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Hospital ICU bed capacity isn’t the only issue with critical Covid care – Vox.com

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As of mid-December, hospitals on average had just 22 percent of their intensive care unit (ICU) beds available across the country, and many were completely full. As the Covid-19 surge continues to intensify, lack of ICU beds can have dire consequences, including not being able to properly care for the sickest patients, potentially rationing lifesaving care.

But even these bed capacity numbers don’t tell the whole story.

Adding extra critical-care beds in other departments or buildings takes precious time, resources, and space. But adding trained staff is much more difficult, especially deep into a pandemic.

When trained staff are in short supply, it’s even harder for hospitals to best meet the needs of critical-care patients. These patients include people very sick with Covid-19, but also many who need to be in the ICU for other reasons, such as those who have had a heart attack or stroke, are recovering from major surgery, or are sick with the flu, among others.

The number of people with Covid-19 currently in the ICU in the US reached an all-time high in mid-November and has been climbing ever since.
Our World in Data, with data from COVID Tracking Project and COVID19 Tracker

Only about a dozen states had more than 30 percent ICU capacity left on December 15, and coronavirus case numbers have only accelerated since then. And the reality on the ground in many areas is much worse, as reporting by the New York Times has shown.

From the Times’s data, gathered from the US Department of Health and Human Services, of about 100 hospitals in the Los Angeles area, more than 65 reported ICU occupancy at 90 percent or higher. Cedars-Sinai Medical Center had an occupancy at 112 percent of its capacity.

In Dallas, the fourth-largest metropolitan area in the country, of the 47 hospitals with more than 20 Covid-19 patients, 80 percent of them had zero or just one ICU bed left. The most open beds any hospital had was five.

In the Minneapolis-St. Paul area, half of the hospitals with more than 20 Covid-19 patients were at more than 95 percent ICU bed capacity.

In Oklahoma, which has the third-highest per capita new case rate in the country, of the hospitals with more than 20 Covid-19 cases, the majority were at more than 90 percent ICU bed occupancy.

Nancy Nagle, a pulmonologist and critical-care physician at Integris health system in Oklahoma City, which reported full ICU occupancy in the most recent data to the HHS, says they have turned regular patient rooms into ICU rooms to try to handle the rush of severely ill people. Even so, she said, “occasionally Covid-19 patients must remain in the emergency department for several hours waiting for a bed to become available.”

And there is little sign of relief in many places around the country, with an average of more than 200,000 new Covid-19 cases reported daily since early December.

“Patients keep coming, and we have to take care of them regardless of our staffing levels,” Gisella Thomas, a respiratory therapist at Desert Regional Medical Center in Palm Springs, California, wrote to Vox in an email. “I worry that there is only so long staff can hold up before breaking, which ultimately, in itself, could limit capacity” further.

The sickest Covid-19 patients can linger in the ICU for weeks — or longer. And although we have learned a lot since the spring about how to better treat severely ill Covid-19 patients, the disease itself is still challenging to address, and we don’t have a cure for it. Which means the 2 percent of people who get Covid-19 and end up needing critical care are often in ICUs until either they are able to recover — which often includes invasive intubation treatment — or die.

One of the reasons ICUs have been filling up is that once a patient with Covid-19 gets that sick, they are not likely to stabilize very quickly. A September study found that an average ICU stay for a Covid-19 patient was about a week — almost double the typical stay of 3.8 days for other ICU patients. Other anecdotal reports show that many patients can be in the ICU for weeks or even months. And pinning down this number is crucial for projecting how many beds might be available in the future if cases continue to climb.

As an October study pointed out, if an average length of stay in the ICU is 10 days, that means that every day there is only a 10 percent chance of a new bed opening up. So when admissions exceed that rate, ICUs are likely to get overwhelmed.

This is something those working with critically ill coronavirus patients have to contend with every day. “Covid-19 patients unfortunately stay in the ICU for a long time,” Nagle said. “The course of the disease is very slow, and this contributes to the shortage of available beds.”

