken as a sign of potential hypoxia and impending organ damage. Before Covid-19, when the oxygen level dropped below this threshold, physicians supported their patients’ breathing with noninvasive devices such as continuous positive airway pressure (CPAP, the sleep apnea device) and bilevel positive airway pressure ventilators (BiPAP). Both work via a tube into a face mask.
In severe pneumonia or acute respiratory distress unrelated to Covid-19, or if the noninvasive devices don’t boost oxygen levels enough, critical care doctors turn to mechanical ventilators that push oxygen into the lungs at a preset rate and force: A physician threads a 10-inch plastic tube down a patient’s throat and into the lungs, attaches it to the ventilator, and administers heavy and long-lasting sedation so the patient can’t fight the sensation of being unable to breathe on his own.
But because in some patients with Covid-19, blood-oxygen levels fall to hardly-ever-seen levels, into the 70s and even lower, physicians are intubating them sooner. “Data from China suggested that early intubation would keep Covid-19 patients’ heart, liver, and kidneys from failing due to hypoxia,” said a veteran emergency medicine physician. “This has been the whole thing driving decisions about breathing support: Knock them out and put them on a ventilator.”..
The question is whether ICU physicians are moving patients to mechanical ventilators too quickly. “Almost the entire decision tree is driven by oxygen saturation levels,” said the emergency medicine physician, who asked not to be named so as not to appear to be criticizing colleagues…
“We need to ask, are we using ventilators in a way that makes sense for other diseases but not for this one?” Gillick said. “Instead of asking how do we ration a scarce resource, we should be asking how do we best treat this disease?”… (C)
“Some doctors are also concerned that ventilators could be further harming certain coronavirus patients, as the treatment is hard on the lungs, the AP reported.
Dr. Tiffany Osborn, a critical-care specialist at the Washington University School of Medicine, told NPR on April 1 that ventilators could actually damage a patient’s lungs.
“The ventilator itself can do damage to the lung tissue based on how much pressure is required to help oxygen get processed by the lungs,” she said.
Dr. Negin Hajizadeh, a pulmonary critical-care doctor at New York’s Hofstra/Northwell School of Medicine, also told NPR that while ventilators worked well for people with diseases like pneumonia, they don’t necessarily also work for coronavirus patients.
She said that most coronavirus patients in her hospital system who were put on a ventilator had not recovered.
She added that the coronavirus does a lot more damage to the lungs than illnesses like the flu, as “there is fluid and other toxic chemical cytokines, we call them, raging throughout the lung tissue.”
“We know that mechanical ventilation is not benign,” Dr. Eddy Fan, an expert on respiratory treatment at Toronto General Hospital, told the AP.
“One of the most important findings in the last few decades is that medical ventilation can worsen lung injury — so we have to be careful how we use it.”
Doctors are trying to find other solutions and reduce their reliance on ventilators
The lack of treatment options for coronavirus patients has caused much of the world to turn to ventilators for the worst-affected patients.
But the high death rates reported among patients on ventilators have prompted some doctors to seek alternatives and reduce their reliance on ventilators, the AP reported.
Dr. Joseph Habboushe, an emergency-medicine doctor in Manhattan, told the AP that until a few weeks ago, it was routine in the city to place particularly ill coronavirus patients on ventilators. Now doctors are increasingly trying other treatments.
“If we’re able to make them better without intubating them,” Habboushe said, “they are more likely to have a better outcome — we think.”
According to the AP, doctors are putting patients in different positions to try to get oxygen into different parts of their lungs, giving patients oxygen through nose tubes, and adding nitric oxide to oxygen treatments to try to increase blood flow.
Dr. Howard Zucker, the New York state health commissioner, said on Wednesday that officials were examining other treatments to use before ventilation but that it was “all experimental,” the AP reported.” (D)
“Only a few weeks ago in New York City, coronavirus patients who came in quite sick were routinely placed on ventilators to keep them breathing, said Dr. Joseph Habboushe, an emergency medicine doctor who works in Manhattan hospitals…
There are widespread reports that coronavirus patients tend to be on ventilators much longer than other kinds of patients, said Dr. William Schaffner, an infectious diseases expert at Vanderbilt University.
Experts say that patients with bacterial pneumonia, for example, may be on a ventilator for no more than a day or two. But it’s been common for coronavirus patients to have been on a ventilator “seven days, 10 days, 15 days, and they’re passing away,” said New York Gov. Andrew Cuomo, when asked about ventilator death rates during a news briefing on Wednesday…
Experts think most people who are infected suffer nothing worse than unpleasant but mild illnesses that may include fever and coughing.
But roughly 20% — many of them older adults or people weakened by chronic conditions — can grow much sicker. They can have trouble breathing and suffer chest pain. Their lungs can become inflamed, causing a dangerous condition called acute respiratory distress syndrome. An estimated 3% to 4% may need ventilators.
“The ventilator is not therapeutic. It’s a supportive measure while we wait for the patient’s body to recover,” said Dr. Roger Alvarez, a lung specialist with the University of Miami Health System in Florida…
“Needing to be ventilated might mean never getting off the ventilator,” he said.” (E)
“Acute respiratory distress syndrome, or ARDS, is the endgame for the unluckiest COVID-19 patients. By that point, the virus has begun to destroy the tiny compartments in the lungs where blood normally collects oxygen. Roaring inflammation, a response to infection, further deteriorates the lung’s ability to draw in air. Without help, these patients could drown.
More than a dozen medications that were developed to treat other diseases are now being tested on COVID-19 patients. Ideally, several of them would allow patients with mild to moderate symptoms recover before their illnesses reach the severe or critical stage.
But researchers are not stopping there.
They are also using artificial intelligence to identify patients who are most likely to develop ARDS and need the gold standard treatment to survive. They’re devising ways to provide breathing assistance with techniques short of mechanical ventilation. If the ventilator shortage becomes desperate, as it has already in some New York City hospitals, doctors will likely try some of these alternatives to rescue dying patients.
Patients who are older, male and have underlying conditions such as heart disease, diabetes or asthma tend to have worse outcomes. But there are exceptions to that pattern. As they assess incoming COVID-19 patients, doctors need better ways to predict the courses their charges will likely take.
A team of researchers in China and at New York University turned to machine learning to see whether useful clues could be found through a massive scouring of symptoms, blood test results and patient characteristics.
Aided by artificial intelligence techniques, the researchers performed an exhaustive scrub of data from 53 patients who were treated in a hospital in Wenzhou, China. Their work identified the three top signs of a patient likely to develop critical illness, as well as their order of importance.
The resulting list amounts to a step-by-step “decision tree” to help doctors triage patients early and set aside scarce ventilators for the right ones.
At the top of the list: a slightly elevated level of the liver enzyme alanine aminotransferase, or ALT. It is one of 20 measures of metabolic and organ function, blood oxygenation and inflammation that’s routinely tested in all hospitalized patients.
In those who would go on to develop ARDS, ALT levels were so slightly above normal that “it would not necessarily set off alarm bells,” said Dr. Megan Coffee of NYU, who has been working on the research while treating COVID-19 patients. But in winnowing out patients most likely to need a respirator, it offers a powerful first clue.
Once that liver enzyme reading has tripped the alarm, a patient’s report of overall achiness appears to hold important information. After that, there’s a high likelihood of trouble ahead if sign No. 3 is present — an elevated hemoglobin level that looks like the opposite of anemia.
A patient’s male gender, higher temperature and abnormal sodium levels were measures 4, 5 and 6 on the list of predictors…
Coffee and her colleague Anasse Bari of NYU’s Courant Institute plan to refine their prediction tool by adding in the disease histories of more than 14,000 COVID-19 patients that have been admitted to New York City hospitals. Bari hopes a reliable decision tree will help guide healthcare workers in countries such as his native Morocco, where hospitals are expected to be overwhelmed in the pandemic.
Another approach is to find existing medical equipment that can function like a ventilator in certain circumstances.
A leading contender is the bilevel positive airway pressure device that is ordinarily used to help patients with breathing problems that have not progressed to the critical stage. BiPap machines could be used to wean some improving patients from the invasive mechanical ventilators, freeing them up for incoming patients, said Dr. Atul Malhotra, a lung specialist at UC San Diego. Already used widely in New York City, where COVID-19 patients are outstripping ventilators, BiPap machines deliver oxygen under pressure through a mask. Patients can readily pull them off to cough or because they are uncomfortable, so they pose extra infection risks to healthcare workers…” (F)
“For weeks, U.S. government officials and hospital executives have warned of a looming shortage of ventilators as the coronavirus pandemic descended.
But now, doctors are sounding an alarm about an unexpected and perhaps overlooked crisis: a surge in Covid-19 patients with kidney failure that is leading to shortages of machines, supplies and staff required for emergency dialysis.
In recent weeks, doctors on the front lines in intensive care units in New York and other hard-hit cities have learned that the coronavirus isn’t only a respiratory disease that has led to a crushing demand for ventilators.
The disease is also shutting down some patients’ kidneys, posing yet another series of life-and-death calculations for doctors who must ferry a limited supply of specialized dialysis machines from one patient in kidney failure to the next. All the while fearing they may not be able to hook up everyone in time to save them.
