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Lessons from the 1918 pandemic: A U.S. city's past may hold clues Print E-mail
Written by J. Alexander Navarro   
Monday, 06 July 2020 18:12

Coronavirus infection rates continue to rise, with the number of new cases climbing in dozens of states and the U.S. reporting record numbers of cases on individual days. Hospitalization across the U.S. has dramatically jumped; some cities are seeing surges that threaten to overwhelm their health care systems.

Meanwhile, the demonstrations over the police killing of George Floyd brought tens of thousands into the streets, congregating shoulder-to-shoulder. Many are the victims of tear gassing by police, potentially increasing the risk of transmission and infection. The latest models indicate COVID-19’s U.S. death toll could reach 170,000 by October. A second wave this fall – or the continuation of an unabated first wave – could make that number even higher.

But these are not unprecedented times.

As a historian of medicine at the University of Michigan, I am a student of the 1918 influenza pandemic. It remains the deadliest public health event in recorded history. There are lessons to be learned from what happened a century ago. True, there are differences between then and now. Then we were a nation at war, with an economy led by manufacturing and a male-dominated workforce. We had far less medical and scientific knowledge. And it was an entirely different virus. But striking similarities exist between how we reacted to the pandemic in 1918, and how we’re responding now.

Lessons from the last century

The city of Denver, Colorado, is perhaps the most relevant case study. As the epidemic skyrocketed, officials ordered the immediate closure of schools, churches, and places of public amusement. Indoor public gatherings were banned. Such action, it was argued, would save lives and money.

The business community agreed. One theater owner put it this way: “I shall sacrifice gladly all that I have and hope to have, if by so doing I can be the means of saving one life.”

That noble sense of civic duty quickly faded as townspeople took to congregating outdoors. They met in the busy downtown shopping district and at outdoor church services and lodge meetings. Business owners and those thrown out of work by the closure orders decried these gatherings; they were bearing the brunt of the closures, they said, while the public shirked its duty. Denver’s health officer, calling out the “criminal neglect” of those at the open-air assemblies, added outdoor gatherings to the prohibitions.

Within just two weeks of the closures, residents grew restless. As records of new cases leveled off, many demanded an end to both the closure order and gathering ban. Giving in to the pressure, the mayor and health officer announced the measures would be lifted on Nov. 11, 1918. That day – in a horrible twist of fate – turned out to be Armistice Day. Thousands thronged the streets, hotels, theaters, and auditoriums of Denver to celebrate both the end of World War I and the pandemic. But only one of them was truly over.

Health authorities realized a new surge of influenza deaths were likely but acknowledged there was little they could do. “There is no use trying to lay down any rules regarding the peace celebration,” said one official, “as the lid is off entirely.”

The next wave hits

The surge came hard and fast. Within a week, physicians reported hundreds of new cases and dozens of deaths per day. Officials responded with another set of closure orders and gathering bans. Theaters, bowling alleys, pool halls, and other places of public amusement were shut down. Affected business owners, complaining they were singled-out, formed an “amusement council,” and demanded the city close all places of congregation or issue a mask order. City officials acceded. They put a mask order in place.

Enforcement was an issue. Residents routinely refused to wear masks even when threatened with arrest and hefty fines. The mayor soon realized the futility of the order. “Why, it would take half the population to make the other half wear masks,” he said. “You can’t arrest all the people, can you?” Officials then backed off again: they would recommend mask use, not require it.

Except for streetcar conductors. They still had to wear them, said the city. Bristled at being singled out, the conductors threatened to strike. A walkout was averted when city officials again watered down the order. Conductors only had to wear them during rush hour commutes. The new provisions were all but useless, and a few days later the mask rule was abolished.

Denver’s epidemic continued for several months. It was unchecked by any public health orders, save for isolation and quarantine for those with the illness. The result: a second spike of deaths higher than the first, and one of the nation’s largest per capita death tolls.

History could repeat itself

Surely at least some of this sounds familiar. If Denver’s story tells us anything, it is that we must do better than in 1918. All of us must continue to combat COVID-19 with face masks and social distancing in public. Recent studies show face masks, along with hand sanitation and social distancing by a majority of the population, can quickly bring this pandemic under control.

