Wednesday, July 22, 2020

As it Was, Ever and Will Be

The daily Covid Chronicles continue with two more significant points: Data Not Complete and Costs and Coordination for Medical Facilities

Here in the hot bed of Covid, the Three Stooges ran around commandeering Naval ships, public parks, conference centers and other facilities to house the thousands of Covid patients expected to arrive on the shores.  They failed to provide adequate testing, tracking and tracing and more importantly do adequate coverage and protections for those in more confined situations that are petri dishes for the virus - the old folks homes, prisons, public housing and veteran facilities. Well that takes time and we are at war with Trump so off with their heads!

By the time you are now tested a week or longer has passed and you have passed on the virus to your two friends and family and they have passed it on and finally when the results are back or quarantine for  you have ended you are onto the next.

Again the mysterious Covid parties are apparently another urban myth with little substantiation, the other, "we never left the house" is actually another myth, as someone did at sometime and they brought back with the essentials a little something extra.

The states have always had odd numbers and data collection from those who test positive to deaths as we have counties and cities not complying nor compiling in any consistent manner.  The reality is that those who have died from "covid related" symptoms are still charted on death certificates as cause of death the primary reason so again not Covid.

Then of course the private Physicians who have tests and in turn do not release the data nor are required to thanks to HIPAA or that again we have everything from false positives to false negatives gumming up the numbers so the real count is just that an anathema.   Shocking, I know. Not really.

We will never know the full numbers and we have a President and his administration that simply refuse to actually take responsibility and accountability for the failures that have continued now well into the year when this all began.  But the question remains: Would this have been any different regardless? And given what we are seeing world wide with regards to stockpiles, surpluses, inventories of needed PPE to even drugs just a basic crisis would have exposed the system as a piece of shit.   Then we have the horrific red tape, lack of communication and coordination systems that have been repeatedly tested and repeatedly failed and never once dealt with. This includes the deluge of Unemployment claims that States across the country demonstrated our outdated systems.  The curtain pulled back, the rock is now overturned and the soft underbelly exposed. And I have not seen or heard anyone discuss this with meaning, intent and a plan. Same as it ever was, is and will be.

Former CDC chief: Most states fail to report data key to controlling the coronavirus pandemic
Not a single state reports on the turnaround time of diagnostic covid-19 tests.

The Washington Post
By Lena H. Sun
July 21, 2020
Six months after the first coronavirus case appeared in the United States, most states are failing to report critical information needed to track and control the resurgence of covid-19, the disease caused by the virus, according to an analysis released Tuesday by a former top Obama administration health official.

The analysis is the first comprehensive review of covid-19 data that all 50 states and Washington, D.C., are using to make decisions about policies on mask-wearing and opening schools and businesses. In the absence of a national strategy to fight the pandemic, states have had to develop their own metrics for tracking and controlling covid-19. But with few common standards, the data are inconsistent and incomplete, according to the report released by Resolve to Save Lives, a New York nonprofit led by former Centers for Disease Control and Prevention director Tom Frieden and part of the global health organization Vital Strategies.

Some essential information that would show response effectiveness is not being reported at all. Only two states report data on how quickly contact tracers were able to interview people who test positive to learn about their potential contacts. Not a single state reports on the turnaround time of diagnostic tests, the analysis found. Week-long waits for results hobble efforts to track real-time virus spread and make contact tracing almost irrelevant.

“Despite good work done in many states on the challenging task of collecting, analyzing, and presenting crucial information, because of the failure of national leadership, the United States is flying blind in our effort to curb the spread of COVID-19,” Frieden said in a statement. “If we don’t get the virus under control now, it will get much, much worse in the coming months.”

Publicly available, standard dashboards with information on life-or-death metrics can make more of a difference than anything else U.S. officials can do in the weeks and months ahead, he said. Of the hundreds of projects the team has done since January, Frieden said Tuesday’s report was the most important.

His team and other public health leaders are recommending that states and counties report 15 indicators they say are essential for an effective response. The metrics were drafted with input from states and public health organizations and modeled after practices from around the world, Frieden said. States should be able to report on nine of the metrics now and the other six within several weeks.

