Amid progress, a surge
COVID-19 mortality rates are down, but as new cases spike will they imperil advancements?
Capital Region doctors say that mortality rates among hospitalized COVID-19 patients appear to be lower this fall than in the spring, but warn that the growing surge of patients threatens to undo hardwon advances, particularly when it comes to care delivery.
Physicians began to notice improved outcomes in the summer, when the chaos of the initial wave of infections had died down in the region and several months of trial and error with medications and therapies had shown progress. In addition to lower death rates, fewer patients seemed to require intensive care and lessintensive methods of oxygen delivery prevented people from going on ventilators — a cohort whose mortality rate had neared 90 percent at one point. Lengths of stay also fell.
“Our initial mortality when we started this, during the first wave, was very high,” said Dr. Jorge Cerda, chief of the department of medicine at St. Peter’s Health Partners, which has hospitals in Albany and Troy. “It was in the order of 20 to 21 percent. Now, it seems to have decreased to around 10 percent. That is very significant.”
Other area hospitals were unable to provide exact mortality figures, but said their rates appear to be falling too. Early studies of hospital data out of New York City and the United Kingdom have reported similar trends, and a recent FAIR Health analysis commissioned by the health news website Stat found rates for the privately insured had dropped to a low of 3.7 percent in September from 11.4 percent in March.
These improvements are likely due to a number of factors, doctors say.
Mortality rates may have appeared inflated in the beginning when limited testing made the true number of infections harder to pin down. Some believe demographics could be playing a role as more young people — who are less likely to develop severe symptoms — defy public health advice and gather with others, resulting in infections and, sometimes, hospitalizations.
People are also coming into the hospital earlier in the course of the disease — a trend officials believe relates to reduced fears around exposure in health care settings and which also helps greatly when it comes to disease management.
“Remember back in the beginning the message was stay home unless you’re really sick,” said Dr. David Liebers, an infectious disease specialist and chief medical officer at Ellis Medicine. “And I don’t think that’s being done anymore. So I think we’re probably getting patients who need medical care sooner than we did in the spring time — in other words, earlier in the illness.”
Treatment advances
Months of trial and error demonstrated that some medications and therapies work better than others.
Doctors discovered that proning, or putting patients on their stomachs rather than their backs, helped open the lungs. They found that intubating patients was, in fact, not the best way to help patients breathe, and that less intensive methods such as oxygen masks did less harm. As it became clear that the virus was not just attacking the lungs but other organs such as the kidney, they used dialysis to help clean toxins and excess fluid from patients’ blood.
They experimented with different medications, abandoning those that appeared not to work such as the anti-malarial
hydroxychloroquine and antibiotic azithromycin, and increasing the use of those that did such as the antiviral remdesivir and the steroid dexamethasone. Disturbing reports of clotting — in the brain, lungs, heart, spleen and elsewhere — were combatted using blood thinners.
More important than the medications and therapies, however, were the improvements made in the timing and delivery of care, doctors say. They are the kind of improvements that come with the passage of time and a more sophisticated understand
ing of a disease, but that also result from having a less overwhelmed hospital system and staff.
Doctors have grown more familiar with aspects of the disease that were once unexpected — such as the patient who seems fine one second and the next begins to crash — and are able to meet those moments with a quicker and more refined intervention.
They also grew familiar with the course the disease would take. Intervention during the first phase — when the virus is
attacking the body — became particularly important.
“I think of all the medications we tried, the one that has given us the most dramatic bang for our buck is good old dexamethasone,” Cerda said.
The drug is a powerful steroid that helps reduce inflammation, and doctors began to administer it earlier than they would for other infections, and much more aggressively, as it helped blunt the damage that overinflammation can have on the lungs and other organs.
Physicians are especially
hopeful that the rollout of monoclonal antibodies, such as the recently approved cocktail developed by the Capital Region's own Regeneron and used to treat President Donald Trump, can be administered even earlier among those who are infected but do not yet require hospitalization.
“The idea is, if we give the antibody early on then we will be able to avoid the severe consequences of the infection because with COVID, the problem is that the initial illness is caused by the virus, but the second phase, which is the worst, is due to the response that the patient has to the virus — it’s the patient’s own immune system doing the damage," Cerda said.
Cerda, who spoke to the Times Union just prior to Thanksgiving, said St. Peter’s was anticipating its first ship
The idea is, if we give the antibody early on then we will be able to avoid the severe consequences of the infection because with COVID, the problem is that the initial illness is caused by the virus, but the second phase, which is the worst, is due to the response that the patient has to the virus — it’s the patient’s own immune system doing the damage."
— Dr. Jorge Cerda, chief of the department of medicine at St. Peter’s Health Partners
ments of antibodies within a week, and was considering setting up an infusion center at Albany Memorial Hospital.
System capacity
A recent growth in hospitalizations threatens to undo some of the advances that have been made in treating the disease, officials say.
“Over the past several months — since the initial burst that we had in
March and April — things have been less chaotic,” Liebers said last month. “We’ve been able to pay better attention to the fewer patients and really apply what we’ve learned.”
Hospitalizations have grown since then — topping the region’s spring peak of 205 on Dec. 2. While officials insist area hospitals have capacity yet to handle another large surge, they warn that the health care system does not have infinite capacity.
More patients mean staff will have less time to give to each patient, which could lead to lapses in care. Rising infection rates mean hospitals will burn through protective gear faster, and sickness and quarantines among staff will exacerbate what some nurses have said is already bare-bones staffing.
“When we had the first wave, the main reason why the mortality was so extremely high is that the system was quite overwhelmed,” Cerda said. “When you have limited resources, your outcomes are worse.”
While it’s true that the share of hospitalized patients entering the ICU has shrunk, the second wave of confirmed infections in the region is already much larger than it was in the spring and is only expected to grow throughout the holiday season.
Gov. Andrew M. Cuomo has asked hospitals to inventory beds, supplies and staff, and in the past week announced he will be pivoting his microcluster containment strategy to focus on hospital admission and capacity trends.
“What we see across a large population is that a lot of people are mildly symptomatic and are asymptomatic, and it’s a subset that unfortunately gets critically ill and ends up in the ICU,” said Dr. Greg Wu, an emergency and critical care doctor at Albany Medical Center.
“But a small percentage of a large number is still potentially a very big number,” he continued. “And I think that’s the scary thing in all this — is how quickly this has spread throughout the world and throughout communities. So just by sheer probability that’s going to increase the number of people who end up in the hospital.”
Many are looking to the imminent arrival of COVID-19 vaccines as the nation’s saving grace, but doses for the general public are still months away and the nation has to make it through the winter months first with hospitalizations and caseloads already at record levels.
“I think the best case scenario is that we find an effective vaccine that really limits the spread … but I think that unfortunately we’re still going to be managing this for a while longer,” Wu said.
“That's why our team is preparing for the months ahead because this is not going to go away as soon as the vaccine rolls out.”