Patient Volumes

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Patient Volume

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Can anyone comment on r/medicine and why over there the reaction appears to be the end of the world? (the opposite to here)
I'm assuming you're talking about the Reddit thread, here and here?

My reaction after reading it, is this. New York is getting hit extremely hard by COVID-1 currently. The reaction is different here on this thread, because the 53 of 53 people that report same or decreased volume, are not getting hit extremely hard, because they don't work in NYC hospitals or nursing homes in Seattle. Will it get worse before it gets better, in those 53 of 53 locations? Probably. Will they get as slammed as a city that had 8 million people teaming around on top of each other, packed to the gills in subways, train stations, sharing cabs and ubers as people exited planes from three international airports from the hot zones of Northern Italy, Iran and Wuhan funneling directly into the urban petri dish? Hopefully not. At the same time, prepare for the worst and hope for the best. That's always the best option. Anything else, is counterproductive.

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So all these overwhelmed, stressed, madmen doctors that the news keeps showing are from the same 3 hospitals or something?

Our system is the same, cutting hours. The CMG I work PRN at is the same, cutting hours.

Our main site I would see somewhere around 30 patients in a shift, and the last shift I worked it was 4 hours between seeing patients looooooool

Basically.

The people getting absolutely crushed are the NYC area hospitals where level 1 trauma centers are running out of vents
 
New York is unique among American cities with population density, and public transit people actually use. Also disgusting street food with limited sanitation capabilities.....
 
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We're looking the same here as far as I can tell. Among other things I'm using our sickle cell pts as a barometer. When they stop coming I know something else is on the horizon. They are still coming despite my very clear instructions to stay home because they are at high risk.
 
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It's also worth noting though, that so far 100% of the respondents to the poll on this thread which includes people in EDs all across the country, are reporting that their EDs have the same or slower volume and 0% report being overwhelmed.

Either way, what I do know with 100% certainty, is that this pandemic needs to end, because it's causing me to spend w a y too much time on SDN. In that sense, I think we can all agree the end to this pandemic will be a great help to us all :laugh: .

May I suggest that there is some selection bias? Those that are swamped aren't spending much time on the internet, while those who are seeing six patients in a shift or who have had hours cut are spending more time on the internet, including here.
 
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May I suggest that there is some selection bias? Those that are swamped aren't spending much time on the internet, while those who are seeing six patients in a shift or who have had hours cut are spending more time on the internet, including here.

+1.

It's all selection and self-selection. Same reason social media turns very echo chamber-ish, SDN EM is tilted towards the negative parts of the specialty, SDN premed forums are a little neurotic, etc.

Many of the folks with a more moderate view of things don't care about coming to share them as much as the more critical folks do. Human nature. The former are probably happier for it, too.
 
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Listening to the EMRAP COVID update that aired on the 25th. They have 2 EPs from the NYC region and both are on quarantine for being COVID +. The bottom line is that only a few EDs in NYC area are overrun with volume, but all are overrun with acuity. They estimate that the region will be out of ventilators within 1 week at their current rate, and are requesting 30,000 additional vents...
 
Listening to the EMRAP COVID update that aired on the 25th. They have 2 EPs from the NYC region and both are on quarantine for being COVID +. The bottom line is that only a few EDs in NYC area are overrun with volume, but all are overrun with acuity. They estimate that the region will be out of ventilators within 1 week at their current rate, and are requesting 30,000 additional vents...

Why can't we temporarily re-distribute from other areas not as hard-hit like NJ, PA, and OH? Since there are "hot spots" in the country, with most other areas down in volume we should be able to move resources to address spikes or areas that are hardest hit.
 
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...and are requesting 30,000 additional vents...

I've seen Cuomo on CNN all week saying this. How on earth would they be able to manage 30k ventilators? To me that's just ridiculous on its' face.
 
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Don’t kid yourselves, this is definitely the calm before the storm. Houston is now seeing a slow uptick in covid related ARDS, although volume is still down. But New Orleans has been hit pretty hard and I suspect it’s only a matter of time before that happens here. That said, Houston has mitigating factors not present elsewhere in the hard hit areas that hopefully will lessen the impact here.


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Just curious @bravotwozero - What do you see as the mitigating factors for Houston that might lessen the impact?
 
Just curious @bravotwozero - What do you see as the mitigating factors for Houston that might lessen the impact?

I don’t have a crystal ball, so don’t take this as gospel, but

1) Houston has a relatively lower population density than the harder hit areas, despite being the fifth largest city in America by population. The city is massively sprawled out. Now, Detroit is also not population dense and they’re getting killed right now, so not sure how much helpful, or to what degree.