It is not yet known whether the kidneys are a major target of the virus, or whether they’re just one more organ falling victim as a patient’s ravaged body surrenders. Dialysis fills the vital roles the kidneys play, cleaning the blood of toxins, balancing essential components including electrolytes, keeping blood pressure in check and removing excess fluids. It can be a temporary measure while the kidneys recover, or it can be used long-term if they do not. Another unknown is whether the kidney damage caused by the virus is permanent…
Kidney specialists now estimate that 20 percent to 40 percent of I.C.U. patients with the coronavirus suffered kidney failure and needed emergency dialysis, according to Dr. Alan Kliger, a nephrologist at Yale University School of Medicine who is co-chairman of a Covid-19 response team for the American Society of Nephrology…
As the coronavirus spread rapidly in New York and in other cities, governors and mayors clamored for thousands more ventilators. But doctors have been surprised by the scarcity of dialysis machines and supplies, especially specialized equipment for continuous dialysis. That treatment is often used to replace the work of injured kidneys in critically ill patients.
The shortages involved not only the machines, but also fluids and other supplies needed for the dialysis regimen. Having enough trained nurses to provide the treatment has also been a bottleneck. Hospitals said they have called on the federal government to help prioritize equipment, supplies and personnel for the areas of the country that most need it, adding that manufacturers had not been fully responsive to the higher demand.
The fluids needed to run the dialysis machines are not on the Food and Drug Administration’s watch list of potential drug shortages, although the agency said it was closely monitoring the supply. The Federal Emergency Management Agency described the shortage of supplies and equipment as “unprecedented,” and said it was working with manufacturers and hospitals to identify additional supplies, both in the United States and overseas.
“Everybody thought about this as a respiratory illness,” said Dr. David Charytan, the chief of nephrology at N.Y.U. Langone Medical Center. “I don’t think this has been on people’s radar screen.”” (G)
“By using ventilators more sparingly on Covid-19 patients, physicians could reduce the more-than-50% death rate for those put on the machines, according to an analysis published Tuesday in the American Journal of Tropical Medicine and Hygiene.
The authors argue that physicians need a new playbook for when to use ventilators for Covid-19 patients — a message consistent with new treatment guidelines issued Tuesday by the National Institutes of Health, which advocates a phased approach to breathing support that would defer the use of ventilators if possible.
As the pandemic has flooded hospitals with a disease that physicians had never before seen, health care workers have had to figure out treatment protocols on the fly. Starting this month, a few physicians have voiced concern that some hospitals have been too quick to put Covid-19 patients on mechanical ventilators, that elderly patients in particular may have been harmed more than helped, and that less invasive breathing support, including simple oxygen-delivering nose prongs, might be safer and more effective.
The new analysis, from an international team of physician-researchers, supports what had until now been mainly two hunches: that some of the Covid-19 patients put on ventilators didn’t need to be, and that unusual features of the disease can make mechanical ventilation harmful to the lungs.
“This is one of the first coherent, comprehensive, and reasonably clear discussions of the pathophysiology of Covid-19 in the lungs that I’ve seen,” said palliative care physician Muriel Gillick of Harvard Medical School, who was one of the first to ask if ventilators were harming some Covid-19 patients, especially elderly ones. “There is mounting evidence that lots of patients are tolerating fairly extreme” low levels of oxygen in the blood, suggesting that such hypoxemia should not be equated with the need for a ventilator….
It’s important to highlight “aspects of Covid-19 that differ from other diseases that require respiratory support,” said Phil Rosenthal of the University of California, San Francisco, editor of the journal. Patients with Covid-19 pneumonia are often less breathless “compared to other patients with similar [blood oxygen] levels,” he said, adding that this difference “may allow physicians to avoid intubation/ventilator support in some patients.”
There is a growing recognition that some Covid-19 patients, even those with severe disease as shown by the extent of lung infection, can be safely treated with simple nose prongs or face masks that deliver oxygen.The latter include CPAP (continuous positive airway pressure) masks used for sleep apnea, or BiPAP (bi-phasic positive airway pressure) masks used for congestive heart failure and other serious conditions. CPAP can also be delivered via hoods or helmets, reducing the risk that patients will expel large quantities of virus into the air and endanger health care workers…
The Covid-19 treatment guidelines released by the NIH do not specifically address what criteria physicians should use for putting patients on a ventilator. But in a recognition of the damage that the ventilators can do, they recommend a phased approach to breathing support: oxygen delivered by simple nose prongs, escalating if necessary to one of the positive-pressure devices, and intubation only if the patient’s respiratory status deteriorates. If mechanical ventilation becomes necessary, the NIH said, it should be used to deliver only low volumes of oxygen, reflecting the risk of damaging healthy lung tissue” (H)
PART 1. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”
PART 2. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”
PART3. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)
PART 4. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….
PART 5. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”
POST 6. Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””
PART 7. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.
PART 8. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”
PART 9. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”
Part 10. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.
PART 11. CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”
Part 12. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”
Part 13. CORONAVIRUS. March 14, 2020. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”
PART 14. CORONAVIRUS. March 17, 2020. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”
PART 15. CORONAVIRUS. March 22, 2020. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.
PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT
PART 17. April 2, 2020. CORONAVIRUS. Florida allows churches to continue holding services. Gun stores deemed “essential.” “New York’s private and public hospitals unite to manage patient load and share resources.
PART 18. April 9, 2020. CORONAVIRUS. “The federal government’s emergency stockpile of personal protective equipment (PPE) is depleted, and states will not be receiving any more shipments, administration staff told a House panel.
PART 19. April 13, 2020 CORONOAVIRUS. “…overlooked in the United States’ halting mobilization against the novel coronavirus: the personal aides, hospice attendants, nurses and occupational or physical therapists who deliver medical or support services to patients in their homes.”
“President Donald Trump said Monday (March 23rd) that he wants to reopen the country for business in weeks, not months, and he claimed, without evidence, that continued closures could result in more deaths than the coronavirus pandemic.
“We can’t have the cure be worse than the problem,” Trump told reporters at a press briefing.
The statement echoed a midnight Sunday tweet from the president in which he said, “We have to open our country because that causes problems that, in my opinion, could be far bigger problems.”
Trump acknowledged there were trade-offs, “there’s no question about that,” but claimed that, if closures stretch on for months, there would be “probably more death from that than anything that we’re talking about with respect to the virus.”” (A)
“But what is the exit strategy? “We’ve managed to get to the life raft,” says epidemiologist Marc Lipsitch of the Harvard T.H. Chan School of Public Health (HSPH). “But I’m really unclear how we will get to the shore.”…
The number to watch in the next phase may no longer be the actual number of cases per day, but what epidemiologists call the effective reproduction number, or R, which denotes how many people the average infected person infects in turn. If R is above 1, the outbreak grows; below 1 it shrinks. The goal of the current lockdowns is to push R well below 1. Once the pandemic is tamed, countries can try to loosen restrictions while keeping R hovering around 1, when each infected person on average infects one other person, keeping the number of new cases steady.
To regulate R, “Governments will have to realize that there are basically three control knobs on the dashboard,” says Gabriel Leung, a modeler at the University of Hong Kong: isolating patients and tracing their contacts, border restrictions, and social distancing.
Singapore, Hong Kong, and South Korea have all managed to keep their epidemics in check through aggressive use of the first control. They identify and isolate cases early and trace and quarantine their contacts, while often imposing only light restrictions on the rest of society. But this strategy depends on massively scaling up testing, which has been hampered by a scarcity of reagents and other materials everywhere. The United States will be able to do millions of tests per week, says Caitlin Rivers of the Johns Hopkins Center for Health Security. “Although our testing capacity has grown a lot in the last couple of weeks, we are not where we need to be yet,” she says.
Contact tracing is another hurdle, and it is labor intensive. Massachusetts is hiring 500 contact tracers, but a recent report by Rivers and others estimates that the United States as a whole needs to train about 100,000 people…
As to the second control knob, border restrictions, most countries have already banned entry to almost all noncitizens. Quarantining returning citizens, as New Zealand and Australia began to do in the past few weeks, further minimizes the risk of new introductions of the virus. Such measures are likely to remain in place for a while; the more a country reduces transmission domestically, the greater the risk that any new outbreaks will originate with travelers. And foreign visitors are generally harder to trace than citizens and more likely to stay at hotels and visit potential transmission hot spots, says Alessandro Vespignani, a disease modeler at Northeastern University. “As soon as you reopen to travelers, that could be something that the contact tracing system is not able to cope with,” he says.
The third dashboard dial, social distancing, is the backbone of the current strategy, which has slowed the spread of the virus. But it also comes at the greatest economic and social cost, and many countries hope the constraints can be relaxed as case isolation and contact tracing help keep the virus in check…
Choosing a prudent path is difficult, Buckee says, in part because no controlled experiments have compared the effectiveness of different social distancing measures. “Because we don’t have really strong evidence,” she says, “it’s quite hard to make evidence-based policy decisions about how to go back.” But Lipsitch says that as authorities around the world choose different paths forward, comparisons could be revealing. “I think there’s going to be a lot of experimentation, not on purpose, but because of politics and local situations,” he says. “Hopefully the world will learn from that.” (B)
“Still, society can’t stay shut down forever. Public health and state leaders are starting to talk about how and when to relax social distancing guidelines, and President Trump is expected to soon announce finalized guidelines to help states make those decisions. Even then, it’s clear that life won’t go back to normal all at once. The decisions will be staggered, and a lot of it will come down to local and regional circumstances.
“We have to do it strategically and safely,” said Dr. Monica Bharel, commissioner of the Massachusetts Department of Public Health, at a briefing by the Association of State and Territorial Health Officials Wednesday. “The worst possible outcome of reopening public life would be a second wave of this pandemic.”