The nine include information about confirmed and probable cases, rates of hospitalization per capita, and emergency department trends showing people who have symptoms of influenza-like illness and covid-19-like illness.

While almost all states report cases, 20 percent of state dashboards did not report same-day data by 5 p.m. local time. Kansas updates data only three times a week.

The CDC, in a statement, said it has been working since the beginning of the outbreak with states and other partners “to collect, analyze and report out data critical to formulate the nation’s response to this unprecedented public health crisis.”

The CDC is already tracking, or has plans with the states to track, 14 of the 15 indicators, the agency statement said. The CDC said the data is posted on its website and many states are also tracking some indicators on their state websites. The statement added: “CDC is always looking at best practices for ways to enhance, consolidate and report data, to make it easier for states and the public to access.”

The CDC said it has no plan to calculate data on the percentage of people wearing masks correctly in public, one of the metrics included in the report.

Without a national coordinated strategy, public health experts say consensus from governors will be vital to suppress and eventually recover from covid-19. That includes agreement on common metrics, a regular system for reporting data, and triggers for implementing social distancing policies and stay-at-home orders.

Most states are not collecting most of these measures, or if they are, reporting on only a small fraction, said Tom Inglesby, an infectious-disease physician and director of the Johns Hopkins Center for Health Security.

“The more we agree on the targets for response that states should achieve, the better the public will understand what it’s going to take to bring this epidemic under control,” Inglesby said in an email. If the target benchmark for a state’s diagnostic test positivity rate should be below 5 percent, for example, but if the state is reporting a positivity rate of 20 percent, that’s a sign that “things are going quite badly.”

Similarly, if a state is reporting that only a small fraction of new covid-19 cases can be linked to prior cases, “things are not going well no matter what a national or local leader might say.”

The D.C. health department published that key metric for the first time Monday. It said the percentage of new coronavirus cases linked to already known cases is just 2.8 percent — meaning most people contracting the virus aren’t aware of who might have exposed them. The city’s goal is 60 percent.

Groups representing state public health officials support the measures.

“Having some standard metrics to compare across the country will make a big difference in identifying where things are going well and where there is need for additional resources and improvements,” said Michael Fraser, chief executive of the Association of State and Territorial Health Officials.

Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists, said the organization supports using consistent indicators to give people information that will help them change behavior and understand the threat of the pandemic.

It’s also important, she said, that Frieden’s team recognized the relative importance of each metric and that “the optimal target may change based on the local status of the pandemic.”

While they praise the effort, public health experts are also concerned that overwhelmed state and local health departments don’t have the resources to report some of these measures at a time when the pandemic is surging and states are experiencing record numbers of infections and hospitalizations.

“Some of these data are going to be very very hard to get without a workforce dedicated to just charting these metrics week by week,” said Jeanne Marrazzo, director of the Division of Infectious Diseases at the University of Alabama at Birmingham School of Medicine.

“If we had this as a road map at the start in confronting the pandemic, that would have been the bomb,” she said.

And across the country today, cities are looking to shut down in States from Los Angeles to Atlanta, the outbreaks are not following the protocol established by the varying Governors, Medical Advice and of course the Millennials who are the largest cohort simply not giving a shit.   Meanwhile we are paying the price for this, in more ways than one.  When it comes to hospital bills this one is a whopper.

This Hospital Cost $52 Million. It Treated 79 Virus Patients.

Red tape and turf battles marked the race to create temporary hospitals for the coronavirus onslaught in New York.

By Brian M. Rosenthal
The New York Times
July 21, 2020

The Queens Hospital Center emergency department has a capacity of 60, but on its worst night of the coronavirus pandemic, more than 180 patients lay on stretchers in the observation bays and hallways. Alarms rang incessantly as exhausted doctors rushed from crisis to crisis.

Less than four miles away, a temporary hospital opened the next morning, on April 10. The facility, which was built at the U.S.T.A. Billie Jean King National Tennis Center to relieve the city’s overwhelmed hospitals, had hundreds of beds and scores of medical professionals trained to treat virus patients.

