Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 72

Grand Rounds today, here @YouTube bit.ly/3cbwhNF. 3 fascinating topics: experience of elders in age of Covid, ICU outcomes at Zuckerberg SF General Hospital, & update on Covid testing. Hope you can watch, but my Cliff Notes below.

2/ @UCSF/SF update: @ucsfhospitals, down to 11 pts, 4 on vents (Fig L). Big news=relaxation of visitor policy in SF – sorting out implementation but removes a big burden bit.ly/2M9V7ms. SF cases trending down (Fig R); no deaths in 11 days (total=40). No signs of a surge.

3/ At Grand Rounds, terrific discussion of Covid issues for elders, with 3 @ucsf experts: @LouiseAronson (her book Elderhood was finalist for Pulitzer amzn.to/3gwjfh6), Carla Perissinotto, expert on loneliness in elderly, & Charleen Harrington, who studies nursing homes.

4/ @ 5:25: Louise: Covid shows “we think about aging as a monolith.” Elders are >60 and “as geriatricians we care for people into their 100s,” so elderhood is nearly half-a-lifetime. @ 8:45: “Ageism is a particularly curious prejudice since it’s a bias against your future self.”

5/ @ 10:25: Carla P: Loneliness linked to poor health outcomes. @ 33:00: Other nations do better: UK has Minister for Loneliness & “social prescribing” (nyti.ms/2HwV1VU). In study w/ @AshwinKotwalMD, 79% of older pts had little/no internet/video usage. Big digital divide.

6/ @ 16:15: Charlene H: 37% of US Covid-related deaths in nursing homes. Staffing in NHs is problematic; those with fewer RNs had more Covid cases. Non-profits/hospital-based NHs do better, for-profits worse. “35% of $s going to NHs goes to nursing care” – rest to profits, admin.

7/ @ 20:50: Carla: assisted living also under-regulated. More pts could live @ home if they had support: not just medical but also for social & functional needs. With Covid, families want to keep pts home, but “if you can’t transfer someone from bed to commode, home won’t work.”

8/ @ 34:00: Carla & Louise: we missed the impact of Covid on elders at 1st because they often lacked “symptoms” (fever, etc) – but they often had “classic geriatric symptoms” such as delirium. Louise: “we know what to do [to better care for older people] so we should just do it.”

9/ Next: Antonio Gomez on ICU care & outcomes. @ 38:55: Detailed timeline shows many of the key decisions they’ve made @ ZSFG, including emphasis on proning and extra nursing care.

10/ @ 40:50: Basic approach to ICU pts on slide. They’re only using evidence-based therapies for ARDS (for example, no steroids, no experimental meds outside of a clinical trial), lots of innovations and small tests of change.

11/ @ 45:10: ZSFG ICU patients a bit younger than elsewhere – many under 60, very heavily Latinx population, majority Spanish as primary language. 100% of patients on ARDS Net protocol, rigid application of care supported by best evidence.

12/ Two key innovations @ 51:00: 1) IV poles outside of rooms so nurses didn’t have to enter room to change settings; 2) “Swim teams” of nurses went room-to-room to put patients in prone position (improved ventilation). Proning is evidence-based for ARDS: bit.ly/2zIpNsl

13/ Outcomes @ 54:40: 34 patients intubated/vented, out of 54 total in ICU. Among those intubated: 4 died out of 34 (2 others died without going on vent due to patient preferences). 17/34 vented have been discharged home, 4 went to outside facility. Only 6 patients still on vent.

14/ So final mortality figure is in flux but will be significantly better than usual literature reports of ~50%. Antonio is certain that the fact that we have not been overwhelmed has led to better outcomes – a powerful argument to flatten the curve and not overwhelm the ICU.

15/ Chaz Langelier @ 1:09:50: in SF we now have enough tests. Most viral tests are reverse-transcriptase PCR tests. ~80% sensitive, so false neg 20%. As always, interpretation depends on prevalence.(My tweetorial on Bayesian reasoning, from Monday, here: bit.ly/2ZHYFo6).

16/ Getting nasal sample not that easy – bad technique can lead to false neg. @NEJM video shows how to do it: bit.ly/2Map8CM @ 1:11:00: Saliva as good as nasal swab. @ 1:12:15: pt can collect own nasal swab sample @ home & send in – results equal to clinician-collected.

17/ @ 1:14:50: Concerns re: Abbott point-of-care test, w/ @nyuniversity study showing 51% sensitivity (Chaz: "coin flip") (Abbott-sponsored study disagreed.) Based on NYU results, @UCSF not using Abbott test; we use another test with ~90 min turnaround if we need rapid results.

18/ Chaz on persistent PCR positivity. @ 1:16:20 Chaz agrees w/ consensus that that after 7-10 days patients no longer have infectious virus even if they have persistently positive PCR. Makes it tricky to know when it is safe to leave hospital or take patient out of isolation.

19/ @ 1:25:45: For now, if pt < 2 weeks out we usually look for 2 negative PCRs tests to prove no active virus. Chaz thinks 2 wks after symptoms is safe cutoff for not infectious. Eventually we’ll have tests to look for live virus in persistent PCR+ situations; not available yet.

20/ @ 1:20:05: Chaz describes exciting work on metagenomic next-gen sequencing: capable of looking at all possible pathogens by assaying host genetic immune response. Can differentiate Covid-19, independent of viral load. Approach may turn out to be more accurate than PCR.

21/ @ 1:23:22: Chaz highlights unique partnership between @ucsf & @czbiohub. CZ became a CLIA-certified clinical lab literally overnight, leading to big bump in testing, which has served many underserved other hospitals, clinics, and depts of public health in Bay area.

22/ Q&A @ 1:25:110: Is PCR more likely to be + in symptomatic pts? Answer: don’t know for sure. We do know viral load highest early in course, but immediately after exposure you don't have enough virus to create pos PCR. Probably less infectious too, but that hasn’t been proven.

23/ Hope you’ll find 90 min to watch Grand Rounds (again, here bit.ly/3cbwhNF).

Tonight, a great Zoom party for our amazing graduating @ucsf residents & @UCSFIMChiefs. Extraordinary MDs & human beings, so proud of them. Below: "Lean on Me" song collage.

More tomorrow