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The risk remains
Strained staff, new COVID-19 infections may still overwhelm Virginia Mason Memorial
 06.29.20

On March 21, officials from Virginia Mason Memorial held an outdoor news conference in front of the Yakima hospital, urging local or state officials to implement a stay-at-home order for Yakima County.

They voiced concerns that the hospital could become overwhelmed in two weeks if no action was taken, and the region saw a rapid rise in COVID-19 hospitalizations.

A day later, the Yakima Health District implemented a stay-at-home order for Yakima County. A statewide stay-at-home order went into effect later that week.

On Tuesday, a little more than three months after that parking lot news conference, Memorial CEO Carole Peet and Tanny Davenport, the hospital’s chief of quality and safety, held another news conference — this time over Zoom.

“We didn’t run into an overrun hospital situation in early April,” Davenport said.

Efforts by residents to abide by county and state stay-at-home orders and to follow other safety measures, such as hand washing, contributed to the hospital avoiding the doomsday situation it feared during that March news conference, he said.

There’s still reason for concern, however: COVID-19 hospitalizations in Yakima County have been increasing since April, when they were in the 20 to 30 range.

In recent weeks, hospitalizations crept into the 40s and 50s, inching close to 60.

The increase in COVID-19 hospitalizations in Yakima County correlates with the rapid rise in cases in the last several weeks. Yakima County has had more than 7,200 reported cases, roughly a thousand less than the number of confirmed cases in Oregon, which has nearly 17 times more residents.

That’s why the hospital remains at risk of being overwhelmed, Memorial officials said.

While Yakima County is home to three hospitals — Memorial, Astria Toppenish Hospital and Astria Sunnyside Hospital — Memorial has cared for the overwhelming majority of COVID-19 patients.

The number of COVID-19 patients at Memorial reached the mid-30s earlier this month. It’s now squarely in the 40s.

On June 18, Memorial reached its peak number of COVID-19 patients — 47. With staff fully occupied treating those patients, the hospital transferred 17 — both dealing with COVID-19 and non-COVID-19 conditions — to other hospitals in the state that day.

In a non-pandemic situation, hospitals will transfer patients to other hospitals if a higher-level of care is needed. For example, a child needing specialized pediatric may go to Seattle’s Children’s Hospital. A patient needing trauma care may be transferred to Harborview Medical Center in Seattle.

But the hospital typically makes a handful of such transfers. Transferring 17 patients in a single day spoke to how stretched Memorial was that day.

“We had a lot of patients that required a high level of care,” Peet said. “It was probably our most challenging day so far.”

That alarmed Yakima Health District officials and prompted them to issue a news release the next day to declare that hospitals countywide had exceeded capacity and that residents needed to adhere to safety measures.

There was one hitch, however: The news release stated that Memorial had no available beds for patients who needed care that night.

Memorial officials would later clarify — as it did during the June 23 news conference — that the hospital had plenty of beds, but a lack of staffing was the issue.

But the narrative of “no room at the hospital” spread so rapidly that Gov. Jay Inslee repeated it during a Tuesday news conference announcing a statewide mask-wearing requirement. After Inslee’s news conference, Memorial officials had to make numerous emails and calls to government officials and media to clarify the situation.

“We’re making sure we’re not scaring the community out of seeking care,” Peet said. “There was a lot of misunderstanding over what capacity means.”

Lilián Bravo, director of community partnerships for the Yakima Health District, said while clarification needed to be made on capacity, it didn’t change the underlying concern it wanted to communicate to the public.

“It is, however, accurate that there was a cause of concern based on ongoing hospitalization trends and Thursday night’s figures across the country,” Bravo wrote in an emailed response to a series of questions from the Yakima Herald-Republic. “As was clarified, there was not enough staff to provide care, and as such, exceeding capacity.”

Hospital capacity picture is complex

Peet said that talking about a hospital’s capacity is “a complex issue.”

Several things, including beds, staffing and equipment, should be factored in considering capacity. And given that patients’ condition can change quickly, so can capacity. That makes it challenging to capture capacity at a given point of time.

When the COVID-19 pandemic first hit the Yakima Valley in mid-March, Memorial thought there would be a need for additional hospital beds, Peet said. In response, the hospital expanded its bed capacity from 226 to 257. The hospital also increased the number of critical care beds from 11 to 27.

There have been more than enough beds: Even at Memorial’s highest occupancy in recent weeks, there were still upward of 50 beds available, Peet said.

Ventilators — an essential tool in treating COVID-19 patients with severe respiratory issues — were also a concern for Memorial and other hospitals nationwide in March and April.

At the time of the March news conference, Memorial had 15 ventilators. It now has 31.

But ventilators didn’t turn out to be the issue either, Peet told reporters Tuesday.

“What we really found as we worked through this pandemic is that it’s really about the workforce,” Peet said.

