In omicron hot spots, hospitals fill up, but ICUs may not

In hospitals across the country, doctors are taking note: this wave of COVID-19 looks different from the previous one.

Once again, faced with the highly contagious variant of omicron, medical staff are exhausted and contract the virus on their own. And the number of patients entering hospitals with the variant is reaching staggering levels, filling much-needed beds, delaying elective procedures and increasing the risk of uninfected vulnerable patients catching the virus.

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But in omicron hotspots from New York to Florida to Texas, a smaller proportion of those patients end up in intensive care units or require mechanical ventilation, doctors said. And many – about 50% to 65% of admissions to some New York City hospitals – present to the hospital for other illnesses and then test positive for the virus.

“We are seeing an increase in the number of hospitalizations,” said Dr. Rahul Sharma, chief emergency room physician at NewYork-Presbyterian / Weill Cornell Hospital. But the severity of the disease appears to be different from previous waves, he said. “We don’t send that many patients to intensive care, we don’t intubate that many patients, and in fact most of our patients who come to the emergency room and test positive actually come out.”

While it is still early for firm predictions, the shift in hospital patterns matches emerging data that omicron may be a variant with inherently milder effects than previous ones, less prone to infecting the lungs, where it can cause serious illness. But the lower proportion of severe cases also occurs because, compared to previous variants, omicron infects more people who have previous immunity, whether through a previous infection or vaccination. The vast majority of omicron patients in intensive care units either go unvaccinated or have severely compromised immune systems, doctors said.

Hospitals, facing a staff shortage, are under enormous pressure. In New York, hospitalizations have passed the peak of the wave last winter. And Governor Larry Hogan of Maryland declared a state of emergency on Tuesday, noting that the state had more COVID-19 patients hospitalized than at any time during the pandemic.

“We’re really in crashed mode,” said Dr. Gabe Kelen, director of the emergency department at Johns Hopkins University School of Medicine in Baltimore.

The number of patients in intensive care is a lagging indicator, likely to increase in the coming weeks, according to experts. What’s more, some states are still struggling under the crush of delta hospitalizations, an older version of the virus perhaps more virulent. (Hospitals often do not know which variant newly admitted patients are infected with.)

Still, several reports suggest that omicron is a different enemy from previous variants. And the challenges hospitals face – at least so far – are less about stocking equipment and more about staffing and contagion, doctors said.

“At the start of the pandemic, we feared we would run out of things, like ventilators, ”said Dr. Ryan Maves, infectious disease and critical care specialist at Wake Forest School of Medicine in Winston-Salem, North Carolina. “Now the real limits are obviously the physical space of the beds, but even more so is the staff. “

When reports emerged in early December that hospitals in South Africa were treating relatively few severe cases of omicron, experts stressed the results should be interpreted with caution. South Africa has a relatively young population, and a large proportion had been infected by previous waves, leaving those affected with some pre-existing immunity.

But now that the virus has spread across the world, there is growing evidence that many people infected with omicron in recent weeks appear to be doing better than those infected with other variants or during previous outbreaks.

In Britain, people with omicron were about half as likely to require hospital care and a third less likely to be admitted to hospital from emergency rooms than those infected with delta, according to a government report published last week. Early reports from Canada suggest a similar trend.

And a new report from the Houston Methodist Health System, which has sequenced the vast majority of viral samples from its patients since February 2020, found much the same.

As of December 20, the new variant was causing more than 90% of new COVID-19 cases in Houston Methodist. In the new analysis, researchers compared 1,313 symptomatic patients who had been infected with omicron as of that date with Houston Methodist patients who had been infected with the delta or alpha variants starting earlier in the pandemic.

The number of omicron cases examined in Houston is low, and it takes time for the worst results to manifest. But less than 15% of those early omicron patients were hospitalized, compared to 43% of delta patients and 55% of alpha patients, according to the study.

Among those who were admitted, omicron patients were also less likely to need mechanical ventilation and had shorter hospital stays than those infected with the other variants.