Those levels of compliance, however, might become increasingly difficult. In 2020, we are bristling much the same way they did in 1918. A century ago, masks were widely despised; many today feel the same way. Yet if we don’t take these measures seriously, we will likely face a resurgence of the virus.

If the past offers us any perspective into the future, it is this: returning to the sweeping closures and stay-at-home orders that we’re emerging from may be difficult. It proved all but impossible to do so a century ago. It very well may prove impossible today.The Conversation

J. Alexander Navarro, Professor of History of Medicine, University of Michigan

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Last Updated on Monday, 06 July 2020 18:22
Aventura Hospital and Medical Center Achieves Healthgrades 2020 Patient Safety Excellence Award Print E-mail
Written by FHInews   
Saturday, 20 June 2020 00:00

Aventura Hospital in the top 5% in the Nation for Patient Safety

Miami, Florida – Aventura Hospital and Medical Center announced recently that it is a recipient of the Healthgrades 2020 Patient Safety Excellence AwardTM. This distinction places Aventura Hospital among the top 5% of all short-term acute care hospitals reporting patient safety data as evaluated by Healthgrades, the leading resource that connects consumers, physicians and health systems.

During the study period (2016 through 2018), Healthgrades 2020 Patient Safety Excellence Award recipient hospitals demonstrated excellent performance in safeguarding patients in the Medicare population, as measured by objective outcomes—risk-adjusted patient safety indicator (PSI) rates—for 13 PSIs defined by the Agency for Healthcare Research and Quality (AHRQ). A 14th PSI included in the evaluation is Foreign Objects Left in Body During a Surgery or Procedure which is a “never” event and does not have an expected rate.

Healthgrades found that patients treated in hospitals receiving the Patient Safety Excellence Award were, on average*:
  • 48.3% less likely to experience a collapsed lung due to a procedure or surgery in or around the chest, than patients treated at non-recipient hospitals.
  • 54.4% less likely to experience a hip fracture following surgery, than patients treated at non-recipient hospitals.
  • 66.8% less likely to experience pressure sores or bed sores acquired in the hospital, than patients treated at non-recipient hospitals.
  • 63% less likely to experience catheter-related bloodstream infections acquired at the hospital, than patients treated at non- recipient hospitals.
In addition, if all hospitals in the country performed at the level of award recipients for each of the 13 patient safety indicators, 110,864 patient safety events could have been avoided.*

“Aventura Hospital and Medical Center is dedicated to delivering on excellence always and keeping patient safety top of mind. Our hospital and medical care teams do so by upholding safeguards in place throughout the entire patient experience at our hospital, says David LeMonte, Chief Executive Officer.”

“Consumers might not know that information around patient safety is readily available and should be considered when researching healthcare options,” said Brad Bowman, MD, Chief Medical Officer, Healthgrades. “We commend the recipients of the 2020 Patient Safety Excellence Award for their dedication to providing excellent care for their patients.” 

View Healthgrades hospital quality methodologies.

*Statistics are calculated from Healthgrades Patient Safety Ratings and Excellence Award methodology which is based primarily on AHRQ technical specifications (Version 2019.0.1) to MedPAR data for years 2016 through 2018 and represent three-year estimates for Medicare patients only.

About Aventura Hospital and Medical Center
Aventura Hospital and Medical Center provides highly specialized tertiary care services, including cardiac surgery, cancer treatment and management, orthopedic and spine surgery, neurosurgery and other complicated treatments or procedures. The facility has served the northern Miami-Dade County area since 1965 and today offers 407-licensed beds. Leveraging the latest technologies and treatment protocols and serving as a designated Level II Trauma Center and Comprehensive Stroke Center, Aventura Hospital meets both the elective and emergency healthcare needs of its neighboring communities and international visitors. As a State of Florida designated statutory teaching hospital, Aventura Hospital is also fulfilling a significant mission to educate and train future medical professionals with residency and fellowship programs in emergency medicine, general surgery, internal medicine, anesthesiology, pulmonology  & critical care, cardiology, gastroenterology, radiology, psychiatry, transitional year, pulmonary disease, infectious disease, podiatry, hospice and palliative care, and geriatrics.

