RemoteICU sues HHS for not reimbursing for telehealth provided by physicians outside of the country

https://www.healthcarefinancenews.com/news/remoteicu-sues-hhs-not-reimbursing-telehealth-provided-physicians-outside-country

Tele ICU - What It Is, How It Works & Its Advantages

The Medicare Act “prohibits Medicare payment for services that are not furnished within the United States,” according to the filing.

RemoteICU, a telemedicine provider group, is suing the Department of Health and Human Services and the Centers for Medicare and Medicaid Services for not reimbursing telehealth services provided by physicians who are located outside the United States, according to a federal lawsuit filed last week in Washington.

RICU wants reimbursement for telehealth services provided within the U.S., but not necessarily by a physician who lives within its borders.

The company employs physicians who live outside the country, but are U.S. board-certified critical-care specialists and licensed in one or more U.S. jurisdictions. With RICU’s telecommunications system, these physicians can provide critical-care services in U.S. hospital ICUs, the lawsuit said.

“Although RICU’s physicians live abroad, they serve as full-time, permanent staff members of the U.S. hospitals at which they serve patients,” the company said in the court filing.

“By employing U.S.-licensed intensivists who live overseas, RICU has enabled the American healthcare system to recapture talent that would otherwise be lost to it – and this has helped to alleviate the ongoing shortage of intensivists in American hospitals.

When CMS expanded the list of telehealth services for which it reimbursed in December 2020 to include critical care services, RICU began offering its physicians to hospitals that couldn’t afford ICU telehealth without Medicare reimbursement, the court filing said.

However, after the company reached out to several officials from HHS and CMS, it was notified that Medicare could not reimburse the client hospitals for RICU’s services, because the Medicare Act “prohibits Medicare payment for services that are not furnished within the United States,” according to the filing.

The company is seeking a preliminary injunction to stop HHS and CMS from denying Medicare reimbursement for telehealth services on the basis of a provider’s physical location outside of the United States at the time of service.

WHAT’S THE IMPACT?

RICU claims that, by failing to reimburse for the critical care telehealth services provided by its physicians, HHS and CMS are causing “immediate harm both to RICU and to the public.”

It argues that it’s filling a gap in critical care that has been exacerbated by the pandemic.

“There remains [a] significant unmet need for critical care services, as desperately sick patients have overwhelmed ICU resources across the country,” RICU said in the court filing.

“In some cases, lack of adequate care can mean the difference between life or death. And one of the groups most at risk from death and serious illness due to COVID-19 is the elderly – the very same population that relies upon Medicare.”

Without reimbursement, RICU says that some of its current clients, as well as potential customers, will not be able to offer its services.

The company argues that this causes “significant, unrecoverable monetary damages” because tele-ICU providers that use physicians located within the U.S. are eligible for reimbursement and therefore have a competitive edge over RICU.

Further, it says that it has already begun losing business because of hospitals’ inability to receive Medicare reimbursement.

THE LARGER TREND

CMS has widely expanded the list of telehealth services it will reimburse for during the pandemic to include services such as emergency department visits, initial inpatient and nursing facility visits, and discharge-day management.

While only 14 states currently have true “payment parity” for telehealth, 43 states and D.C. have implemented a telemedicine coverage law, according to Foley & Lardner report.

That report, among others, claims telehealth will continue to grow as an integral part of healthcare as time goes on.

Last year, Geisinger health system in Danville, Pennsylvania, implemented telehealth ICU technology in several of its hospitals to support its in-person clinical staff.

ON THE RECORD

“The Critical Care Ban is causing irreparable harm to RICU, which is suffering ongoing financial and reputational harms that cannot be remedied in the future,” the court filing said.

The balance of the equities favors an injunction, because Defendants have already admitted that there is a desperate medical need for the critical care that RICU would provide but for the Critical Care Ban.

“And, finally, preliminary injunction would be in the public interest because, across the United States, Americans stricken by the COVID-19 pandemic are in desperate need of critical care – a need that RICU can help meet. It is not hyperbole to say that the requested injunctive relief is in the public interest because it could save lives.”

More Evidence Points to Role of Blood Type in COVID-19

Additional evidence continued to suggest blood type may not only play a role in COVID-19 susceptibility, but also severity of infection, according to two retrospective studies.

In Denmark, blood type O was associated with reduced risk of developing COVID-19 (RR 0.87, 95% CI 0.83-0.91), based on the proportion of those with type O blood who tested positive for SARS-CoV-2 compared with a reference population, reported Torben Barington, MD, of Odense University Hospital, and colleagues.

However, there was no increased risk for COVID-19 hospitalization or death associated with blood type, the authors wrote in Blood Advances.

Limitations to the data include that ABO blood group information was only available for 62% of individuals, and that the sex of the testing population was skewed, with women accounting for 71% who tested negative and 67% who tested positive.

They pointed to the recent research that blood type plays a role in infection, noting the lower than expected prevalence of blood group O individuals among COVID-19 patients. Researchers also observed how blood groups are “increasingly recognized to influence susceptibility to certain viruses,” among them SARS-CoV-1 and norovirus, adding that individuals with A, B, and AB blood types may be at “increased risk for thrombosis and cardiovascular diseases,” which are important comorbidities among patients hospitalized with COVID-19.

