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.
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.
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.
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.
“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.”
Those on the front lines of the fight against the novel coronavirus worry about keeping themselves, their families and their patients safe.
That’s especially true for nurses seeking the reprieve of their hospitals returning to normal operations sometime this year. Many in the South and West are now treating ICUs full of COVID-19 patients they hoped would never arrive in their states, largely spared from spring’s first wave.
And like many other essential workers, those in healthcare are falling ill and dying from COVID-19. The total number of nurses stricken by the virus is still unclear, though the Centers for Disease Control and Prevention has reported 106,180 cases and 552 deaths among healthcare workers. That’s almost certainly an undercount.
National Nurses United, the country’s largest nurses union, told Healthcare Dive it has counted 165 nurse deaths from COVID-19 and an additional 1,060 healthcare worker deaths.
Safety concerns have ignited union activity among healthcare workers during the pandemic, and also given them an opportunity to punctuate labor issues that aren’t new, like nurse-patient ratios, adequate pay and racial equality.
At the same time, the hospitals they work for are facing some of their worst years yet financially, after months of delayed elective procedures and depleted volumes that analysts predict will continue through the year. Many have instituted furloughs and layoffs or other workforce reduction measures.
Healthcare Dive had in-depth conversations with three nurses to get a clearer picture of how they’re faring amid the once-in-a-century pandemic. Here’s what they said.
Elizabeth Lalasz, registered nurse, John H. Stroger Hospital in Chicago
Elizabeth Lalasz has worked at John H. Stroger Hospital in Chicago for the past 10 years. Her hospital is a safety net facility, catering to those who are “Black, Latinx, the homeless, inmates,” Lalasz told Healthcare Dive. “People who don’t actually receive the kind of healthcare they should in this country.”
Data from the CDC show racial and ethnic minority groups are at increased risk of getting COVID-19 or experiencing severe illness, regardless of age, due to long-standing systemic health and social inequities.
CDC data reveal that Black people are five times more likely to contract the virus than white people.
This spring Lalasz treated inmates from the Cook County Jail, an epicenter in the city and also the country. “That population gradually decreased, and then we just had COVID patients, many of them Latinx families,” she said.
Once Chicago’s curve began to flatten and the hospital could take non-COVID patients, those coming in for treatment were desperately sick. They’d been delaying care for non-COVID conditions, worried a trip to the hospital could risk infection.
A Kaiser Family Foundation poll conducted in May found that 48% of Americans said they or a family member had skipped or delayed medical care because of the pandemic. And 11% said the person’s condition worsened as a result of the delayed care.
When patients do come into Lalasz’s hospital, many have “chest pain, then they also have diabetes, asthma, hypertension and obesity, it just adds up,” she said.
“So now we’re also treating people who’ve been delaying care. But after the recent southern state surges, the hospital census started going down again,” she said.
Amy Arlund, registered nurse, Kaiser Permanente Medical Center in Fresno, California:
Amy Arlund works the night shift at Kaiser Fresno as an ICU nurse, which she’s done for the past two decades.
She’s also on the hospital’s infection control committee, where for years she’s fought to control the spread of clostridium difficile colitis, or C. diff., in her facility. The highly infectious disease can live on surfaces outside the body for months or sometimes years.
The measures Arlund developed to control C. diff served as her litmus test, as “the top, most stringent protocols we could adhere to,” when coronavirus patients arrived at her hospital, she told Healthcare Dive.
But when COVID-19 cases surged in northern states this spring, “it’s like all those really strict isolation protocols that prior to COVID showing up would be disciplinable offenses were gone,” Arlund said.
Widespread personal protective equipment shortages at the start of the pandemic led the CDC and the Occupational Safety and Health Administration to change their longstanding guidance on when to use N95 respirator masks, which have long been the industry standard when dealing with novel infectious diseases.
The CDC also issued guidance for N95 respirator reuse, an entirely new concept to nurses like Arlund who say those changes go against everything they learned in school.
“I think the biggest change is we always relied on science, and we have always relied heavily on infection control protocols to guide our practice,” Arlund said. “Now infection control is out of control, we can no longer rely on the information and resources we always have.”
The CDC says experts are still learning how the coronavirus spreads, though person-to-person transmission is most common, while the World Health Organization recently acknowledged that it wouldn’t rule out airborne transmission of the virus.
In Arlund’s ICU, she’s taken care of dozens of COVID positive patients and patients ruled out for coronavirus, she said. After a first wave in the beginning of April, cases dropped, but are now rising again.
