After cases rose steeply, so did hospitalizations

Following a spike in COVID-19 cases over the last five weeks in the region, it was predictable that hospitalizations also would begin to rise.

But the full impact of the spike reached new heights this past week as Allegheny County set several new highs for COVID-19 hospitalizations.

On Friday the county had its highest number of new daily hospitalized COVID-19 patients — 22 — which contributed to the highest single seven-day stretch of hospitalizations — 66 — since the pandemic began in March. The prior highest seven-day period was a week earlier, July 11-17, when there were 57 new hospitalizations.

On Friday, the state reported that Allegheny County hospitals collectively had 184 COVID-19 patients, and the 14-day average daily hospitalization count was 145.1, also a new high, and nearly six times higher than the 25.6 daily average just a month ago.

The seven surrounding counties in southwestern Pennsylvania have seen similar surges, although the figures are significantly smaller than Allegheny’s, with daily average case-counts in the seven counties combined rising from just about two cases a day a month ago, to 25 cases a day as of Friday.

Despite all of that — and thanks to the prior surge in hospitalizations in April and May — hospitals are reporting better outcomes for patients, fewer severe cases to begin with, and no shortage of beds or equipment for COVID-19 patients.

Allegheny County Health Department director Dr. Debra Bogen said she is in regular contact with the hospitals’ chief medical officers, who report despite the record numbers, “they have plenty of bed space and plenty of [intensive care unit] space [and] they’re very careful at watching their numbers and have plans to respond appropriately if they need to make more beds available. So I have not heard any concerns from any of our hospitals that they are anywhere near capacity at this point.”

The better outcomes, so far, are at least partially because “they all have plenty of experience now taking care of patients with COVID-19, and that experience does help them, I’m sure, manage their patients more easily.”

Hospital officials agree, saying even having better supplies of protective equipment have helped.

“I think people have more comfort in what they’re seeing now,” said Dr. Carol Fox, chief medical officer for Excela Health, which has three hospitals in Westmoreland County.

“And, internally, we all remember when everything was a panic in spring: Do I have enough personal protective equipment on? Am I wearing it correctly? Are we supplied well?” she said. “But those things don’t seem to be happening as quickly and rapidly as they were.”

Equally important has been the demographics of the patients who are coming to the hospital now compared to spring, she said.

“Among our patients, a much higher percentage of them are younger and don’t require hospitalization,” Dr. Fox said. And those who do are slightly younger, she said. “In the spring, clusters of patients were coming to us from skilled nursing facilities. And we haven’t seen many from [skilled nursing facilities] in quite some time.”

Westmoreland County has seen its 14-day average daily hospitalization grow proportionately like Allegheny County’s, from about one patient per day a month ago to eight per day as of Friday.

Dr. Thomas Walsh, medical director of Allegheny Health Network’s antimicrobial stewardship program, said AHN had been seeing 20 to 25 patients in its six hospitals in the region, “with a majority of them requiring ICU care.”

That fell off in June, down to five or 10 cases a day, only to spike in the last two weeks to 50 or 60 patients per day, “but we’re seeing a lower proportion of them needing ICU care.”

“The people with severe COVID-19 [reactions] tend to be older and have more comorbidities,” Dr. Walsh said.

He rejected the notion — pushed by UPMC officials two weeks ago but not supported by other experts — that the virus is simply less severe now.

“We really don’t have good data that the virus is any less virulent,” he said.

UPMC would not make anyone available to be interviewed for this story.

Experience helps

Like Dr. Fox, Dr. Walsh believes the reason for fewer severe cases — and, so far, fewer deaths — is the makeup of those contracting the virus now, advances in treatment, and providing earlier treatment or better detection.

“Some we may be diagnosing earlier, [and] some we may be giving better treatment,” Dr. Walsh said.

Dr. Fox said in Excela hospitals “people are presenting themselves more readily and we’re testing them more quickly. Back in March and April, we didn’t know the full spectrum of symptoms, and there were lengthy turnaround times for test results.”

Therefore, people are coming to the hospital earlier in their illness, she said, and they are getting better treatment.

For example, she said, “early on in the pandemic it was thought it was better to put a patient on a ventilator more quickly to give them a chance to fight the virus. But we’re not doing that as quickly anymore.”

That is partially because using a ventilator carries risks, including aspiration by the patient or internal trauma through using the ventilator itself.

AHN also has placed a smaller percentage of patients on ventilators, Dr. Walsh said, part of the health system’s effort “to tease out what is working, what is the best indicator of success.”

“We’ve certainly adjusted the way we care for our patients throughout this,” he said. “And we do use three upfront treatments more quickly now.”

Three treatments

The treatments that have improved care at AHN hospitals, Dr. Walsh said, have been:

• Convalescent plasma, which gives patients plasma from the blood of those who have been infected and survived. The plasma contains antibodies to help newly infected patients battle the virus. AHN, along with UPMC, is part of a study with Mayo Clinic, tracking the results of plasma use on COVID-19 patients, and early results show promising outcomes, Dr. Walsh said.

• Dexamethasone, a steroid, which has been found in early results to cut mortality for people infected with COVID-19.

• Remdesivir, a broadspectrum antiviral drug that has fairly widespread use around the world as a treatment for COVID-19. In part because of the drug’s success, the federal government controls the supply of remdesivir, and it is in relatively short supply in some places around the country.

“We use those three agents up front, early on,” Dr. Walsh said.

The rise in positive cases and in hospitalizations have not resulted in a spike in deaths.

Both Dr. Walsh and Dr. Fox, as well as Dr. Bogen, say the better and earlier treatments and younger patients can prevent an increase in deaths. But they remain wary.

“I hope that we won’t see a dramatic spike. Again, hospitals have learned how to manage these cases better, [we have] more younger cases; hopefully it’s keeping out of our long-term care facilities as much as possible as well,” said Dr. Bogen. “So I think all of those strategies with that, we should hopefully not see a surge in our death rate here.”

Dr. Walsh has an additional concern.

“When schools open, we’re worried [COVID-19] would be spread to older teachers, staff and administrators, or the kids will bring it home to grandparents,” he said. “But we’re all prepared for that.”