When a COVID-19 patient requires hospitalization, they’re quite sick and need a level of care that involves treatment from multiple providers and nurses.

Many times, a single COVID-19 patient will require the care of a team of providers and nurses.

“It takes a lot more of a team and more hours from the team to take care of COVID-19 patients,” Davenport said.

Also, COVID-19 patients end up staying in the hospital for upward of 30 days well above the average stay of four days.

What may seem like a small increase in hospitalizations countywide really means a more significant strain on critical care physicians, nurses and other providers, Davenport said.

When the staff has been at its limit, Virginia Mason transferred patients to hospitals with enough personnel to provide the high-level care patients need, Peet said.

The hospital has tried to increase its staff capacity. It has four critical care providers and has hired temporary doctors, Davenport said. It has also tapped other specialists, such as an anesthesiologist, whose experience may be useful in the care of COVID-19 patients.

“We do need to have a bigger number of critical care physicians in our community,” he said.

Memorial intends to hire at least two additional critical care physicians, he said.

The hospital has also hired nurses who recently graduated from nursing school and trained them as critical care nurses, Peet said.

In March, when he issued a statewide stay-at-home order, Inslee also banned elective medical procedures to help conserve personal protective equipment. The ban affected Virginia Mason Memorial’s bottom line and in April, Peet announced the hospital was cutting pay, reducing hours and furloughing staff.

Peet said Tuesday that support staff was furloughed in areas such as billing. The cuts did not affect patient care, she said.

“Our direct patient care workforce has never been furloughed,” Peet said.

What about Astria Health?

Yakima County’s hospital capacity decreased dramatically in January when Astria Health decided to close Astria Regional Medical Center, its 214-bed hospital in Yakima.

Astria Health, which filed for bankruptcy protection in May 2019, said it no longer had the financial wherewithal to run the hospital.

At the end of March, the state Department of Health approached Astria Health about leasing Astria Regional. But two weeks later, state officials decided it was best not to reopen Astria Regional and redirected resources to long-term care centers.

During a news conference June 20, retired Vice Adm. Raquel Bono, the head of the state’s COVID-19 health care response team, said there were no plans to reopen Astria Regional since there was enough capacity statewide to care for COVID-19 patients.

Peet also addressed reopening Astria Regional, stating that it would have been difficult to sufficiently staff it.

Memorial hired dozens of former Astria Regional employees. Others Astria Regional employees ended up working at Astria Health’s other hospitals or taking jobs with other hospitals outside the Yakima Valley.

A qualified workforce isn’t “just sitting out there,” Peet said. “It’s actually a very complex process to go in reopening an acute care facility.”

Astria Health continues to operate Astria Toppenish Hospital and Astria Sunnyside Hospital. Like Memorial, both hospitals expanded capacity.

As a critical access hospital, Astria Sunnyside wasn’t permitted to exceed 25 beds. But Astria received federal approval to expand capacity to 51 beds at Sunnyside and 74 beds at Toppenish.

Astria Health officials were not available for interviews, but spokeswoman Ashleigh Oswalt emailed the organization’s responses to questions from the Yakima Herald-Republic.

“The hospitals have recently seen fluctuations in the census that some moments the facilities are close to capacity, and at other times, there is excess capacity,” the email said.

Both Astria hospitals have plenty of ventilators, which includes the supply from Astria Regional. The organization said while about 25% of its patients have COVID-19, the hospitals are only using about 20% of available ventilator capacity. Some of that difference can be attributed to patient use of Remdesivir, an anti-viral drug that has shown to have some positive effect on COVID-19 patients.

Like Memorial, Astria Health is looking to hire additional nurses. “We are seeking to fill additional nursing positions to support and augment our current staff as the acuity, and the mix of patients continue to evolve,” the organization wrote.

The big picture

Hospital occupancy is a critical metric state public health officials are using to determine whether counties can advance in the state’s four-part reopening plan.

The high number of new cases in Yakima County is one metric that has kept it stuck in Phase 1, while most other counties are in Phase 2 or 3.

But the county also has not met hospitalization benchmarks set by the state Department of Health.

The state considers a county to have adequate total bed capacity when it has fewer than 80% of beds occupied. The state also wants counties to aim for fewer than 10% total bed occupancy by confirmed and suspected COVID-19 patients.

As of Wednesday, about 78% of Yakima County’s 316 licensed beds were occupied, meeting that state benchmark. However, the percentage of occupancy by COVID-19 patients was at 19.3%, the highest among all counties statewide. Only two other counties, Benton and Franklin, have COVID-19 occupancy rates above 10%

In comparison, the total number of beds occupied overall and by COVID-19 patients statewide was 65.5% and 2.6%, respectively.

At Tuesday’s news conference, Peet said that while the hospital usually transfers patients to hospitals in the Seattle area, it has sent a small number of patients to hospitals in the Tri-Cities so they could be closer to home.

