Current COVID-19 Status:
- Johns Hopkins Global Coronavirus Tracker: 18,364,694 confirmed; 10,965,634 recovered; 695,848 deaths. In the United States, 57,543,852 have been tested; 4,742,277 are confirmed; 1,513,446 have recovered. The United States has a population of 328.2 million people. 8/4/20, 3 p.m.)
- 112,441 confirmed cases in Tennessee; 73,259 recovered; 1,117 deaths. Tennessee Department of Health (TDH). 8/4/20
- 5,669 confirmed cases in Hamilton County, 4,155 recovered, 48 deaths; 674 cases/638 recovered/1 death in Bledsoe County; 1,739 cases/1,211 recovered/10 deaths in Bradley County; 102 cases/68 recovered/2 deaths in Grundy County; 209 cases/122 recovered/4 deaths Marion County; 493 cases/339 recovered/20 deaths in McMinn County; 99 confirmed/52 recovered in Meigs County; 511 cases/372 recovered/1 death in Rhea County; 96 cases/62 recovered in Sequatchie County
- 197,948 confirmed cases in Georgia; 3,921 deaths. 8/4/20 Georgia Department of Public Health (DPH)
- 572 cases in Catoosa County, 9 deaths; 581 in Walker, 16 deaths; 114 cases, 1 death in Dade; 3,272 cases, 27 deaths in Whitfield County; 1,039 cases, 23 deaths in Gordon County.
- 4,649,102 confirmed cases in the U.S.; 154,471 deaths; 55 jurisdictions (50 states, District of Columbia, Puerto Rico, Guam, Northern Marianas, and US Virgin Islands) 37 jurisdictions report more than 10,000 cases of COVID-19. CDC 8/3/20
CHI Memorial COVID-19 Response
Visit the resource bank on Mnet for all current COVID-19 information.
Key Actions and Updates
*New* COVID Isolation Protocol
Following updated guidelines, new isolation protocols have been developed for transferring COVID-19 positive patients out of the CDU and CCU, as well as clarifies the process for retesting patients who may need an aerosolizing procedure. The new protocol becomes effective Wednesday, Aug. 5, 2020. Click here to view the protocol.
*New* CommonSpirit Health COVID-19 Bulletin
Important information about the ministry’s response to COVID-19 is published in CommonSpirit Health’s Daily Bulletin. The July 30, July 28, and Aug. 4 editions are most recent. Others can be found on the Mnet.
*New* Anderson Comments on Superspreaders
Mark Anderson, MD, Medical Director of Specialty Care and Director of Infection Control, was featured in a NewsChannel story about superspreaders. Read More
*New* Georgia Governor Extends Public Health State of Emergency
Governor Brian Kemp signed two executive orders extending the Public Health State of Emergency and existing COVID-19 safety measures. The current public health state of emergency was set to expire Aug. 10 and this executive order extends the State of Emergency to Sept. 10. The Public Health State of Emergency allows for enhanced coordination across government and the private sector for supply procurement, comprehensive testing, and health care capacity.
*New* AHA, AMA and ANA Release Public Service Announcement
Together, the American Hospital Association (AHA), the American Medical Association (AMA), and American Nurses Association (ANA) released a public service announcement (PSA) on Friday urging the American public to take three simple steps to help stop the spread of COVID-19: wear a mask, practice physical distancing and wash hands frequently. The PSA is the first element of a comprehensive campaign to increase public acceptance of these essential actions and builds on the groups’ open letter to the public released last month. Watch the PSA
*New* Article from physician e-news: Covid-19: ED Visits Declined in Early Months of Pandemic 8/3/2020 - By Scott Harris Contributing Writer BreakingMED™
Emergency department (ED) visits declined considerably in the early phases of the Covid-19 pandemic—and as a result, according to authors of a recent study, clinicians should make a concerted effort to encourage patients to visit the ED for serious illnesses and other conditions when needed, despite the ongoing pandemic.