Other changing guidance weighing heavily on nurses is how to effectively treat coronavirus patients.
“Are we doing remdesivir this week or are we going back to the hydroxychloroquine, or giving them convalescent plasma?”Arlund said. “Next week I’m going to be giving them some kind of lavender enema, who knows.”
Erik Andrews, registered nurse, Riverside Community Hospital in Riverside, California:
Erik Andrews, a rapid response nurse at Riverside Community Hospital in California, has treated coronavirus patients since the pandemic started earlier this year. He likens ventilating them to diffusing a bomb.
“These types of procedures generate a lot of aerosols, you have to do everything in perfectly stepwise fashion, otherwise you’re going to endanger yourself and endanger your colleagues,” Andrews, who’s been at Riverside for the past 13 years, told Healthcare Dive.
He and about 600 other nurses at the hospital went on strike for 10 days this summer after a staffing agreement between the hospital and its owner, HCA Healthcare, and SEIU Local 121RN, the union representing RCH nurses, ended without a renewal.
The nurses said it would lead to too few nurses treating too many patients during a pandemic. Insufficient PPE and recycling of single-use PPE were also putting nurses and patients at risk, the union said, and another reason for the strike.
But rapidly changing guidance around PPE use and generally inconsistent information from public officials are now making the nurses at his hospital feel apathetic.
“Unfortunately I feel like in the past few weeks it’s gotten to the point where you have to remind people about putting on their respirator instead of face mask, so people haven’t gotten lax, but definitely kind of become desensitized compared to when we first started,” Andrews said.
With two children at home, Andrews slept in a trailer in his driveway for 12 weeks when he first started treating coronavirus patients. The trailer is still there, just in case, but after testing negative twice he felt he couldn’t spend any more time away from his family.
He still worries though, especially about his coworkers’ families. Some coworkers he’s known for over a decade, including one staff member who died from COVID-19 related complications.
“It’s people you know and you know that their families worry about them every day,” he said. “So to know that they’ve had to deal with that loss is pretty horrifying, and to know that could happen to my family too.”
Analysis has “great implications in the COVID era”
Delirium was linked to long-term cognitive decline in both surgical and nonsurgical patients, a meta-analysis showed.
Patients who experienced an episode of delirium were more than twice as likely to show long-term cognitive decline than patients without delirium (OR 2.30, 95% CI 1.85-2.86), reported Terry Goldberg, PhD, of Columbia University in New York City, and co-authors.
Delirium was associated with long-term cognitive decline with a Hedges g effect size of 0.45 (95% CI 0.34-0.57, P<0.001) in a meta-analysis of 23 observational studies (after one outlier study with an exceptionally high OR was excluded), they wrote in JAMA Neurology. Effect sizes were similar between surgical and nonsurgical groups.
“The connection between delirium and cognitive decline that we observed was highly significant and remarkably consistent,” Goldberg said.
“What we propose is that delirium is not simply a marker for those patients already on a downward trajectory, but may be causative in and of itself,” he told MedPage Today. “This may be especially relevant to COVID patients, many of whom experience delirium in the ICU.”
Delirium is “ubiquitous and spares no age groups or populations, occurring in 20% to 70% of hospitalized patients, with the higher numbers seen in critically ill patients on mechanical ventilation,” said Pratik Pandharipande, MD, co-director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University in Nashville, who wasn’t involved with the meta-analysis.
“This study has great implications in the COVID era,” Pandharipande told MedPage Today. “Mechanically ventilated patients with COVID are at a much higher risk of developing delirium because they are subject to all the major risk factors — deeper levels of sedation, high severity of illness, often older age, and additionally, social isolation due to limited visitation rules in the hospital and the fact that the virus can directly affect the brain and lead to neuroinflammation.”
“The meta-analysis reported here shows a consistent message; all selected studies showed that delirium and longer duration of delirium were associated with cognitive impairment,” Pandharipande continued.
“While it is unclear if delirium causes dementia, there is mounting evidence — and the meta-analysis adds to this — that there are structural brain changes with delirium and this puts you at a worse cognitive trajectory,” he said.
“Incorporating strategies such as the ABCDEF bundle from the Society of Critical Care Medicine into the care of your patients — including mechanically ventilated COVID patients — is likely to reduce delirium and possibly its long-term consequences,” he added.
The meta-analysis included a systematic search of articles from 1965 through 2018. The researchers looked for studies that contrasted patients with and without delirium, had objective continuous or binary measures of cognitive outcome, and had a final time point of 3 months or later after the delirium episode.