The Yakima Health District June 19 news release indicated that transfers to Tri-Cities hospitals might become more difficult as Benton and Franklin have also seen a rise in COVID-19 cases.

“We can all agree that it is preferred to keep the patient local to ensure timely care as well as to ensure the patient can be near their family,” Bravo said in her email Wednesday.

‘An approach that does work’

Three months after that outdoor news conference, Memorial’s message hasn’t changed: Stay home, wash your hands and keep your distance from others.

Memorial has also voiced support for the use of face coverings in public. Davenport joined Inslee in a news conference June 20 where Inslee announced a “No mask, no service” order for Yakima County.

The order took effect Friday. It prohibits Yakima County businesses from admitting or doing business with anyone who isn’t wearing a mask.

During that news conference, Davenport shared how, despite having frequent contact with COVID-19 patients, only 1% of Memorial employees were infected with COVID-19.

That, for Davenport, spoke to the effectiveness of using masks.

“We have learned this is an approach that does work,” he said during that news conference.

Tuesday, both Davenport and Peet again stressed the importance of wearing masks and voiced support for a statewide requirement for wearing them.

Such measures are crucial to reducing COVID-19 infections — and preventing COVID-19 hospitalizations, they said.

Keeping hospitalizations down would provide some relief to a strained staff.

“Our staff and our physicians have put in hours after hours,” Peet said. “They’ve given up their vacations. They’ve not had days off. As our critical care increases, it puts a strain on our workforce.”


Update
New COVID-19 cases drop back to double digits Sunday in Yakima County
 06.28.20

Yakima County saw new cases of COVID-19 decline by 100 this week.

There were 765 new cases of the virus June 22 through 28, compared to 865 the week before. That’s a decline of about 14 new cases a day countywide, according to figures from the Yakima Health District.

Despite a spike of 204 new reported cases Thursday, the week also included three days below 100 — Tuesday (72), Wednesday (68) and Sunday (71). For the week, the county averaged 109.3 new cases a day.

The week before, the county averaged 123.6.

“While we are still in a worrisome situation, we are seeing recent trends demonstrating a plateau and in some cases the start of a decline — something we frankly haven’t seen before — which is good news, said YHD spokeswoman Lilian Bravo.

The county saw reports of new cases dip back into double digits Sunday with 71, while deaths remained at 136. That brings the total number of infections to 7,241, according to the health district’s website.

Of those who died, 132 were known to have underlying health conditions.

Hospitalizations increased by three Sunday to 52, with 14 patients on respirators.

The health district has been counting case since mid-March. Of the 7,241 infections, 3,772 had recovered as of Sunday, the health district reported.

The decline comes after the implementation of campaigns requiring people to mask up in public. Local businesses more than a week ago had embarked on a “Mask Up, Open Up” campaign encouraging everyone to wear a mask in public.

On Friday, Gov. Jay Inslee’s order requiring the public to wear masks took effect, with Yakima County businesses being ordered not to serve customers who refused to mask up.

“The decline is likely due to a higher adherence to following the public health recommendations overall — including masking,” Bravo said.

Although masking is credited with much of the recent decline, Bravo urges the community to continue abiding by the other guidelines, such as maintaining 6 feet of distance from others while in public, washing your hands frequently and staying home unless going out is essential.

“We are cautiously optimistic and hope we can continue to see these trends as more community members double down and following the public health recommendations,” Bravo said Sunday. “It’s by all of us working together that we can change the trajectory of the disease in Yakima.”


Business
AP
Summer may decide fate of leading shots in vaccine race
 06.28.20

People on six continents already are getting jabs in the arm as the race for a COVID-19 vaccine enters a defining summer, with even bigger studies poised to prove if any shot really works — and maybe offer a reality check.

Already British and Chinese researchers are chasing the coronavirus beyond their borders, testing potential vaccines in Brazil and the United Arab Emirates because there are too few new infections at home to get clear answers.

The U.S. is set to open the largest trials — 30,000 people to test a government-created shot starting in July, followed about a month later with another 30,000 expected to test a British one.

Those likely will be divided among Americans and volunteers in other countries such as Brazil or South Africa, Dr. Anthony Fauci of the National Institutes of Health told The Associated Press.

While he’s optimistic, “we’ve been burned before,” Fauci cautioned.

Multiple successes, in multiple parts of the world, are vital.

“This isn’t a race of who gets there first. This is, get as many approved, safe and effective vaccines as you possibly can,” Fauci said.

Vaccine experts say it’s time to set public expectations. Many scientists don’t expect a coronavirus vaccine to be nearly as protective as the measles shot.

If the best COVID-19 vaccine is only 50% effective, “that’s still to me a great vaccine,” said Dr. Drew Weissman of the University of Pennsylvania.