Public health leaders agree that in order to safely lift social distancing restrictions we must create and sustain systems that can rapidly stamp out any new coronavirus flare-ups so they don’t spiral out of control. Here are five key things health experts say must be addressed as we begin to start businesses and community life up again.
1. Improve rapid testing
2. Massively upgrade contact tracing capacity
3. Create systems to isolate the sick and protect the vulnerable
4. Build up hospital capacity and the PPE supply chain
5. Zero in on effective treatments…
Gottlieb says the combination of effective treatments as well as expanded testing and surveillance would put us in a situation where we can live with the virus, instead of being paralyzed by it.
“I think that [would be] a robust enough set of tools that this could become a livable threat, that we can get back to a fairly normal way of life and be able to mitigate the risk from coronavirus even before we have a vaccine in place,” he says. “Now, life will never be perfectly the same until we have a vaccine that can fully vanquish it.”
There are dozens of compounds being evaluated for the development of a vaccine, but that’s at least a year off.” (C)
“Everyone wants to know when we are going to be able to leave our homes and reopen the United States. That’s the wrong way to frame it.
The better question is: “How will we know when to reopen the country?”…
Hospitals in the state must be able to safely treat all patients requiring hospitalization, without resorting to crisis standards of care…
A state needs to be able to at least test everyone who has symptoms…
The state is able to conduct monitoring of confirmed cases and contacts…
A robust system of contact tracing and isolation is the only thing that can prevent an outbreak and a resulting lockdown from recurring…
This will be a big challenge for most areas. Other countries have relied on cellphone tracking technology to determine whom people have been near. We don’t have anything like that ready, nor is it even clear we’d allow it. The United States also doesn’t have enough people working in public health in many areas to carry out this task…
In suppression, cases will dwindle at an exponential fashion, just as they rose. It’s not possible to set a benchmark number for every state because the number of infections that will be manageable in any area depends on the local population and the public health system’s ability to handle sporadic cases…
Until we get a vaccine or effective drug treatments, focusing on these major criteria, and directing efforts toward them, should help us determine how we are progressing locally, and how we might achieve each goal.
It would also prevent us from offering false hope about when America can start reopening. Instead of guesses, people could have clear answers about when they might be able to go back to a closer-to-normal way of life.” (D)
“CDC PLAN
The Framework for Reopening America provides guidance to state, local, tribal, and territorial governments to adjust restrictive community mitigation measures in a controlled way that supports the
safe reopening of communities when appropriate, supporting Americans reentering civic life.
Why Is the Plan Important to the American People
The strict community mitigation measures the majority of the United States is currently experiencing have succeeded in slowing the spread of COVI-19. This level of mitigation however cannot be adhered to forever, and has negative consequences on economic and long term health outcomes. Lifting stay-at-home orders carefully, on a community by community basis, only when ready, will help extend the gains made from this time of collective social distancing. Coming out of mitigation in a controlled way, with robust monitoring systems in place to contain new cases and outbreaks will be critical to navigating the next phase of this pandemic. Leaders at all levels will need to prepare communities for occasionally returning to stricter mitigation measures for brief periods as needed to continue containing the disease. This plan describes the conditions in which it is appropriate to lift community mitigation measures, the phased steps to reduce community mitigation measures, and indicators to rigorously monitor to inform decisions about adjusting mitigation measures.” (E)
“President Donald Trump announced federal guidelines to reopen the U.S. on Thursday that put the onus on governors of making decisions about their states’ economies…
Under the first phase of the three-phase plan, restaurants, movie theaters and large sporting venues would be appropriate to reopen under certain conditions, while schools, day care centers and bars would not.
The plan, released Thursday afternoon, is designed to “mitigate the risk of resurgence” of the pandemic and to “protect the most vulnerable,” according to the guidelines.
It is “implementable on a statewide or county-by-county basis” at the discretion of each state’s governor — a stark contradiction from the president’s earlier assertion that he had “total authority” to direct governors how and when to reopen.
The guidelines do not suggest any reopening dates, and Trump acknowledged that it would be “a gradual process.”
To begin implementing the guidelines, states must first meet a “gating” criterion that includes a “downward trajectory of documented cases within a 14-day period” or a “downward trajectory of positive tests as a percent of total tests within a 14-day period (flat or increasing volume of tests),” as well as hospital preparedness.
If that criterion is met, states, could then enter Phase One, according to the guidelines.
Under Phase One protocols, large venues like restaurants, movie theaters, sporting venues and places of worship would be allowed to reopen if they “operate under strict physical distancing protocols,” according to the guidelines…
Under Phase One, “all vulnerable individuals should continue to shelter in place” and members of households with vulnerable residents “should be aware that by returning to work or other environments where distancing is not practical, they could carry the virus back home.”
It also calls for the employers to allow employees to telework.
The plan also emphasizes that all people should continue to practice social distancing when in public and that they should continue to minimize nonessential travel.
Phase Two, the guidelines state, applies to states and regions “with no evidence of a rebound” that “satisfy the gating criteria a second time.”…
Phase Three would then kick in for states and regions with “no evidence of a rebound” that “satisfy the gating criteria a third time.”
At that point, “vulnerable individuals” could resume public interactions but should practice social distancing, according to the guidelines. Low-risk populations should still “consider minimizing time spent in crowded environments.”
Only in Phase Three could work sites resume normal staffing protocols without restrictions and visits to senior care facilities and hospitals could resume. People who interacted with residents and patients would still have to remain “diligent regarding hygiene.” Under Phase Three guidelines, large venues could operate under “limited” social distancing protocols, gyms could remain open with “standard” sanitation protocols and bars could operate with “increased standing room occupancy.”
The White House views Trump’s announcement as guidance under which “governors will have to make decisions what’s right for their individual states,” a White House official told NBC News.” (F)
GUIDELINES FOR OPENING UP AMERICA AGAIN (G)
“Anthony Fauci, director of the National Institute of Allergy and Infectious Disease (NIAID) and head of the White House Coronavirus Task Force, spoke on CBS Wednesday night about the developments needed in public health before Americans can safely return to work.
Fauci explained that in order to have a successful rolling re-entry program, where the economy would slowly open back up, we’d need to “test, identify, isolate, get someone who is infected out of circulation, and do a degree of contact tracing” to better monitor the virus’s status.
“The absolute thing that you would need is to be able to respond and contain whatever rebound you get so that you don’t wind up in a situation where you have another escalation,” he told CBS’s Norah O’Donnell…
Schaffner notes that while the emphasis is now on mitigation efforts, reopening the economy will be a question of health departments’ ability to switch back to containment strategies, meaning investigating every case and ensuring the individuals who had contact with infected patients are quarantined. He is not sure that local health departments in all jurisdictions have the resources or energy for a more intensive case-by-base public health follow up, but notes that it would be ideal to avoid future outbreaks.
In terms of reopening public spaces, Schaffner supports the idea of opening the least affected parts of the country in a “rolling fashion,” but to take a gradual approach.” (H)
“Let’s start with the good. Mr. Trump offered a three-phase approach recognizing that reopening is going to be a gradual process. The phases are tied not to strict dates — remember “open by Easter”? — but to achieving metrics.
In addition, the relaxing of emergency precautions will be scaled according to the intensity of the problem within a given state or region. The uncertainty that has dominated the national psyche will be abated by tangible milestones like school reopenings (phase two) and allowing visits to senior living facilities (phase three).
The plan also recognizes that not all businesses and facilities pose equal risks of spreading the coronavirus. Distancing and sanitation at a gym is conceivably more difficult than in a bar, though we should be on the lookout for new research to expand our understanding of that nuance. Therefore, different businesses should be allowed to reopen at a pace appropriate to their risk.
Finally, the plan rightly emphasizes vulnerable populations and senior living facilities. These facilities will remain at a high risk of explosive growth in cases until we can achieve widespread testing, vaccination and immunity. So the plan prohibits visits to them until the final phases and requires strict hygiene protocols when visits do occur.
That’s the good. Now the bad. The plan is a failure when it comes to testing, which everyone recognizes as a linchpin in any effort to reopen the country. It certainly assumes that testing will occur: A key metric for each phase of reopening is the trend in coronavirus cases. Accordingly, within a 14-day period there needs to be a “downward trajectory” of either documented cases or the percent of positive tests.
But there is no requirement that states first show that they have tested enough people to establish that the trajectories they are seeing are truly reflective of population-level trends. Overall, testing has been far too low for these trajectories to be relied on. Even after six weeks, barely 1 percent of the country’s population has been tested for Covid-19 and new daily tests have plateaued around 150,000. This is also not enough testing for effective levels of contact tracing.
More important, the plan calls for measuring a relative decline, and not an absolute threshold for very limited spread. So there could be a 14-day decline and yet the number of new cases could still be too high. We need a firm threshold, such as 20 new cases per one million people, that ensures a low number of new coronavirus cases when we start to re-open.
Another big concern with the plan is that, like the current C.D.C. testing guidelines, it still focuses on testing symptomatic people. If we are to stop the spread, the focus has to broaden to asymptomatic coronavirus-infected people who can be unwitting super-spreaders and ignite a resurgence…
Finally, nothing is mentioned in the “Opening Up America Again” plan about how states should handle a resurgence. There is no guidance on defining a significant uptick in cases or how to respond. As Dr. Anthony Fauci mentioned in the press briefing announcing the plan, there may be instances where states must “pull back.” But what does pulling back entail? How will states know when to do this? There is no guidance.” (I)
“As some governors consider easing social distancing restrictions, new estimates by researchers at Harvard University suggest that the United States cannot safely reopen unless it conducts more than three times the number of coronavirus tests it is currently administering over the next month.