And while Covid patients are there, meeting their needs can be extremely labor-intensive. “Covid-19 patients can be incredibly ill, with multiple machines to watch and adjust, multiple medications to give, and lab results to draw and results to watch,” Nagle said. And although we now have a better understanding of possible treatments for seriously ill patients, “patients still respond in varying ways, and their progress and possible outcome is always unpredictable.” This is another reason hospitals don’t always have a good projection for how many ICU beds they might have in the coming weeks or days.

Caring for Covid-19 patients also requires many more steps and precautions than when ICU staff work with other patients, further jamming units. All staff entering an ICU Covid-19 room must don full gowns and PPE each time, which is resource-intensive. “This also creates real difficulties if someone crashes because it slows down our response,” Thomas said. “The need to more thoroughly clean all equipment also creates delays and makes normal staffing levels inadequate for the pandemic.”

In the meantime, doctors, nurses, and other health care workers are struggling to provide the best care they can while being asked to handle more and more patients. “Critically ill patients are very complex,” said Orlando Garner, a pulmonary critical-care physician at Baylor College of Medicine. “There are a lot of moving parts at the same time that require the same amount of priority.” But, he said, “when you are stretched out beyond capacity, you can’t deliver the same quality care unless you create more skilled health care workers, and as we have found out, these are a scarce resource.”

Although hospitals can often somewhat expand the number of beds and amount of supplies, staff are in much shorter supply. “The most precious resource in any hospital are the human beings who are knowledgable and capable of caring for patients,” Sarah Delgado, an acute care nurse practitioner and clinical practice specialist with the American Association of Critical-Care Nurses, wrote to Vox in an email. “It is the limiting factor.” Without enough of these people to care for all of those who are very sick, “patient outcomes are likely to suffer,” she said.

And it is not just ICU physicians and nurses who are in short supply. “Critical care is more of a team sport,” Garner said. “This means physician-delivered care and interventions, but also careful medication selection dosage with pharmacists, skilled nursing care, respiratory therapists, midlevel providers, nutritionists, early mobilization with physical therapists.” To that list, Nagle also adds all of the other hospital staff needed to perform other essential tasks in ICUs, including bathing patients, changing linens, and other functions.

To accommodate surges of very ill Covid-19 patients, many hospitals have had to rework their staffing structure. At Christiana Hospital in Delaware, critical-care nurse Lauren Esposito and her colleagues typically work with critical cardiac patients. But this year, her unit has served as overflow for critical Covid-19 cases. “At first it was a little uneasy,” she wrote for the American Association of Critical-Care Nurses.

Their hospital implemented a tiered staffing strategy in which cardiac nurses would work under trained ICU nurses. “During the shift, if a patient was crashing, we were able to flex and have the ICU nurse go to that patient to provide care,” she wrote. They were also able to provide quick training to nursing staff, for example, on working with intubated patients. Still, the overflow duties were straining, and they weren’t made easier given the intensive isolation these patients are in to stop the spread of infection. “I remember the first time I walked into a patient’s room, it really hits you that you are the primary caregiver and no one else can come in.”

Also, staff now often have to attend to more patients at a time. In California, where last week an average of more than 44,600 people each day tested positive for the coronavirus, Gov. Gavin Newsom dropped the state’s nurse-to-patient ratio from 1:2 to 1:3 in an effort to meet the surging numbers of Covid-19 hospitalizations.

In Oklahoma, Nagle notes that although the ICU nurses she works with usually take care of one to two patients during a shift, “with the shortage of critical-care nurses, each nurse may have three, and under very extreme conditions, even four patients to care for.”

This increase in patients each nurse is seeing — especially in a complex illness like Covid-19 — is a major adjustment. “Nurses are at the patient’s side every hour of every day, administering lifesaving medications, collaborating with other health care team members, translating information to families, and providing end-of-life presence when those families cannot visit due to strict isolation requirements,” Delgado said. “This work cannot be done when the number of patients exceeds staffing capacity.”

And staff themselves often fall ill with the virus. According to a November report, as many as a quarter of Covid-19 infections in some states are among health care workers.