“We need to start having this conversation now,” so people won’t be surprised, he added.

And for all the government promises of stockpiling doses in hopes of starting vaccinations by year’s end, here’s the catch: Even if a shot pans out — and it’s one that your country stockpiled — only some high-risk people, such as essential workers, go to the front of a very long line.

“Will you and I get vaccinated this year? No way,” said Duke University health economist David Ridley.

THE HOME STRETCH

Vaccines train the body to rapidly recognize and fend off an invading germ. About 15 experimental COVID-19 vaccines are in various stages of human studies worldwide.

And while there’s no guarantee any will pan out, moving three different kinds into final testing offers better odds — especially since scientists don’t yet know just how strong an immune reaction the shots must spark to protect.

Measuring that with the first proven vaccine will “really help us understand for all the other vaccines in development, do they also have a chance?” said Oxford University lead researcher Sarah Gilbert.

Only China is pushing out “inactivated” vaccines, made by growing the new coronavirus and killing it. Vaccines by Sinovac Biotech and SinoPharm use that old-fashioned technology, which requires high-security labs to produce but is dependable, the way polio shots and some flu vaccines are made.

Most other vaccines in the pipeline target not the whole germ but a key piece — the “spike” protein that studs the surface of the coronavirus and helps it invade human cells. Leading candidates use new technologies that make shots faster to produce but haven’t yet been proven in people.

Oxford’s method: Genetically engineer a chimpanzee cold virus so it won’t spread but can carry the gene for that spike protein into just enough cells to trick the immune system that an infection’s brewing.

Another vaccine made by the NIH and Moderna Inc. simply injects a piece of the coronavirus genetic code that instructs the body to produce harmless spike copies that the immune system learns to recognize.

CHASING THE VIRUS

Researchers must test thousands of people not where COVID-19 is surging — because then it’s too late — but where it’s smoldering, Fauci said.

Only if the virus starts spreading through a community several weeks after volunteers receive either a vaccine or a dummy shot — time enough for the immune system to rev up — do scientists have the best chance at comparing which group had more illness.

Lacking a crystal ball, the NIH has vaccine testing networks in the U.S., South America and South Africa on standby while finalizing decisions on the summer tests.

“We’re going to be doing it in multiple sites with a degree of flexibility” so researchers can rapidly shift as the virus moves, Fauci said. “Nothing is going to be easy.”

The Oxford shot, with a 10,000-person study underway in England, already encountered that hurdle. Gilbert told a Parliament committee last week that there’s “little chance, frankly” of proving the vaccine’s effectiveness in Britain after infections plummeted with the lockdown.

So her team looked abroad. In addition to the planned U.S.-run study, Brazil last week began a last-stage test of the Oxford shot in 5,000 health workers, the first experimental COVID-19 vaccinations in South America. In another first, South Africa opened a smaller safety study of the Oxford shot.

With few new infections in China, Sinovac next month will begin final tests in 9,000 Brazilian volunteers. And SinoPharm just signed an agreement with the United Arab Emirates; that study’s size isn’t clear.

EXPECT IMPERFECT PROTECTION

Animal research suggests COVID-19 vaccines could prevent serious disease but may not completely block infection. One study that dripped the coronavirus into monkeys showed vaccinated animals avoided pneumonia but had some virus lurking in their noses and throats. Whether it was enough to spread to the unvaccinated isn’t known.

Still, that would be a big win.

“My expectations have always been that we’ll get rid of symptomatic disease. From what we’ve seen of the vaccines so far, that’s what they do,” said Penn’s Weissman.

The initial vaccines might be replaced with later, better arrivals, as historically happens in medicine, noted Duke’s Ridley.

And while shots in the arm are the fastest to make, those for respiratory diseases require virus-fighting antibodies to make their way into the lungs. Gilbert said Oxford eventually will explore nasal delivery.

WARNING AGAINST SHORTCUTS

Some U.S. lawmakers worry about pressure from the Trump administration to push out an unproven shot during the fall election season.

“We want a vaccine, not a headline,” Sen. Jack Reed, a Democrat from Rhode Island, said at a recent Senate committee hearing.

Dr. Stephen Hahn, commissioner of the Food and Drug Administration, pledged to a House committee last week that any decision would be based on science.

Different countries have different rules about when to release a vaccine. For the U.S., Fauci insisted there will be no safety shortcuts, a key reason NIH is investing in such huge studies.

Regardless of how and when a vaccine arrives, each country also will prioritize who’s first in line as doses become available. Presumably they’ll start with health workers and those most vulnerable to severe disease — as long as each shot is proven to work in at-risk groups such as older adults.

Because each vaccine works differently, “which population group it will protect, we don’t know yet,” said Dr. Mariangela Simao of the World Health Organization, which is advising countries on how to choose.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.