Day 2 of hospital service

A few observations about the whole "hospitalized for COVID" versus "hospitalized with COVID"

This distinction matters

But may be not in the way people think

First, we have a few patients in the hospital for COVID

But not many, thank goodness

Not many because RI is highly vaccinated state

More common on our service is folks admitted with COVID

That is, they came to hospital for something else and found to have COVID

Its tempting to say that COVID here incidental and therefore, doesn't matter

Not quite right

There are two types of "with COVID" patients and they both have an impact on care, utilization, stress to the system

The first type is: had COVID -- was "mild" -- but now have complications

Example (changing details for confidentiality)

The 86 y.o. man with kidney disease

This 86 year-old had COVID a week ago with 2 days of fevers, sore throat

Two days of fevers caused him to become dehydrated, go into acute kidney failure

His COVID is "better" but he's in the hospital with kidney failure

Was he admitted for COVID? No

With COVID? Yes

The second type is the 65 year old with hip fracture after fall

Found in ER to have COVID

Don't think COVID caused the fall (but not sure)

But now, while patient gets evaluated, stabilized and ready for surgery

They are in a COVID isolation room

These rooms are not plentiful
And every time you enter a room for patient WITH COVID

Its gowning, gloves, face shield, making sure N95 is snug

Slows everyone down from seeing other patients

Its isolating for patients who get fewer visits

And makes surgery, everything else much more complicated

Thankfully seeing fewer admissions from COVID (vaccines!!)

But high community transmission means there are still large spillover effects

And admissions with COVID is still very disruptive to the healthcare system

At a time when it can't afford more disruption


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More from @ashishkjha

3 Jan
We know how to keep people safe in schools during COVID

For an airborne virus

Masking and ventilation/filtration substantially slow spread

As does regular testing

And vaccines protect from bad outcomes

So I've been puzzling over why this isn't happening everywhere

If key strategies include masking, ventilation, testing, vaccines

Masks became widely available late 2020

By early 2021, there was lots of $ from Feds for improving vent/filtration as well as testing

By fall 2021, every adult & school-aged kid was eligible for vaccines

So barriers are now primarily not money or availability (though testing is currently a challenge)

So what are the main barriers?

First, misinformation

Like schools are always safe (you have to make them safe)

Or masks don't work (they do, some more than others)

Read 6 tweets
29 Dec 21
.@ezraklein asks a great question

What is the goal at this point?

I think it needs another element

What costs we are willing to pay to achieve that goal?

My goals?

Save lives, prevent hospitals getting overwhelmed, keep essential things (schools) open

In that order


Let's talk about other goals and costs we're willing to bear

Reduce infections? Yes!

Low cost things like encouraging indoor masks will help

But to really suppress infections? We likely need hard lockdowns

Which makes no sense at this point in pandemic

So the other goals...
Saving lives, keeping hospitals functional, schools open?

We know how to do that

1. Vaccines & boosters for all but especially high risk folks

2. Lots of rapid tests in key settings (nursing homes, schools, etc)

3. More ventilation/filtration

This all feels doable

Read 4 tweets
28 Dec 21
While new CDC isolation guidelines are reasonable, here's what I would have done differently

1. Required a neg antigen test after 5 days

2. Had different guidelines for vaccinated (contagious for shorter time) versus unvaccinated

3. Specified higher quality masks

Short thread
So why are CDC guidelines still reasonable?

Because if you actually follow what CDC says,

They require people be asymptomatic

And wear a mask for 5 more days

And if people actually followed the guidelines

I can't come up with how they aren't quite reasonable

The critique appears to be that people won't follow CDC guidelines

That they'll stop isolating after 5 days even with symptoms and/or not wear a mask

Yes. That'll happen for some

But shorter isolation means lower barrier to test/isolate

Which will motivate others to test

Read 5 tweets
26 Dec 21
As Omicron cases explode

We need a strategy for isolating folks who test positive

We need to think about the purpose of isolation clearly

Because if we don't get it right,

It'll both be hugely disruptive and won't keep us safe

So let's discuss what we need to do

First principles:

Why ask people to isolate at all?

Well, that’s obvious

We don’t want them spreading

So what we care about is CONTAGIOUSNESS

We want folks to isolate when they're contagious

So when are people contagious?

Well, it varies. A lot

OK, so what to do?

How long folks are contagious depends on two things

1. When they test positive (i.e. early in the phase of infection vs. late)

2. Their immune system's ability to clear the virus

Take the average person who tests PCR+ today

How long will they be contagious?

Read 15 tweets
18 Dec 21
Lets talk about why we'll soon see an uncoupling of infections and hospitalizations

No, its not because Omicron is "mild"

I'm not sure it is

Its because Omicron has so much immune evasion

That we'll see a change in who gets infected

How to think about it

We know among unvaccinated

About 5% of infected folks get hospitalized

Among vaccinated

About 0.5%

Throughout the pandemic (including delta wave), most infections were among unvaccinated

So hospitalization rates have been about 5% of cases
Omicron is different

It'll cause many more infections among 2-shot vaxxed folks

So we'll see large increases in infections in that crowd

So as cases spike

Rate of hospitalization will not spike to the same degree

Because many of the cases will be of vaccinated folks

Read 5 tweets
17 Dec 21
The conversation about the coming Omicron wave vacillates between

OMG -- Omicron will be cataclysmic


I'm done with this pandemic and have moved on

Neither is helpful

A middle course can help navigate this complex time without massive disruptions or a lot of deaths

First, lets get on the same page

We should expect a large wave of infections

Likely gathering steam in late December peaking sometime in mid January

And likely falling quickly to low numbers by end of February

This is about the next 2 months

What should our goal be?

Given how transmissibility of Omicron

It'll be hard to suppress infections without very large restrictions

There is neither appetite for big restrictions

Nor do I think needed

So what should our goal be?

Saving lives, keeping hospitals functional, schools open

as starters
Read 10 tweets

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