Garner, whose whole family got sick with Covid-19 earlier this year, including his 4-month-old daughter, says getting the illness himself gave him a new perspective on the patients now flooding into local Texas ICUs.

“It could have been me, my wife, or one of my kids on that ICU bed,” he said. “It’s easy to rationalize the amount of sick patients by thinking, ‘oh, well they weren’t distancing,’ or, ‘they weren’t wearing masks,’ but the fact is that nobody deserves to catch this virus and get sick from it, not even the people who doubt it. As the spike continues to grow, compassion is the only thing that can keep us from becoming jaded and burned out.

The flip side of that is remembering compassion for the health care workers caring for these patients, especially as the holidays approach. Not only will many of these workers continue long shifts through the holidays, they will do so knowing that many people are disregarding public health warnings to avoid gatherings.

“We need the public to do its part,” Delgado said. “Stop nonessential travel, adhere strictly to mask-wearing and social distancing guidelines, and limit gatherings with those outside your household,” Delgado said.

Katherine Harmon Courage is a freelance science journalist and author of Cultured and and Octopus! Find her on Twitter at @KHCourage.

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Fauci predicts U.S. will not return to lockdowns despite Delta variant risks | Saltwire – SaltWire Network

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By Sarah N. Lynch

WASHINGTON (Reuters) – President Joe Biden’s chief medical adviser Dr. Anthony Fauci said on Sunday he does not expect the United States will return to lockdowns, despite the growing risks of COVID-19 infections posed by the Delta variant.

“I don’t think we’re going to see lockdowns,” Fauci, who is also director of the National Institute of Allergy and Infectious Diseases, said on ABC’s “This Week.”

“I think we have enough of the percentage of people in the country – not enough to crush the outbreak – but I believe enough to not allow us to get into the situation we were in last winter.”

Although Fauci does not think the United States will need to shut down again as it did last year, he warned on ABC that “things are going to get worse” as the Delta variant continues to spread.

“We have 100 million people in this country who are eligible to be vaccinated who are not getting vaccinated,” he said.

The average number of new cases reported each day has nearly doubled in the past 10 days and the number of hospitalized patients in many states is surging, according to a Reuters analysis. https://tmsnrt.rs/2WTOZDR

At the same time, the number of Americans getting vaccinated has increased. (Graphic on global vaccinations) https://tmsnrt.rs/3tUM8ta

“The silver lining of this is that people are waking up to this and this may be a tipping point for those who have been hesitant,” National Institutes of Health Director Francis Collins told CNN on Sunday. “That’s what desperately needs to happen if we’re going to get this Delta variant put back in its place, because right now it’s having a pretty big party in the middle of the country.”

(Reporting by Sarah N. Lynch and David Lawder; Editing by Daniel Wallis and Lisa Shumaker)

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A look at COVID-19 reopening plans across the country – North Shore News

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As COVID-19 vaccination rates increase and case numbers drop across the country, the provinces and territories have begun releasing the reopening plans for businesses, events and recreational facilities.

Most of the plans are based on each jurisdiction reaching vaccination targets at certain dates, while also keeping the number of cases and hospitalizations down. 

Here’s a look at what reopening plans look like across the country:

Newfoundland and Labrador:

Newfoundland and Labrador is moving to the second step of its reopening plan two weeks ahead of schedule.

Beginning today (Aug. 1), fully and partially vaccinated travellers from Canada no longer have to provide proof of a negative COVID-19 test, nor will they have to self-isolate.

With 52 per cent of residents aged 12 and over now fully vaccinated, the province says its mandatory mask requirements will be up for review during the week of Aug. 9.

If case counts, hospitalization and vaccination targets are met, the province expects to reopen dance floors as early as Aug. 15, and lift capacity restrictions on businesses, restaurants and lounges while maintaining physical distancing between tables.

Nova Scotia:

Nova Scotia has further reduced COVID-19 public health orders after entering the fourth phase of its reopening.

Under the new rules, retail stores can operate at full capacity, churches and other venues can operate at half capacity or with a maximum of 150 people, and up to 50 people can attend outdoor family gatherings.

Capacity limits for dance classes, music lessons and indoor play spaces have also been lifted.