An average of 146,000 people per day have been tested for the coronavirus nationally so far this month, according to the COVID Tracking Project, which on Friday reported 3.6 million total tests across the country. To reopen the United States by mid-May, the number of daily tests performed between now and then should be 500,000 to 700,000, according to the Harvard estimates.
That level of testing is necessary to identify the majority of people who are infected and isolate them from people who are healthy, according to the researchers. About 20 percent of those tested so far were positive for the virus, a rate that the researchers say is too high.
“If you have a very high positive rate, it means that there are probably a good number of people out there who have the disease who you haven’t tested,” said Ashish Jha, the director of the Harvard Global Health Institute. “You want to drive the positive rate down, because the fundamental element of keeping our economy open is making sure you’re identifying as many infected people as possible and isolating them.”
The researchers said that expanded testing could reduce the rate to 10 percent, which is the maximum rate recommended by the World Health Organization. In Germany, that number is 7 percent, and in South Korea, it is closer to 3 percent…
A shortage of test kits and technical flaws in the United States significantly delayed more widespread testing of the virus, letting it spread undetected for weeks. With more than 695,000 cases as of Friday, the country has the highest number of known cases in the world…
“We need to switch from saying to people, ‘if you have mild symptoms, if you’re not feeling super sick, don’t come and stay at home,’ to ‘if you have any symptoms, you need to come in to get tested right away,’ ” he said.” (J)
Governor Andrew Cuomo: (08:44)
How are you building the bridge? It’s going to be a phased reopening, right? During the phased reopening, the priority is make sure you do no harm and keep your eye on the public health issue. That is what is key in all of this. It’s going to be a calibration of reopening based on public health safety and that infection rate. Because what we have done in the reducing of the infection rate is a pure function of what New Yorkers have done and what people across the country have done. When you relax that social distancing, you could very well see an increase in the infection rate. It’s all a calibration to the public health, but it’s going to be a gradual increasing of economic activity in calibration with the public health standards.
Governor Andrew Cuomo: (09:42)
The single best tool to doing this gauging is large scale testing. Test, trace and isolate, it’s what everybody’s talking about. What does this mean? It means you test, you find a positive, you trace back who they were with, where they were, test those people and you isolate the people who are positive. It’s inarguable. It’s just very, very hard to do. It opens this new world of testing. This new world of testing is a new world to all of us by the way. There’s diagnostic testing. Are you positive or negative? There’s then testing for antibodies. Were you exposed? If I find out that you were already exposed and you had the virus, now you can go back to work because you had the virus, you have antibodies.
Where do you do the testing? We’ve been doing testing in hospitals. Frankly, that’s not a great place to do testing. You don’t want people walking into a hospital emergency room who may be positive for COVID. Our drive-thru locations are better, but how do you bring that to scale? Then even if you have the equipment and the testing site and the personnel to do the testing, where do you get the labs to test all of these tests? This is a whole world of questions that nobody has ever seen before.
Governor Andrew Cuomo: (12:06)
The bottom line is, you need large scale testing. Let’s do it. We can’t do it yet. That is the unvarnished truth. I know because New York has been doing this since this started exploring this new world. We have done more tests than any other state. We’ve done over 500,000 tests, which is more than the other states that are near us combined. We’ve been very aggressive here, but in all this time we’ve only done 500,000 tests. Now, that’s a large number of tests, yes. But this is over a one-month period. Even 500,000 tests, you’re talking about a state with 19 million people. You get a sense of the scale of what we have to do here.
Governor Andrew Cuomo: (13:10)
We cannot do it without federal support. I’ve been saying this for days. If you have a state that has a lower need, yes, they may be able to do it. But when you have a state that has to do a large number of these tests, I’m telling you we can’t do it without federal support. I’ve said that from day one. We will coordinate and we have been coordinating all the tests in our state. That’s how we got to that 500,000 number, more aggressive than I think anyone else. We have 228 private laboratories in this state. We will coordinate with them. We’ll make sure that we’re not competing with ourselves because there are a lot of groups that are now testing. New York State Department of Health developed their own antibody test. That test is going to be very important. It’s in our control because we’ll actually do those tests. We don’t need a private lab. We don’t need anyone else.” (K)
““Our best scientists & health experts assess that states today have enough tests to implement the criteria of phase one, if they choose,” Vice President Mike Pence said at a press conference the night of April 17.
But according to the Covid Tracking Project, the US has averaged fewer than 150,000 tests each day so far in the week of April 13, including at both public and commercial labs. That’s an improvement from the early days of March, when the country reported new tests in the dozens and later the hundreds. But it’s not an increase from more recent weeks: In the week of April 6, the country also averaged fewer than 150,000 tests a day.
What the country needs to properly do testing, according to experts, is at least 500,000 tests a day. Some experts call for much more than that — millions or even tens of millions a day — but the general point is that the US needs to be doing multiple times the testing that it’s currently doing to be able to test everyone with symptoms and their close contacts…
The recent slowdown in new tests is driven by shortages in nasal swabs, personal protective equipment, reagents, test kits, and machines needed to run the specific tests required. According to David Lim at Politico, some labs also complain that the Centers for Disease Control and Prevention’s testing criteria — which prioritizes hospitalized patients, health care workers, and those vulnerable to the virus, such as older people — is holding back potential tests, leaving existing testing capacity unused.
To fix the gaps, experts argue, the federal government needs to relax criteria for testing, invest in new supplies and labs, and better coordinate supply chains to address, among other issues, chokepoints. States, with limited resources and little control of the national supply chain, simply can’t do this all on their own.
Such fixes, however, are easier said than done. Experts warn the next phase of testing will be much more difficult than the initial phase, which largely required getting existing labs to start doing coronavirus testing — the low-hanging fruit.
“We’ve made substantial progress ramping testing this month,” Scott Gottlieb, a former commissioner of the Food and Drug Administration, wrote in a tweet on April 10. “But many gains were made by getting players into fight (clinical labs, academic labs). Now we must expand lab capacity, platforms, throughput, test kits. Getting next million tests/week will be harder than getting first.”
This is one reason the plans to end social distancing are so grim: Not only do they suggest that some level of social distancing will be needed for the next year or so (until a vaccine or a similarly effective treatment is widely available) — which we don’t know if the country can sustain — but they call for a level of surveillance and testing the US simply hasn’t yet shown the ability and willingness to build and manage…
But unless something changes, America is simply not meeting the benchmark of aggressive testing that experts say is necessary to start to reopen the country. As eager as Trump is to get the economy going again, the US just isn’t ready to do it in a safe way yet.” (L)
“On Wednesday, Singapore reported 142 new cases of COVID-19 — the highest single-day record for the city-state. In the last week, Singapore had two record-breaking numbers of new infections — with 120 new confirmed cases on April 5 and 106 on April 7, according to data collected by Worldometer — after weeks of successfully controlling the outbreak within its borders.
The new cases have been connected to foreign workers living in compact dormitories, the Straits Times reported. The recent resurgence of infections has prompted the government to implement a lockdown, closing down schools and most workplaces for a month…
Singapore was one of several Asian countries whose coronavirus response efforts were hailed as a “gold standard” of how to bring an outbreak under control.
While many other countries have imposed city-wide lockdowns and ordered citizens to stay at home, Singapore relied on surveillance, quarantine, and social distancing to curb the spread of infection. The city-state boldly resisted aggressive lockdown measures to limit disruptions to companies and workers in hopes of softening the inevitable economic blow of the pandemic…
However, the recent spike of cases in Singapore underscored how easily the virus can spread even with social distancing measures in place — and it may give a glimpse at what the US may be in for if the government lifts the orders too early…
Vice President Mike Pence announced that the Centers for Disease Control and Prevention is considering loosening its guidelines for self-isolation.
Under the proposed guideline, people who are exposed to the novel virus could be allowed to return to work if they are asymptomatic, wear a face mask, and monitor their temperature twice a day, a person familiar with the proposal told the Associated Press.
However, as the Trump administration eyes loosening restrictions, some estimates show that the US has yet to hit the peak of its coronavirus outbreak. Some estimate that it could occur in late April or early May.
Experts, including those on the White House Coronavirus Task Force, warned that lifting restrictions too early could result in a “second wave” of COVID-19 cases in the country.
An epidemiologist told Business Insider that countries might need to impose new lockdowns every three months until a vaccine is available. Lifting lockdown measures could lead to a re-emergence of the virus. As residents emerge from their homes, go to work, take their children to school, and go shopping, people could be asymptomatic but still spread the novel virus to others.
On Wednesday, Dr. Deborah Birx, the White House coronavirus response coordinator, cautioned against reading “early signs of hope” and doubled down on maintaining social distancing measures.
“What’s really important is that people don’t turn these early signs of hope into releasing from the 30 days to stop the spread. It’s really critical,” Dr. Deborah Birx, the White House coronavirus response coordinator, said on Wednesday.
“So, if people start going out again and socially interacting, we could see a very acute second wave very early. We are really encouraging every American to continue to follow the guidelines for these 30 days,” she added.” (M)
“Sloppy laboratory practices at the Centers for Disease Control and Prevention caused contamination that rendered the nation’s first coronavirus tests ineffective, federal officials confirmed on Saturday.