2) The city has a well developed medical infrastructure vis a vis the Texas medical center, basically a huge Mecca of healthcare centers, that have satellite hospitals all over the city. We’ve got about 43 icu beds per 100,000 people, not the highest per capita, but well above the lowest. Given the state of Texas has put all elective cases on hold, this should help us absorb surge capacity. We shall see in about 2 weeks whether or not this advantage holds true.


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I don’t have a crystal ball, so don’t take this as gospel, but

1) Houston has a relatively lower population density than the harder hit areas, despite being the fifth largest city in America by population. The city is massively sprawled out. Now, Detroit is also not population dense and they’re getting killed right now, so not sure how much helpful, or to what degree.

2) The city has a well developed medical infrastructure vis a vis the Texas medical center, basically a huge Mecca of healthcare centers, that have satellite hospitals all over the city. We’ve got about 43 icu beds per 100,000 people, not the highest per capita, but well above the lowest. Given the state of Texas has put all elective cases on hold, this should help us absorb surge capacity. We shall see in about 2 weeks whether or not this advantage holds true.


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Thanks @bravotwozero -- That was my thinking as well. Not to mention a very civically-minded population in general with a positive 'can-do' attitude. (Except for a few "invincible" wackos.) By the way, we're up to 4th largest population.
 
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Why can't we temporarily re-distribute from other areas not as hard-hit like NJ, PA, and OH? Since there are "hot spots" in the country, with most other areas down in volume we should be able to move resources to address spikes or areas that are hardest hit.

Because the expected duration of mechanical ventilation in these patients is up to 14-21 days. Other states may not get them back in time.

Also, there's no mechanism in place for this. You think the local for-profit hospital chain is going to give up their vents for goodwill?

This is the downside of not having a medical system.
 
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I've seen Cuomo on CNN all week saying this. How on earth would they be able to manage 30k ventilators? To me that's just ridiculous on its' face.

Twenty years ago, I’d say that it would be ridiculous that some goat fu<>er could use commercial airliners as cruise missiles against the heart of our financial infrastructure. Well, 20 years and 4 deployments later - I’ve reconsidered the ridiculous and impossible.

There are roughly 8 million people in the 5 Boroughs. If we assumed just a 10% infection rate and only 5% critical care rate among the infected, then that is 40,000 patients potentially needing a ventilator. I’d say those numbers are not even a plausible worst case scenario which could be triple those numbers. A driving factor of outcome seems to be the availability of advanced respiratory care with vents per 100,000 people being a good measure. In Italy, they had roughly 6 per 100,000 and were overrun many times over. We have 30-50 per 100,000 depending on location, but many fear that is less than half the number that we could need (source EMRAP).

Already, the city is looking to annex convention centers and arenas, hotels, and universities as makeshift hospitals.


The idea is to be able to flex increase the ICU capable beds by several thousand. There is also a need to have spare vents as some will inevitably need to be taken out of service.

It is not that our leaders think all of those vents and ICU beds will be necessary. The issue is that in the unlikely but plausible event that they are necessary and nobody thought to prepare, well...
 
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It is not that our leaders think all of those vents and ICU beds will be necessary. The issue is that in the unlikely but plausible event that they are necessary and nobody thought to prepare, well...

Great post. My issue is not with anticipating 30k people needing ventilatory care in NYC. Rather, it's with my suspicion that they don't have the manpower to manage even a fraction of that.
 
How many people does it take? Just assume 1:1 nursing care is no longer an option.

Our hospital is flexing it's number of vents way up and has already asked who is in the ED would be comfortable flexing to the ICU to help out if we were given some vent instruction.

I would guess the effect of me going to the ICU will increase mortality.
Great post. My issue is not with anticipating 30k people needing ventilatory care in NYC. Rather, it's with my suspicion that they don't have the manpower to manage even a fraction of that.
 
Why can't we temporarily re-distribute from other areas not as hard-hit like NJ, PA, and OH? Since there are "hot spots" in the country, with most other areas down in volume we should be able to move resources to address spikes or areas that are hardest hit.

Makes sense to me...but the areas where they are not hard hit "need to prepare" for being hit hard.
 
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Isn't it just about inevitable that every HCW at the front lines in NYC will come down with SARS-2 themselves? There is no way you can be exposed to hundreds of these patients over the course of a few days and think you're not going to catch it, particularly with the comedic PPE situation. Are we expecting these people to work through symptoms and increase their chance of death, or what is the contingency planning here as staffing levels progressively deplete? This thing isn't the flu where you bounce back well within a week, it seems to linger for 2-3 weeks on average and it's typically at the end of the 2nd week where you start feeling better that the critical junction between full recovery and precipitous decline takes place. In other words, HCWs who get knocked out will stay out for the duration of the peak of the crisis.
 
