After an up and down week, we closed out the week with another slight decrease in the amount of patients we currently have hospitalized with COVID. Our inpatient census is based on a just a handful of variables. First, how many new patients are we admitting each day. Second, how long do COVID patient stay in the hospital. Our census escalates quickly if we have a lot of patients staying a long time. We learned early that it’s not unusual for COVID patients to be hospitalized for 2 to 3 weeks, though many of our patients do get discharged in under a week. The third factor is how many patients are discharged each day. If our new admissions each day outnumber the discharges, our inpatient census is going to climb. Therefore, our inpatient census declines if we are admitting less patients than are leaving the hospital. I don’t know how many patients the hospitalists discharge a day. A friend in a similar sized hospital reported that her hospital discharged 18 patients in one day. I suspect we’re about the same. That brings us to the fourth factor–the death rate. About 10% of our COVID patients continue to die. If we have a lot of patients die over a few days, that can lower the number as well. Our inpatient census is a key data point that is available publicly on a variety of websites, one of which I posted two weeks ago. Additional good news on the metrics front, is that it looks like we had less patients require our COVID isolation procedure than last week. We also admitted less of these patients this week than we had in previous weeks. Now let’s turn toward testing data. Our percent positive rate among symptomatic patients is actually down a touch compared to the previous month and the number of patients that we diagnosed as having symptomatic COVID are also down to the lowest number I have seen since approximately December 10. These trends are also true when we look at all patients tested for COVID in the emergency department. We diagnosed less people with COVID over this past week than we have seen in about 5 weeks and our percent positive rate is the lowest it has been since early December. The decline is not enough for any clinician or staff member to feel like we’re seeing less COVID. But that’s why we follow the data. What I do not know is whether this is the tail end of the Thanksgiving surge and we have not really seen the holiday surge yet or is this the end of the holiday rush. My take is that the peak we see in the ER is really 4-6 weeks after the event so potentially we won’t see a holiday peak for a couple more weeks. And for comparison, all of these numbers are much higher over the last 7 weeks since Thanksgiving than prior to Thanksgiving. I’ll certainly keep you posted.
I’m thrilled to be part of a hospital that is so involved in community health. Last weekend, as the VA Governor moved vaccine distribution to 1B, VHC announced their plan to open outpatient clinics to vaccinate people. 9000 signed up over the weekend alone and more than 12000 through the week. That’s amazing. But here’s where the Governor’s actions have issues. VHC does not have the infrastructure to vaccinate 9000 people quickly. This requires more effort by the state with space and staffing allocations. Some states have moved to vaccinations in stadiums and using the national guard. There was no Federal vaccination plan and there are tremendous infrastructure issues at the state level that need to be solved immediately to meet the demand for vaccine. Things that need to be addressed at the mass level include space, registration (websites and IT support), pharmacy issues (dealing with frozen vaccinations in multidose vials that need to be warmed, diluted, drawn up into syringes), staffing (vaccine administered and documented), and then have space for patients to be observed in case there are anaphylactic reactions. I’m honestly super in awe of all the hospital has done to start vaccinating the community but I believe requires resources provided at the state level. And that’s before we get into the actual supply of vaccine since it appears the National Stockpile is empty at this point.
A large percentage of our hospital staff are now vaccinated. We are starting to see a decline in the weekly number of employees we have “off duty” because they are positive. Hopefully, that is because the vaccination is working. However, I’ve had a couple of friends and colleagues who did test positive despite receiving the first dose of the vaccine. One was pretty sick. He avoided hospitalization though had he actually gone to the ER and been a patient, he more than qualified for inpatient care. (You cannot get COVID from the vaccine but you can still get COVID if you’ve had the vaccine). The Johnson and Johnson vaccine in making news this week. The phase 1/2a trials were successful and published in the NEJM. There was a good antibody response in about 90% of patients, including younger and older patients. It’s a single dose vaccine that requires traditional refrigeration, which is a win for pharmacies, administration in schools, rural areas, and other hospitals that don’t have deep freezers. Phase 3 has been underway for a period of time and its likely interim results will be available in a few weeks. This potentially means the vaccine is on pace for FDA emergency use authorization and rollout in March.
As we think about the different mutated viruses floating around, particularly the UK variant which has a much higher transmission rate, many of us in healthcare have wondered how long they’ve been around. We’ve seen a large number of HCW get sick with COVID over the past month or so, despite taking all their routine precautions that kept them safe for so long. My social media feed was filled with HCW testing positive right around when they were due to get their vaccine. I’m sure it’s in part related to the greater prevalence in society and the virus just caught up with them, but I do wonder if it’s a mutated virus that is just more transmittable. The White House Task Force released a statement this week basically validating what we were seeing: “This fall/winter surge has been at nearly twice the rate of rise of cases as the spring and summer surges. This acceleration and the epidemiologic data suggest the possibility that some strains of the US COVID-19 virus may have evolved into a more transmissible virus.” The new UK variant increases transmission rates and could rapidly heat up the numbers of new cases. Slowing down the spread is still critical to preventing more mutations from taking place.
As many states use existing testing infrastructure to become vaccination centers, we can’t lose track of the importance of testing. Testing will likely be even more critical as the UK variant increases the numbers of cases in the US. Last summer, the hot news was the development of cheap, at home, saliva testing, but that never materialized. Access to testing is still critical.
I’ve not talked much about the monoclonal antibody therapy that is recommended in a subset of patients that don’t require hospitalization. Though I’m not convinced of its effectiveness, it is a treatment option that is currently underutilized. Again, this is at least in part because there’s not a national strategy on how to provide the infrastructure to get it administered. Maryland has state run facilities that administer it. There are pros and cons to that when factoring in socioeconomic issues but the state is providing the staffing and making it accessible.
Masks and physical distancing remain the cornerstone of mitigation strategies that need to be practiced. It’s not easy and I know everyone wants to get back to school, work, and life. I miss my friends and family, but we are all so close to getting to the end, if we can be patient, do the right thing, and work with our government leaders to provide the infrastructure, we can get past this pandemic and get back to normal. The vaccine will take time to get into everyone’s arm. So we still need to protect ourselves by doing the basics.
Science matters. Wear a mask. Practice physical distancing.
PS Attaching a picture tonight to show that we do have a little fun at work. I’m on the right in the white coat and moving to the left is our Senior Director of Staff Development, then our AVP of Emergency and Outpatient Services (and my work spouse for the last 8 years), and then on the far left is another ER doc. I don’t take my mask off when I’m working clinically, but if I do, it will certainly be to eat some of the Peanut M&M’s that were on the Sunshine Cart.