Last Updated on Thursday, 25 June 2020 13:56
A Family With Five Doctors — And Two COVID Deaths Print E-mail
Written by Natalia Megas, The Guardian   
Tuesday, 16 June 2020 09:35

On the morning of April 1, Dr. Priya Khanna inched her way from the bedroom to the front door, using walls, doors and railings to hold herself up long enough to get to the stretcher waiting outside. She had been battling COVID-19 for five days and was struggling to breathe.

Her mother, also COVID-positive, watched helplessly as EMTs in full personal protective equipment guided Priya into the ambulance. Priya waved to Justin Vandergaag, a childhood friend walking alongside her. “I’ll see you later,” he said.

Ten days earlier, a similar scene unfolded when Priya’s father, Dr. Satyender Dev Khanna, was hospitalized for COVID-19.

The Khannas would soon suffer the most appalling of fates, as the two doctors from the same family encountered an illness against which they were fatally powerless.

Their story reveals the conundrum facing health care workers, who care for their patients while exposing themselves and their loved ones to risk. And it underscores how unprepared U.S. hospitals still were more than a month after news of community transmission of COVID-19 was first detected in the country.

COVID-19 has hit New Jersey hard, particularly in the north where the Khannas live. According to a database maintained by The New York Times, the state has recorded nearly 165,000 confirmed coronavirus cases and more than 12,300 deaths.

News of the pandemic had unsettled Priya, a 43-year-old nephrologist in the town of Glen Ridge. She suffered from a rare autoimmune disorder called small-cell vasculitis, and the medication she took to treat it compromised her immune system. She knew that if she contracted COVID-19 she would become very ill.

Priya, which means “beloved” in Hindi, had decided in college to become a doctor and graduated from Kansas City University of Medicine and Biosciences in 2003. Both her sisters were also doctors. She became certified in both internal medicine and nephrology, opened her own practice and was the director of two dialysis centers.

“She navigated the world with kindness and delight,” said a childhood friend, Laura Stanfill. She was “extremely selfless, a fiercely devoted friend and loyal,” said another, Melissa Auriemma. She gave long bear hugs and loved Lizzo, Hello Kitty, designer purses and anyplace with a beach.

Priya’s father fell ill in early March; the family is unsure how. Satyender, 78, was an immigrant from India who came to the U.S. with a medical degree and so little money that he did not know if he could afford the taxi ride to the hospital where he was to start his internship. In the 1980s, he became one of the first doctors in New Jersey to perform laparoscopic surgery, and was a trauma and general surgeon his whole career.

Five days after Satyender became sick, Priya’s mother, Kamlesh, a retired pediatrician, did, too. Priya, who lived with her parents, immediately isolated herself from them. She grew worried about her own health after a patient coughed directly in her face.

On March 20, Satyender was hospitalized, and a day later was placed on a ventilator. As a courtesy to Priya’s mother, the ICU physicians let her see her husband at the hospital he had worked at for more than 35 years. She suited up in her own personal protective equipment (PPE) and held his hand for a few minutes before being ushered away. It was a few weeks before what would have been their 50th anniversary.

“That was the last time she physically saw him alive,” said Dr. Anisha Khanna-Sharma, Priya’s younger sister and a pediatrician. “After that, we could only virtually see him on the iPad.”

Priya herself was taken to Clara Maass medical center, the 427-bed facility where her father was being cared for, on April 1. Because her sister Sughanda, an ER doctor, had her own full-body protective suit, she was able to gain better access than most visitors and found a situation reminiscent of a war zone.

There wasn’t enough proper PPE. Sughanda recalled intervening when the registration clerk, not wearing protective gear, leaned into Priya’s face to ask her questions. Priya didn’t receive a blanket or a pulse oximeter, and was not continuously connected to a patient monitor, the family said.

Sughanda and Anisha took turns FaceTiming with Priya. She was having trouble breathing, despite receiving 100% oxygen, and almost urinated on herself because she was too weak to walk to the common bathroom. She asked for a commode but never got one.

“They didn’t feed her,” said Anisha. “My sister didn’t get a meal at the hospital for the first 2½ days.” Instead, Anisha and Sughanda asked a nurse they knew to deliver food to her, and raised the alarm with hospital executives.

