July 2020 - Are you seeing more COVID?

[kidthor]

Public health reporting suggests an exponential rise in COVID infections and hospitalizations. Are you seeing this at your hospitals?

We're experiencing a slight upward trend in COVID patients at my SoCal hospital - many are entirely asymptomatic but happen to be there for other unrelated things (trauma, urgent-non-related surgeries, and even entirely elective surgeries). And then we also help to intubate some very sick COVID patients in ICUs. But the COVID burden to healthcare where I am isn't that dramatic... yet.

I'm wondering if we're experiencing the calm before a horrible storm or is this next wave less severe?

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[Man o War]

Our hospitalizations/deaths are down from the first wave. I am not paying much attention to new cases being reported by the health dpt because we are testing more people, so of course we have more cases, and false positive rates. Have had a couple patients test “positive” before surgery...absolutely zero symptoms, I question the accuracy of current testing. The tests we use have up to a 30% false positive rate I’m told.

 

[deleted162650]

My SoCal hospital is seeing a steady gradual increase. Went from 9 2 weeks ago to 13 last week to 16 this week. About 1/2 vented.

 

[IMGASMD]

We are up. For a few weeks we had zero cases in house or coming to OR.

It’s worrisome that we treated ORs as this sacred ground for the first wave, and kept everyone out of here. Now elective cases are here, and up tick in the hospital (presumably community) is up.

 

[Arch Guillotti]

We are on the uplsolpe again bigly.

 

[Angus Avagadro]

Although we had a large percentage increase, the actual numbers in our area are not that great. Less than 200 cases, 9 admitted to hospital yesterday. Avg age of new cases in our area is 27. Lots of icu capacity. Hospitals in surrounding counties have single digit to 0 icu patients. Governor snapped back quickly for 1 week with mandatory masks and closed bars. If you look at the data from 1918, flu peaked in June and dropped dramaticslly in late august. Had a smaller 2nd wave that winter and following summer if i remember correctly. Its on CDC website. Im afraid by surpressing spread, the first wave might just run into the 2nd wave this winter.

 

[Propofool123]

I’m in a state which saw a “the highest number of cases” last week but our COVID numbers in the icu are down trending and non -ICU covid numbers are steady. Have not heard of any hospital in our area being overwhelmed.

I have a couple of concerns.

1) as mentioned above, we really need to consider the false positive rate on these tests especially when we’re testing asymptomatic people in large droves.

2) both sides of the aisle are turning this into a political issue. Repubs want to make trump look good, many are making light of wearing masks, and they’re downplaying the seriousness of covid. Democrats will do anything to make trump look bad and will twist the data into however they can to win back the White House.

3) which leads to me to my last point which is the most important - cdc put out a report last week that the actual number of covid cases may be 10x time what was originally reported. So..... does that mean the case fatality rate isn’t 5% and in fact MUCH lower?

 

[dannyboy1]

I’m in a state which saw a “the highest number of cases” last week but our COVID numbers in the icu are down trending and non -ICU covid numbers are steady. Have not heard of any hospital in our area being overwhelmed.

I have a couple of concerns.

1) as mentioned above, we really need to consider the false positive rate on these tests especially when we’re testing asymptomatic people in large droves.

2) both sides of the aisle are turning this into a political issue. Repubs want to make trump look good, many are making light of wearing masks, and they’re downplaying the seriousness of covid. Democrats will do anything to make trump look bad and will twist the data into however they can to win back the White House.

3) which leads to me to my last point which is the most important - cdc put out a report last week that the actual number of covid cases may be 10x time what was originally reported. So..... does that mean the case fatality rate isn’t 5% and in fact MUCH lower?

Agreed. We just don’t know enough about this virus. I have had multiple patients test positive after coming in for something unrelated. Completely asymptomatic. Are the tests faulty? Are they detecting old infections? Has the virus mutates to become far less lethal?Who knows. Another thing, back in March- April in the tri state area there were almost no tests available for the general population. We have no idea what the percent positive would have been. It could be that there is some herd immunity in the places that got hit hard (because to be honest, I haven’t seen too much social distancing going on for the last 6-8 weeks, yet the numbers continue to decline)
The most reliable indicator of what is actually going on would be to look at hospitalizations and deaths.