ABO and RhD blood group information was available for 473,654 individuals who were tested for SARS-CoV-2 from February 27 to July 30, as well as for 2,204,742 individuals not tested for SARS-CoV-2 as a reference.

Of the individuals tested, 7,422 tested positive for SARS-CoV-2. About a third of both those who tested positive and negative were men, and those with positive tests were slightly older (52 vs 50, respectively).

Among individuals testing positive for SARS-CoV-2, about 38% (95% CI 37.5-39.5%) belonged to blood group O versus about 42% of those in the reference population. There were significantly more group A and AB individuals in the positive testing group versus the reference population, though the difference was non-significant for group B. When group O individuals were removed, there was no difference between the remaining groups.

Blood Type Linked to COVID-19 Severity?

Meanwhile, a second, smaller study in Blood Advances did report a connection between blood type and COVID-19 severity.

Blood types A or AB in COVID-19 patients were associated with increased risk for mechanical ventilation, continuous renal replacement therapy, and prolonged ICU admission versus patients with blood type O or B, according to Mypinder Sekhon, MD, of the University of British Columbia in Vancouver, and colleagues. Inflammatory cytokines did not differ between groups, however.

These authors also cited research that found that blood groups were linked to virus susceptibility, but that the relationship between SARS-CoV-2 infection severity and blood groups remains “unresolved.” However, COVID-19 appears to be a multisystem disease with renal and hepatic manifestations.

“If ABO blood groups play a role in determining disease severity, these differences would be expected to manifest within multiple organ systems and hold relevance for multiple resource-intensive treatments, such as mechanical ventilation and continuous renal replacement therapy,” Sekhon and colleagues wrote.

They collected data from six metropolitan Vancouver hospitals from Feb. 21 to April 28, identifying 95 COVID-19 patients admitted to an ICU with known ABO blood type.

Among these patients, 57 were group O or B, while 38 were group A or AB. A significantly higher proportion of A/AB patients required mechanical ventilation versus O/B patients (84% vs 61%, respectively, P=0.02). Similar figures were seen for patients requiring continuous renal replacement therapy (32% vs 9%, P=0.04). Median ICU stay length was also longer for A or AB patients compared with O or B patients (13.5 days vs 9 days, P=0.03).

There was no difference in probability of ICU discharge, and eight patients died in the O/B group versus nine patients in the A/AB group. Not surprisingly, biomarkers of renal and hepatic dysfunction were higher in the A/AB group, as well.

“The unique part of our study is our focus on the severity effect of blood type on COVID-19. We observed this lung and kidney damage, and in future studies, we will want to tease out the effect of blood group and COVID-19 on other vital organs,” Sekhon said in a statement.

About 25% of patients were missing data on blood group, and the nature of the study makes it impossible to infer causality, the authors acknowledged. Ethnic ancestry and outcomes in patients with COVID-19 could be an unaddressed confounder. Additionally, anti-A antibody titers may affect COVID-19 severity, and these were not measured.

Scripps CEO: Care rationing near if Californians ignore COVID-19 mitigation efforts

Prepare for Health Emergencies Like War Says CEO - Scripps Health

Hospitals in Southern California will need to start rationing care if more action isn’t taken by the community to mitigate the spread of COVID-19, Chris Van Gorder, president and CEO of Scripps Health, wrote in a Dec. 28 op-ed for The San Diego Union-Tribune

As of Dec. 29, 20,642 California residents were hospitalized with COVID-19. The state’s hospital bed capacity is 72,511. In San Diego County, where Scripps is headquartered, 18 intensive care unit beds were available as of Dec. 28, “not even enough to handle a single mass casualty incident,” Mr. Van Gorder wrote. Out of Scripps’ 173 ICU beds, seven staffed beds were available as of Dec. 28.

“This past weekend, one of our community hospitals ran out of room in their morgue. We are nearing the point where we have to make the decision of who gets care and who does not,” Mr. Van Gorder wrote.

He pleaded with the San Diego and California community to adhere to mask-wearing and social distancing guidelines, especially as the New Year’s Day holiday approaches. He called on residents to stay home for New Year’s, wear a mask, wash their hands, and not eat or drink with people who aren’t in their immediate family household.

Mr. Van Gorder’s commentary comes as Kaiser Permanente hospitals in Northern California are suspending elective, non-urgent procedures through Jan. 4 as they continue to face a surge in COVID-19 hospitalizations. The Oakland, Calif.-based system announced the suspension Dec. 26, days after Chair and CEO Greg Adams said during a news conference, “We simply will not be able to keep up if the COVID surge continues to increase. We’re at or near capacity everywhere.”

It will be darkest before dawn

https://mailchi.mp/e38b070b8787/the-weekly-gist-december-18-2020?e=d1e747d2d8

It's Always Darkest Before The Dawn – Peter Scott

But first, we have a difficult period to get through. This week again saw record-breaking numbers of cases, hospitalizations, and deaths from COVID-19, with Thursday alone bringing more than 238,000 new cases—and a staggering 3,293 fatalities.

Nearly 115,000 Americans are currently hospitalized with COVID, a rise of 16 percent from just two weeks ago, and in many places a precarious capacity situation has turned perilous. Conditions have worsened precipitously in California, with only Tennessee, Oklahoma, and Rhode Island registering more daily COVID cases per 100,000 population than the Golden State, although cases are still on the rise across 80 percent of states and territories.