"As the Covid-19 pandemic developed and intensified in the U.S. during the first 4 months of 2020, we found that ED visit counts decreased and the rates of hospital admissions from the ED increased in 5 health care systems in 5 states," wrote study first author Molly Jeffery, PhD, of the emergency medicine department at the Mayo Clinic in Minnesota, and colleagues, in JAMA Internal Medicine. "From their height in January to their lowest point in April, ED visits decreased by more than 40% in all the health care systems and by more than 60% in New York, where the pandemic was most severe."
In the pandemic’s infancy, experts recommended hospitals and patients reduce non-essential care to reduce transmission of the virus. Previous reports had shown evidence of declines, with reductions potentially spurred by patients failing to seek emergency care even under life-threatening (and non-Covid-related) circumstances.
The cross-sectional study from Jeffery and colleagues examined daily ED visit and hospitalization rates from January 1 to April 30. The data were gathered from 24 EDs in 5 large health care systems in Colorado (n=4), Connecticut (n=5), Massachusetts (n=5), New York (n=5), and North Carolina (n=5). Before the pandemic, average annual ED volume ranged from 13,000 to 115,000 visits per year.
Jeffery and colleagues unearthed major ED decreases across all 5 systems, with steeper declines beginning the week of March 11—a week when Covid-19 cases accelerated considerably around the country. In descending order, rates of decrease in ED use among systems in the study were 63.5% in New York, 57.4% in Massachusetts, 48.9% in Connecticut, 46.5% in North Carolina, and 41.5% in Colorado.
What’s more, rates of hospital admission from the ED held steady until local Covid-19 case rates began to climb, with admission rates increasing by 149% in New York, 51.7% in Massachusetts, 36.2% in Connecticut, 29.4% in Colorado, and 22% in North Carolina.
Although the study covered January and February—a time before the coronavirus spiked in earnest in the United States—the biggest ED declines in the study clearly occurred after Covid-19 gained higher levels of local, national, and global prominence.
"The weeks with the most rapid rates of decrease in visits were in March 2020, which corresponded with national public health messaging about Covid-19," Jeffery and colleagues observed. "Rates of hospital admission from the ED were stable until Covid-19 cases increased locally, suggesting lower patient volume and higher acuity in the ED as the Covid-19 pandemic spread…A possible explanation for these temporal associations is that the public responded more to national-level risk messaging about Covid-19 than to changes in the local situation with regard to reported cases."
According to Jeffery and colleagues, limitations in the study included the fact that the findings may not be generalizable outside the health care systems included in the study, and that the data did not capture diagnoses.
In an accompanying editorial, David Schriger, MD, MPH, an emergency physician with University of California, Los Angeles and associate editor of JAMA, but who was not affiliated with the study, wrote that a decrease in ED visits may be the result of not only a change in patient perceptions but a rapid expansion and acceptance of alternate options in anticipation of a potential crush of Covid-19 patients in the ED.
"Even if some sicker patients are not presenting to the ED, this does not mean that they are forgoing medical care altogether," Schriger wrote. "Many hospitals and clinics rapidly instituted better access to practitioners and care coordinators via the telephone or telemedicine, providing patients with alternatives."
Moving forward, Jeffery and colleagues said physicians and care teams should make a concerted effort to ensure patients felt comfortable seeking emergency care when necessary.
"These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the Covid-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings," the study authors wrote.
Schriger suggested the pandemic might ultimately provide a "silver lining" for learning more about ED use patterns and care delivery as a whole.
"At a time of great social discord in the U.S. and when funding priorities for various government functions are being rethought, a potential silver lining of the Covid-19 pandemic is the opportunity to consider how health care resources could be better used, particularly with respect to emergency care," Schriger wrote. "What might we learn from the patients who avoided or deferred ED care and who did not have a condition thought to benefit unambiguously from that care?"
No source appearing in this report disclosed any relevant financial relationship with industry.