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Why can't we temporarily re-distribute from other areas not as hard-hit like NJ, PA, and OH? Since there are "hot spots" in the country, with most other areas down in volume we should be able to move resources to address spikes or areas that are hardest hit.


NJ is very hard hit.

My hospital on the west coast has a current COVID19 census of 5 but we are expecting the majority of our beds to be filled by COVID19 patients in 2-3 weeks. We sure as f*** aren’t sending any vents out.
 
Isn't it just about inevitable that every HCW at the front lines in NYC will come down with SARS-2 themselves? There is no way you can be exposed to hundreds of these patients over the course of a few days and think you're not going to catch it, particularly with the comedic PPE situation. Are we expecting these people to work through symptoms and increase their chance of death, or what is the contingency planning here as staffing levels progressively deplete? This thing isn't the flu where you bounce back well within a week, it seems to linger for 2-3 weeks on average and it's typically at the end of the 2nd week where you start feeling better that the critical junction between full recovery and precipitous decline takes place. In other words, HCWs who get knocked out will stay out for the duration of the peak of the crisis.

You are absolutely correct. All of us have either already been exposed, or WILL be exposed to this. Unless you are willing to wear PAPR all day long on every shift, you will get this. Fortunately I don't think it will take out as many healthcare workers as you suspect. The symptoms will still be mild for the vast majority, and shouldn't be out longer than 7-14 days. A few will get very very sick and will be out for months.
 
New York is unique among American cities with population density, and public transit people actually use. Also disgusting street food with limited sanitation capabilities.....

Yep. Its the most foul place I've ever been in the USA.
Besides New Jersey.
Nope. Rather be in Jersey.
 
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New York is unique among American cities with population density, and public transit people actually use. Also disgusting street food with limited sanitation capabilities.....
Don’t forget it’s run by Democrats too!
 
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My volumes have plummeted. It was normal volume, now.... eerie
 
ED Volumes way down in Central Florida . I’ve been on swing shift and had 5-10 pts a shift last 2 weeks in a 67k volume a year site Calm before the surge?? 5 of our ED nurses already went to NYC for $10,000 a week to work 21 days straight. I heard Envision cut doctors hours as they always do going from high to low season all throughout FL, but it was just way sooner & sudden. A lot of midlevels furloughed and some I am told had there contract hours cut in half. Makes me think about sticking with sites with 12 hr shifts now and no way to cut hrs if you’re the only doc.
 
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At a 12 hour single coverage site they could always go to midlevel coverage with telehealth oversight. 100% cut.
ED Volumes way down in Central Florida . I’ve been on swing shift and had 5-10 pts a shift last 2 weeks in a 67k volume a year site Calm before the surge?? 5 of our ED nurses already went to NYC for $10,000 a week to work 21 days straight. I heard Envision cut doctors hours as they always do going from high to low season all throughout FL, but it was just way sooner & sudden. A lot of midlevels furloughed and some I am told had there contract hours cut in half. Makes me think about sticking with sites with 12 hr shifts now and no way to cut hrs if you’re the only doc.
 
ED Volumes way down in Central Florida . I’ve been on swing shift and had 5-10 pts a shift last 2 weeks in a 67k volume a year site Calm before the surge?? 5 of our ED nurses already went to NYC for $10,000 a week to work 21 days straight. I heard Envision cut doctors hours as they always do going from high to low season all throughout FL, but it was just way sooner & sudden. A lot of midlevels furloughed and some I am told had there contract hours cut in half. Makes me think about sticking with sites with 12 hr shifts now and no way to cut hrs if you’re the only doc.

One of the sites I moonlight at is like that (contract holder is a predatory sdg). They just cut midlevel support by 60% and pay by 10%.

Anyone have any thoughts on what the most ethical locums agency is?
 
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At a 12 hour single coverage site they could always go to midlevel coverage with telehealth oversight. 100% cut.
Not in my state. At least not unless it's a very rural county. And most of those are already closed.
 
For whom the bell tolls

Yeah, today was one of those days where admin was walking around at 11am "flexing" nurses off like they were beach muscles.
So of course at 3pm when every room was full, and EMS was lining the hallways, nothing could get done.
Thanks guys. Big help. It's weird how you mandate "surge capacity" into everything but ER nursing staff.
 
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Get their point, but a savage thing to do to the day shift. Hopefully they really weren’t forced to work a 24.