Two of the three C.D.C. laboratories in Atlanta that created the coronavirus test kits violated their own manufacturing standards, resulting in the agency sending tests that did not work to nearly all of the 100 state and local public health labs, according to the Food and Drug Administration.
Early on, the F.D.A., which oversees laboratory tests, sent Dr. Timothy Stenzel, chief of in vitro diagnostics and radiological health, to the C.D.C. labs to assess the problem, several officials said. He found an astonishing lack of expertise in commercial manufacturing and learned that nobody was in charge of the entire process, they said.
Problems ranged from researchers entering and exiting the coronavirus laboratories without changing their coats, to test ingredients being assembled in the same room where researchers were working on positive coronavirus samples, officials said. Those practices made the tests sent to public health labs unusable because they were contaminated with the coronavirus, and produced some inconclusive results.
In a statement on Saturday, a spokeswoman for the F.D.A., Stephanie Caccomo, said, “C.D.C. did not manufacture its test consistent with its own protocol.”” (N)
“Despite the campaignlike and hopeful title of the briefing — “Opening up America Again” — there’s still a very long road ahead for the overwhelming majority of the country. Consider that the 20 states, including D.C., with the fewest coronavirus cases make up just 11% of the U.S. population.
States with the most cases and the largest populations will have to act like mini-countries. It’s going to produce a patchwork of plans that could wind up looking pretty similar to the red-blue electoral maps, and there are still lots of questions.
1. How do issues with testing impact governors’ ability to meet the benchmarks laid out in the guidelines?
2. Will the reopenings give a false sense of security to rural places?
3. How will employers screen and do contact tracing?
4. How will travel work between states in different phases?
States will likely get to different phases at varying rates. So, how much of a gap will this create between states in different phases? And what about travel between those places? Until there’s a vaccine or a treatment, there’s no way to be sure there won’t be flare-ups or outbreaks that could lead to places with few cases, which may have relaxed restrictions, seeing unnecessary deaths.” (O)
“Across the country, governors are finding themselves caught between increasingly competitive pressures, several said on Sunday, as they balance maintaining restrictions meant to curb the spread of the coronavirus against growing frustration with the restrictions and the economic anguish they cause.
In Maryland and Virginia, governors said stay-at-home orders would have to remain in effect until those states begin to see decreases in the number of Covid-19 cases. Elsewhere in the nation, state officials said they would need to conduct far more testing before easing restrictions, and continue to face shortages of supplies and testing kits.
“We are fighting a biological war,” Gov. Ralph Northam of Virginia said on the “State of the Union” program on CNN. He added that governors have been forced “to fight that war without the supplies we need.”..
Public health experts have said testing would need to at least double or even triple to begin considering even a partial reopening of the country’s economy, and business leaders reiterated the message in a conference call with Mr. Trump last week…
Dr. Deborah Birx, the coronavirus response coordinator for the White House, also pushed back against criticism that enough people were not being tested, saying that not every community required high levels of testing and that tens of thousands of test results were probably not being reported.
She said the government was trying “to predict community by community the testing that is needed,” Dr. Birx said on the CBS program “Face the Nation” on Sunday. “Each will have a different testing need, and that’s what we’re calculating now.”
On the ABC program “This Week,” Dr. Birx said she thought statistics on testing were incomplete: “When you look at the number of cases that have been diagnosed, you realize that there’s probably 30,000 to 50,000 additional tests being done that aren’t being reported right now.”
As some governors look to ease coronavirus restrictions, public health experts say the country needs at least half a million tests per day to safely reopen.
There are currently about 150,000 diagnostic tests conducted each day, according to the Covid Tracking Project. Researchers at Harvard estimated last week that in order to ease restrictions, the nation needed to at least triple that pace of testing.
When the host of “This Week,” George Stephanopoulos, asked Dr. Birx about that estimate, she said current testing levels were adequate.
“We believe it’s been enough in a whole series of the outbreak areas — when you see how Detroit has been able to test, Louisiana, Rhode Island, New York and New Jersey,” Dr. Birx said.
She said that a team at Walter Reed National Military Medical Center in Maryland was calling hundreds of labs around the country to determine exactly what supplies they need “to turn on full capacity, which we believe will double the number of tests that are available for Americans.” (P)
Inside America’s 2-Decade Failure to Prepare for Coronavirus
Top officials from three administrations describe how crucial lessons were learned and lost, programs launched and canceled, and budgets funded and defunded.
He Could Have Seen What Was Coming: Behind Trump’s Failure on the Virus
An examination reveals the president was warned about the potential for a pandemic but that internal divisions, lack of planning and his faith in his own instincts led to a halting response.
The ‘Red Dawn’ Emails: 8 Key Exchanges on the Faltering Response to the Coronavirus
Experts inside and outside the government identified the threat early on and sought to raise alarms even as President Trump was moving slowly. Read some of what they had to say among themselves at critical moments.
PART 1. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”
PART 2. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”
PART3. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)
PART 4. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….
PART 5. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”
POST 6. Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””
PART 7. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.
PART 8. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”
PART 9. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”
Part 10. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.
PART 11. CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”
Part 12. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”
Part 13. CORONAVIRUS. March 14, 2020. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”
PART 14. CORONAVIRUS. March 17, 2020. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”
PART 15. CORONAVIRUS. March 22, 2020. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.
PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT
PART 17. April 2, 2020. CORONAVIRUS. Florida allows churches to continue holding services. Gun stores deemed “essential.” “New York’s private and public hospitals unite to manage patient load and share resources.
PART 18. April 9, 2020. CORONAVIRUS. “The federal government’s emergency stockpile of personal protective equipment (PPE) is depleted, and states will not be receiving any more shipments, administration staff told a House panel.
PART 19. April 13, 2020 CORONOAVIRUS. “…overlooked in the United States’ halting mobilization against the novel coronavirus: the personal aides, hospice attendants, nurses and occupational or physical therapists who deliver medical or support services to patients in their homes.”
New York hospitals are beginning to operate as one system under a new plan by Gov. Andrew Cuomo as the state tries to increase its medical capacity to stop the coronavirus pandemic.
Right now, New York’s hospitals are no longer operating as independent facilities. Under the plan announced this week by New York Gov. Andrew Cuomo, there is effectively one big New York state hospital system fighting off the coronavirus…
Cuomo announced that he had met with New York hospital leaders and come up with a plan to, in effect, merge them into one operating system with many different locations. From Buffalo to NYC, hospitals will be sharing staff, patients, and supplies for the foreseeable future, with Albany overseeing the distribution of resources.
“It’s not unusual for a time of an emergency for regulatory authorities to basically say, ‘Hospitals, you must do this.’ Usually there are provisions in state law that enable that to happen,” Susan Dentzer, a senior policy fellow at Duke University’s Margolis Center for Health Policy, told me. Hurricane Katrina is one recent example she gave.
But the plan is still remarkable. There are about 200 hospitals in New York state, totaling 53,000 beds before Cuomo told them to double their capacity. About 20,000 of those beds are in New York City.
It is a matter of necessity, as New York has already seen more than 100,000 Covid-19 cases and 1,500 deaths — with the peak still projected to be a week away, according to the Institute for Health Metrics and Evaluation’s estimates, requiring as many as 100,000 beds.
“This is on a scale that has not happened in the United States ever, with the possible exception of 1918,” Dentzer said of the New York strategy. “Nothing on this scale has ever happened in at least 100 years.”
I asked Peter Viccellio, associate chief medical officer at the Stony Brook emergency department in Long Island, about the New York hospitals plan. I want to share his response in full:
We’re in an almost apocalyptic crisis, which requires cutting through the bullshit. If hospital A has resources and hospital B doesn’t, it’s in the best interest of the patient that hospital A and B work together. Protective equipment should be available to all health care providers, not just those who work at a place with a better procurement officer. We ALL need the proper equipment to treat the patient, and adequate space. Fighting against each other for resources — this isn’t the time. Resources need to be distributed in a rational way. The current rugby scrum is nonsense.
The top priority in Cuomo’s plan is moving staff from less affected hospitals to those buckling under a surge of Covid-19 cases. Doctors and nurses from upstate hospitals will be transferred to NYC facilities. Likewise, hospitals will try to send patients from overcrowded hospitals to those with available beds. Ventilators, which support critical patients’ breathing, could also be shuffled between hospitals based on need.
The New York state department of health will manage the movement of staff and resources, in conjunction with hospitals. It will set certain thresholds for the number of occupied ICU beds or ICU Covid-19 cases that would trigger some of these transfers. The state will also coordinate the distribution of the protective gear that helps keep doctors and nurses healthy and able to work from the various state and hospital stockpiles…
This kind of coordination is relatively commonplace within a single hospital system that has multiple facilities. What’s unique here is the scale: an entire state merging all of its hospital systems into one.
And that will present plenty of challenges both logistical (what happens when patients move from an in-network hospital to an out-of-network one?) and personal (are patients going to be moved far away from their families?). A few more questions, via the Kaiser Family Foundation’s Larry Levitt: What are the payment rates and who is paying? Do hospitals have to pay each other when one sends another resources?
“I do think it’s going to be incredibly messy and complicated to sort out reimbursement of all this on the back end,” he said.
Another one: Is Congress going to provide more funding to bail out hospitals in New York and elsewhere, which have taken a brutal financial hit as they cancel elective surgeries to free up more beds and staff to battle Covid-19?
