As virus spreads, concerns surge about testing, hospitals, and nursing homes

calguardvirusaid-300x169The coronavirus outbreak spreading across the globe may be providing Americans with an unhappy view of the dirty downsides of the too-often dysfunctional U.S. health care system as it grapples with spiking Covid-19 infections.

Congress has appropriated more than $8 billion, so the federal government can provide the nation the support it needs in battling the respiratory illness that exploded out of central China a few weeks ago. Almost 100,000 people globally have been infected with the virus, which has killed thousands. The deaths in this country are rising into the dozens, while infections are increasing into the hundreds. In Italy, the government took a drastic step in dealing with steeply rising infections and ordered a virus-related quarantine of much of the northern part of the country — a tough lock down because the Lombardy area is the largest economic powerhouse of the nation.

In the U.S., federal efforts to stockpile needed medical supplies, notably masks, gloves, and gowns — personal protective equipment or PPEs — continue to lag. The administration is under fire for its slow and ineffectual roll-out of virus testing kits. Vice President Pence promised that big numbers of screening supplies would be available quickly — at least 1 million, asap — but he since has been forced to walk back that pledge. Even as he talked about 75,000 test kits becoming available soon, the Atlantic magazine reported that as few as 1,895 Americans have been tested so far for the virus.

States have howled at the federal Centers for Disease Control and Prevention and its parent Health and Human Services agency not only over limited test kits but also restrictive guidelines about who may be tested for Covid-19. Critics ask: How will the nation know how serious the viral infection has become, where to battle it hardest, and if the Covid-19 fight is working, without better testing?

Health care officials are providing pointed criticism of the administration handling of the growing number of viral infections and deaths, noting that caregivers are at the front lines and at high risk. Nurses in California and Washington have blasted the government, saying they have been put at risk and provided too few resources and even less guidance about treating patients suspected or having Covid-19. Figures displayed from the states by respected organizations like the Johns Hopkins Covid-19 Resource Center do not match comparable numbers coming from the CDC or other federal agencies.

Critics have assailed President Trump for broadcasting “hunches” about important epidemic information, such as the mortality rate of those infected, and for advocating — at least to critics’ ears — the opposite of what public health officials advise — he’s suggested that those who are ill should keep showing up to work. In public appearances with top medical scientists, Trump has claimed counter factually that a Covid-19 vaccine may be imminent, while experts tell him it’s at least a year away. Experts had to all but wrestle him to the floor to persuade him that, no, patients would not get protection from a flu shot against Covid-19.

He made inaccurate statements at a CDC visit about the availability of virus tests, while also saying he was upset about decisions about the care of those aboard another infection-carrying cruise ship off the California coast simply because it affects the nationwide counts of U.S. virus cases. He launched an unprovoked attack on Gov. Jay Inslee, who is battling the current deadliest U.S. virus outbreak.

It may be key, sadly, to ignore the elected leader of the free world when he talks about the disease and the fight against it, concentrating on evidence-based information from medical experts with bona fides.

They would hear from them rising concern about how Americans may need to take bigger steps to curtail the virus’ spread, including having older people — especially those with serious health conditions — stay at home more and avoid crowds.

This recommendation comes, even as virus-related cancellations and closures abound: Some Seattle area schools are shut for now, as are San Francisco performances of the city’s esteemed symphony orchestra. Organizers canceled the popular and influential SXSW tech, music, and film festival. Sponsors said health officials’ emergency declarations nearby led them to put off this year’s BNP Paribas Open, one of professional tennis’ major tour stops in Indian Wells, near Palm Springs, Calif. Stanford University has told students classes will be conducted online only for a while, as has Columbia University, and the University of Southern California has told students it will test online teaching next week, so don’t plan to attend classes in person.

Sen. Ted Cruz and Rep. Paul Gosar both announced that, in an abundance of caution, they would self-quarantine because the Republicans were exposed to an individual who tested positive for Covid-19 and had met them at the recent Conservative Political Action Conference (CPAC) meetings in Maryland. Neither the Texan nor Arizonan has shown symptoms of illness.

Authorities said a Washington, D.C., rector has tested positive for the illness, and cases have been diagnosed in Maryland and Virginia.

The credibility and capacity for some crucial institutions to fight infections, of course, always has been sketchy, at best. Safety advocates long have hounded hospitals and nursing homes about their poor performance in protecting patients from infections acquired while undergoing care within their walls.

Preventable hospital deaths kill more than 160,000 Americans annually — four times as many lives as were lost to vehicle wrecks in 2017, more than twice the deaths attributable to opioids and drug overdoses that year, and more than the toll of stroke or Alzheimer’s disease, according to a recent disturbing new report on hospital deaths from  Johns Hopkins Medicine’s Armstrong Institute for Patient Safety and Quality and the Leapfrog Group, a national nonprofit founded by large employers and others concerned and focused on safety and quality in health care.

Nursing homes and long-term nursing care facilities have significant infection control, safety, and quality issues of their own, the New York Times reported recently.

Betsy McCaughey, a former lieutenant governor of New York who leads the nonprofit Committee to Reduce Infection Deaths, told the newspaper that the non-hospital treatment facilities “are cauldrons that are constantly seeding and reseeding hospitals with increasingly dangerous bacteria. You’ll never protect hospital patients until the nursing homes are forced to clean up.”

The newspaper, which also described the patient suffering that the infections cause, reported this:

“The story is far bigger than one nursing home or one germ. Drug-resistant germs of all types thrive in such settings where severely ill and ventilated patients … are prone to infection and often take multiple antibiotics, which can spur drug resistance. Resistant germs can then move from bed to bed, or from patient to family or staff, and then to hospitals and the public because of lax hygiene and poor staffing. These issues have also vexed long-term, acute-care hospitals, where patients typically stay for a month or less before going to a skilled nursing home or a different facility.”

