Is your bedroom the new hospital?

In his book “Home Game: an Accidental Guide to Fatherhood,” author Michael Lewis tells the story of his infant son’s admission to the hospital for a lung infection with respiratory syncytial virus, commonly known as “RSV.” His son requires oxygen during his stay but gets no other treatment: no antibiotics, no steroids, no ventilator. Michael speculates that the only reason his kid was admitted was so that nurses and doctors could check on him daily in case he got worse and needed to be intubated. And so, feeling the burn of a lost night’s sleep for both himself and his son, Michael stages a minor protest to allow his son to rest. He meets every potential visitor to the room at the door and demands to know their purpose. Nurses are mostly let in. But if the visitor is a resident or medical student “checking in,” for example, he gives them an update on his son’s respiratory rate and oxygen level and shoos them away. After a couple days his son improves and is discharged home.

As of the writing of this blog post roughly 130,000 Americans are hospitalized with COVID-19, up from ~96,000 at the beginning of December, resulting in more than a third of America’s hospitals operating at at least 90 percent capacity. Some of those inpatients are like Michael Lewis’s son: they’ve been admitted because of frailty or a combination of risk factors (age, other diseases, etc.) that put them at higher risk of death, and the primary treatments they are receiving are oxygen and steroid medications that could theoretically be delivered at home.

Like telemedicine, our very idea of the purpose of hospitalization may be morphing under the pressure of a viral pandemic, prompting changes that have been smoldering for decades. CMS is exploring ways to increase hospital capacity during the COVID-19 surge. We can’t solve this problem by building new hospitals. That takes time (at least outside of China), and hospital beds are needed in relatively small numbers in the US (compared to places like Germany) when viral pandemics aren’t raging uncontrollably. CMS is instead encouraging hospitals to be more aggressive in deciding who can be cared for at home in a program they call, unimaginatively, the “Acute Hospital Care At Home” program, a waiver allowing qualifying health systems to provide hospital-level care at patients’ homes for more than 60 conditions, including common reasons for admission like asthma, congestive heart failure, and pneumonia. You can’t be “admitted” to your own bedroom via telemedicine; you have to be transferred from an in-person emergency department or traditional inpatient hospital bed after an in-person evaluation by a physician. And surgical care clearly needs to be done in the traditional setting, at least for now.

Some companies, having anticipated this need, are marketing equipment or even using artificial intelligence-based systems for monitoring “hospitalized” patients at home. And it seems to work. “Hospital at home” may be marginally better than traditional hospitalization: a study in the Annals of Internal Medicine showed that with one home hospital program, only 7% of patients had to be readmitted to the hospital within 30 days of discharge, compared to 23% of inpatients in traditional care, and the average cost of care of home was 38% lower than care in the hospital.

So the next time you’re on your way to the hospital (heaven forbid), be sure to keep your choice in the back of your mind before you hit the door: would you rather be cared for in the hospital, or would you rather convalesce in the comfort of your own bed?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Is it time to retire the handshake?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Last Sunday at my church the congregation turned, as we always do, to greet one another. The pastor had a runny nose, but she repeatedly reassured all of us that it was from allergies, not an infection. I, too, was experiencing some rhinorrhea, mine exercise-induced from a hard bike ride that morning in the cool air. But as people started to reach for my hand I couldn’t block the results of an experiment from my mind. Bill Bryson wrote about it in his book “The Body: A Guide for Occupants.” The Mythbusters later re-created it. In the experiments, a confederate wore a device in his nose to a party. The device imitated a runny nose: it dripped at 60 mL per hour, roughly the same rate as someone with a viral cold. The fluid was clear, but fluoresced under black light so that investigators could track it later. The partygoers—who were unaware this was happening—went about their business, and at the end of the night everyone was examined with a black light to see where the fake, fluorescent snot ended up. Not surprisingly, everyone at both parties ended up covered in it. In the Mythbusters version, even people who had been instructed to “act like germophobes” had demonstrable contamination with the fluid. The one exception? A woman who had refused to shake hands with the drippy confederate.

With this information roiling around inside my head I ducked out of the sanctuary and into the bathroom. I washed my hands for twenty seconds and returned to my seat. With a worldwide viral pandemic unfolding, I wondered, is it time to retire the handshake?

I asked around. One of my medical school classmates told me he attends church with a lawyer who asks for a fist bump instead of a handshake. My neighbor, a realtor, told me that handshakes are such an integral part of the ceremony of his work that he can’t imagine changing. (Ironically, he was diagnosed with influenza A last week. Don’t worry. He’s doing fine)

So I dove into the literature. In spite of mountains of evidence that our hands are filthy, we are very into shaking hands: 78% of patients want their physician to shake their hand, and docs and patients shake hands 83% of the time. But maybe there’s a middle ground. Dr. Leonard Mermel from Brown University (paywall) points out that studies have shown that alternate practices of greeting, such as fist bumps and high-fives(!), decrease the transfer of organisms from one person to another by 50-90%. And some clinical sites have gone so far as to ban handshakes (paywall), comparing the challenge of the discontinuation of the handshake in clinics to the change in smoking practices among doctors in the 1950s and 1960s.

The handshake is a powerful signal. It can bring adversaries together in a moment of shared respect. It can give unequal parties a moment of balance and equity. It can help a person quickly project that she is trustworthy, confident, and prepared. But it can also transmit a stunning number of organisms from one person to another in a short amount of time.

So for this winter or the COVID-19 pandemic, whichever ends first, let’s fist bump instead.