I'm sure this wont be the last work stoppage we see. Everyone has their breaking point and stories like these will galvanize workers across the country.

Hopefully healthcare workers seize this opportunity to organize and take some power back from the hospital administrators.
 
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I just got the daily update email form the hospital I’m on staff at. Still, only 4 COVID positive patients, 1 on a vent. The vast majority of the otherwise 300+ bed hospital is empty.

They’re not overwhelmed by patients, but overwhelmed with the lack of patients leading to mass layoffs and pay cuts.
 
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Update to my previous, volumes way down now. All my and my co-resident's moonlighting shifts have been pulled. Unfortunately they just replaced us with cheaper NPs but that's a different sob story.
 
More than half of our small group of PAs just got laid off yesterday. The surviving few of us - the ones who have made the hospital the most money historically, of course - will be “privileged” to work a handful of shifts per month with the HOPES that we will be offered our old contract back when volumes pick up. Essentially I have gotten about an 80 percent pay cut. I feel sick for the ones who didn’t make the cut. I feel sick about the uncertainty of my job which I thought was stable. My heart hurts today.
 
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More than half of our small group of PAs just got laid off yesterday. The surviving few of us - the ones who have made the hospital the most money historically, of course - will be “privileged” to work a handful of shifts per month with the HOPES that we will be offered our old contract back when volumes pick up. Essentially I have gotten about an 80 percent pay cut. I feel sick for the ones who didn’t make the cut. I feel sick about the uncertainty of my job which I thought was stable. My heart hurts today.
I'm sorry. I hope this turns around ASAP.
 
Our group announced no bonuses for second quarter. "Will reassess in third quarter." I work at an RVU based shop, bonuses make up about half our salary. I've become less distracted by COVID 19, and far more anxious about having to dive into my emergency fund to pay the bills. Got a family of 4 to feed. This has become a really strange time. Still get to go work in COVID infested inner city ED like the rest of you. Hoping for the silver lining to kick in at some point in all of this...

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My shop hit its nadir of 39 patients yesterday.
This time of year, we're usually around the 80-100 patients/day mark.
 
Volume actually seemed to be up quite a bit today at my shop. Actually saw about 1.5 pph, up from the recent less than 1 pph.
 
It’s a good thing that envision and team health are going to get millions of dollars to not pay any of you with. I was getting worried that their investors might have to not buy their second yacht.
 
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400% spike in out of hospital cardiac arrests in NYC. Undoubtedly some die primarily from COVID, but I suspect most are the MIs, strokes, and sepsis that we are not seeing.


 
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I have to admit, the reduced volume has done wonders for my burnout. Nearly all my patients actually should be in the ED, instead of the steady stream of PCP dumps, chronic complaints and minor care issues. While I wonder when my shops will be asked to take a paycut, I can't help but enjoy it while it lasts. This might make me a terrible person. I dunno. But I like the bounce in my step.
 
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I agree with you. I've actually enjoyed going to work over the last few weeks. Even though I have to wear an N95 all shift and leave with a bruised nose and a headache, I finally feel like I have a purpose.
 
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Honestly, I’m shocked numbers are so down, if anything I would imagine them
To be higher. I mean, you can’t close an ER and who knows when things will get better with this new disease
 
Enough people are terrified to come in to the ER. We had an EMS call the other night for a refusal of transport. Old lady who had fallen and clearly broken her hip (shortened, rotated, unable to raise leg). She refused to come in, convinced that coming to the ER would be a death sentence. They could not get her to agree to transport, and she was competent, so they left her at home.

That’s an extreme example, but extrapolate that across all the urgent (but maybe not emergent) complaints we see, and it equals a 40-50% drop in volume.

Honestly, I’m shocked numbers are so down, if anything I would imagine them
To be higher. I mean, you can’t close an ER and who knows when things will get better with this new disease
 
Enough people are terrified to come in to the ER. We had an EMS call the other night for a refusal of transport. Old lady who had fallen and clearly broken her hip (shortened, rotated, unable to raise leg). She refused to come in, convinced that coming to the ER would be a death sentence. They could not get her to agree to transport, and she was competent, so they left her at home.

That’s an extreme example, but extrapolate that across all the urgent (but maybe not emergent) complaints we see, and it equals a 40-50% drop in volume.

She'll be in soon enough. When she poops on herself for the third time.
 
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Honestly, I’m shocked numbers are so down, if anything I would imagine them
To be higher. I mean, you can’t close an ER and who knows when things will get better with this new disease
I've watched about a half a dozen close in one large Texas city. And hospital based, not just freestandings.
 
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