We’ll need answers to those questions. But the time for radical action is here. As Joynt Maddox put it, “If not now, when?”
“This is the kind of organization we need in a pandemic, with very clear guardrails around the scenarios under which it’s put into place and under which it no longer applies,” she said. “I can see plenty of potential problems, but plenty of upside too.”
New York is the first state to take such a dramatic step as the coronavirus takes its toll there. But it may not be the last. (A)
The state’s largest private employer (the Mayo Clinic) is instituting across the board pay cuts and furloughs to shoulder a projected $3 billion loss this year.
Mayo Clinic’s cost-cutting measures follow its decision in mid-March to halt elective surgeries and procedures — a move that was quickly applied statewide as part of Gov. Tim Walz’s executive order to suspend non-critical medical procedures not deemed essential to save a life.
“The decision to eliminate elective surgeries and outpatient visits was the right decision in terms of protecting the safety of our patients and staff, and also preserving limited PPE (personal protective equipment),” said Chief Administrative Officer Jeff Bolton. “But it has led to significant reductions in revenues.”
Bolton said the hospital in Rochester is at about 35 percent of capacity, while capacity in Mayo’s surgery services is at about 25 percent.
“If you go back to the Great Depression, the institution went through a very similar financial crisis, and salaries were reduced during that period of time,” said Bolton. “There were a lot of actions that were very similar to the ones we are taking today.”
The pay and work reductions, which will apply to all employees at Mayo’s campuses in Minnesota, Florida and Arizona, will start in May, and last until the end of the year. Together, Mayo employs more than 63,000 people…
Mayo Clinic executives, including CEO Gianrico Farrugia, will take a 20 percent cut starting this month. Physicians and senior administrators will take a 10 percent salary cut, other salaried employees will take a seven percent reduction, while other workers will be asked to take extended furloughs.
That’s in addition to a hiring freeze, laying off contract employees and halting some construction projects, Bolton said.
Even after these changes, Mayo will face a $900 million shortfall at the end of the year, which will be covered by Mayo’s reserves established over the last decade, Bolton said.
Bolton said cost-cutting measures will not affect the pay rate of hourly workers.
The financial blow of halting elective services comes on the heels of what Mayo officials had described as a “year of remarkable growth.” In 2019, Mayo reported revenue of $13.8 billion, which was up nearly 10 percent from the previous year.
For the first time in Mayo’s history, net operating income topped out at $1 billion…
Bolton added that Mayo’s ability to rebound after the end of the year will also depend on how long the pandemic lasts, and if a global recession impacts how many patients travel to Mayo for treatment.” (B)
“HHS’ Office of Inspector General released a report April 6 that details the challenges hospitals are confronting due to COVID-19, how they are responding, and what they are asking of the government to better meet their needs during the coronavirus crisis.
The OIG conducted brief telephone interviews March 23-27 with administrators from 323 hospitals across 46 states, the District of Columbia and Puerto Rico, which were part of a random sample. Hospital administrators shared the following challenges their organizations face in response to COVID-19, as well as how they would like the government to respond:
1. Challenge: Severe shortages of testing supplies and extended waits for results. Hospitals reported frequently waiting seven days or longer for test results, which results in a number of “rule-out” cases that strain existing challenges with staffing, bed availability and shortages of personal protective equipment. According to one hospital, 24 hours is typically considered a long turnaround time for virus testing.
Hospitals’ ask: Hospitals expressed a need for greater coordination from the federal government around testing kits and supplies to provide “equitable distribution of supplies throughout the country,” according to the report. Hospitals also asked for the government to provide testing kits, take steps to ensure that supply chains can provide hospitals with a sufficient supply of tests, and expedite results by allowing more entities to produce and conduct tests.
2. Challenge: Widespread shortages of PPE. stockpile, or that the supplies they had received were insufficient in quantity or quality.
3. Challenge: Difficulty maintaining adequate staffing and supporting staff. Hospitals cited need for specialized staff, concerns that staff exposure to the virus will exacerbate shortages and overwork, and concerns about the emotional toll that staff face.
4. Challenge: Decreased revenue, increased costs and gaps in reimbursement. Hospitals have essentially stopped elective procedures and many other services, which accounts for a substantial portion of hospitals’ revenue.
5. Challenge: Changing and/or inconsistent guidance from authorities. (C)
“CMS announced April 9 that it has delivered more than $51 billion in payments to hospitals and other healthcare providers in the past week through the Accelerated and Advance Payment Program.
CMS expanded the payment program to a broader group of healthcare providers in late March to help offset the financial impact of COVID-19. On April 7, the agency said it had distributed $34 billion in funds to healthcare providers and suppliers through the program in the past week. Two days later, CMS said the amount had grown to $51 billion.
CMS has received roughly 32,000 requests from healthcare providers and suppliers for advance payments in the past week, and 21,000 of those requests have been approved. That’s compared to the 100 total requests CMS approved in the past five years.” (D)
“The $2 trillion federal coronavirus aid package signed into law that includes $100 billion for nonprofit hospitals won’t completely cover the revenue hospitals will lose as a result of the pandemic, Moody’s Investors Service wrote in an April 3 note.
While the aid package includes several provisions like compensation for lost revenue, increased Medicare reimbursement and advances on future Medicare reimbursement, cash flow at nonprofit hospitals will still likely be materially lower for the next several months. Postponed services alone are likely to reduce hospital revenue by 25 percent to 40 percent a month on average, Moody’s said, a reduction that is affecting even hospitals that aren’t treating large COVID-19 case loads.” (E)
“As the coronavirus crisis intensified, and many Americans started losing their employer-based health coverage, the Trump administration considered creating a special open-enrollment period for the Affordable Care Act. It seemed like a common-sense move, which had the backing of private insurers.
But the White House balked, to the surprise of nearly everyone involved in the process. As Politico reported the other day, the decision appeared to be largely political: Team Trump didn’t want to turn to “Obamacare” to help people in a crisis.
“You have a perfectly good answer in front of you, and instead you’re going to make another one up,” one Republican close to the administration said. “It’s purely ideological.”
It also left the White House in search of a policy alternative. Roll Call reported on the apparent solution: the administration plans to reimburse providers for uninsured COVID-19 patients.
Health and Human Services Secretary Alex Azar said at a White House press briefing that hospitals and health care providers would be reimbursed at Medicare rates for the treatment of uninsured patients. Providers would be banned from balance billing patients or sending them a surprise medical bill to make up the difference in costs not covered by the government.
Note, there was already a policy in place to cover the cost of virus testing, regardless of coverage status. This new policy goes considerably further: uninsured Americans who get the virus will be able to go to the hospital and receive care, and the federal government will reimburse the medical facilities for the cost…
There are, however, some lingering concerns. For one thing, many hospital administrators have said their facilities are facing a severe financial crunch now, and the new policy is based on after-the-fact reimbursements. That money will arrive, but not anytime soon…
A New York Times report added that there are other concerns about whether the funding will go to facilities in the states hardest hit by the crisis: “The administration’s plan … would tend to shift more money toward states with more uninsured patients. New York, California and Washington, which have experienced early surges in infections, entered the crisis with very low levels of uninsured residents. Republican-led states, like Florida and Texas, that have declined to expand Medicaid are likely to benefit more from funding targeted directly at uncompensated care.” (F)
“Hospital CEOs are blasting HHS’ decision to distribute the first $30 billion in emergency funding based on Medicare fee-for-service revenue, according to Kaiser Health News.
HHS said April 10 it would allocate money to hospitals and providers based on their historical share of revenue from the Medicare program, rather than the burden caused by the coronavirus or number of uninsured patients treated….
Kenneth Raske, CEO of the Greater New York Hospital Association, wrote in a memo to association members that the method is “woefully insufficient to address the financial challenges facing hospitals at this time, especially those located in ‘hot spot’ areas such as the New York City region.”..
An HHS spokesperson told Kaiser Health News the agency decided to use Medicare revenue as the basis of distribution because it “allowed us to make initial payments to providers as quickly as possible.” (T)
“The CEO and executive leadership team at Mount Sinai Health System will take pay cuts to help offset the significant COVID-19 costs the New York City-based health system is facing.
Mount Sinai President and CEO Kenneth Davis, MD, and his executive team offered and agreed to take a 50 percent pay cut, according to information the health system shared with Becker’s Hospital Review April 9. The pay cuts will continue “as long as necessary so that these dollars can be directed to our front lines in this fight,” the health system said.” (G)
“California Gov. Gavin Newsom said April 8 that the state is working to gather more demographic information on COVID-19 patients. One major finding revealed that healthcare workers made up roughly 10 percent of the confirmed cases as of April 7, according to The New York Times.” (H)
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“All day, most days, for $10 an hour, Marley Brownlee comes and goes from the homes of the old and the weak.
She has almost none of the equipment that could protect her vulnerable clients — or herself — from the deadly virus that has transformed life across the United States. No masks, goggles or gown. She takes what precautions she can using gloves, hand sanitizer and disinfectant wipes. Her hands are raw from washing, and last week, she considered spraying herself down with Lysol between appointments.
It is a sprawling sector of the U.S. health-care delivery system — and one whose fortunes could be critical in efforts to contain covid-19, the deadly lung disease caused by the coronavirus. With nursing homes across the country locked down and hospitals preparing for an onslaught of covid-19 patients, many who require medical services or help with the basic tasks of daily living are likely to be confined to their homes in the weeks and months ahead. Yet the providers of those services say they are unprepared to step into the breach, hamstrung by regulations ill-suited to the current pandemic and unable to access protective gear that could shield workers and clients alike from infection.