 Intensive care availability in Southern California hit zero, with ICU volume there expected to double or triple by this time next month. The same stresses are playing out in dozens of markets across the country, leading to a staffing sustainability crisis that can’t be solved through paying overtime, cancelling vacations or looking to travel nurses to fill the gaps in a now nationwide crisis. With the Christmas and New Year’s holidays still ahead, experts predict COVID cases won’t peak until sometime in mid-January, with a peak in hospitalizations and deaths following several weeks after.

Several states and cities tightened restrictions on gatherings and issued new stay-at-home orders, in an effort to keep new cases at a level that allows hospitals to manage through the next several weeks and maintain care quality and access for COVID and non-COVID patients alike. The coming weeks will require every American to take greater precautions than at any time during the course of this pandemic.

U.S. Hits Highest 1-Day Toll From Coronavirus With 3,054 Deaths

https://www.npr.org/sections/coronavirus-live-updates/2020/12/09/944844088/u-s-hits-highest-one-day-death-toll-from-coronavirus-with-3-054?fbclid=IwAR0mP-0McBNWX43iXLzLWIJyQmI8dR73ChPEg98YtDAS6F1DI_36ZOpjnA4

4 bar charts showing key COVID-19 metrics for the US over time. Today, states reported 1.8M tests, 210k cases, 106,668 currently hospitalized (record), and 3,054 deaths (record).

The coronavirus pandemic pushed the U.S. past another dire milestone Wednesday, the highest daily death toll to date, even while the mortality rate has decreased as health experts learn more about the disease.

The Covid Tracking Project, which tracks state-level coronavirus data, reported 3,054 COVID-19 related deaths — a significant jump from the previous single-day record of 2,769 on May 7.

The spread of the disease has shattered another record with 106,688 COVID-19 patients in U.S. hospitals. And overall, states reported 1.8 million tests and 210,000 cases. According to the group, the spike represents more than a 10% increase in cases over the last 7 days.

Additionally, California nearly topped its single-day case record at 30,851. It is the second highest case count since December 6, the organization reported.

Chart showing COVID-19 deaths over time by day. Deaths hit a record high today (Dec 9) at 3,054.

The staggering spike in fatalities and infections has overwhelmed hospitals and intensive care units across the nation, an increase attributed by many experts to people relaxing their precautions at Thanksgiving.

What seven ICU nurses want you to know about the battle against covid-19

What seven ICU nurses want Americans to know about COVID - Washington Post

They have been at this for almost a year. While politicians argued about masks, superspreader weddings made the news, a presidential election came and went, and at least 281,000 Americans died, nurses reported for work. The Post asked seven ICU nurses what it’s been like to care for the sickest covid patients. This is what they want you to know.

As of Dec. 7, Idaho has seen 110,510 total confirmed cases, 1,035 deaths, and 477 people are currently hospitalized with the virus.

Kori Albi, 31

Covid unit intensive care nurse and unit supervisor, Saint Alphonsus Regional Medical Center

Our staff are getting sick. Our physicians are getting sick. And they’re not getting it from the hospital. They’re getting it from the community. We are almost lucky to care for the covid patients because we know who they are. Anytime we go into these rooms, we know exactly what we need to do. We have all the PPE we need. And as long as we are diligent and follow all the processes that are in place, we can keep ourselves safe. That’s not what worries me at all. Going out into the community is scarier than coming into work every day. Because you don’t know who has it.

This virus has caused this feeling, this sense of isolation. The covid unit is an isolated desert. Every door is shut. Every room has negative airflow. By the time you put your N95 mask on and then your surgical mask over the top of that, then you put your isolation gown on and your face shield on top of that, you can’t tell who is who. So much of health care is about that personal touch — now, our patients can’t even see our name badges because they are on under our gowns. All they see are our eyes through our face mask.

A lot of families are hesitant to have Zoom calls with patients because it can be uncomfortable and awkward. Especially if these patients are sedated and intubated. There’s always that awkwardness of: Can they hear you? Can they not hear you? Even as nurses, we feel like we’re talking to the wall. But we talk to them just as if they were awake. Allowing families to play their music that they like or pray with them or just talk to them can absolutely help. You see vital signs change.

One patient, all she wanted to do was have her son sing her a song. I think I spent over an hour in the room listening to him play the guitar and sing her a song. He sang her mostly hymns.

Death is a very intimate event that normally involves a lot of family members that help bring closure and that helps everyone process. In normal circumstances, health care providers form these relationships with the family at the bedside. All of that has been removed. And we now have to try to form those relationships over the telephone. It’s a traumatic experience. And it’s a long drawn-out process. A lot of people don’t make it out of here. It’s a slow, lonely death.

The amount of death with covid is profound. As nurses, we have learned to process death, but the amount of death has happened in such a short span of time — that’s what’s been overwhelming. I had a patient that we did a Zoom call with. His four-year-old granddaughter lived with him. And she brought tears to the room. The naivete of a four-year-old. Her grandfather was intubated so he couldn’t talk. But he could kind of look around the room. But the innocence of her, saying, “Come home, Pa. I miss you, Pa. I love you Pa,” all through a video screen. The 14-year-old that also lived with them couldn’t formulate words to say anything, and he didn’t know what to do or say in that video. But the four-year-old was telling Pa to come home.