Organized sports practices, games, league play, competitions and recreation programs can involve up to 25 people indoors and 50 people outdoors without physical distancing.

Day camps can operate with 30 campers per group plus staff and volunteers, following the day camp guidelines. In addition, professional and amateur arts and culture rehearsals and performances can involve up to 25 people indoors and 50 outdoors without physical distancing.

Meanwhile, fully vaccinated residents of long-term care homes can now have visitors in their rooms and visit their family’s homes, including for overnight stays.

New Brunswick:

The province has lifted all public health orders and its mask mandate has also expired. 

That means all limits on gatherings are now removed, including in theatres and stores. 

Restaurants, gyms and salons can also operate at full capacity, as long as customer contact lists are kept.

New Brunswick had earlier moved into the second phase of its reopening plan, which opened travel without the need to isolate to all of Nova Scotia after earlier opening to P.E.I. and Newfoundland and Labrador.

Travellers from elsewhere in Canada who’ve had at least one dose of a COVID-19 vaccine can enter the province without the need to isolate, while those who haven’t had a shot must still isolate and produce a negative test before being released from quarantine.

Prince Edward Island: 

Prince Edward Island has dropped its requirement that non-medical masks be worn in public indoor spaces.

Chief public health officer Dr. Heather Morrison says masks are still encouraged to reduce the spread of COVID-19, and businesses are free to adopt stricter rules.

Officials say those who serve the public, such as in restaurants, retail stores and hair salons, should continue to wear a mask.

All health-care facilities will continue to require masks until 80 per cent of eligible P.E.I. residents are fully vaccinated.

Meanwhile, the province has allowed personal gatherings to increase so that up to 20 people can get together indoors and outdoors. Restaurants are allowed to have tables of up to 20. Special occasion events like backyard weddings and anniversary parties of up to 50 people hosted by individuals are permitted with a reviewed operational plan.

Organized gatherings hosted by a business or other organization are permitted with groups of up to 200 people outdoors or 100 people indoors.

On Sept. 12, the province expects physical distancing measures to be eased, as well as allowing personal and organized gatherings to go ahead without limits. 

Quebec: 

Quebec’s government has removed capacity restrictions in retail stores across the province and reduced the two-metre physical distancing health order to one metre.

Quebecers from separate households are now required to keep a one-metre distance from one another indoors and outdoors instead of two metres. 

The previous two-metre distance now applies only at places characterized by physical activity or singing.

Outdoor events are limited to a maximum of 5,000 people, while Indoor events are capped at 3,500 spectators.

Fans and those attending theatres or other performance venues must keep at least one empty seat between each other, and wearing a mask in public spaces remains mandatory.

All of Quebec is now at the lowest green alert level under the province’s COVID-19 response plan as public health restrictions continue to ease.

The province permitted gyms and restaurant dining rooms to reopen in June. Supervised outdoor sports and recreation are also allowed in groups of up to 25 people.

Quebec ended its nightly curfew on May 28, and also lifted travel bans between regions.

Ontario:

Ontario has moved to the third step of its reopening plan, allowing for more indoor activities including restaurant dining and gym use, while larger crowds are permitted for outdoor activities. 

Masking and physical distancing rules, however, remain in place.

Social gatherings are limited to 25 people indoors and 100 people outdoors. Religious services and other ceremonies are allowed indoors with larger groups of people who are physically distanced.

Nightclubs and similar establishments are open to 25 per cent capacity. Crowd limits have expanded for retail stores and salons, which can offer services that require masks to be removed.

Spectators are permitted at sporting events, concert venues, cinemas and theatres, with larger limits on crowds for outdoor events. 

Museums, galleries, aquariums, zoos, bingo halls and amusement parks are also open with larger crowd limits on outdoor attractions. 

Manitoba:

Manitoba is loosening restrictions and allowing extra freedoms for people who have received two doses of a COVID-19 vaccine as it moves into the second phase of its reopening plan.

Indoor gatherings are now allowed for up to five people, on top of those who live in a household, and 25 people in indoor public spaces. Outdoor gatherings are expanded to 25 people on private property and 150 in public spaces. 