 

[psychbender]

Covid ICU census continues to decrease (about 3-4 the last two weeks), hospitalized Covid continues to decrease (10-18 the list two weeks). Screening for procedures has increased, and we're picking up more asymptomatics coming for surgery, OB, etc, that go right home and are not being readmitted (so far) for Covid issues. My state seemed to peak early, though, and continues to downtrend as a whole.

 

[nimbus]

3) which leads to me to my last point which is the most important - cdc put out a report last week that the actual number of covid cases may be 10x time what was originally reported. So..... does that mean the case fatality rate isn’t 5% and in fact MUCH lower?

Overall CFR is probably 0.5-1% and much lower for healthy young people.

 

[wholeheartedly]

I thought this one was interesting.

Clinical and immunological assessment of asymptomatic SARS-CoV-2 infections

Clinical and immunological assessment of asymptomatic SARS-CoV-2 infections - Nature Medicine

A cohort of asymptomatic patients infected with SARS-CoV-2 had significantly lower levels of virus-specific IgG antibodies compared to a cohort of age- and sex-matched symptomatic infected patients.

www.nature.com

 

[kmurp]

I thought that I had read that the problem with the Covid swab RNA test was a relatively high false negative rate, especially in the way we use it to screen asymptomatic elective surgery patients. I was unaware that it had a significant false positive rate.

 

[teacher2md]

Check this out-- my hospital facility in North Carolina has been doing PCR swabs on all surgical patients for many weeks now. During this time, we are told that rate of positive patients has apparently stayed at 0.4-0.5%.

However, the antibody prevalence in North Carolina has been rising dramatically for several weeks now. (Updates and Data). During the month of June, the antibody prevalence increased from ~4% and was ~13% as of June 30. So that means that 2.5% of the population has a new infection per week.

BUT, the PCR positivity rate should be much higher, as viral RNA should be detectable for an average of 4 weeks after infection, even in asymptomatic patients (Interpreting Diagnostic Tests for SARS-CoV-2).

So during the month of June, the PCR positivity rate should have been closer to ~10%. This would mean that our hospital's PCR test may be missing >90% of asymptomatic infections.

 

[psychbender]

Could it instead mean that you hospitals exists in an area with a very low prevalence, with most of the cases in your state isolated to a few pockets? That's the case in my state, nearly all cases were centered in two regions, with a smattering elsewhere, and some areas with near zero positives.

Check this out-- my hospital facility in North Carolina has been doing PCR swabs on all surgical patients for many weeks now. During this time, we are told that rate of positive patients has apparently stayed at 0.4-0.5%.

However, the antibody prevalence in North Carolina has been rising dramatically for several weeks now. (Updates and Data). During the month of June, the antibody prevalence increased from ~4% and was ~13% as of June 30. So that means that 2.5% of the population has a new infection per week.

BUT, the PCR positivity rate should be much higher, as viral RNA should be detectable for an average of 4 weeks after infection, even in asymptomatic patients (Interpreting Diagnostic Tests for SARS-CoV-2).

So during the month of June, the PCR positivity rate should have been closer to ~10%. This would mean that our hospital's PCR test may be missing >90% of asymptomatic infections.

 

[teacher2md]

Could it instead mean that you hospitals exists in an area with a very low prevalence, with most of the cases in your state isolated to a few pockets? That's the case in my state, nearly all cases were centered in two regions, with a smattering elsewhere, and some areas with near zero positives.

Nope, major academic medical center with patients from across the region.

For anyone else who practices in the south, what has been the trend of PCR tests among surgical patients?

 

[nimbus]

Check this out-- my hospital facility in North Carolina has been doing PCR swabs on all surgical patients for many weeks now. During this time, we are told that rate of positive patients has apparently stayed at 0.4-0.5%.

However, the antibody prevalence in North Carolina has been rising dramatically for several weeks now. (Updates and Data). During the month of June, the antibody prevalence increased from ~4% and was ~13% as of June 30. So that means that 2.5% of the population has a new infection per week.

BUT, the PCR positivity rate should be much higher, as viral RNA should be detectable for an average of 4 weeks after infection, even in asymptomatic patients (Interpreting Diagnostic Tests for SARS-CoV-2).

So during the month of June, the PCR positivity rate should have been closer to ~10%. This would mean that our hospital's PCR test may be missing >90% of asymptomatic infections.