But in the entire month that the site remained open, it treated just three patients from the Queens Hospital Center emergency department, records show. Over all, the field hospital cost more than $52 million and served only 79 patients.

The pandemic has presented unique challenges for officials grappling with a fast-moving and largely unpredictable foe. But the story of the Billie Jean King facility illustrates the missteps made at every level of government in the race to create more hospital capacity in New York. It is a cautionary tale for other states now facing surges in cases and for New Yorkers bracing for a possible second wave.

Doctors at the Queens Hospital Center, a public hospital in Jamaica, and at other medical centers wanted to transfer patients to Billie Jean King. But they were blocked by bureaucracy, turf battles and communication failures, according to internal documents and interviews with workers.

New York paid as much as $732 an hour for some doctors at Billie Jean King, but the city made them spend hours on paperwork. They were supposed to treat coronavirus patients, but they did not accept people with fevers, a hallmark symptom of the virus. Officials said the site would serve critically ill patients, but workers said it opened with only one or two ventilators.

“I basically got paid $2,000 a day to sit on my phone and look at Facebook,” said Katie Capano, a nurse practitioner from Baltimore who worked at Billie Jean King. “We all felt guilty. I felt really ashamed, to be honest.”

As the coronavirus spread in March, the federal government, state leaders, city officials and hospital executives all began creating their own temporary medical facilities, at times competing against each other. Gov. Andrew M. Cuomo’s office oversaw most transfers to the centers, but city officials say the state did not closely coordinate with other players.

The federal government’s biggest contribution, the Navy hospital ship U.S.N.S. Comfort, arrived in New York with great fanfare but initially did not accept coronavirus patients at all, prompting one hospital executive to call it “a joke.”

Even once the Comfort began treating people with Covid-19, the illness caused by the coronavirus, the hospital ship and another overflow facility run by the state, located at the Jacob K. Javits Convention Center, mostly accepted patients transferred from private medical centers, not from the public hospitals that were the most besieged, according to government data.

Billie Jean King, the only emergency hospital built by the city, should have been a success story: It opened at the height of the pandemic, with a full staff eager to treat virus patients.

An aide to Mayor Bill de Blasio who helped oversee the site, Jackie Bray, said the city acted quickly to open it but ultimately concluded patients were best treated at existing hospitals, even if they were crowded. She added that she expected the federal government to reimburse the city for the cost of the facility.

Officials with the city and the state said Billie Jean King and other temporary sites treated so few patients because New York’s statewide shutdown curtailed the virus and hospitals expanded their own capacity, reducing the need for extra beds.

“The alternative space was less used than we expected it to be because we broke the curve, thank goodness,” Ms. Bray said.

Doctors disagreed.

“The conditions in the emergency room during this crisis were unacceptable and dangerous,” said Dr. Timothy Tan, the director of clinical operations at the Queens Hospital Center emergency department. “Knowing what our patients had to endure in an overcrowded emergency department, it’s frustrating how few patients were treated at facilities such as Billie Jean King.”

In past disasters, such as during Hurricane Sandy in 2012, the state created a unified system across multiple agencies to transfer patients between hospitals. That did not happen during the coronavirus pandemic, leaving hospitals in low-income areas overwhelmed, while some wealthy private medical centers had open beds.

Instead, with projections forecasting a severe shortage of beds, officials focused on building field hospitals.

The largest facilities opened in Manhattan in late March — the Comfort and the Javits Center. They treated about 1,400 patients, although only about 300 came from public hospitals, data shows.

Hospitals also opened overflow locations, including a Central Park tent hospital that treated 300 patients from Mount Sinai Hospital. The city’s public hospital system created a wing at a nursing home on Roosevelt Island.

Facing a projected shortage of 50,000 beds, federal officials spent more than $320 million to build facilities at two state colleges and the Westchester County Center, and the city spent about $20 million on a center at the Brooklyn Cruise Terminal, records show. In the end, reality never neared the dire projections, and none of those facilities opened.

The only makeshift hospital the city opened was at Billie Jean King.

The complex, home of the U.S. Open, is at the site of the 1964 World’s Fair in Flushing Meadows and is one of the largest tennis centers in the world.