Data from 24 observational studies, including 3,562 patients who experienced delirium and 6,987 controls who did not, were used. One study with an OR greater than 41 — an order of magnitude greater than any other study — was excluded from some analyses.
Mean study age was about 75 and mean follow-up after a delirium episode was 2.4 years. On average, men made up about 47% of the study populations. The Confusion Assessment Method (CAM) or CAM–intensive care unit was the most frequent delirium measure used, and the Mini-Mental State Examination was used most frequently as a cognitive outcome.
“In all studies, the group that experienced delirium had worse cognition at the final time point,” Goldberg and co-authors wrote.
Meta-regression did not show differences in cognitive outcomes between surgical and nonsurgical studies, suggesting “the underlying pathophysiological events associated with delirium may be similar and speculatively may be associated with inflammatory processes common to both contexts,” they added.
The researchers also did not find significant differences between cognition treated as a continuous variable based on neurocognitive test scores or as a binary variable based on the presence or absence of dementia.
The I2 measure of between-study variability in g was 0.81. Studies of longer duration yielded greater differences, while those with more covariates, and those without baseline cognitive matching, yielded smaller differences.
The observational studies used in this meta-analysis cannot show that delirium is a causative factor in subsequent cognitive decline, the researchers noted. Differences in cognitive outcome measures and the way dementia was diagnosed may be sources of variability, but meta-regressions did not find significant differences among them in terms of their effect on g, they added.
Importantly, the study could not evaluate delirium in the context of other factors, such as frailty, and unmeasured confounders may have influenced results.
- A man in Washington state who spent more than two months in the hospital and more than a month in the Intensive Care Unit with COVID-19 received a 181-page itemized bill that totals more than $1.1 million, The Seattle Times reported.
- Michael Flor, 70, will likely foot little of the bill due to his being insured through Medicare, according to the report.
- “I feel guilty about surviving,” Flor told The Seattle Times. “There’s a sense of ‘why me?’ Why did I deserve all this? Looking at the incredible cost of it all definitely adds to that survivor’s guilt.”
A 70-year-old man in Seattle, Washington, was hit with a $1.1 million 181-page long hospital bill following his more than two-month stay in a local hospital while he was treated for — and nearly died from — COVID-19.
“I opened it and said ‘holy (expletive)!’ ” the patient, Michael Flor, who received the $1,122,501.04 bill told The Seattle Times.
He added: “I feel guilty about surviving. There’s a sense of ‘why me?’ Why did I deserve all this? Looking at the incredible cost of it all definitely adds to that survivor’s guilt.”
According to the report, Flor will not have to pay for the majority of the charges because he has Medicare, which will foot the cost of most if not all of his COVID-19 treatment. The 70-year-old spent 62 days in the Swedish Medical Center in Issaquah, Washington, 42 days of which he spent isolated in the Intensive Care Unit (ICU).
Of the more than one month he spent in a sealed-off room in the ICU, Flor spent 29 days on a ventilator. According to the Seattle Times, a nurse on one occasion even helped him call his loved ones to say his final goodbyes, as he believed he was close to death from the virus.
While in the ICU, Flor was billed $9,736 each day; more than $80,000 of the bill is made up of charges incurred from his use of a ventilator, which cost $2,835 per day, according to the report. A two-day span of his stay in the hospital when his organs, including his kidneys, lungs, and heart began to fail, cost $100,000, according to the report.
In total, there are approximately 3,000 itemized charges on Flor’s bill — about 50 charges for each day of his hospital stay, according to The Seattle Times. Flor will have to pay for little of the charges — including his Medicare Advantage policy’s $6,000 out-of-pocket charges — due to $100 billion set aside by Congress to help hospitals and insurance companies offset the costs of COVID-19.
Flor is recovering in his home in West Seattle, according to the report.
Factors such as how many patients would need ICU treatment, average length of stay and fatality risk are straining hospital resources.
When it became evident that the COVID-19 pandemic would spread across the U.S., lawmakers, scientists and healthcare leaders sought to predict what the financial and operational impact on hospitals would be. In those early days, policymakers relied on data from China, where the pandemic originated.
Now, with the benefit of time, the early predictions seriously underestimated the coronavirus’ impacts. University of California Berkeley and Kaiser Permanente researchers have determined that certain factors — such as how many patients would need treatment in intensive care units, average length of stay and fatality risk — are much worse than previously anticipated, and put a much greater strain on hospital resources.