The government, confronting a major coronavirus outbreak that has killed at least seven in a nursing home in Kirkland, Washington, has announced a crackdown on nursing homes and their infection-fighting efforts. That’s a good step, but the independent, nonpartisan Kaiser Health News service has pointed out that long before the world and nation struggled with the coronavirus, nursing homes — including the purported best of them — too often were tagged for infectious outbreaks:

“Since the beginning of 2017, government health inspectors have cited more nursing homes for failing to ensure that all workers follow those prevention and control rules than for any other type of violation, according to a Kaiser Health News analysis of federal records. In all, 9,372 nursing homes, or 61%, were cited for one or more infection-control deficiencies, the analysis showed. It also found violations were more common at homes with fewer nurses and aides than at facilities with higher staffing levels. Even among nursing homes crowned with the maximum government rating of five stars for overall quality, 4 in 10 have been cited for an infection-control lapse. Those include the Life Care Center of Kirkland …  where [residents] have died [in the coronavirus outbreak.] Inspection reports from around the country show many errors are rudimentary, such as workers not washing their hands as they moved to the next patient, or failing to don masks, gloves and gowns when in the rooms of contagious patients in isolation.”

Paying heightened attention to the well-being of institutionalized loved ones may be an important way to safeguard them during these infection-challenged times.

And lest anyone think that hospitals, especially academic medical centers, deal with infections any better than nursing home, well, ProPublica, the Pulitzer Prize-winning investigative web site, has the reporting to disabuse the gullible of this myth:

“[I]nfection control has been a recurring problem at some of the very hospitals that would likely be called upon to treat COVID-19 patients, a ProPublica review of hundreds of hospital inspection reports found. This raises concerns that they could become hotbeds for disease, putting patients at risk and rendering infected workers unable to care for others … There is no list of designated centers to handle the most critical COVID-19 patients, experts said. But the [CDC], during the 2014-16 Ebola outbreak, named 55 hospitals it considered to be in the first tier of treatment centers to handle that kind of crisis — mostly large, urban teaching hospitals capable of complex care like blood transfusions and ventilation. ProPublica analyzed five years of federal hospital inspection reports for these facilities and found violations for infection control failures or other factors that could hamper the response to an outbreak at more than half of them. About 1 in 5 of the facilities had four or more violations; the analysis found more than a hundred overall. It’s not clear by looking at the reports how many of the violations led to patient infections. Problems that get cited on the inspection reports are required to be corrected as part of the regulation process. But it’s also true that inspections only flag a small number of the actual problems in hospitals. American hospitals, overall, are so bad at preventing infections that hospital-acquired infections are considered a leading cause of death in the United States. The hope would be that the sites designated as specialized infection-control centers would do better.”

ProPublica calls out a Washington, D.C., institution, too, of course:

“MedStar Washington Hospital Center in Washington, D.C., says it’s ready to screen coronavirus patients. Inspectors have cited the facility more than a dozen times since 2017, including for infection control failures. Among the violations: Staff did not wear and dispose of masks according to federal guidelines. Short staffing caused scores of patients to go without respiratory treatments. There were sewage leaks in operating rooms. In an email, a spokeswoman said the hospital has addressed the failures: ‘We maintain a constant state of readiness for treating complex illnesses, including the coronavirus.’”

Hospitals insist they are readying for the virus, but their concerns are growing, too. Many academic medical centers may have special areas to treat infectious patients, notably rooms with special ventilation systems designed to avert pathogens’ spread. But these facilities are resource-intensive, especially with highly trained staff, and aren’t designed to handle large numbers. With respiratory illnesses, patients may flock to emergency rooms or urgent care centers — contaminating them and infecting many others, including health care workers.

As always, costs become a huge issue in the U.S. health care system. Patients already have expressed outrage at the potential financial burdens they may face, starting with virus testing. States have moved to require insurers to cover Covid-19 screening, and insurance industry groups have urged members to step up and tell consumers this expense will be paid for.

But if patients contract the coronavirus and require hospitalization, particularly specialized care in infectious isolation, they could face staggering costs. Medical experts also say that the patients that seem now to be most vulnerable to infection — individuals 60 and older with existing health conditions — might face extensive and expensive for longer periods. Who will help them with such costs? Insurers? The government?

Battles already have broken out over future, health-related viral economics, such as the cost and profits from a potential vaccine. Big Pharma has rushed in, with companies working with alacrity to develop such an inoculation and therapies for Covid-19. Much of their effort, of course, builds on extensive research paid for by taxpayers. The administration has declined to denounce prospective profiteering and deflected questions on this topic.

While policy wonks have pressed at the state and federal levels, politicians and policy makers also haven’t stepped in to deal with other giant challenges in dealing with the virus, including the lack of paid sick leave for so many Americans (hard to tell folks to stay home when ill, if they go broke doing so) or how the nation might assist increasing numbers of people who are put on involuntary leaves or furloughs due to declining business tied to the virus.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the benefits they can reap by staying healthy and out of the troubled U.S. health care system. Besides its problems with hospital acquired infections, it also has major challenges with medical error and misdiagnoses. That said, at this difficult moment, we need to support doctors, hospitals, and public health officials as they marshal science, evidence, and facts to battle the global menace of Covid-19. We’ve got a lot of work to do to protect the health of hundreds of millions of Americans.

Photo credit: California National Guard. Corpsman, with CDC experts, airlifted to California cruise ship with Covid-19 testing kits.
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