JACKSON, MISS.

As of Dec. 7, Mississippi has seen 166,194 total confirmed cases, 3,961 deaths, and 1,157 people are currently hospitalized with the virus.

Catie Carrigan, 28

ICU, University of Mississippi Medical Center

There are some patients who have been in their younger 20s and their younger 30s, and I think maybe those are the hardest cases. They have families and they have kids just like I do, and it’s hard coming into work and taking care of them. Knowing they’re supposed to be going to college, they’re supposed to be getting married, they’re supposed to be having kids and, instead, they’re laying in a hospital bed on a ventilator fighting for their life.

They have their whole entire lives ahead of them, and then they get hit with this disease that everybody thinks is a hoax and then they die.

I worked in the ER a month ago, so I know exactly what’s going on down there, and now I work in the ICU, so I know exactly what’s going on on both sides of it. There are no ICU beds in the hospital. None. When there are no ICU beds, we hold them in the ER, or we hold them in the PACU (post-anesthesia care unit). The ER still has to treat our trauma patients, our car accidents, our gunshot victims. So when we have those ICU holds in the ER, it obviously makes the jobs of nurses and doctors in the ER way more difficult than it needs to be. We are treating patients in the hallway. They’re just trying to do the best they can with the resources that we have.

There is no room left, essentially, and I think that’s really what people don’t seem to understand. And I get it, when you’re not in health care you don’t really see our side of it, but we’re seeing the worst of it. It’s hard for us to convey that to the public because they don’t seem to want to take our word for it — but take our word for it. Take our word for it.

IOWA CITY

As of Dec. 7, Iowa has seen 244,844 total confirmed cases, 2,717 deaths, and 898 people are currently hospitalized with the virus.

Allison Wynes, 39

Medical intensive care unit, University of Iowa Hospitals and Clinics

I cry every day when I walk in to work, and I cry every day when I walk to my car after work.

You get it out of your system before you show up and you do your job and you’re fine. Then, you go home and you cry before you get home. And then you go home and be mom.

My 9-year-old daughter asks frequently, “Mommy, how many patients were there today? Mommy, how many sick ones were there today? Were you safe? Was everything okay? Do you have to go to work again? How many patients?” She gets it.

I think one thing that people do not appreciate is it’s not only the number or volume of patients that comes through — it’s the level of care that they require, which is so much greater than a standard patient in the ICU or a standard patient in the floor, because they can get very, very sick very quickly.

We were walking a patient who was on ECMO, which is extracorporeal membrane oxygenation, and it took five people to walk her. That’s not normal.

I work in the MICU, so it’s never like a party up in here, but it used to at least be, nine times out of ten, calm and controlled and tidy and clean. Occasionally stuff would go bad and we would all run and help, and then we would all go about our days. Now it just feels like, especially of late, there is equipment everywhere. There are gowns everywhere. There are gloves everywhere, there are people everywhere, and there are fires everywhere.

I’m actually scared, and I’ve never been scared at work before. I am scared that we will lose control.

It’s the human resources we are running low on. We can make a bed, we can find a ventilator, we have PPE. But it’s the human cost of caring for these patients that has been keeping me up at night the past couple of weeks and really making me nauseous every day.

I didn’t think it would be over by now, but I didn’t think we’d be getting hit this hard this late. I thought we’d still just be smoldering. I didn’t know that we would just be a raging fire at this point in time. We’re not prepared for that, but here we are.

After this, I’m going to take my kids to a beach or somewhere.

GLENVIEW, ILL.

As of Dec. 7, Illinois has seen 796,264 total confirmed cases, 14,216 deaths, and 5,190 people are currently hospitalized with the virus.

Luisa Alog Penepacker, 51

ICU, Glenbrook Hospital

I’ve taken care of a lot of husband-wife patients, unfortunately. One of the cases was one in which the husband had tested positive for covid first, but he was a mild case. She was a little bit more serious. She ended up on our unit.

The husband ended up in the hospital the next day, but he was on the step-down unit. When I admitted her, she was terrified, especially knowing that her husband was upstairs in another unit. She was having a hard time breathing, and she grabbed onto my hand and looked at me. She goes, “Am I gonna die?” I mean, I didn’t know what to say. And I just told her, “Not on my watch.” So we just kept on going. But unfortunately, she got intubated the next day.

Then I was sent to work upstairs on the step-down unit. I had her husband that next day, and he was actually quite happy that I saw her. He goes, “You took care of my wife, how is she? I heard that she’s not doing well.” I didn’t know what to say to him, either. I just said, “You know, she’s in the best of care. We’ll take really good care of her.” And he looked really relieved. He goes, “I’m just so glad that someone who had seen her is here now to talk to me.” And my heart broke with that.

She ended up passing. A few days after, he went home, and I didn’t see him, so I don’t know how he took it. He wasn’t able to see her before she passed.

We wear personal air purification respirators on our heads — these big white domes over our heads with a respirator hose going to a machine strapped around our waist, and we look like astronauts walking through the unit, going in and out of patients’ rooms with our plastic gowns and gloves.