WHAT’S THE IMPACT
Looking primarily at California and Washington, data showed the incidents of COVID-19-related hospital ICU admissions totaled between 15.6 and 23.3 patients per 100,000 in northern and southern California, respectively, and 14.7 per 100,000 in Washington. This incidence increased with age, hitting 74 per 100,000 people in northern California, 90.4 per 100,000 in southern California, and 46.7 per 100,000 in Washington for those ages 80 and older. These numbers peaked in late March and early April.
Those numbers are greater than the initial forecast, especially when factoring in the virus itself. Modeling estimates based on Chinese data suggested that about 30% of coronavirus patients would require ICU care, but in the U.S., the probability of ICU admissions was 40.7%. Male patients are more likely to be admitted to the ICU than females, and also are more likely to die.
Length of stay was also higher than had been predicted. By April 9, the median length of stay was 9.3 days for survivors and 12.7 days for non-survivors. Among patients receiving intensive care, the median stay was 10.5 days, although some patients stayed in the ICU for roughly a month.
Long durations of hospital stay, in particular among non-survivors, indicates the potential for substantial healthcare burden associated with the management of patients with severe COVID-19 — including the need for ventilators, personal protective equipment including N95 masks, more ICU beds and the cancellation of elective surgeries.
The considerable length of stay among COVID patients suggests that unmitigated transmission of the virus could threaten hospital capacity as it has in hotspots such as New York and Italy. Social distancing measures have acted as a stop-gap in reducing transmission and protecting health systems, but the authors said hospitals would do well to ensure capacity in the coming months in a manner that’s responsive to changes in social distancing measures.
THE LARGER TREND
These challenges have placed a financial burden on hospitals that can’t be overstated. In fact, a Kaufman Hall report looking at April hospital financial performance showed that steep volume and revenue declines drove margin performance so low that it broke records.
Despite $50 billion in funding allocated through the CARES Act, operating EBITDA margins fell to -19%. They fell 174%, or 2,791 basis points, compared to the same period last year, and 118% compared to March. This shows a steady and dramatic decline, as EBITDA margins were as high as 6.5% in April.
The Trump administration is facing intense criticism for the lack of a national plan to handle the coronavirus pandemic as some states begin to reopen.
Public health experts, business leaders and current administration officials say the scattershot approach puts states at risk and leaves the U.S. vulnerable to a potentially open-ended wave of infections this fall.
The White House has in recent days sought to cast itself as in control of the pandemic response, with President Trump touring a distribution center to tout the availability of personal protective equipment and press secretary Kayleigh McEnany detailing for the first time that the administration did have its own pandemic preparedness plan.
Still, the White House lacks a national testing strategy that experts say will be key to preventing future outbreaks and has largely left states to their own devices on how to loosen restrictions meant to slow the spread of the virus. Trump this week even suggested widespread testing may be “overrated” as he encouraged states to reopen businesses.
The Centers for Disease Control and Prevention (CDC) on Thursday night issued long-awaited guidance intended to aid restaurants, bars and workplaces as they allow employees and customers to return, but they appeared watered down compared to previously leaked versions.
Some experts said the lack of clear federal guidance on reopening could hamper the economic recovery.
“A necessary condition for a healthy economy is a healthy population. This kind of piecemeal reopening with everyone using different criteria for opening, we’re taking a big risk,” said Mark Zandi, chief economist at Moody’s Analytics.
The lack of coherent direction from the White House was driven home this week by damaging testimony by a former top U.S. vaccine official who claims he was ousted from his post improperly.
“We don’t have a single point of leadership right now for this response, and we don’t have a master plan for this response. So those two things are absolutely critical,” said Rick Bright, who led the Biomedical Advanced Research and Development Authority until he was demoted in late April.
The U.S. faces the “darkest winter in modern history” if it does not develop a more coordinated national response, Bright said. “Our window of opportunity is closing.”
From the start, the White House has let states chart their own responses to the pandemic.
The administration did not issue a nationwide stay-at-home order, resulting in a hodgepodge of state orders at different times, with varying levels of restrictions.
Facing a widespread shortage, states were left to procure their own personal protective equipment, ventilators and testing supplies. Trump resisted using federal authority to force companies to manufacture and sell equipment to the U.S. government.
Without clear federal guidance, state officials were competing against each other and the federal government, turning the medical supply chain into a free-for-all as they sought scarce and expensive supplies from private vendors on the commercial market.
“The fact that we had questions about our ability to have enough mechanical ventilators, and you had states basically bidding against each other, trying to secure personal protective equipment … it shouldn’t be happening during a pandemic,” said Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security.
