April 9, 2020 Update
Dear All,
What should hospitals be doing to prepare for COVID?
First and foremost, they should be planning for varying ranges of patient loads since it’s impossible to know how many patients they’ll end up getting. They should be planning for how they would manage 40 cases to 400. Things such as where they can flex additional beds, ventilators, personal protective equipment (PPE), medications and staffing.
Speaking of staffing, it takes A LOT of staff to manage COVID patients. Not only because many require ICU level care but because your staff will get sick and need to call out. Thus, you should be prepared for this and think about what departments you can pull from if needed to cover those who contract COVID.
Last point on staffing – I would strongly urge hospitals and local departments of health to prioritize antibody testing to healthcare workers. It is clear that widespread testing is not around the corner, but we know that certain labs will start being able to look for antibody response to COVID very soon. These limited tests should be prioritized for hospital workers with the goal of identifying what doctors, nurses, cleaning staff already have antibodies to COVID. We’ll talk more about immunity below, but suffice to say, that those who’ve gotten it are at less risk of contracting it again, and therefore, those people should be asked to serve on COVID teams over those without antibody protection.
Why is this last point so important?
Healthcare workers are understandably scared about contracting COVID themselves. As we’ve discussed in prior posts, anyone regardless of age or health status can end up on a ventilator, thus, it’s incredibly stressful for healthcare workers who have not had COVID to have to go and expose themselves to COVID over and over.
When your numbers become as high as they are here in New York City and your entire 400-500 bed hospital is a COVID hospital, you have no choice but to convert everyone to caring for COVID patients regardless. But, for hospitals where the census is lower, there may be an opportunity to identify your healthcare workers who’ve already been exposed and reduce the risk of transmitting the virus to other healthcare workers.
Testing the workforce and creating COVID teams with antibody protection would be a top priority if I were a hospital preparing to manage COVID patients.
Last aside – I forgot to include this in my last post but several of my patients were healthcare workers from around the city. One in particular, a nurse in her 50’s, remains hospitalized today and very much on the fence as to whether she’s heading closer to home or the ICU at the moment. Sadly, taking care of a healthcare worker in New York City is no longer newsworthy because it’s now common place to see healthcare workers from around the city occupying hospital beds.
What else should hospitals be doing?
Hospitals should be looking to collaborate with fellow hospitals in the community and create transparent lines of communication. These entities may typically consider themselves competitors, but close coordination is incredibly valuable to ensure everyone gets the care they need. Hospitals should be coordinating closely on patient census, PPE supplies, medication supplies, ventilators, etc, and working to ensure no single entity gets overwhelmed.
The other key point is to think about how you can safely discharge patients back to the community. Many patients may be able to go home faster if home oxygen and home monitoring services are available. I would be contacting your home oxygen suppliers and those who can monitor patients at home to coordinate. This could be your ambulatory doctors or RN care managers via telehealth or partnering with local paramedics to check in on patients who have been recently discharged.
Knowing that oxygen therapy is a common barrier to discharge, strategizing how to break that constraint safely would be highly valuable to keeping your beds open for critically ill patients who can’t be monitored at home.
And, finally, hospitals can see if local food trucks want to come park outside the hospital and hand out free coffee and snacks to staff. We were fortunate at NYU to have a food truck outside most days which was greatly appreciated.
What’s the deal with immunity? Can you catch COVID again once you’ve had it once?
The short answer is no one knows with certainty. Remember, this virus didn’t exist 6 months ago so anyone claiming with confidence whether you have immunity at 6 months or 12 months is speculating. Having said that, several virologists I follow feel confident that those with antibodies will likely have immunity for at least 3-12 months, and possibly longer. While the virus does mutate, it does not appear that the spike protein component of the virus has mutated which is how the body’s immune system would recognize the pathogen and limit re-infection.
Again, no one knows with 100% certainty and I would not advise anyone interacting with COVID patients without appropriate PPE, but those with some degree of immunity are likely in better position to care for COVID patients than those with none. This is an evolving question and will be re-assessed as more information becomes available.
Everyone is talking about hydroxychloroquine (plaquenil). Were you using at NYU? Did it work?
Yes. Every admitted patient got hydroxychloroquine, azithromycin, and high-dose zinc. It is unclear if this had positive benefit as the data is not there to say one way or the other. I can tell you that many of our patients that received it still ended up in the ICU on a ventilator so I would not be counting on this as a cure or wonder drug.
My hunch is that it may help to some degree, but we’ll need to wait for the data to know with confidence.
What are the clinical notes from taking care of COVID patients?
Click here for my clinical notes from my time on service for those interested in those details.
Tomorrow or Saturday I will review the curve in NYC and discuss leading/lagging indicators as well as answer common questions I’m hearing from folks.
Thanks and be well,
Harry
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