*New* Article from physician e-news: Avoiding Care During the Pandemic Could Mean Life or Death 8/2/2020 - By John McKenna Associate Editor BreakingMED™
These days, Los Angeles acting teacher Deryn Warren balances her pain with her fear. She’s a bladder cancer patient who broke her wrist in November. She still needs physical therapy for her wrist, and she’s months late for a cancer follow-up.
But Warren won’t go near a hospital, even though she says her wrist hurts every day.
"If I go back to the hospital, I’ll get Covid. Hospitals are full of Covid people," says Warren, a former film director and author of the book "How to Make Your Audience Fall in Love With You."
"Doctors say, ’Come back for therapy,’ and my answer is, ’No, thank you.’"
Many, many patients like Warren are shunning hospitals and clinics. The coronavirus has so diminished trust in the U.S. medical system that even people with obstructed bowels, chest pain and stroke symptoms are ignoring danger signs and staying out of the emergency room, with potentially mortal consequences.
A study by the Centers for Disease Control and Prevention found that emergency room visits nationwide fell 42% in April, from a mean of 2.1 million a week to 1.2 million, compared with the same period in 2019.
A Harris poll on behalf of the American Heart Association found roughly 1 in 4 adults experiencing a heart attack or stroke would rather stay at home than risk getting infected with the coronavirus at the hospital. These concerns are higher in Black (33%) and Hispanic (41%) populations, said Dr. Mitchell Elkind, president of the American Heart Association and a professor of neurology and epidemiology at Columbia University.
Perhaps even more worrisome is the drastic falloff of routine screening, especially in regions hit hard by the virus. Models created by the medical research company IQVIA predict delayed diagnoses of an estimated 36,000 breast cancers and 19,000 colorectal cancers due to Covid-19’s scrambling of medical care.
At Hoag Memorial Hospital Presbyterian in Newport Beach, California, mammograms have dropped as much as 90% during the pandemic. "When you see only 10% of possible patients, you’re not going to spot that woman with early-stage breast cancer who needs a follow-up biopsy," said Dr. Burton Eisenberg, executive medical director of the Hoag Family Cancer Institute.
Before the epidemic, Eisenberg saw five melanoma patients a week. He hasn’t seen any in the past month. "There’s going to be a lag time before we see the results of all this missed care," he said. "In two or three years, we’re going to see a spike in breast cancer in Orange County, and we’ll know why," he said.
Dr. Farzad Mostashari, former national coordinator for health information technology at the U.S. Department of Health and Human Services, agreed. "There will be consequences for deferring chronic disease management," he said.
"Patients with untreated high blood pressure, heart and lung and kidney diseases are all likely to experience a slow deterioration. Missed mammograms, people keeping up with blood pressure control — there’s no question this will all cause problems."
In addition to fear? Changes in the health care system have prevented some from getting needed care.
Many medical offices have remained closed during the pandemic, delaying timely patient testing and treatment. Other sick patients lost their company-sponsored health insurance during virus-related job layoffs and are reluctant to seek care, according to a study by the Urban Institute.
A study by the American Cancer Society’s Cancer Action Network found that 79% of cancer patients in treatment had experienced delays in care, including 17% who saw delays in chemotherapy or radiation therapy.
"Many screening facilities were shuttered, while people were afraid to go to the ones that were open for fear of contracting Covid," said Dr. William Cance, chief medical and scientific officer for the American Cancer Society.
And then there are patients who have fallen through the cracks because of the medical system’s fixation on Covid-19.
Dimitri Timm, a 43-year-old loan officer from Watsonville, California, began feeling stomach pain in mid-June. He called his doctor, who suspected the coronavirus and directed Timm to an urgent care facility that handled suspected Covid patients.
But that office was closed for the day. When he was finally examined the following afternoon, Timm learned his appendix had burst. "If my burst appendix had become septic, I could have died," he said.
