Why are hospital ICUs so full now?
MGH's Dr. Jarone Lee offers a COVID-19 update
This is another in a series of conversations between Dr. Jarone Lee, a frontline critical care and emergency physician at Massachusetts General Hospital and associate professor at Harvard Medical School, and Dr. Paul Hattis, a senior fellow at the Lown Institute, a former commissioner of the Health Policy Commission, and co-host of CommonWealth’s Health or Consequences Codcast.
PAUL HATTIS: Jarone, it has been a while since we talked about what is going on with the care of COVID patients at Massachusetts General Hospital. During this Delta variant era of COVID, what is happening in terms of the demographics of COVID patients that you are seeing now in the ICU?
JARONE LEE: Similar to the rest of the nation, we are seeing COVID hospitalizations and ICU needs steadily increase. The average age of a COVID patient in the ICU is clearly lower than last winter’s surge. Most importantly, COVID patients in our hospitals and ICUs are overwhelmingly unvaccinated. While there have been media stories on the topic, breakthrough infections of those COVID vaccinated requiring an ICU stay continue to be incredibly rare—on the order of less than 0.005 percent of all people vaccinated. Clearly, vaccination continues to be our best bet to get us out of this pandemic.
HATTIS: Over the course of the COVID era, have there been any evolutions in the treatment of sick COVID patients?
The other major innovation is giving high-dose immunosuppression with steroids for any hospitalized COVID patient who requires oxygen support–it clearly reduces progression of COVID illness and saves lives. During the early part of this pandemic, there was a lot of controversy about giving steroids to COVID patients based on previous research that showed that steroids worsened outcomes among patients with flu virus-related severe lung injury. The good news is that we now have very good science and data that support the use of steroids with COVID-19.
But we must be careful as the data also shows that steroids are helpful to only a subset of COVID-19 patients – those that require oxygen support. The research, published this February, also showed that steroids could be harmful with higher mortality among COVID-19 patients that did not need oxygen. So, giving steroids to all COVID-19 patients would lead to more harm than benefit. It’s amazing to me that in less than a year we saw a clinical practice change based on good research and publication—something that normally takes years to implement, even after scientific publication.
Lastly, much of what we learned over the last year is not about new technology or drugs; rather, it was about operations and processes of care. Examples include how we learned to use PPE efficiently and effectively; to transport COVID-19 patients safely throughout the hospital; and to deploy testing protocols to keep both COVID, non-COVID patients, and our staff safe. I truly believe the importance of improving processes of care and operations can be just as important as scientific discoveries. We need both, but without a streamlined and efficient mechanism to distribute and provide access to the new treatments, it would be like not having effective treatment at all. In healthcare, we can only move as fast as our logistics permit.
HATTIS: Even though COVID-related ICU admissions are nowhere near last year’s levels, ICUs are still running pretty full right now, why is that?
LEE: Within our system, COVID patients represent a much smaller fraction of very sick patients as compared to previous pandemic waves, as most of our ICU patients are admitted for non-COVID reasons—everything from heart attacks and strokes to traumatic injuries. But like ICUs across Massachusetts and the US, ours are quite full and this capacity crunch is multi-factorial in its cause.
First, even though COVID patient numbers are lower than previous surges, once a COVID patient is sick enough to need an ICU, they stay in an ICU bed for a long time. Typically, they need an ICU bed for weeks, sometimes months. Most of our ICU patients before COVID stayed for at most a week or two. This leads to less overall ICU beds available for other patients
Second, many of the community hospitals both in Massachusetts and across our nation operate small ICUs, typically around six to 10 beds; as compared to the 150 ICU beds we have at MGH. At a smaller hospital, if three out of six beds are taken up by COVID patients, this means there are only three other beds available. One ICU bed does not equate to one patient. Given the slow turnover time for COVID patients, one ICU bed occupied for 2-3 weeks usually could have accommodated 8-10 patients with shorter, 1-2 day stays. Unfortunately, with three COVID patients, that six-bed ICU has lost half its capacity to take care of other patients, from post-operative cases to emergencies, such as heart attacks and car accidents. This leads to them needing to transfer additional cases to referral hospitals such as MGH, which then also fills our beds.