Officials put out a call on March 18, saying they needed a contractor that could open a hospital in seven days and run it. Only one vendor said it could do it: SLSCO, a company from Galveston, Texas, best known for helping build part of President Trump’s border wall.

SLSCO had spent $90,000 annually to lobby New York in recent years and received contracts after Hurricane Sandy, records show. The company referred questions to city officials.

The contract paid SLSCO whatever costs it incurred for creating and operating 470 beds for “Covid-positive patients of medium and high acuity” — plus an additional 18 percent for profit and overhead, the deal said. The final bill is still being tallied; it could top $100 million.

“This is a war effort,” Mr. de Blasio said in a news conference at the tennis center in late March, announcing it would open April 7. “This facility will be crucial.”

The site opened on April 10, during the grimmest week of the pandemic, with records in statewide hospitalizations and deaths.

The night before, the patients in the Queens Hospital Center emergency department included 66 who were so sick that they had already been admitted and were waiting for beds, according to a hospital log.

City officials said emergency department patients were inappropriate for Billie Jean King. The site did not have all of the equipment, drugs and services available at a permanent hospital, so it was not the best place for unstable patients, they said.

Dani Lever, communications director for Mr. Cuomo, said the Queens Hospital Center transferred 11 patients to the Javits Center that night, and could have sent more. The state accommodated every transfer request from hospitals, Ms. Lever said.

Other nearby hospitals were also in crisis, including Elmhurst Hospital Center and several small private hospitals.

SLSCO had recruited hundreds of workers from across the country. It paid most doctors about $600 an hour, or $900 for overtime, according to the contract — far more than the typical rates at hospitals. Registered nurses made more than $250 an hour, as did pharmacists and physician assistants.

But in the early days, they spent hours in orientation to learn computer systems, waiting to get fitted for masks and looking for equipment, workers said. They also said they had to complete repetitive paperwork.

“Extreme dysfunction,” Dr. Kim Sue said about working there. “Bureaucracy and dysfunction, and all kinds of barriers to serving patients.”

But the biggest barrier was simple: Hospitals did not send many patients to Billie Jean King.

The city did not allow ambulances to take 911 calls to Billie Jean King because health officials said they did not trust the facility to triage patients. The site had its own ambulances, but they could not pick up transfers because, according to some workers at the site, hospitals had exclusive agreements with ambulance companies. So doctors had to wait for transfers. Few came.

In interviews, doctors at overwhelmed private hospitals said they were told they could not transfer to Billie Jean King because it was only for patients from public hospitals.

Several doctors at public hospitals said they believed their bosses did not want to transfer because the hospitals in the public system each had their own budgets, and they did not receive revenue from patients they sent away. Some said they were told Billie Jean King could treat only people with extremely mild symptoms.

There were at least 25 medical conditions that disqualified patients from being transferred to Billie Jean King, including “spiking” fevers, a city spokesman acknowledged. The Javits Center had similar rules.

At Billie Jean King, seven workers said in interviews that even with limited ventilators, they could treat most severely ill patients. They said they grew increasingly frustrated to report every day to a sea of empty beds. Several mentioned that three men with mild symptoms died while quarantining at a Manhattan hotel.

“We were sitting on all of these beds with hundreds of people trained to watch over patients exactly like that, and these people died,” said Elizabeth Ianelli, a social worker at the site. “That was preventable.”

City officials said the men were not sick enough for Billie Jean King’s level of care. They said all hospitals could transfer to the site, which had enough ventilators, and said the ambulances did not pick up because they needed to be available in case patients at Billie Jean King deteriorated and needed to be transferred. Nobody was thinking about patient revenue, they said.

“The thing that saved the most lives was to treat them in expanded capacity in the hospitals, and bring staff into the hospitals, and that’s what we were focused on,” said Matt Siegler, a senior vice president at the city’s public hospital system, which oversaw the site.

Mr. Siegler said he could not think of anything the city should have done differently.

On April 27, the city amended the contract to pay SLSCO for only a 100-bed facility for patients with “low to moderate” needs, records show. The site became a quarantine location for homeless people, and some staffers left to work in other hospitals.

Billie Jean King closed on May 13, and workers returned home.

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