The degree to which non-Covid patients are falling through the cracks may vary by region. Doctors in Northern California, whose hospitals haven’t yet seen an overwhelming surge of Covid-19 cases, have continued to see other patients, said Dr. Robert Harrington, chairman of the Stanford University Department of Medicine and outgoing president of the American Heart Association. Non-Covid issues were more likely to have been missed in, say, New York during the April wave, he said.
The American College of Cardiology and American Heart Association have launched campaigns to get patients to seek urgent care and continue routine appointments.
The impact of delayed care might be felt this winter if a renewed crush of Covid-19 cases collides with flu season, overwhelming the system in what CDC Director Robert Redfield has predicted will be "one of the most difficult times that we’ve experienced in American public health."
The health care system’s ability to handle it all is "going to be tested," said Anthony Wright, executive director of Health Access California, an advocacy group.
But some patients who stay at home may actually be avoiding doctors because they don’t need care. Yale University cardiologist and researcher Dr. Harlan Krumholz believes the pandemic could be reducing stress for some heart patients, thus reducing heart attacks and strokes.
"After the nation shut down, the air was cleaner, the roads were less trafficked. And so, paradoxically, people say they were experiencing less stress in the pandemic, not more," said Krumholz, who wrote an April op-ed in The New York Times headlined "Where Have All the Heart Attacks Gone?" "While sheltering in place, they were eating healthier, changing lifestyles and bad behaviors," he said.
At least some medical experts agree.
"The shutdown may have provided a sabbatical for our bad habits," said Dr. Jeremy Faust, a physician in the division of health policy and public health at Boston’s Brigham and Women’s Hospital. "We’re making so many changes to our lives, and that includes heart patients. If you go to a restaurant three times a week or more, do you realize how much butter you’re eating?"
While some patients may be benefiting from a Covid-19 change of regimen, many people have urgent and undeniable medical needs. And some are pressing through their fear of the virus to seek care, after balancing the risks and benefits.
In March, when the virus took hold, Kate Stuhr-Mack was undergoing a clinical trial at Hoag for her stage 4 ovarian cancer, which had recurred after a nine-month relapse.
Members of her online support group considered staying away from the facility, afraid of contracting the virus. But Stuhr-Mack, 69, a child psychologist, had no choice: To stay in the trial, she had to keep her regular outpatient chemotherapy appointments.
"We all make choices, so you have to be philosophical," she said. "And I thought it was far more risky not to get my cancer treatment than face the off-chance I’d contract Covid on some elevator."
This KHN story first published on California Healthline, a service of the California Health Care Foundation.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
*New* Article from physician e-news: Covid-19 Outbreak Among Georgia Campers Does Not Augur Well for School Openings 8/2/2020 - By Candace Hoffmann Managing Editor BreakingMED™
A report published in the CDC’s Morbidity and Mortality Weekly Report, which found that SARS-CoV-2 easily spread among attendees at a Georgia youth camp, may not augur well for school re-openings this fall.
"The overall attack rate was 44% (260 of 597), 51% among those aged 6–10 years, 44% among those aged 11–17 years, and 33% among those aged 18–21 years," Christina M. Szablewski, DVM, from the Georgia Department of Public Health, and colleagues reported.
There were 597 attendees in all, and the campers’ ages ranged from 6-19 years, with a median of 12 years. More than half of the attendees were female. Staff members were ages 14-59, with a median age of 17 years, and more than half of the staff were female. Of the test results available for 344 campers — 76% were positive for Covid-19, and the attack rate increased the longer people stayed at the camp, with staff members having the highest attack rate (56%).
While the camp implemented most of the CDC’s recommendations for Youth and Summer Camps to prevent or lessen the spread of Covid-19, it did not require cloth masks for camper or increasing ventilation in buildings by opening doors and windows. Masks were required for all staff members. However, being camp, attendees did engage in indoor and outdoor activities, including singing and cheering.