HATTIS: How are you and colleagues feeling right now about where CDC Director Rochelle Walensky came out on who should be receiving booster shots?
LEE: When I first heard of the initial CDC advisory panel recommendation to not include high-risk occupations, such as healthcare workers like myself, I was disappointed. I believe that those people who are at high-risk of contracting COVID because of occupational exposure should have early access to a third shot. This includes not only health care workers, but also grocery workers, teachers, public transport workers, and many other professions that regularly and directly interact with the public—all in jobs that have a much higher risk of COVID exposure. The data from Israel and other regions seem to show that antibody levels against COVID do wane over time with the Pfizer vaccine. Though the implications for what this means for cellular mediated immunity protection that is not based on antibody levels is unknown, most experts nevertheless believe that this data suggests that we should offer boosters to the highest risk groups for serious illness or exposure risks.
We do regularly use boosters with other vaccines, such as Tetanus. Most of our childhood vaccines require at least two doses, many three or four. COVID should likely be no different. Lastly, the COVID vaccines have proved to be extremely safe, where major side effects are rare and few. We need to focus on the millions and billions of people helped and saved by the vaccines, instead of the rare side effects.
So, when Walensky announced that she would overrule the advisory group and recommend boosters for occupations at highest risk during this first phase of offering boosters to Pfizer vaccine recipients, I was relieved. I believe many of my colleagues had the same sentiment.
HATTIS: Last year, when I asked you about the availability of antibody therapy for those COVID patients who were not seriously ill, but experiencing symptoms—you noted there was not a lot interest. Is that still the case?
LEE: Yes, initially there was little interest. The opposite is true now as it is tough to find antibody treatments because there is a lack of available appointments and, in some instances, a shortage of antibody treatments. My sense is the reason for this change in interest for antibody treatments is because of a big push by multiple sources, including many politicians and leaders across the nation, who seem hesitant about vaccination, but focused on antibody therapy. This has led to a massive influx of demand, including here in Massachusetts.
For the COVID infected, but not yet seriously ill, patient, last week’s announcement by Merck that its new drug, molnupiravir, could be an important additional contributor to reducing the likelihood of serious illness was promising. But like with monoclonal antibody therapy, it needs to be taken early in the onset of COVID symptoms, and unfortunately if you are sick enough to be hospitalized, most likely it is too late for the new drug to offer much benefit.
HATTIS: Some of the COVID news headlines indicate patients and families are demanding the drug ivermectin. Are you experiencing that at MGH?
LEE: Unfortunately, yes. We regularly get requests by patients and family members to give unapproved and dangerous therapies, such as ivermectin, high-dose vitamins, and a few others. I’ll say that most folks I’ve met and treated have been reasonable and understanding when I explained the dangers of these unproven therapies.
But I want to talk about ivermectin for a minute because its appropriate use can intersect with COVID patients. First, we do not use ivermectin to treat COVID illness per se, as it is unproven and potentially dangerous. Instead, we at times give it to patients requiring high doses of immunosuppression who have risks of parasite infections. Suppressing the immune system can unmask and reactivate parasites that are normally controlled by an intact immune system. These parasites rapidly spread throughout the body. To prevent this, we routinely screen for risk factors for these parasites. As we talked about earlier, our sicker COVID-19 patients that need oxygen support typically get high-dose steroids. So, if a patient is at risk for parasitic infection and needs high-dose steroids for COVID, we treat them with ivermectin to clear the parasite—please note that this is not for direct treatment of the COVID infection.HATTIS: How have things been going lately with COVID family wise for you, your wife, and 6-year-old son?
LEE: Things are good. We had a great summer and felt like it was post-pandemic for a short period of time. Our son is back with in-person school, which is a major relief, especially for my wife. She has overwhelmingly taken the heaviest burden with this pandemic in terms of career and childcare responsibilities. Since our son is still unvaccinated, we do worry about him getting COVID. We continue to stay safe by having play dates primarily outdoors with select friends. I do not think we will be completely comfortable with him in certain environments until he is fully vaccinated. The good news is Pfizer might be available for his age group soon.