It can be frightening to family members if they’re allowed to come to visit and definitely for patients because we’re kind of scary-looking. It can be frantic at times. You walk through the hall, and you see a lot of patients on ventilators. You hear a lot of beeping. People are rounding constantly to check on patients. It’s a busy place.

You don’t know what to tell family members when you see them. What can you say? You just say, “I’m sorry.” You can’t even hug them. I used to be able to hug family members, but you can’t with all the gear.

When patients are scared, I will hold their hand even though I’m wearing gloves. I look them in the eyes as much as I can because really, that’s all you can see. You can’t see our faces. You can barely even hear past the mask. So I’ll make sure to look at them. I try to make an effort to smile with my eyes and to just hold their hand if they need it.

MURRAY, UTAH

As of Dec. 7, Utah has seen 215,407 total confirmed cases and 939 deaths.

Tammy Kocherhans, 41

Respiratory ICU, Intermountain Healthcare

These patients are different than the typical patient. They’re very complex. They can change in the blink of an eye. And it’s very hard as a nurse when you wrap your heart and soul into taking care of these patients. I started noticing that I was emotionally tired. I was physically completely exhausted. And I was beginning to question whether or not I could continue forward being a nurse at all. I was past my physical capacity.

I happened to be working a day where another health care worker who was a veteran said that this was like a combat zone, and for some reason in my head, that validated the way that I was feeling. So I reached out to one of my best friends who is a veteran, a flight medic, and he said, “I meditate and do yoga.”

Once I started doing that, I was able to handle the emotional crises, the physical pain of working so, so many long, hard hours. We do something called proning, where you take patients and flip them over onto their bellies. And that sounds really easy, but it takes a team of a minimum of five people. It is extremely taxing on your body. It hurts. And I lift weights! The meditation and yoga really has saved my life, my mental capacity, my spiritual capacity, my physical capacity, everything that is required to give to these patients.

Hopefully by 8 p.m., I’m out in the parking lot and spend a minute in my car to unload from my day. It’s all about taking a moment to breathe for myself and then going through whatever came up that day that I need to let go of. It depends on how complicated my patient was that day, whether I can let my whole day go or if I have to spend time to go through each piece and work it down to: What did I do right? Did I miss something? Sometimes I just can’t let some details go quickly, and I have to work them down to allow myself to say I did everything that I possibly could for this individual this day, in this time, in this situation. And whatever the outcome was or is, I followed protocol. I did everything that I knew how to do. And it’s going to be OK.

I find it very frustrating when I go out and about on my days off and I see people very blatantly not wearing masks or trying to tell me how come they don’t work or telling me that this pandemic isn’t real. I find it completely disrespectful to the work we do to save people’s lives, to have people think that this pandemic isn’t real, to show utter disregard for people around them, not trying to do their part.

And I really wish that I could take people on a day with me so that they can see what I see. So that they can feel your feet ache so bad that you wish they’d just fall off, because you’re on that concrete for so many hours. Your back aches because you’re wearing equipment to save your life — so that you can save somebody else’s life. And your head hurts. I’ve never had so many headaches in my life because part of the equipment sits on your head, and after 12 hours, it starts to exert so much pressure that you start to have a headache, and you’re dehydrated.

Early in the pandemic, I remember walking into this room, and this young patient was crying and asked me if they were going to die. And I’m a mom of teenagers. For me, that was awful because this patient was all alone, and we as staff were minimizing contact because we didn’t want to get the virus.

This patient started physically trembling in the bed. I couldn’t take it anymore, and I went over and just held this patient because that’s what I’d want somebody to do for my children. That was my first patient that I held like that. And there have been many since.

MURRAY, UTAH

As of Dec. 7, Utah has seen 215,407 total confirmed cases and 939 deaths.

Nate Smithson, 28

Respiratory ICU, IntermountainHealthcare

A few weeks ago, my wife and I were on a date at a restaurant. And in the middle of nowhere, I had this panic attack and went and hid in the bathroom stall for half an hour. I have no idea what brought it on. I just couldn’t handle being there right then, which was weird for me. That’s the first time anything like that has happened. But since then, it’s happened multiple times, where the anxiety and stress is overwhelming, and I can’t handle it. So I have to go and excuse myself for a little bit.

Balancing work and life is something that used to seem possible. Now it doesn’t seem like there is any difference between the two. I fall asleep and I dream about my patients.

When we got our first covid patient in February in the hospital, in the ICU, we all kind of thought it was a little bit of a joke, to be honest. I had this patient, and he was sitting there with minimal amounts of oxygen in the room just watching TV. He’s like, “I’m fine. I don’t know why everyone’s freaking out about this.” And I thought the same thing. And then a few hours later, he stands to go pee, and I’m looking at his monitor. And it drops down to the low 90s. Ninety-two is about as low as you want to go. And then it starts dropping down lower, to about the 70s. Then it gets down into the 60s and 50s. And that’s dangerous territory. That’s where brain cells start dying and you start having some serious problems.

I run into the room. We get him back into bed and throw all the oxygen that we have in the room on him, crank everything up, and he’s not recovering from it. We had to intubate right then and there. And about an hour later, he finally starts recovering a little bit. But at this point, he’s sedated, he’s on the ventilator. Everything is worse. And that’s the first time where it’s like: Oh, crap, this is serious. This is something else. I’ve never seen anything like that before.

