July 15, 2020
Dear Members of the Baylor College of Medicine Community,
You want the bad news first?
Houston remains among the hardest hit regions in the global pandemic. You do not need me to tell you it has been a difficult week. You have lived it; you have been affected by it. Once a week, I try to reflect on our collective experience – to honestly assess the difficulties we face, but to also point out the positives. The bad news is easy to find. Sometimes you have to dig a little more for good news.
First the bad news. We have been carefully watching the Rt value, a measure of infectivity. If the Rt is greater than 1, we will see community spread. If it is less than 1, stabilization or even contraction of new viral cases. Last week the Rt was good news – this week it is bad. After peaking at almost 2 during the third week of June, physical distancing and masking efforts drove the Rt down to less than 1 in early July. Then came July 4. Since then, we have seen the Rt climb steadily back up to 1.5, where we would expect to see growth in community virus spread.
In fact, that is exactly what the numbers show. Bad news. After seeing daily new COVID-19 cases climb rapidly, we enjoyed about 2½ weeks of stabilization. Unfortunately, on July 14 we experienced a new high in community cases – 2,962 confirmed new cases in a single day in Harris and surrounding counties.
These two facts frame the challenge for our public officials. Does the Rt drop and subsequent rise mean that all the masking, limited closures and public education efforts were successful, and that July 4 is a momentary blip that will quickly pass? Or did we never really effectively impact the viral infectivity? Keep in mind, any action we take today will not impact new cases for about two weeks, and improvement in hospital dynamics will lag another week or so. Do we stay the course – and risk accelerated community spread? Or do we implement more aggressive community lock-down efforts – and create economic hardship for many? These economic hardships will be borne disproportionately by those in the community that can afford it the least. Good people will disagree on the right path forward, but I would contend that anyone that thinks the answer is obvious has not thought deeply enough. This is hard.
Now for some good news. Across all TMC facilities, mortality rates for patients admitted with a confirmed diagnosis of COVID-19 have dropped significantly. In April and May, the mortality rate was almost 17% – currently, it is about 8%. I have previously discussed the reasons this is probably occurring – younger patient population, better therapeutics, improved systems of care. This is good news, and a testament to the power of learning health systems.
More good news. After a period of steady growth, hospitalizations (both ICU and general medical/surgical admissions) seem to have stabilized at about 350 per day. By way of comparison, for most of May the rate was about 50 per day. The cumulative ICU capacity of the TMC is barely into “Phase 2”, and does not seem to be at risk of overwhelming our ICUs for at least the next four weeks. There is one major caveat here: these are aggregate numbers across all TMC institutions. Individual hospitals may be at different stress points. For example, due to Ben Taub Hospital’s unique role in our community, caring for the most vulnerable among us, it seems to be impacted the earliest in patient surges, and relief seems to be the most delayed as things improve. Still, stabilization of new hospitalizations is good news.
You might reasonably wonder: If we are seeing 6-7 times the number of daily COVID-19 patients compared to May, how are our hospitals not being completely overrun? Data from Baylor St Luke’s Medical Center (BSLMC) help to answer this question, and it is more good news.
Let’s compare April and May at BSLMC with June and July. In April/May if a patient was admitted to the hospital, the average length of stay (LOS) was just over 18 days. Currently, LOS is averaging 5.3 days, less than a third of what it was. Good news. (Full disclosure, there are still patients in the hospital that have not yet discharged, so the 5.3 days may creep up, but it will not erase the substantial improvement).
In April/May, if you were admitted to BSLMC you had a 57% chance of winding up in an ICU, and you would stay there for more than 20 days, on average. Currently, you would only have a 35% chance of ICU admission, and your stay would only be about 5 days. Good news.
In April/May, if you were admitted with COVID-19 you would wind up on a ventilator about 44% of the time. Currently, the rate of mechanical ventilation is approaching 14%. Good news.
All of these dynamics – shortened length of stay, less need for ICU resources – help to create capacity, and are a big part of the reason we are not entirely overwhelmed. This should in no way be interpreted as minimizing the seriousness of the current crisis – a crisis in which we are now squarely in the middle. But it is a good opportunity to pause to recognize the incredible work our physicians, nurses, respiratory therapists, residents, fellows and other providers have done to deliver an exceptional level of quality care – and continually improve that care – in extraordinarily challenging times. This is probably the best news of all.
I am sure all of you join me in my fervent hope this recent surge is a temporary July 4 effect. We will learn much in the next week about where this is headed. There will be more news, good and bad. Regardless of what hand we are dealt in this next round, I remain confident that the talent, knowledge and commitment of the Baylor community will get us though. Hang in there, take care of yourselves, and take care of each other.
James McDeavitt, M.D.
SVP and Dean of Clinical Affairs