In a statement to The Guardian, RWJBarnabas Health, which operates the hospital, said it adhered to the guidelines of the Centers for Disease Control and Prevention regarding the proper use of PPE.

“Providing high-quality patient care is our priority, and that has never wavered even as we continue to treat those who are suffering from the coronavirus,” said spokesperson Stacie Newton. “While we do not comment on individual patients, we can assure you that all of our patients are treated with the utmost dignity and respect and any family concern is treated with attention, discretion, and privacy.”

Priya was weak but still reviewed patient files and texted with her replacement physician up until she went on a ventilator. Meanwhile, her sisters tried valiantly to find treatments. They put Priya and her father on a waitlist for the COVID-19 drug remdesivir. They sought and found hundreds of matches for an experimental treatment in which blood plasma from people who have recovered from COVID-19 is administered to patients.

Yet there were numerous bureaucratic delays. By the time the sisters were able to administer units to Priya and Satyender, it was too late, they said. Although it remains unclear at what point in the course of the illness the unapproved therapy is most helpful, Priya’s sisters are convinced their family could have benefited from earlier treatment.

“I think the doctors and nurses and staff did a phenomenal job in terms of doing what they could with what they had,” Sughanda said. “Was the hospital prepared for this? Absolutely not. Did they have enough resources to treat? Absolutely not. They did not have enough of anything to cover the surge of patients that were coming through the hospital.”

On April 13, Priya passed away, followed by her father on April 21.

After Priya died, Sughanda and Anisha both received packages in the mail of clothing Priya had bought for their children.

Every now and then, Auriemma, the childhood friend, rereads messages she sent Priya while she was in the hospital to cheer her up.

We gotta go to Oregon.

We gotta go out for lunch.

We gotta do our movie date.

“She was an excellent nephrologist. But it was short-lived,” said Kamlesh, Priya’s mother. “She touched so many lives, I can’t even tell you. She was the kindest, sweetest person I ever met in the whole world. I think that’s why God took her away from us. She was an angel.”

Last Updated on Tuesday, 16 June 2020 09:38
A Real Alternative to Laying Off Employees, Try Independent Contracting? First Understand the IRS’s 20 Factor Test Print E-mail
Written by Ben Assad Mirza, Esq., LLM, CPA, MPHA, CHC   
Monday, 08 June 2020 18:09

The pendulum from employee to independent contractor has started to swing. As Covid-19 plays out in the economy, department heads of healthcare organizations are being asked to cut their budgets.  Employers are unsure of demand and how to pay for employee salaries, payroll taxes and benefits. If there is not enough work to keep an employee working, employers are looking at independent contracting as an option to hold on to the worker.  The following are some great ideas to evaluate and implement that can help save money and commercial relationships.

Compensation Models - Independent contracting compensation generally takes one of three forms or a combination there of: (i) pay by the job/task, (ii) pay by the hours worked, or (iii) pay for end financial results.  The compensation can come in the form of an hourly rate, a fixed fee per procedure/task, or a percentage commission of the end financial result.  Depending on level of uncertainty and the desired goal the employer has in mind, it might be best to come up with a blended formula that draws upon these compensation combinations and that serves both parties best. 

IRS Requirements – IRS by far is the go-to authority on whether a person is an independent contactor or an employee, because it means collection of payroll taxes to the IRS.  Not all relationships are independent and worthy of independent contracting according to the IRS.  See IRS Publication 1779.  Even though an employer and contractor may agree to be independent, the IRS will look at the following factors to determine the independence of contractors:

Behavioral Control:  If the employer instructs the worker on how, when, or where to do the work, what tools to use, or what assistants to hire to help with the work; such extensive behavioral control make the worker more of an employee and less of an independent contractor.

Financial Control:  The worker may be an independent contractor if: the employer does not reimburse the person for all expenses; if the worker realizes a profit or incur a loss in the relationship.

Relationship of the Parties:  If there is a written contract that shows the mechanics of the intended transactions/work, that is also an indicia of the independent relationship.  However, if the worker receives employee type benefits like insurance or pension or paid leave, then no the person is deemed an employee. 