“There’s no doubt that we’re being sort of forgotten in all this, and I fear that mentality is going to eventually come back and punish us,” said Joe Russell, executive director of the Ohio Council for Home Care and Hospice. “If we’re carrying this disease from household to household, these people are just as vulnerable as anybody in a hospital or a nursing home.”..
Such concerns are being pressed in states across the country and in Washington, where home-care industry leaders are pleading with Trump administration officials and members of Congress not to exclude their providers from the nation’s belated efforts to launch a coherent policy response to the pandemic.” …
They have two primary requests: An adequate supply of protective equipment — including the scarce N95 masks that are most effective in preventing transmission of the coronavirus — and increased flexibility in Medicare regulations that govern person-to-person contact at patients’ homes…
The home-care industry lacks the prominence and cachet of American hospitals, especially its most celebrated medical centers. No agency that sends workers into houses to help a stroke victim learn to mount the stairs again or assist a patient with a wheelchair in the bathroom vies for recognition with Johns Hopkins Hospital or the Cleveland Clinic. Yet home care has grown into a pillar of the medical and senior-care systems, serving both older clients who wish to avoid nursing homes — now more than ever — and people with disabilities, who in previous decades were often clustered in large institutions.” (S)
“Washington (CNN)A sailor who tested positive for Covid-19 on the USS Theodore Roosevelt has died of coronavirus, the US Navy said Monday.
The Navy did not disclose the name of the sailor, who was admitted to the intensive care unit of a US Navy hospital on Thursday. CNN previously reported a sailor from the USS Theodore Roosevelt who tested positive for the virus March 30 was found unresponsive and placed in the intensive care unit during a daily medical check.
The Navy said that the sailors who found him unresponsive attempted to administer CPR prior to his being transferred to the intensive care unit.
In addition, a US defense official told CNN that four sailors from the ship have been transferred to hospital.
Nearly 600 sailors on the Roosevelt have tested positive for Covid-19, the US Navy said in a statement, adding that 92% of the Roosevelt’s crew members have been tested for the virus.
The impact of the coronavirus pandemic on the Roosevelt was at the center of a controversy that led to the resignation last week of acting Navy Secretary Thomas Modly, who had dismissed the aircraft carrier’s captain Brett Crozier after the leak of a memo in which he implored Navy officials to urgently evacuate the ship to protect the health of its sailors. Crozier also flagged his concerns about challenges of trying to contain the virus aboard the ship and requested that sailors be allowed to quarantine on land.
“We are not at war. Sailors do not need to die. If we do not act now, we are failing to properly take care of our most trusted asset: our Sailors,” he wrote in the memo that three US defense officials confirmed to CNN.
More than 4,000 sailors have since been evacuated and moved ashore in Guam. Sailors who have tested negative for the coronavirus are being housed in isolation in local area hotels.
The Navy says it is required to keep about 1,000 sailors aboard the vessel to perform key functions such as the operation of the ship’s nuclear reactors…
Vice Chairman of the Joint Chiefs of Staff Gen. John Hyten told reporters Thursday the US military needed to plan for similar outbreaks in the future as the Defense Department works to cope with the virus’ impacts.
“I think it’s not a good idea to think the Teddy Roosevelt is a one-of-a-kind issue. We have too many ships at sea, we have too many deployed capabilities. There’s 5,000 sailors on a nuclear-powered aircraft carrier. To think it will never happen again is not a good way to plan. What we have to do is figure out how to plan in these kind of Covid environments,” Hyten said.
Nearly 3,000 US service members have tested positive for coronavirus, two service members have died.” (I)
“There is much that the military can do to protect the American populace from the coronavirus’s ravages, and service members undoubtedly wish they could do more. They should have been well positioned to do just that: Internal 2017 documents obtained Wednesday by The Nation show that the military had planned for a coronavirus-type pandemic and predicted many of the same equipment shortages that the U.S. is now experiencing. But the data and murmurs emerging from the U.S. national security complex paint a picture of a hamstrung bureaucracy that’s as ill-prepared to protect its own people as most states are.
Numbers tell part of that story. As of last Friday, the Pentagon had reported 613 cases of Covid-19 in its combined military and civilian workforce, putting its total ahead of 28 states’. (The Department of Defense’s “population” of about 2.9 million people, by contrast, only makes it bigger than the population of 15 states.) But by Monday, military-linked infections had already topped 1,000, and Esper had ordered all U.S. commanders across the globe to stop reporting new infections on their installations to the public, calling such reports “information that is classified as a risk to operational security.” Subordinates of Esper at several U.S. military bases told Stars & Stripes that the order “could harm their ability to inform their own force and strain their ability to work with officials in their surrounding civilian communities amid the pandemic.”
Local military commands are already in disarray in many respects. The Navy is fast learning that ships and bases are breeding grounds for the coronavirus; in addition to the Roosevelt outbreak, cases have been reported on the USS Ronald Reagan and USS Boxer, as well as at the service’s boot camp and the Naval Academy. New York–based recruiters for the Marine Corps begged the service last week to shut down its boot-camp training base at Parris Island, South Carolina—always a close-quarters hotbed for germs. “Decision-makers are absolutely in denial if they believe high rates of infection and hospitalization will not happen on the depot under close proximity and enclosed spaces,” one Marine told Military.com. By Monday, Marine Corps officials were forced to relent, after at least 20 Parris Island recruits and trainers tested positive for the virus; the service’s West Coast boot camp in San Diego, however, remains open.” (J)
“At Crown Heights Center for Nursing and Rehabilitation in Brooklyn, workers said they had to convert a room into a makeshift morgue after more than 15 residents died of the coronavirus, and funeral homes could not handle all the bodies.
At Elizabeth Nursing and Rehabilitation Center in New Jersey, 19 deaths have been linked to the virus; of the 54 residents who remain, 44 are sick.
After 13 people died in an outbreak at the New Jersey Veterans Home in Paramus, the governor called in 40 combat medics from the National Guard…
The virus has perhaps been cruelest at nursing homes and other facilities for older people, where a combination of factors — an aging or frail population, chronic understaffing, shortages of protective gear and constant physical contact between workers and residents — has hastened its spread.
In all, nearly 2,000 residents of nursing homes have died in the outbreak in the region, and thousands of other residents are sick.
As of Friday, more than half of New York’s 613 licensed nursing homes had reported coronavirus infections, with 4,630 total positive cases and 1,439 deaths, officials said…
In New York, nursing home administrators said they had been overwhelmed by an outbreak that quickly spun beyond their control. They were unable, they said, to have residents tested to isolate the virus or to get protective equipment to keep workers from getting sick or transmitting the virus to residents.
“The story is not about whether there’s Covid-19 in the nursing homes,” said Scott LaRue, the chief executive of ArchCare, which operates five nursing homes in New York. “The story is, why aren’t they being treated with the same respect and the same resources that everyone else out there is? It’s ridiculous.”” (K)
“POLICE FORCES ACROSS the country are being increasingly hobbled by the coronavirus outbreak, with officers falling ill and operations being adjusted as the numbers of cases and deaths increase exponentially.
Approximately 17% of uniformed New York City Police Department employees – more than 6,000 total – are currently out sick, a department spokeswoman says. But 1,400 NYPD officers have now tested positive for the coronavirus, Commissioner Dermot Shea told CNN – a large increase over the number reported by the department as recently as Tuesday…
But police departments are being crunched in many other cities. Detroit Mayor Mike Duggan announced Monday that nearly 500 of the city’s police officers and more than 100 civilian employees were quarantined due to exposure to the coronavirus, according to WJBK-TV in Detroit. Sixty-nine Detroit Police Department officers and employees had tested positive as of Monday. Major metropolitan police departments in cities like Boston, Chicago, Los Angeles and New Orleans have positive cases as well, according to The Associated Press…
Police agencies across the country are responding to the crisis in a variety of ways, according to the Police Executive Research Forum, an independent research organization.
Some departments have begun suspending in-person briefings, while many others have postponed training and limited public access to police facilities, according to the organization. Garcia says the San Jose Police Department started conducting its daily briefings outside so that people could spread out more.
Policing itself is also being adjusted – many agencies are directing officers to avoid handling calls in person when possible and discouraging arrests for low-level offenses, the forum finds.
Garcia says that while his department started making preparations six weeks ago – long before California Gov. Gavin Newsom issued a stay-at-home order for the state’s 40 million residents – the outbreak has since affected operations, including shift changes and the daily briefings tweaks. But he is proud of how his staff has “risen to this challenge.”..
But Garcia notes that, in San Jose at least, “things pop up every day,” including calls regarding gatherings that might be violating the shelter-in-place order.
“There’s no playbook for this,” Garcia says. “Every day there’s something different that we’re trying to come up with.” (L)
“Much attention in this terrible pandemic is being focused on the country’s hospitals, and rightly so. But the battle is also being fought by the nation’s front-line emergency medical workers, paramedics and E.M.T.s. These skilled professionals are responding to a deluge of calls, risking their lives to aid millions of sick Americans.
In New York City, where the Fire Department’s roughly 4,400 emergency medical workers are already underpaid and overworked, the pandemic is taking an enormous toll.