One of your employees is likely to get coronavirus disease. What should you know about it ahead of time?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Let’s get the semantics out of the way. “Viruses” are little more than small packaged strands of genetic material—DNA or RNA—that invade cells and trick those cells into reproducing the virus. The duplicates of the virus take up too much space inside an infected cell, and the cell ruptures like a balloon. This is how tissue damage occurs, like the sore throat you get with many respiratory viruses. Most viruses infect other organisms, ranging from bacteria to mammals and birds, and are harmless to humans. You can find hundreds of harmless viruses in a few ounces of seawater, for example.

But sometimes viruses cross over from other hosts to infect humans. We call such infections “zoonotic.” Coronaviruses are a family of RNA viruses similar in many ways to influenza. They are called “corona” viruses because of their “crown” of spiky proteins. Four common coronaviruses—229E, NL63, OC43, and HKU1—have long been known to infect humans. They cause colds. We’ve seen outbreaks of two other coronaviruses in the last couple decades. Severe Acute Respiratory Syndrome (SARS) was transmitted to humans from civet cats. Middle East Respiratory Syndrome (MERS) came from camels. The novel coronavirus discovered in 2019 in Wuhan, China, the seventh known coronavirus to infect humans, is likely either from bats or pangolins, those scaly mammals that look like a cross between a raccoon and a lizard.

The newly discovered virus is now officially known as “SARS-CoV-2,” short for “severe acute respiratory syndrome coronavirus 2.” The disease that SARS-CoV-2 causes is officially known as “COVID-19,” short for “coronavirus disease 2019.” But for the sake of conversation, let’s use “COVID-19” for the next 800 words.

By contrast, COVID-19 seems only slightly more contagious than a generic influenza strain, with an r0 so far between two and three. It is also a fairly middling organism, mortality-wise: it has a current observed mortality rate of two percent, a number which will probably decrease over time.

The identification and naming of the virus and the work already done toward producing a vaccine is a testament to the advancement of science. We have accomplished all this in the time it took to even identify H5N1 23 years ago. But in spite of this, we are unlikely to be able to contain the virus. Since the original index case of presumed bat-to-human or pangolin-to-human transmission, COVID-19 has proven able to be transmitted directly from human to human. We measure the human-to-human contagiousness of a virus by a statistic called r0 (pronounced “R naught”). The r0 is complex to calculate, but it ultimately reflects the number of other people a person with an infection can be expected to, in turn, infect. Some viruses have an astonishingly high r0. A person with measles, for example, can be expected to infect between twelve and eighteen others. HIV’s r0 is 4.3.

By contrast, COVID-19 seems only slightly more contagious than a generic influenza strain, with an r0 so far between two and three. It is also a fairly middling organism, mortality-wise: it has a current observed mortality rate of two percent, a number which will probably decrease over time. A particularly bad influenza virus has a mortality rate of 20 percent (as in the 1918 Spanish flu, which may have in fact originated in Kansas) or even 60 percent, as observed in Asian Avian Influenza A (H5N1). But the fact that COVID-19 kills few of its victims has the paradoxical effect of increasing its transmission. Those H5N1 patients either died quickly or got so ill so quickly that they could be isolated right away, so only a few hundred people eventually died. As Dr. James Hamblin writes in the Atlantic this week, “…much ‘milder’ flu viruses, by contrast, kill fewer than 0.1 percent of people they infect, on average, but are responsible for hundreds of thousands of deaths every year.”

So even with the quarantine of hundreds of millions of people in China and elsewhere, COVID-19 cases are now in dozens of countries, including the United States. We’ve now seen the first case of likely “community-acquired” COVID-19 in the U.S. Epidemiologist Dr. Mark Lipsitch told James Hamblin that, eventually, 40 to 70 percent of the world’s population will become infected, likely resulting in flu and cold seasons being slightly worse in intensity and slightly more diverse, virus-wise.

What do we tell our employees, then? The news is fast-moving, and I’ve already revised this blog post twice in two days before posting, so nothing mentioned here should be considered irrefutable. But the fundamentals of disease containment are well-established, they’re not sexy, and they don’t differ for COVID-19 at this point compared to other infections. If you get sick, CDC recommends that you:

1. Stay home except to get medical care.

2. Separate yourself within the home from others, including pets.

3. Wear a facemask if you’re forced to be around others, including pets.

4. Cover your coughs and sneezes.

5. Don’t touch your eyes or nose.

6. Wash your hands for at least 20 seconds with soap and water. If you can’t get to soap and water, use a hand sanitizer with at least 60% alcohol. THIS IS LIKELY THE BEST PIECE OF ADVICE WE HAVE.

7. Don’t share household items.

8. Clean all your “high-touch” surfaces, like counters and doorknobs, daily.

9. Once you are free from fever without using medications, free from symptoms including cough, and have had two negative sputum tests, CDC says you can be released from isolation.

If you’re around someone who is sick, CDC’s advice is the same: help the patient with basic needs to allow him or her to stay home, like groceries; monitor his symptoms, and if he’s getting sicker call his doctor; and wear a facemask and gloves when you interact or do laundry.

For businesses, CDC has similar interim guidance:

1. Encourage sick employees to stay home.

2. Separate and send home sick or coughing employees right away.

3. Encourage good hand hygiene and cough/sneeze etiquette.

4. Clean surfaces often.

5. Check CDC Traveler’s Health Notices before traveling.

And for heaven’s sake, if you haven’t already had a vaccination against influenza, get one now. It is not too late. You are still far, far more likely to get sick or die from influenza than from COVID-19; influenza causes between 12,000 and 61,000 deaths per year in the United States, yet we can’t get much more than about 50% of people to get immunized in any given year.