If a patient’s heart stops or if they stop breathing, we call a code blue, and that’s when the doctor, respiratory therapist, nurses, everybody comes into the room. We start chest compressions or CPR or that kind of stuff. This one patient’s heart is not working. So I call the code blue. We all get in there. We start doing the chest compressions. Five minutes later, we get the patient back. We all go back about our work. Twenty minutes later, same thing happens again. We start doing the chest compressions. We start pushing medications as fast as we can to get the patient back again.

The spouse comes into the hospital. I explain: “Just so you know, this is what happened before. It could possibly happen again. If it does, I’m going to need you to step outside of the room.” And as I’m explaining this, sure enough, it happens again. We lose the pulse. We lose the heartbeat. So I ask her to leave the room. Everyone gets in there, and we start going for it. We went for almost two hours: chest compressions, pushing medications, shocking the patient’s heart.

The doctor is ultimately the one who makes the decision about when we stop, and they call time of death. But typically in situations like that, where it’s unexpected and sudden, they want to make sure that everybody can go home that night feeling OK about what they did, knowing that they did everything. And after an hour, he stops, turns to the room and asks: Does anyone have a problem with us stopping?

I didn’t have a problem, but then as he’s saying that, I look out the window, and the patient’s wife is just watching us. She’s been sitting out there watching us for an hour, and no one’s saying anything.

And I ask them to keep going.

So we did. We went almost for another hour after that, and we didn’t get the patient back. He ended up dying.

But I think for me, that was important — to keep going. Not because we thought we would get them back, but so that his wife would know that we did everything we could.

I still go to bed with her face kind of burned into my mind, of just seeing her sitting out there watching us, and that’s what kills me.

COLUMBUS, OHIO

As of Dec. 7, Ohio has seen 475,024 total confirmed cases and 6,959 deaths.

Kahlia Anderson, 32

ICU, Ohio State University Wexner Medical Center

I graduated from nursing school in May 2019. I started here at the Wexner in August. Our orientation is a 20-week program, and so I came out on my own Jan. 12, 2020. The pandemic hit us at the end of February.

In nursing school, I think your biggest fears are making med errors, or harming your patient in some way, or just not knowing how to do everything. Did I check my patient’s blood pressure before I gave this blood pressure medication, or did I give the correct dose of a specific medication? I had heard stories about that on the unit, like make sure you’re careful with the needle stick, or make sure you’re careful with this medication. And I don’t even think about those kinds of things anymore.

Now it’s the fear of the unknown. It’s the fear that anything could happen because of this virus and my patient could die regardless of what I do.

When I got my first covid-positive patient, I remember thinking: Somebody did the assignment wrong because there’s no way that they believe that I should be taking care of this patient. I can remember the feeling. I can remember the day. It was a weekend. I was on a day shift. And I was thinking to myself: Who trusted me, the new nurse to take care of a covid-positive patient? How am I going to do this? How am I going to keep this patient safe? How am I going to keep myself safe? Am I safe? Wait, who cares about me? Let’s get back to the patient. What do they need?

At the time, I didn’t even understand some of the ventilator settings because I was still that new, and it was still that fresh to me. And I thought: This machine is doing that much work for them, and I don’t know enough about it, but I’m going to make sure that I get it done and I’m going to figure it out today to make sure that this patient gets everything that they need. And I’m going to call their family and double check with them and check in with them and call them.

That patient is alive. That patient is no longer in the hospital. As far as I know, that patient is home and safe with family.

I would feel like: There’s someone more experienced. There’s someone more adequate to deal with this. And I was like — oh, it’s me. This is me, I’m doing this, and I’ve been doing it ever since.

I saw new nurses come out of orientation, and I saw the type of assignments that they would get. So my mind fixated on like: I’m going to get patients that are ready to transfer out. They can talk, they can eat. They’re just waiting for a bed on another unit. Or maybe it’s a patient who needs long-term care. So they’re waiting to go to a facility to be discharged. And so I was thinking to myself: I’m going to get my feet wet. It’s going to be great. I’m going to build up this experience, and then I’m going to start getting sicker patients, and I’m going to be ready.

Once covid hit, there was no room for those types of patients anymore. Everyone had covid, everyone was sick, everyone was intubated or approaching intubation.

And for me, I just wanted my first experience. I wanted to have the simple experience of building and getting better. But that’s not what was in store. And I can’t say that I’m upset about it today. I’m grateful for this experience. I don’t wish this pandemic on anyone. I wish it was not here. I wish that it was different. But as a nurse, as a new nurse, these experiences are unique to me. It’s making me a better nurse. It’s made me a better person, and I can only continue to just be.

We did cry in the beginning, and now not so much. I think we all struggled when we had a young death. Someone in their 20s was very difficult for us. Because you think: That was a young life. What a young life that was, and they’re not here anymore. Because of a virus. That’s hard. It’s very hard.

But now it’s just — it’s almost everyone’s story.

Hospitals continue to crack under the surge

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Hospitals across the country are reaching their breaking point on ICU and bed capacity as COVID surges, forcing many health systems to begin diverting patients from emergency rooms and ration care, Axios’ Orion Rummler reports.