Internally, the administration struggled to mount a unified front as various agencies jockeyed for control. Multiple agencies have been providing contradictory instructions.
At first, Department of Health and Human Services (HHS) Secretary Alex Azar led the White House coronavirus task force.
Roughly a month, later he was replaced by Vice President Pence. The Federal Emergency Management Agency (FEMA) was later tasked with leading the response to get supplies to states, while senior White House adviser Jared Kushner led what has been dubbed a “shadow task force” to engage the private sector. Now, FEMA is reportedly winding down its role, and turning its mission back over to HHS.
The CDC has been largely absent throughout the pandemic. Director Robert Redfield has drawn the ire of President Trump as well as outside experts, and he has been seen infrequently at White House briefings.
“I think seeing the nation’s public health agency hobbled at a time like this and looking over its shoulder at its political bosses is something I hoped I would never see, and I’ve been working with the CDC for over 30 years,” said Lawrence Gostin, a professor of public health at Georgetown University.
“I think that people will die because the public health agency has lost its visibility and its credibility and that it’s being politically interfered with,” he added.
The administration recently has taken some steps to improve on the initial response to the pandemic.
Ventilator production has increased, and the U.S. is no longer seeing a shortage of the devices.
Testing has improved dramatically as well, though experts think the U.S. needs to be testing thousands of more people per day before the country can reopen.
The administration also unveiled plans to expand the Strategic National Stockpile’s supply of gowns, respirators, testing supplies and other equipment, after running out of supplies early in the pandemic.
Adalja said the administration’s positive steps are coming way too late.
“It’s May 15, we should have been in this position January 15,” he said.
McEnany on Friday for the first time detailed the White House’s preparedness plan that replaced the Obama-era pandemic playbook, an acknowledgement that Trump’s predecessor did leave a road map, despite claims to the contrary from some of the president’s allies.
She did not give many specifics on the previously unknown plan. Instead, McEnany declared the Trump administration’s handling of the virus had been “one of the best responses we’ve seen in our country’s history.”
Yet as states look to reopen businesses and get people back to work, the White House is taking a back seat as governors set their own guidelines for easing stay-at-home orders and restrictions on social activities.
The White House in April issued a three-step plan for states to reopen their economies, but it has largely been ignored by states and by the president.
Dozens of governors have begun easing restrictions on businesses and social activities without meeting the White House guidelines. Trump has been urging them to move even faster, backing anti-lockdown protesters in Michigan, Virginia, Minnesota and Pennsylvania.
Even scaled-down guidance from federal agencies is critical for providing a road map for state and local leaders, and for businesses considering how best to resume operations, said Neil Bradley, chief policy officer with the U.S. Chamber of Commerce.
“We need guidance because it helps instill confidence about the right types of approaches to take, but when you begin to move away from guidance and into either regulations or very strict approach, then that’s increasingly going to be unworkable in lots of different locations,” Bradley said.
A top vaccine doctor who was ousted from his position in April is expected to testify Thursday that the Trump administration was unprepared for the coronavirus, and that the U.S. could face the “darkest winter in modern history” if it doesn’t develop a national coordinated response, according to prepared testimony first obtained by CNN.
The big picture: Rick Bright, the former head of the Biomedical Advanced Research and Development Authority (BARDA), will tell Congress that leadership at the Department of Health and Human Services ignored his warnings in January, February and March about a potential shortage of medical supplies.
- He will testify that HHS “missed early warning signals” and “forgot important pages from our pandemic playbook” early on — but that “for now, we need to focus on getting things right going forward.”
- Bright’s testimony also reiterates claims from a whistleblower report he filed last week that alleges he was ousted over his attempts to limit the use of hydroxychloroquine — an unproven drug touted by President Trump — to treat the coronavirus.
What he’s saying: Bright will testify he urged HHS to ramp up production of
masks, respirators and medical supplies as far back as January. Those warnings were dismissed, Bright says, and he was “cut out of key high-level meetings to combat COVID-19.”
- “I continue to believe that we must act urgently to effectively combat this deadly disease. Our window of opportunity is closing. If we fail to develop a national coordinated response, based in science, I fear the pandemic will get far worse and be prolonged, causing unprecedented illness and fatalities.”
Bright will call for a national strategy to combat the virus, including “tests that are accurate, rapid, easy to use, low cost, and available to everyone who needs them.”
- “Without clear planning and implementation of the steps that I and other experts have outlined, 2020 will be darkest winter in modern history.”