Restaurants and bars are allowed up to 50 per cent capacity and opening hours are extended until midnight. Retail stores can run at 50 per cent capacity or 500 people, whichever is lower. Fitness centres can open at 50 per cent capacity, but masks are still required.

Outdoor weddings and funerals can have up to 150 people and indoor events now have a limit of 25. Faith-based gatherings can expand to half capacity or 150 people indoors.

Businesses, such as casinos, museums and movie theatres, can open at 50 per cent capacity but only fully vaccinated Manitobans can take part. An upcoming Blue Bombers CFL game will also be open fully to fans who are double-vaccinated.

Saskatchewan:

Saskatchewan has removed all public health orders — including the province-wide mandatory masking order, as well as capacity limits on events and gathering sizes.

Premier Scott Moe says the province decided to go ahead with full implementation of Step 3 of its Reopening Roadmap because more than 70 per cent of residents over the age of 18 and 69 per cent of those over 12 have received their first dose of a COVID-19 vaccine.

Despite the lifting of the health orders, Regina and Saskatoon say they will still keep up extra cleaning in municipal facilities.

Alberta: 

All remaining COVID-19 restrictions were lifted on July 1.

There are no longer limits on weddings, funerals or bans on indoor social gatherings. In addition, there are no more limits on gyms, sports or fitness activities, no more capacity limits at restaurants, in retail stores or in places of worship.

Anyone with a confirmed case of COVID-19 will still be required to self-isolate and protective measures at continuing care centres may remain.

Alberta, meanwhile, has announced that close contacts of people who test positive for COVID-19 are no longer legally required to isolate, nor are they notified by contact tracers.

And as of Aug. 16, infected individuals won’t need to isolate. Testing will also be curtailed.

The overall requirement for masks in public indoor spaces has ended, but masks may still be required in taxis, on public transit and on ride shares.

Some remaining COVID-19 health restrictions in continuing-care centres have also been eased.

The province says it is no longer limiting the number of visitors, since vaccination rates are rising and there have been few cases in care homes.

Visitors, however, still need to be screened for COVID-19 symptoms or known exposure, and masks are still required in common areas.

The province recommends people wear a mask at all times when visiting a care home if they have not been fully vaccinated, including children under 12.

Limits on dining and recreation activities have been eliminated, and residents are not required to be screened if they are re-entering the building or go into quarantine if they have gone off site.

British Columbia:

The province took the next step in its reopening plan on Canada Day when most COVID-19 restrictions were removed and outdoor gatherings of up to 5,000 people got the go ahead.

Restaurants and pubs no longer have limits on the number of diners, but people are still not allowed to mingle with those at other tables. Masks are no longer mandatory and recreational travel outside the province can resume.

Casinos and nightclubs are open again, but some barriers remain in place and socializing between tables is not allowed.

Provincial health officer Dr. Bonnie Henry says some businesses may want people to continue wearing masks for now, and everyone should comply with those requirements or face the potential of fines.

Some restrictions have been reinstated in part of a health region in the Interior after an outbreak led to rapidly spreading infection in that area of the province. 

That means masks are mandatory in all indoor public places in central Okanagan communities including Peachland, West Kelowna, Kelowna, Lake Country and West Bank First Nations lands. Gyms and exercise facilities must also require patrons to wear masks and reintroduce enhanced cleaning and physical distancing.

The face coverings are recommended outdoors in the region if residents are unable to physically distance, but they will be optional for children under the age of 12 when they’re attending summer camps or similar settings.

Nunavut:

Nunavut’s chief public health officer says people living in the territory are no longer required to wear masks, but they are still strongly encouraged. 

Dr. Michael Patterson says indoor public gatherings — such as in community halls — are now allowed to have 75 per cent capacity.

Restaurants, bars, theatres and places of worship can open to 75 per cent capacity and there are no limits on outdoor gatherings.

Northwest Territories:

Up to 25 people are allowed in a business that is following an approved COVID-19 plan. Households can have up to 10 people with a maximum of five guests from another household.