The researchers also noted: "During June 21–27, occupancy of the 31 cabins averaged 15 persons per cabin (range = 1–26); median cabin attack rate was 50% (range = 22%–70%) among 28 cabins that had one or more cases. Among 136 cases with available symptom data, 36 (26%) patients reported no symptoms; among 100 (74%) who reported symptoms, those most commonly reported were subjective or documented fever (65%), headache (61%), and sore throat (46%)."
The study authors did report three limitations to their findings:
- The attack rates may be underestimated, as some people may not have been tested, or test results may not have been reported.
- Some transmission may have occurred before or after camp attendance.
- Adherence to prevention measures by individuals was not possible to assess between and within cabins, and masks were not required of the campers.
Nonetheless, with the U.S. teetering on school openings, this report adds to a growing body of literature regarding what is known and not known about Covid-19 transmission.
"Asymptomatic infection was common and potentially contributed to undetected transmission… This investigation adds to the body of evidence demonstrating that children of all ages are susceptible to SARS-CoV-2 infection and, contrary to early reports, might play an important role in transmission. The multiple measures adopted by the camp were not sufficient to prevent an outbreak in the context of substantial community transmission," Szablewski and colleague warned.
*New* Article from physician e-news: Covid-19: Obesity Ups Risk of Intubation, Death in Adults 65 or Younger 7/31/2020 - By Candace Hoffmann Managing Editor BreakingMED™
Obesity is associated with an increased risk of death or intubation in patients younger than age 65 who contract Covid-19, according to a retrospective cohort study published in the Annals of Internal Medicine.
This association was independent of age, sex, race/ethnicity, and comorbid conditions, Michaela R. Anderson, MD, MS, of Columbia University Irving Medical Center, in New York, and colleagues reported. They did note that the associations varied by age.
"Obesity was strongly associated with intubation or death among adults younger than 65 years, but not among those aged 65 years or older," Anderson and colleagues noted. "Our findings provide evidence to support recommendations from the Centers for Disease Control and Prevention in the United States and the National Health Service in the United Kingdom, which state that patients with a BMI of 40 kg/m2 or greater are at high risk for poor outcomes from Covid-19 and should therefore consider prolonged social distancing. As the United States and other countries begin to lift stay-at-home orders, these findings might inform discussions between health care providers and patients regarding advanced care planning and benefits of prolonged social distancing, particularly for younger adults with class 2 or 3 obesity."
Obesity is implicated as a risk factor for many diseases — cardiovascular disease, diabetes, cancer, osteoarthritis, and others, including, as the study authors point out, for pneumonia and acute respiratory distress syndrome. In their study, they wanted to find out the role obesity plays in Covid-19 and whether it is associated with intubation or death, inflammation, cardiac injury, or fibrinolysis.
The study included 2,466 hospitalized adults "laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection over a 45-day period with at least 47 days of in-hospital observation."
The cohort of patients had a median age of 67 years, 49% were Hispanic, and 58% were male. The median BMI was 29.7kg/m2 (IQR, 24.3 to 32.6 kg/m2), more than half of the patients had hypertension, and less than half (40%) had diabetes. The median number of comorbid conditions was two.
"Compared with all other BMI classes, patients with class 2 or 3 obesity (BMI >35 kg/m2) were younger, less likely to be male, more likely to be Black non-Hispanic, and less likely to have chronic kidney disease or a history of smoking," Anderson and colleagues wrote. "Patients with BMI less than 18.5 kg/m2 or greater than 35 kg/m2 were more likely than those in other BMI classes to have asthma, chronic obstructive pulmonary disease, or pulmonary heart disease."
Along with measuring BMI, the researchers also looked at other inflammation biomarkers on admission — C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]), cardiac injury (troponin level), and fibrinolysis (D-dimer level)."
A composite of intubation or death was the primary endpoint of the trial.
