Since the start of the coronavirus pandemic in March, Dr. Valerie Briones-Pryor has experienced more deaths than in nearly 20 years as a physician. There have been so many losses due to the highly infectious virus that she keeps a list of the patient names so she can remember them all. Last week Briones-Pryor, who works at the COVID-19 unit of Louisville’s Jewish Hospital, says she had to add seven new names to that list.
“Each of those patients, I held their hand and I told them that it was going to be okay,” says Briones-Pryor. We can’t allow family in, so we’re it, me, the nurses, the physical therapists... We’re the ones holding their hands because patients are scared.”
Kentucky now faces the highest COVID caseloads of the pandemic, with more than 20,000 people testing positive in the last week alone. Not everyone will need hospitalization, but those who do are taxing the state’s health care system and frontline workers.
“We have [bed] capacity,” Briones-Pryor says. “The problem is, is we don’t have staff.”
Despite all the personal protective equipment (PPE) and safety procedures, she says doctors and nurses are just vulnerable to COVID as anyone else. When a health care worker gets sick or is quarantined because of a non-work-related exposure, that leaves fewer people available to work in hospitals.
“So when you take even one or two nurses out… that’s two less nurses that can take care of eight to 10 patients,” says Briones-Pryor.
Hospitals Face Staffing and Financial Burdens
As case numbers have increased in the commonwealth this fall, so have hospitalizations.
“Over the last four weeks, we’ve seen about a 67 percent increase in the number of COVID patients in our hospitals,” says Kentucky Hospital Association President Nancy Galvagni. “We’ve seen about 51 percent increase in COVID patients in the ICU.”
Hospitals have contingency plans that enable them to add more beds for COVID patients by converting non-care areas into treatment space or by increasing intensive care capacity. Galvagni says those facilities also have ways to supplement nursing staff by putting nursing administrators into service, calling up retired nurses, and asking local health departments to release quarantined nurses who are not sick themselves.
Staffing issues are especially challenging for the state’s smaller hospitals in outlying and rural areas.
“We are stretched very thin,” says Dr. Fadi Al Akhrass, infectious disease specialist at the Pikeville Medical Center. “We have too much strain on our health care system.”
Although his hospital admits only “the sickest of the sickest,” Al Akhrass says they now have 79 COVID patients, including 26 who are in intensive care and 15 who are on ventilators. As the numbers continue to increase, he says the hospital has had to move resources away from other service areas like cardiology and oncology to handle the coronavirus patient loads.
“Our counties are setting records on a daily basis, and the problem is the very next day we are breaking these records,” says Al Akhrass. “That tells me only that we are not following the mitigating measures… We are sticking our heads in the sand.”
Doctors and hospital officials bristle at allegations that they are inflating COVID case numbers to enhance their profits.
“In no way are hospitals profiting from COVID,” says Galvagni. “These patients are very expensive to care for. They require more PPE, they require more staffing, they require additional treatments – more than the average patient.”
Kentucky hospitals will lose more than $2.6 billion this year due to the pandemic, according to Galvagni. Hospitals were eligible for some federal CARES Act relief funding, but she says that addressed only about 40 percent of the losses incurred by those facilities. To make matters worse, many COVID patients in the state have Medicare or Medicaid, which reimburse hospitals at lower rates. And hospitals have reduced elective procedures, which Galvagni says usually help offset the costs of more expensive treatments.
“Before the pandemic, we had identified about 28 rural hospitals… at risk of closure,” says Galvagni. “Now, with the financial condition that’s out there today, we don’t really know how they’re going to weather the pandemic.”
Even private practices are suffering. Dr. Alexander Ding, who is medical director at Humana and a clinical assistant professor of radiology at the University of Louisville, says his former practice has lost 70 percent of its revenues and furloughed many of its doctors and staff. While revenues have rebounded some, he says following COVID safety protocols will require patient capacity to remain below normal for some time.
Diagnostic and Preventive Services on the Decline
Health care providers are also experiencing lower demand for preventive services. Ding says a recent study by the Journal of the American Medical Association revealed a 70 percent reduction in mammograms and colonoscopies. He says fewer children are getting routine vaccinations and people are delaying other forms of care.
“During COVID we’ve seen a about 50 percent drop in diagnoses of new cancer,” says Ding. “That of course does not mean new cancer is not happening, but rather that it just isn’t being diagnosed and treated.”