They are responding to 6,000 to 7,000 calls a day; in normal times, the average is about 4,000. Nearly a quarter of these workers are on sick leave, according to Fire Department officials. At least three are in critical condition with coronavirus symptoms.
One question amid the shortage is how many face masks in the city’s stockpile are actually making it to the E.M.T.s, paramedics and other city workers who are most at risk. City officials declined to respond to repeated inquiries about how the masks and other critical medical supplies were being distributed across city agencies.
Mayor Bill de Blasio said at a news conference Tuesday that the F.D.N.Y. commissioner, Daniel Nigro, had assured him the department had the supplies it needed. The mayor said the department was meeting a “crisis standard” of personal protective equipment held as acceptable by the Centers for Disease Control and Prevention. “Anything more they need, they will get,” Mr. de Blasio said.
In interviews, they said some stations started running out of N95 masks weeks ago. They said they have been forced to reuse masks, gowns and other protective gear. To request additional N95 masks, they said they must explain in writing how they used their previous supply. And they said there is little or no coronavirus testing available to them or their colleagues…
How did this happen in New York, a city with a world-class department justly celebrated for its heroic service during the Sept. 11 attacks?
Emergency medical services have been an afterthought in New York for years. In much of the country, firefighters also serve as paramedics or E.M.T.s. But in New York, E.M.S. is a separate division within the Fire Department. Firefighters receive a base pay of about $85,000 after five years on the job, compared to about $65,000 for paramedics and $50,000 for E.M.T.s. The firefighting force is three-quarters white and about 99 percent male; more than half of E.M.S. workers are minorities, and more than a quarter are women, according to city data.” (M)
“As the coronavirus preys on the most vulnerable, it is taking root in New York’s sprawling network of group homes for people with special needs.
As of Monday, 1,100 of the 140,000 developmentally disabled people monitored by the state had tested positive for the virus, state officials said. One hundred five had died — a rate, far higher than in the general population, that echoes the toll in some nursing homes.
Separately, a study by a large consortium of private service providers found that residents of group homes and similar facilities in New York City and surrounding areas were 5.34 times more likely than the general population to develop Covid-19 and 4.86 times more likely to die from it. What’s more, nearly 10 percent of the homes’ residents were displaying Covid-like symptoms but had not yet been tested, according to the consortium, New York Disability Advocates.
Trouble throughout the New York City region — and, to a lesser extent, the state — was revealed in interviews with caregivers, parents, advocates and senior officials.
In Brooklyn, two parents of adult children in a group home said they were unnerved after another resident died in a suspected coronavirus case. “If it is the virus, what the hell are we going to do?” one of them said, while adding that the staff “deserve a lot of credit” for showing up.
On Staten Island, three state employees who are direct caregivers said 50 of their roughly 600 colleagues in the borough had tested positive. They described the challenges they faced on the job.
“One of the individuals here is positive, and his behavior is to get up, to pace, and he wants to give me a hug, shake my hand,” said one of the caregivers, asking that his name not be used because he was not authorized to speak.” (N)
“Seventy people at San Francisco’s largest homeless shelter have tested positive for the coronavirus, Mayor London Breed said on Friday.
The outbreak, which included two staff members, is the largest reported at a single shelter in the United States. It reinforces a major fear that homeless people, many whom have pre-existing respiratory illnesses, are especially vulnerable to the pandemic.
Advocates in San Francisco, where there are more than 8,000 homeless people, had expressed concern in recent weeks that the city had not moved quickly enough to use empty hotel rooms to thin out the shelter system.
California has procured more than 8,000 hotel rooms for homeless people and those who need to quarantine themselves, far short of the more than 100,000 people in the state who sleep on the streets.
The shelter where the outbreak occurred, Multi-Service Center South, normally houses around 400 people. In recent weeks, the city had reduced that number of occupants to 144, all of whom were tested on Friday.
The outbreak underlined the breathtaking speed at which the virus can spread in a congregate setting…
Experts say cities face a dilemma in addressing the homelessness crisis during the pandemic. Bringing people indoors offers access to showers and bathrooms but might also make the virus more transmissible.
“The shelters present a greater risk of transmission because you have people interacting and sleeping in close quarters,” said Linsey Marr, an expert in airborne disease transmission at Virginia Tech. “You have much greater density of people.”
Mr. Kositsky said that in addition to homeless people, hundreds of city employees charged with looking after them were also vulnerable to the virus.
“I’m out with the outreach workers and none of us have protective gear,” he said.” (O)
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“The Coronavirus crisis has exposed the ways in which big investors of hospitals are squeezing the sick and injured for as much money as possible after they leave the hospital.
The New Yorker reported Thursday about the way private equity firms have been throwing “surprise medical billing” on patients that accepted their health insurance. In some cases the hospital may be in-network for a patient, but the emergency surgeon isn’t or the radiologist, or anesthesiologist isn’t in-network…
Eileen Appelbaum at the Center for Economic and Policy Research has kept a watchful eye on the effort. She discovered that private equity firms “investment funds that purchase companies and try to increase their profitability,” are the ones responsible for changing the face of a hospital.
“In many cases, companies were sending work to other countries where labor costs were lower. In others, they were practicing ‘domestic outsourcing’: subcontracting out parts of their businesses to other U.S.-based companies, to run their accounting departments, corporate cafeterias, or janitorial services, among others, rather than employing those workers directly,” the report explained.
“They moved away from the idea of, How do we make our current workforce more productive? to, How do we move workers off our payroll and onto a contract company? And then they can do whatever they want with the workers,” Appelbaum said. “And, if you’re a contract company, how do you get the contract? By being the lowest bidder. You’re at rock bottom, offering just barely enough to attract any workers at all.”
She explained that given the coronavirus, the issue of “surprise billing” is even more important. COVID-19 has a tendency to go from bad to dangerous in some who come down with the virus. That can be the moment that people are forced to go to the hospital or call an ambulance. It’s exactly the conditions where surprise billing can surface and bankrupt people, even if they are fully insured.” (P)
“Doctor Ming Lin is the first emergency room doctor to be fired for going public with his concerns about poor hospital emergency room safety practices and shortages of medical supplies and protective gear for health workers. He won’t be the last.
Like many hospitals in the US, PeaceHealth St. Joseph Medical Center in Bellingham Washington, where Ming Lin worked for the past 17 years as an emergency room doctor, has outsourced the management and staffing of its emergency room. So, Lin works on-site at the hospital’s ER, but he is employed by a physician staffing firm that runs the ER. These staffing firms are often behind the surprise medical bills for ER services that patients receive after their insurance company has paid the hospital and doctors, but not the excessive out-of-network charges billed by these outside staffing firms.
About a third of hospital emergency rooms are staffed by doctors on the payrolls of two physician staffing companies — TeamHealth and Envision Health — owned by Wall Street investment firms. Envision Healthcare employs 69,000 healthcare workers nationwide while TeamHealth employs 20,000. Private equity firm Blackstone Group owns TeamHealth, Kravis Kohlberg Roberts (KKR) owns Envision.
Care of the sick is not the mission of these companies; their mission is to make outsized profits for the private equity firms and its investors. Overcharging patients and insurance companies for providing urgent and desperately needed emergency medical care is bad enough. But it is unconscionable to muzzle doctors who speak out to advocate for the health of their patients and co-workers during the global pandemic that is rapidly spreading across the US…
The American Academy of Emergency Medicine protested Dr. Lin’s ouster and questioned how TeamHealth is allowed to provide hospital services when the law requires that physician practices must be owned by a licensed medical practitioner. TeamHealth skirts the law by owning all the assets of the physician practices it acquires — the real estate, offices, equipment, supplies, inventory, and even accounts receivable.
On paper, the physician practices are owned by a doctor-led organization that TeamHealth has set up to comply with the law. But what does it mean to own a physician practice if the practice has no assets and no possibility to exist on its own?
The furor over patients hit by surprise medical bills revealed that TeamHealth controls the billing for the doctors it supplies to hospital emergency rooms. The firing of Doctor Ming Lin pulls back the curtain and reveals that TeamHealth controls the doctors as well.” (Q)
“Hospitals taking money from the $2.2 trillion stimulus bill will have to agree not to send “surprise” medical bills to patients treated for COVID-19, the White House said Thursday…
“The Trump administration is committed to ensuring all Americans are not surprised by the cost related to testing and treatment they need for COVID-19,” White House spokesman Judd Deere said in a statement.
The stimulus bill includes $100 billion for the health care system, to ease the cash crunch created by the mass cancellation of elective procedures in preparation to receive coronavirus patients. Release of the first $30 billion, aimed at hospitals, is expected soon.
The prohibition on surprise billing will protect patients covered by government programs, employer plans or self-purchased insurance.
Hospitals that accept the grants will have to certify that they won’t try to collect more money than the patient would have otherwise owed if the medical attention had been provided in network.
“In a time when nothing is certain, patients can take solace in knowing that they will not receive outrageous, unavoidable bills weeks and months after they have survived the virus,” Annette Guarisco Fildes, head of the ERISA Industry Committee, said in a statement. ERISA is the name for a federal law that sets terms and conditions for multistate employer plans.
A spokeswoman for the organization said it’s their understanding that the ban on surprise billing will apply to doctors as well as hospitals.” (R)
Hope, and New Life, in a Brooklyn Maternity Ward Fighting Covid-19,
In a hospital at the center of the crisis, nearly 200 babies have arrived since March. Some pregnant women have fallen extremely ill, but doctors are winning battles for their lives and their children’s.
