A Blog by Jonathan Low

 

Sep 20, 2020

Why Doctors and Hospitals Say They Are Better Prepared To Treat Covid This Fall

Doctors and hospitals have learned a lot in the past six months. They know which drugs to use and which not to use. They have stocked up on PPE and other supplies. And they have learned which parts of the body the virus infects, which makes more comprehensive treatment and lower death rates possible.

Patients are helping by being better informed and seeking treatment earlier, which also helps in delivering more positive outcomes. JL

Sarah Toy and Caitlin McCabe report in the Wall Street Journal:

Hospitals expect to be better prepared if a second wave of Covid-19 cases hits in coming months, doctors and administrators say, after gaining a better understanding how to triage patients, which drugs to use and what supplies are needed. They are stockpiling masks, protective equipment and Covid-19 drugs to meet any surge in demand. Another important factor in treatment is a deeper understanding of Covid-19’s wide-ranging effects on the body, such as a greater risk of blood clots. (And) patients seek care earlier, enabling treatment before their cases worsen and become harder to treat.
U.S. hospitals expect to be better prepared if a second wave of Covid-19 cases hits in coming months, doctors and administrators say, after gaining a better understanding how to triage patients, which drugs to use and what supplies are needed.
When the new coronavirus first struck, beds filled up at record speed, ventilators were in short supply and proven treatments were scant.
Since then, doctors say, they have developed a better understanding of who needs a ventilator and how quickly a patient can be discharged, and studies have pointed to a few drugs like the antiviral remdesivir and the steroid dexamethasone that can help.
Hospitals say they are stockpiling masks, other protective equipment and Covid-19 drugs to meet any surge in demand should cases pick up.
The spring “was ultimately baptism by fire,” said Donald Landry, physician in chief of NewYork-Presbyterian/Columbia University Irving Medical Center. Now “we understand the illness; we have a variety of treatments.”
“Obviously this can get out of control—we don’t have a magic bullet for it yet—but your prospects are actually very good,” Dr. Landry added.
The reported progress mirrors some gains doctors and hospitals in Europe said they saw after a challenging start, which helped to reduce deaths among the sickest patients.
In the U.S., there are signs the changes are contributing to better outcomes for Covid-19 patients, doctors and hospitals say.
At Hackensack Meridian Health, New Jersey’s largest hospital system, the percentage of Covid-19 patients admitted to intensive care has dropped by more than half since April, as has the percentage of Covid-19 patients on ventilators, said Daniel Varga, Hackensack’s chief physician executive.
Death rates among Covid-19 patients hospitalized in the system have also fallen during that period, he said.
The death rate for Covid-19 patients also has declined at Lifespan, Rhode Island’s largest health system, said Mitchell Levy, medical director of the medical intensive care unit at Rhode Island Hospital, which Lifespan operates.
In June through August, the death rate among all hospitalized Covid-19 patients was about 14%, down from almost 19% in March through May, he said. Deaths among Covid-19 patients in the intensive care unit have also dropped, Dr. Levy added.
“These folks seem to be getting better,” he said. “And for a long time that was not necessarily the case.”
Factors beyond improved treatment also probably have played a role in the improving outcomes, doctors and hospitals say.
Many hospitals, especially in the Northeast, have benefited from fewer Covid-19 admissions in recent months, which allows doctors to spend more time with each patient. Younger and healthier patients have also helped.
Patients also seem to be seeking care earlier than before, physicians say, enabling treatment before their cases worsen and become harder to treat.
Yet doctors say they are also better able to manage care for hospitalized patients, as studies have shown which drugs work and which don’t. Now, doctors say they are regularly using remdesivir and the steroid dexamethasone, while avoiding antimalaria drugs.
Another important factor in treatment, doctors say, is a deeper understanding of Covid-19’s wide-ranging effects on the body, such as a greater risk of blood clots.
Daniel Griffin, chief of infectious diseases at physician practice ProHealth Care New York, said doctors were initially told not to put hospitalized Covid-19 patients on blood thinners, but some would develop clots, which can cause a stroke or embolism.
Now, Dr. Griffin and his colleagues routinely screen patients for signs of clots upon admission and prescribe anticlotting drugs, he said.
Another major shift: Many doctors say they have pulled back on putting many patients on ventilators, which can increase the risk of developing other infections or injure the lungs. Instead, doctors say they are trying less-invasive treatments, such as prongs called high-flow nasal cannulas that blow heated, humidified oxygen into patients noses.
“Not everybody benefited from being on a ventilator,” said Faisal Masud, medical director of critical care at Houston Methodist Hospital, and for many, when you put them on, that led to another cascade of problems.
Hospital staff now feel more comfortable using alternative oxygen therapy, Dr. Masud said. About 9% of Covid-19 cases in the Houston Methodist system used a ventilator in July, down from almost 22% in April, according to data provided by the system.
Doctors say they also are trying to help patients breathe by turning them on their stomachs, which helps boost oxygen levels partly by reducing the pressure of the heart and diaphragm on the lungs.
Also, to reduce the risk that a hospitalized patient will develop a complication during their stay, many hospitals say they have a better handle on which patients can stay home while monitoring their oxygen levels and symptoms.
Other patients, some hospitals say, can also be discharged to continue their care at home after receiving treatment in the hospital.
At Temple Health in Philadelphia, doctors in some cases are discharging patients who still require some breathing assistance or steroids, if tests indicate they are doing better and the treatment team believes they can handle continued treatment at home, said Gerard Criner, chair and professor of thoracic medicine and surgery at the Lewis Katz School of Medicine at Temple University.
Doctors and hospital administrators worry about a second wave of coronavirus cases this fall, especially as flu season emerges.
Yet several hospitals say they will be better prepared for an influx of patients now that they have a better idea what to expect.

The Hackensack, N.J., hospital system is training staff for redeployment to Covid-19 treatment should cases surge again and accumulating a 180-day stockpile of masks, gowns and other personal protective equipment, Dr. Varga said.
Likewise, Houston Methodist is amassing supplies of medications such as remdesivir as well as drugs used when intubating patients. It has also been stocking up on reusable protective equipment.
“If I have to turn your unit into a Covid-19 unit now, it’s much different,” said Roberta Schwartz, executive vice president of Houston Methodist Hospital. “We’re getting much more adept at making changes.”

2 comments:

Emma Jasmine said...

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