NOTE: Here is a downloadable Word file with the IRS’s 20 Factor Test at www.HealthcareAttorney.Net – Resources page:

Benefits of an Independent Contractor Relationship – Both the employer and worker typically have more freedom to contract with other.  The employer is not burdened with employer taxes; while the worker typically  gets paid at a higher rate and has the ability to write off expenses.
Author Contact Information:
Ben Assad Mirza, Esq., LLM, CPA, MPHA, CHC
Healthcare Law Partners, LLC
Fort Lauderdale

Last Updated on Tuesday, 09 June 2020 08:58
ICUs Become A ‘Delirium Factory’ For COVID Patients Print E-mail
Written by Liz Szabo, Kaiser Health News   
Wednesday, 03 June 2020 15:39

Doctors are fighting not only to save lives from COVID-19, but also to protect patients’ brains.

Although COVID-19 is best known for damaging the lungs, it also increases the risk of life-threatening brain injuries — from mental confusion to hallucinations, seizures, coma, stroke and paralysis. The virus may invade the brain, as well as starve the organ of oxygen by damaging the lungs. To fight the infection, the immune system sometimes overreacts, battering the brain and other organs it normally protects.

Yet the pandemic has severely limited the ability of doctors and nurses to prevent and treat neurological complications. The severity of the disease and the heightened risk of infection have forced medical teams to abandon many of the practices that help them protect patients from delirium, a common side effect of mechanical ventilators and intensive care.

And while COVID-19 increases the risk of strokes, the pandemic has made it harder to diagnose them.

When doctors suspect a stroke, they usually order a brain MRI — a sophisticated type of scan. But many patients hospitalized with COVID-19 are too sick or unstable to be wheeled across the hospital to a scanner, said Dr. Kevin Sheth, a professor of neurology and neurosurgery at the Yale School of Medicine.

Many doctors also hesitate to request MRIs for fear that patients will contaminate the scanner and infect other patients and staff members.

“Our hands are much more tied right now than before the pandemic,” said Dr. Sherry Chou, an associate professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh School of Medicine.

In many cases, doctors can’t even examine patients’ reflexes and coordination because patients are so heavily sedated.

“We may not know if they’ve had a stroke,” Sheth said.

A study from Wuhan, China — where the first COVID-19 cases were detected — found 36% of patients had neurological symptoms, including headaches, changes in consciousness, strokes and lack of muscle coordination.

A smaller, French study observed such symptoms in 84% of patients, many of which persisted after people left the hospital.

Some hospitals are trying to get around these problems by using new technology to monitor and image the brain.

New York’s Northwell Health is using a mobile MRI machine for COVID patients, said Dr. Richard Temes, the health system’s director of neurocritical care. The scanner uses a low-field magnet, so it can be wheeled into hospital rooms and take pictures of the brain while patients are in bed.

Staffers at Northwell were also concerned about the infection risk from performing EEGs, tests that measure the brain’s electrical activity and help diagnose seizures, Temes said. Typically, technicians spend 30 to 40 minutes in close contact with patients in order to place electrodes around their skulls.

To reduce the risk of infection, Northwell is using a headband covered in electrodes, which can be placed on patients in just a couple of minutes, he said.

The Brain Under Attack

“Right now, we actually don’t know enough to say definitely how COVID-19 affects the brain and nervous system,” said Chou, who is leading an international study of neurological effects of the virus. “Until we can answer some of the most fundamental questions, it would be too early to speculate on treatments.”

Answering those questions is complicated by the limited data from patient autopsies, said Lena Al-Harthi, a professor and the chair of the microbial pathogens and immunity department at Rush Medical College in Chicago.

Authors of a recent study from Germany found the novel coronavirus in patients’ brains.

But many neuropathologists are unwilling or unable to perform brain autopsies, Al-Harthi said.

That’s because performing autopsies on patients who died of COVID-19 carries special risks, such as the aerosolization of the virus during brain removal. Pathologists need specialized facilities and equipment to conduct an autopsy safely.

Some of the best-known symptoms of COVID-19 might be caused by the virus invading the brain, said Dr. Robert Stevens, an associate professor of anesthesiology and critical care medicine at Johns Hopkins University.

Research shows that the coronavirus may enter a cell through a gateway known as the ACE-2 receptor. These receptors are found not only in the lung, but also on organs throughout the body, including many parts of the brain.