What’s happening:

  • New Mexico Gov. Lujan Grisham (D) plans to allow hospitals to ration care depending on how likely a patient is to survive, the Washington Post reports. Grisham required residents to wear masks and re-enacted strict mitigation efforts.
  • Georgia: Major hospitals, including Grady Memorial and Emory University, have had to turn away patients brought in ambulances, the Atlanta-Journal Constitution reports.
  • South Dakota: The Monument Health Rapid City Hospital and Sanford USD Medical Center — some of the biggest in the state — say they have no more ICU beds, the Mitchell Republic reports.
  • Colorado: More than a third of hospitals across the state said in a survey they expect staffing shortages this week, Colorado Public Radio reports.

Context: White House coronavirus task force coordinator Deborah Birx noted on Sunday’s “Meet the Press” that U.S. hospitals are usually anywhere from 80 to 90% full in the fall and winter — and “when you add 10, 15, 20% COVID-19 patients on top of that, that’s what puts them at the breaking point.”

U.S. Covid Hospitalizations Reach 7-Week High As Cases Surge In Midwest

TOPLINE

More Americans are now in the hospital with Covid-19 than at any other point since late August, causing some states to nearly run out of hospital beds, as coronavirus infections continue to increase nationwide ahead of a potential end-of-year surge.

KEY FACTS

Some 37,048 coronavirus patients were hospitalized as of Wednesday, the highest level in almost two months according to new data from the COVID Tracking Project, though total hospitalizations are still below their mid-April peak of almost 60,000.

Among hospitalized patients, 7,156 were in ICUs and 1,776 are currently on ventilators — both of those numbers have increased slightly in recent weeks.

Texas leads the nation with more than 4,000 patients in hospitals, followed by California and Florida, though all three states’ hospital counts declined since the summer.

Hospitalizations and new cases soared in Wisconsin over the last month, and officials opened an emergency field hospital near Milwaukee this week as medical centers across the state fear they will run out of space.

Hospital numbers are also on the rise across other parts of the Midwest and South: Missouri reported a new record this week, and levels in Kentucky and Ohio are both within striking distance of their summertime peaks.

BIG NUMBER

217,933. That’s the total number of Americans who have died from Covid-19, according to figures from Johns Hopkins University. Daily fatalities are still below their peak in April, but they remain steady at more than 700 per day.

KEY BACKGROUND

When the coronavirus first surged in the New York City area, some hospitals nearly buckled under the pressure, contending with thousands of sick patients and inadequate protective equipment. Covid-19 cases gradually decreased nationwide but never fully subsided. The West Coast and Deep South dealt with cascading upticks after states loosened coronavirus restrictions during the summer, and the Midwest and small states like South Dakota are now struggling to open up more hospital capacity as new infections surge. Some experts warn cases could spike yet again over the fall and winter, straining the nation’s medical system and making it tough to get sick patients the medical attention they need.

CRUCIAL QUOTE

“When we see an overwhelming number of patients get infected, a lot of them are going to need hospitalization and support,” Dara Kass, a New York-based emergency room physician, told CBS News on Thursday. “We’re seeing hospitals in Wisconsin be overwhelmed with no ICU beds … This is a big concern of those of us who are looking to prevent as many deaths as possible.”

America’s newest wave of Covid-19 cases, explained

https://www.vox.com/coronavirus-covid19/2020/10/11/21511641/covid-19-us-cases-update-testing-deaths-hospitalizations

A new wave of Covid-19 cases is building across the United States, a harbinger of difficult winter months ahead.

America is now averaging nearly 48,000 new confirmed cases every day, the highest numbers since mid-August, according to the Covid Tracking Project. More than 34,500 Americans are currently hospitalized with Covid-19 in the US, up from less than 30,000 a week ago. Nearly 700 new deaths are being reported on average every day, too — and while that is down from August, when there were often more than 1,000 deaths a day, deaths are going to eventually start increasing if cases and hospitalizations continue to rise. It’s a pattern we have seen before.

Public health experts have been warning for months that fall and winter could lead to a spike in Covid-19 cases. Why? Because the best way to slow down the coronavirus’s spread is to keep your distance from other people and, if you are going to be around others, to be outside as much as possible — and both become harder when the weather gets cold.

We may now be seeing those predictions start to come true. The US already has more than 7.7 million confirmed cases and 214,000 deaths. Both numbers will continue to climb.

Eight months into the pandemic, America’s failures to contain Covid-19, and states’ eagerness to reopen even if they haven’t gotten their outbreaks under control, is once again leading to a surge in cases and hospitalizations.

Covid-19 cases are rising everywhere across the country

Earlier in the year, there was limited value to discussing “waves” because some states would have a decline in cases while other states were experiencing surges. What distinguishes this autumn wave is that it seems to be happening everywhere.

Case numbers are up in the Northeast, the Midwest, and the West. The South appears to be, at best, plateauing at a level even higher than that which the Northeast endured during the worst of New York’s outbreak.

What’s so worrisome is that no one state or region can be blamed for this new wave. Just 13 states have seen their number of new Covid-19 cases drop over the last two weeks, according to Covid Exit Strategy. Cases are up in all the others.