"Over a median hospital length of stay of 7 days (interquartile range, 3 to 14) days, 533 patients (22%) were intubated, 627 (25%) died, and 59 (2%) remained hospitalized," the study authors wrote. "Compared with overweight patients, patients with obesity had higher risk for intubation or death, with the highest risk among those with class 3 obesity (hazard ratio, 1.6 [95% CI, 1.1 to 2.1]). This association was primarily observed among patients younger than 65 years and not in older patients (P for interaction by age = 0.042). Body mass index was not associated with admission levels of biomarkers of inflammation, cardiac injury, or fibrinolysis."
Anderson and colleagues noted that their study adds to the current literature in its demonstration that obesity’s effect on outcomes in Covid-19 differs by age. They also noted that their findings are consistent with others in the literature showing an association between obesity and "bacterial and viral pneumonia, intensive care unit admissions for H1N1 influenza, and ARDS."
"In contrast to prior studies that demonstrate an association between obesity and lower mortality in critically ill patients with pneumonia and ARDS, known as the ’obesity paradox’, we found that obesity was associated with an increased risk for death among mechanically ventilated patients with Covid-19," Anderson and colleagues wrote. "We found that obesity is associated with intubation or death independent of several comorbid conditions, including diabetes and hypertension, which have been associated with adverse outcomes in Covid-19."
As to why they did not find the association between intubation and death in older adults, they noted that "may reflect a high mortality due to comorbidity, frailty, or worse immune function with older age, which can all occur independently of BMI. "
Among the limitations of the study were that data on BMI was missing for 28% of the patients, because of the way BMI was recorded, there may have been selection bias, and they were unable to determine if respiratory management differed between underweight or obese patients "including the likelihood of ’do not intubate’ or ’do not resuscitate’ orders." Anderson and colleagues also noted that the follow-up was short. Another limitation the authors noted, was likely due to the overwhelming number of patients during the study period, and while comorbidities were culled from the electronic medical record, the record might have been incomplete.
This study was supported by grants from the NIH, the Stony-World Herbert Foundation, and the Parker B. Francis Foundation
*Reminder* New CDC Guidance & Antibody Testing
Matt Kodsi, MD, Vice President of Medical Affairs, sits down with Mark Anderson, MD, Medical Director of Specialty Care and Director of Infection Control, to discuss new guidance from the CDC and antibody testing. If you have questions you would like answered in the next video, please email COVID@memorial.org. Watch
*Reminder* PPE Supply Guide Alert
CHI Memorial has tracked its supply of PPE in real time, since the beginning of the COVID-19 pandemic, and measures par levels against documented usage. This Guide is a confidential internal document and is not to be emailed or shared outside our organization. Our intent is to make certain that all employees are informed on the exact product that will be stocked by type. Click here to review CHI Memorial’s PPE Supply Guide Alert from July 29.
*Reminder* Reporting When Sick
Employees must call Employee Health when sick. We advise against getting a rapid COVID-19 test on your own as you will be required to repeat the test as it is ordered by Employee Health.
*Reminder* Antibody Test Does Not Exempt You from Wearing PPE
Many employees are seeking COVID-19 antibody tests on their own to determine if they have had an exposure and were asymptomatic. Should you have a test and it is positive for COVID-19 antibodies, it does not exempt you from wearing appropriate PPE. You must follow all protocols and standards for PPE.
As a reminder to all, make certain that patients and family members are wearing masks prior to entering a room. Should you have a patient that is not capable of keeping a mask on, you will wear your N95 with a loop mask over, even if the patient is not a COVID-19 positive or PUI patient. We must take adequate precautions in every instance.
*Reminder* Need Hours? Labor Pool Has Openings
There are empty slots available on all campuses. If you can cover a shift at Hixson or Glenwood, please call 495-2294 and for Georgia call 706-858-2761.
Fear less, hope more; eat less, chew more; whine less, breathe more; talk less, say more; hate less, love more; and all good things are yours. - Swedish Proverb