When that cancer patient is finally diagnosed, Ding says it will be at a later stage of the disease, which will make harder to treat and could lead to a worse prognosis.
Fear seems to be driving these reductions. Ding says Humana has surveyed insurance enrollees, who report that they prefer to stay home during the pandemic. They especially try to avoid visiting a doctor because they think it will increase their risk of exposure to COVID.
“Patients really need to get back on track with their care,” says Ding. “Health care facilities are some the safest places for you to go at this time because they’ve really got a stringent focus on the safety protocols that they have had firmly in place for many months now.”
But these fears have had one positive result, according to Foundation for a Healthy Kentucky Vice President Allison Adams: A wider acceptance of telemedicine, which uses computer video connections to enable patients access to routine health care services without leaving home.
“Telehealth... met with a little bit of resistance, not only from providers but also from patients,” says Adams. “Now out of necessity, we’ve proven that it’s doable and can provide the best outcomes for the patients.”
Testing and Vaccines
COVID cases aren’t the only numbers surging.
“We’ve seen a huge demand increase in testing over the last week,” says Dr. Sarah Moyer, who is chief health strategist for the city of Louisville. “I think a lot of that is people wanting to get tested before they spend Thanksgiving with their friends and family.”
But Moyer and other doctors warn that a negative test result doesn’t guarantee you’re virus free, and shouldn’t preclude continuing to follow guidance on masking, social distancing, frequent hand washing, and gathering in groups of fewer than eight people.
“A positive or a negative test is a snapshot in time,” says Dr. Jay Grider, chief physician executive for UK HealthCare. “That means today you are negative, you are not having viral loads that are detectable via the test. That doesn’t tell you a whole lot about 36 hours from now.”
COVID has a long incubation period, and patients are generally at greatest risk of spreading the virus one or two days before they show any symptoms of having it. But Al Akhrass adds that 40 percent of patients never develop symptoms, yet they can still transmit COVID to others.
“The virus is constantly cooking,” says Al Akhrass.
The doctor says winter is an especially dangerous season for the virus. People spend more time together indoors, and the air tends to be drier, which scientists believe allows virus-infected respiratory droplets to linger longer in the air. Moyer says that reinforces the need to follow the safety guidelines.
“We know from large scale research studies that people are more likely to get it when they’re in close contact, talking without a mask on,” says Moyer. “We only have a short amount of time to take this seriously to save lives, so I’m hoping people can buckle down.”
There is hopeful news in the search for a COVID vaccine. Drugmakers AstraZeneca, Moderna, and Pfizer recently reported that their respective vaccines are 90 to 95 percent effective in clinical trials.
“If it were available at this exact moment, I would get the vaccine and I would encourage anybody to do so,” says Grider.
Traditional vaccines use weakened or inactivated versions of a germ to stimulate the body’s immune response. But Grider says the COVID vaccines being developed by Moderna and Pfizer use pieces of RNA and DNA to replicate proteins on the surface of the virus, not the virus itself. Once in the body, our cells use this genetic information to produce the antigens needed to fight infection. Grider says that process makes these vaccines safer and more effective.
But producing a working vaccine is different from delivering it to billions of people worldwide. Grider says high-risk patients and health care workers will be the first to be inoculated. Al Akhrass says the general public may not be vaccinated for another six to nine months.
Given concerns about how quickly the medicines have been developed and moved to market, public health officials fear some Americans may resist getting vaccinated. There are also significant logistical challenges of getting the vaccines distributed to all areas of the country. Adams says that’s where local public health officials can help.
“The health department can play a huge role in promoting the safety and the efficacy of the vaccine,” says Adams. “Also the benefit that health departments have is they can go to the people, they bring the vaccine to the people... That’s something that we have to be cognizant of is not everyone can come to the vaccine, so how do we have plans to get the vaccine to the people.”
Until a vaccine is widely distributed, these health professionals stress the importance of continuing to follow the guidance for containing the virus, especially over the next few weeks. Dr. Briones-Pryor says she’ll also be thinking about all the empty chairs around Thanksgiving tables that represent the people the virus has already taken.
“I wish everyone happy holidays,” she says, “but I also want them to have more holidays down the line, and to do that we have to make some changes to how we do things this year and be creative in how we spend time with each other.”