Raw case numbers can, of course, obscure important differences in population; 100 new cases means something different for California than it does for Wyoming. Experts will use another metric — new cases per million people — to gauge how saturated a given state is with Covid-19.

The goal would be to have fewer than 40 new cases per million people. But just three states — Maine, Vermont, and New Hampshire — meet that threshold. Meanwhile, North Dakota (627 cases per million), South Dakota (596), Montana (474), and Wisconsin (434) are some of the states seeing very high levels of new infections.

As Vox’s German Lopez reported this week, just one state — Maine — meets all of the benchmarks established by experts for a state to consider its Covid-19 outbreak contained. And yet, most states have reopened many of the businesses that were closed in the spring: 40 or so states have reopened restaurants, bars, gyms, movie theaters, and nonessential retail.

“Part of the problem is America never really suppressed its Covid-19 cases to begin with,” Lopez wrote, explaining why experts were anticipating a new surge in cases. “Think of a disease epidemic like a forest fire: It’s going to be really difficult to contain the virus when there are still flames raging in parts of the forest and small embers practically everywhere. The country always risks a full blaze with each step toward reopening and with each failure to take precautions seriously.”

Too many Covid-19 tests are coming back positive right now

Another closely watched indicator for renewed Covid-19 spread is the percentage of coronavirus tests that come back positive. The number of tests being conducted doesn’t actually tell you all that much; if a high percentage of them are positive, that suggests that many others aren’t being caught at all and the virus could continue to spread unchecked.

So while the US is now averaging nearly 1 million tests every day, that is not quite the triumph it might sound like (or President Donald Trump would like to believe it is). The country’s positive test rate is 5 percent, right at the threshold experts say would reflect adequate testing. Ideally, it would be even lower, 2 percent or less.

But even with that passable national positivity rate, most states are still not conducting nearly enough testing. Here are the 10 states with the highest positive test rates, according to Covid Exit Strategy:

  1. Idaho (25 percent)
  2. South Dakota (20.6 percent)
  3. Wisconsin (19.5 percent)
  4. Iowa (17.1 percent)
  5. Kansas (16.1 percent)
  6. Wyoming (15.5 percent)
  7. Utah (14.7 percent)
  8. Nevada (14.4 percent)
  9. Indiana (13.6 percent)
  10. Alabama (13.3 percent)

It’s really only a handful of better-performing states — namely, New York, with more than 115,000 tests conducted per day and a 1.2 percent positivity rate — that’s keeping the US’s overall positive test rate from looking a lot worse.

America has never had a cohesive Covid-19 testing strategy. Since February, there have been regular supply shortages delaying test results. States have been fighting each other for precious testing resources. Contact tracing has not been a priority for the federal government, and most states have still not hired nearly enough people to perform that work.

Wealthy countries like Germany and South Korea have used effective test-trace-isolate programs to keep their Covid-19 outbreaks in check. The US, meanwhile, is still struggling to perform enough tests or scale up its contact tracing capabilities. Just 11 states, plus the District of Columbia, could realistically expect to perform adequate contact tracing, according to Covid Exit Strategy, considering their positivity rate.

Without improvement in both of those areas, it will continue to be difficult for the US to contain the coronavirus before a vaccine becomes available.

More Americans are being hospitalized with Covid-19 too

Both case numbers and the positive test rate can be a little deceptive, depending on how many tests are being performed. They suggest what’s happening on the ground — in this case, Covid-19 is spreading — but they do have their limitations. There is some truth to the president’s claim that more tests will mean more cases, though that is not a reason to stop testing.

Hospitalizations, on the other hand, are more concrete. If more people are developing symptoms severe enough to warrant being hospitalized, that is a strong indicator that the real number of people being infected with Covid-19 is growing, regardless of whether they are getting tested.

And after a dip in September, the number of Americans currently in the hospital with Covid-19 is higher than it’s been in a month. That trend has been seen across the country.

The worry becomes that if hospitals take in too many patients, they’ll have to turn other people away, or that overwhelmed staff and facilities could lead to some patients receiving substandard care. According to Covid Exit Strategy, 20 states currently have reduced ICU capacity that puts them in a danger zone; 21 states have an elevated occupancy rate in their regular hospital beds.

Wisconsin, where the number of hospitalized Covid-19 patients has risen over the last month from about 300 to 876 today, recently established a new field hospital on its state park fairgrounds over fears that the state’s hospitals wouldn’t have enough beds given the recent surge in cases.

Fortunately, hospitals have gotten much better at treating Covid-19. They have proven treatments, like remdesivir and dexamethasone, that reduce the length of hospital stays and reduce mortality in patients with severe symptoms. They have learned techniques like putting patients on their stomach to improve breathing. Hospitals that have endured multiple spikes of Covid-19 cases report patients in the later waves are spending less time in the hospital and dying less frequently.

Nevertheless, more people developing severe symptoms, as we are starting to see, will inevitably lead to more deaths. Over the summer, people wondered why deaths were falling while cases and hospitalizations rose — until deaths did start to increase. There is a long lag between cases rising and deaths rising, because it can take a month or more between when a person first contracts Covid-19 and, if they die, when their death is reported.

That’s why these new Covid-19 trends in the US are so worrisome. Cases are rising, as are hospitalizations. It could be only a matter of time before deaths start to spike as well.