In a recent study, Japanese researchers reported finding the novel coronavirus in the cerebrospinal fluid that surrounds the brain and spinal cord.

Some of the most surprising symptoms of COVID-19 ― the loss of the senses of smell and taste ― remain incompletely understood, but may be related to the brain, Stevens said.

A study from Europe published in May found that 87% of patients with mild or moderate COVID-19 lost their sense of smell. Patients’ loss of smell couldn’t be explained by inflammation or nasal congestion, the study said. Stevens said it’s possible that the coronavirus interacts with nerve pathways from the nose to the brain, potentially affecting systems involved with processing scent.

A new study in JAMA provides additional evidence that the coronavirus invades the brain. Italian researchers found abnormalities in an MRI of the brain of a COVID-19 patient who lost her sense of smell.

Many COVID patients develop “silent hypoxia,” in which they are unaware that their oxygen levels have plummeted dangerously low, Stevens added.

When hypoxia occurs, regulatory centers in the brain stem — which control respiration — signal to the diaphragm and the muscles of the chest wall to work harder and faster to get more oxygen into the body and force out more carbon dioxide, Stevens said. The lack of this response in some patients with COVID-19 could indicate the brain stem is impaired.

Scientists suspect the virus is infecting the brain stem, preventing it from sending these signals, Temes said.

Collateral Damage

Well-intentioned efforts to save lives can also cause serious complications.

Many doctors put patients who are on mechanical ventilators into a deep sleep to prevent them from pulling out their breathing tubes, which would kill them, said Dr. Pratik Pandharipande, chief of anesthesiology and critical care medicine at Vanderbilt University School of Medicine in Nashville, Tennessee.

Both the disease itself and the use of sedatives can cause hallucinations, delirium and memory problems, said Dr. Jaspal Singh, a pulmonologist and critical care specialist at Atrium Health in Charlotte, North Carolina.

Many sedated patients experience terrifying hallucinations, which may return in recovery as nightmares and post-traumatic stress disorder.

Research shows 70% to 75% of patients on ventilators traditionally develop delirium. Delirious patients often “don’t realize they’re in the hospital,” Singh said. “They don’t recognize their family.”

In the French study in the New England Journal of Medicine, one-third of discharged COVID-19 patients suffered from “dysexecutive syndrome,” which can be characterized by inattention, disorientation or poorly organized movements in response to commands.

Research shows that patients who develop delirium — which can be an early sign of brain injury — are more likely to die than others. Those who survive often endure lengthy hospitalizations and are more likely to develop a long-term disability.

Under normal circumstances, hospitals would invite family members into the ICU to reassure patients and keep them grounded, said Dr. Carla Sevin, director of the ICU Recovery Center, also at Vanderbilt.

Just allowing a family member to hold a patient’s hand can help, according to Dr. Lee Fleisher, chair of an American Society of Anesthesiologists committee on brain health. Nurses normally spend considerable time each day orienting patients by talking to them, reminding them where they are and why they’re in the hospital.

“You can decrease the need for some of these drugs just by talking to patients and providing light touch and comfort,” Fleisher said.

These and other innovative practices — such as helping patients to move around and get off a ventilator as soon as possible — can reduce the rate of delirium to 50%.

Hospitals have banned visitors, however, to avoid spreading the virus. That leaves COVID-19 patients to suffer alone, even though it’s well known that isolation increases the risk of delirium, Fleisher said.

Although many hospitals offer patients tablets or smartphones to allow them to videoconference with family, these devices provide limited comfort and companionship.

Doctors are also positioning patients with COVID-19 on their stomachs, rather than their backs, because a prone position seems to help clear the lungs and let patients breathe more comfortably.

But a prone position also can be uncomfortable, so that patients need more medication, Pandharipande said.

All of these factors make COVID-19 patients extremely vulnerable to delirium. In a recent article in Critical Care, researchers said the intensive care unit has become a “delirium factory.”

“The way we’re having to care for patients right now is probably contributing to more mortality and bad outcomes than the virus itself,” said Dr. Sharon Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, a long-term care facility in Boston. “A lot of the things we’d like to do are just very difficult.”

Last Updated on Wednesday, 03 June 2020 15:46
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