Non-essential travel outside the territory is not recommended, and leisure travel into the territory is not permitted.

The territory is no longer requiring masks to be worn in public places in Yellowknife and three other communities.

Chief public health officer Dr. Kami Kandola says it’s still a good idea to wear a mask indoors when there is a crowd, poor ventilation, or shouting or singing.

Yukon:

Yukon has expanded the rules for gatherings, allowing up to 200 people to get together, as long as masks are worn indoors and other health protocols are followed. 

Fully vaccinated people can have personal gatherings of up to 20 people indoors and 50 outdoors, but the unvaccinated are encouraged to stick with their “safe six” because they are at significantly higher risk. 

Bars and restaurants are allowed to operate at full capacity with restrictions.  

The government says starting Aug. 4, people returning to the territory will not be required to self-isolate and masks in indoor public places will not be required.

Bars and restaurants will also be allowed to return to full capacity without the need for physical distancing.

This report by The Canadian Press was first published Aug. 1, 2021.

The Canadian Press

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Why an Israeli company is developing an oral Covid vaccine – MENAFN.COM

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(MENAFN – AFP)

Imagine a Covid-19 vaccine that came as a pill: no needles, no medical professionals required to administer it, potentially delivered directly to people’s homes.

Israeli pharmaceutical Oramed is attempting to accomplish just that, and is poised to start its first clinical trial in early August, CEO Nadav Kidron told AFP in an interview.

With just 15 percent of the world’s population fully vaccinated, the global fight to end the pandemic is far from over.

Oral vaccines are particularly attractive for the developing world, because they reduce the logistical burden of immunization campaigns, said Kidron.

But they could also increase uptake in wealthy countries where needle aversion is an often missed factor in hesitancy.

A recent survey found nearly 19 million Americans who decline vaccines would take them if they had a pill option.

“In order for the vaccine to really work well, we need as many people to take it as possible,” said Kidron.

Other benefits include reduced syringe and plastic waste, and potentially fewer side effects.

– Challenges for oral delivery –

Despite many theoretical advantages, there have been few successful oral vaccines because the active ingredients tend not to survive the journey through the gastro-intestinal tract.

Exceptions include vaccines for diseases that are themselves transmitted through the mouth and digestive system — for example there is an effective oral polio vaccine.

Oramed, which was founded in 2006, believes it has overcome the technical hurdles by designing a capsule that survives the highly acidic environment of the gut.

It invented its technology for a previous product, an experimental oral form of insulin, the lifesaving drug required by diabetics that has until now been only administered by injection.

Developed with Nobel Prize winning biochemist Avram Hershko who is on Oramed’s scientific advisory board, the company’s capsule has a highly protective coating that makes it slow to degrade.

It also releases molecules called protease inhibitors that stop enzymes in the small intestine from breaking down the insulin, and an absorption enhancer to help the insulin cross into the bloodstream.

This drug has been dosed in hundreds of patients in late stage clinical trials in the US, with results expected in September 2022.

Oramed has now launched a new majority-owned company called Oravax, which takes the capsule technology from the oral insulin product and uses it for an oral Covid-19 vaccine.

– Virus-like particle –

To evoke an immune response, the company’s scientists have designed synthetic coronavirus-like particles.

These mimic three key structures of the pathogen: the spike protein, the envelope protein and the membrane protein.

Most currently authorized vaccines, like Pfizer or AstraZeneca, are based on the spike protein alone, making them less protective over time as the spike protein of the coronavirus mutates.

By targeting multiple parts of the virus, including structures that mutate less, the Oravax vaccine could be more variant-proof, Kidron said.

The company has applied to begin trials in multiple countries and expects to begin its first in Israel within weeks, pending approval from the health ministry.

Kidron said he foresaw a role for the vaccine initially in developing countries which haven’t yet bought up enough supply of current vaccines — before eventually developed markets.

A vaccine pill could become especially attractive if ongoing boosters are required.

If it’s successful, it would also represent a proof of concept for future orally administered vaccines, he added.

“Imagine… the flu vaccine comes to you in the mail, you take it, you’re done.”

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