Are they swabbing correctly? You could get false negatives if they don’t really get back there with the swabs.

 

[MoMoGesiologist]

If case numbers are up and mortality is declining, does it really matter?

 

[ButterButter]

Our total in-house COVID numbers have stayed the same over the past month or so but our number of critical patients has gradually increased. This is problematic bc these patients typically remain intubated for weeks. So even a few extra critical admits per week could get out of control pretty quickly.

We recently had a woman come in as a trauma (beginning of June), tested positive for COVID and had a prolonged hospitalization with multiple procedures and tested positive every time she was taken back to the OR. Turns out she and her husband both fell ill in April, tested positive at that time, and despite improving symptomatically, continued to test positive even up until her discharge in late June..

 

[nimbus]

Our community positive tests are up 90% over the past week. Hospital census had been steady at 30-35 patients and our icu numbers are actually down from 15-20 to 10-15.

 

[nimbus]

We recently had a woman come in as a trauma (beginning of June), tested positive for COVID and had a prolonged hospitalization with multiple procedures and tested positive every time she was taken back to the OR. Turns out she and her husband both fell ill in April, tested positive at that time, and despite improving symptomatically, continued to test positive even up until her discharge in late June..

We’ve had a similar trauma patient who was initially COVID-. He did poorly postop requiring continued ventilation. Subsequently COVID+. Unclear if he acquired COVID in the community or in the hospital.

 

[linkin06]

If case numbers are up and mortality is declining, does it really matter?

well the mortality may be a lagging indicator. next few weeks will be more telling.

 

[Angus Avagadro]

well the mortality may be a lagging indicator. next few weeks will be more telling.

I dont think so. We have had a small spike in our area and the avg age was 27. But mortality might climb in your area
Agreed, we will have to wait and see.

 

[AMEHigh]

If case numbers are up and mortality is declining, does it really matter?

Yes it matters. I’ve said it over and over, we have to look at morbidity too. People sitting in the ICU for 1 month and surviving isn’t great either. Especially if they’re under 65 and likely working/contributing to society.

Now I’m not saying that morbidity is going up, but I hate when people especially physicians who should know that being hospitalized and especially being in the ICU isn’t just a road to going right back to being a normal productive member of society, keep saying well people aren’t dying no biggie.

I think we need to follow morbidity and long term consequences as well while we safely open businesses not to max capacity and schools.

 

[linkin06]

I dont think so. We have had a small spike in our area and the avg age was 27. But mortality might climb in your area
Agreed, we will have to wait and see.

Those younger folks may spread to older. In my area, there are reports that the spiking is spreading now to older age groups. I hope it won’t be the end result, but it is summer time, and students and young millennials may be home.

 

[amyl]

Our numbers are definitely up lately. as stated above, mortality isnt everything. I personally have seen significant morbidity as well - the first round of covid survivors have returned to the or to be trached and pegged and a few younger patients have come to have their sacral decubitus wounds washed out....

 

[Angus Avagadro]

Our numbers are definitely up lately. as stated above, mortality isnt everything. I personally have seen significant morbidity as well - the first round of covid survivors have returned to the or to be trached and pegged and a few younger patients have come to have their sacral decubitus wounds washed out....

This is a good point. I have read some preliminary articles about neueological deficits in Covid survivors. I believe they were on Medscape

 

[pjl]

My state is one of those which basically threw the rules out and we have no state wide rulings in place for businesses.

We have seen a consistent decrease of hospitalized covid patients since early May. Max census was ~40 patients, currently in low teens.
Our community and preop testing rate of positive results as a %tested was lowest 2 weeks ago. That rate has increased, as have the actual number of positive tests. Despite this, the hospital numbers continue to decline week over week.
I have definitely seen an increase in anecdotal “my friend tested positive” within the community.

On the up side, mask use in stores/public around here has gone from ~10% to ~80 over the past week. Most stores and restaurants appear to be doing brisk business.

 

[nimbus]

Our numbers are definitely up lately. as stated above, mortality isnt everything. I personally have seen significant morbidity as well - the first round of covid survivors have returned to the or to be trached and pegged and a few younger patients have come to have their sacral decubitus wounds washed out....

Trach/peg combos are the most common procedure we do on COVID patients.