“On average – and I stress the average – omicron cases are less severe,” said Dr. James Musser, president of pathology and genomic medicine at Houston Methodist, who led the research. He added: “And this is obviously good news for our patients.”

Omicron patients were also younger and more likely to be vaccinated than those with previous variants, which may partly explain the milder disease.

While the reports are encouraging, it is still too early and there is not yet enough detailed data to draw definitive conclusions about the inherent severity of omicron, Natalie Dean, a biostatistician at Emory University, told Atlanta.

“There really wasn’t enough time,” Dean said. It took months for many large studies on the risk of delta hospitalization to appear.

In New York, cases have steadily increased since December and are now mostly represented by omicron. COVID-19-related hospitalizations have also risen sharply, and intensive care admissions have increased more slowly.

At Langone Health at New York University, for example, about 65% of patients admitted with COVID-19 were found to “accidentally” carry the virus, and their hospitalizations were not primarily due to the disease. In NewYork-Presbyterian, just under half of COVID-19 admissions were accidental.

Hospitals in other cities have also reported higher rates of accidental infections. At Jackson Health System hospitals in Florida, 53% of the 471 COVID-19 patients were admitted to hospital primarily for other reasons. At Johns Hopkins Medicine in Maryland, 20% of patients seeking treatment for complaints unrelated to COVID-19 test positive for infections, said Kelen of Johns Hopkins.

Accidental infections can still pose significant risks to people hospitalized for other health problems. And the high number of hospitalized patients with asymptomatic COVID-19 presents an additional challenge for infection control.

“You should always put them in isolation,” said Dr Carlos del Rio, an infectious disease specialist at Emory University School of Medicine. “You should still treat them as patients who could potentially transmit COVID to the hospital. And when you have less staff, then you really have a problem. “

At NYU Langone, ICU admissions are 58% lower among people hospitalized with COVID-19 than they were in January 2021, spokeswoman Lisa Greiner said. At Mount Sinai South Nassau in Oceanside, New York, doctors are also seeing fewer patients requiring intensive care compared to previous peaks, but the number of cases means more people are falling seriously ill than in recent months. .

“I would say overall the disease is less severe,” said Dr. Aaron Glatt, chief infectious disease officer and epidemiologist at the hospital. But, he added, “We have had deaths from COVID, which we haven’t seen for a long time. And we see patients in intensive care and on ventilators, which we haven’t had in a long time. “

The majority of people who enter intensive care units are either unvaccinated or are vaccinated people from higher risk groups, experts said. And among people who enter intensive care units, cases can still be as severe as with previous variants.

The increase in hospitalizations has increased pressure on overcrowded hospitals.

Many hospitals were already struggling with staff shortages before the emergence of omicron. Even when hospital beds are available, the outflow of health professionals during the pandemic has made it more difficult to provide care.

“There just isn’t the capacity,” said Dr. Megan Ranney, emergency physician and academic dean of Brown University’s School of Public Health in Providence, Rhode Island. “There is no adequate staff for the beds that exist.

The rise in hospitalized cases of COVID-19 has come along with an increase in hospitalizations for other conditions, said Sharma of NewYork-Presbyterian / Weill Cornell, putting further strain on hospitals. At the height of the pandemic in 2020, those admissions plummeted as people without COVID-19 avoided hospitals.

“People are not afraid to come to hospitals like they were in 2020. Our volumes in our emergency rooms are almost back, if not higher, than pre-pandemic numbers,” Sharma said. “It means we’re busy; capacity becomes an increased challenge.

Staffing shortages are prompting many hospitals to consider cutting back on elective surgeries.

“We’re never going to rule out strokes, and we’re never going to rule out heart attacks,” said Ed Jimenez, CEO of the University of Florida’s Health Shands Hospital System. “But if it continues like this, we’re going to have hospitals that need to start considering slowing down their scheduled admissions.”

At Grady Hospital in Atlanta, “we hope we don’t cancel elective surgeries, but we did consider it,” del Rio said. “The reality is that we are seeing some of these elective surgeries canceling themselves because people come in and test positive for COVID. “

It has been about six weeks since the world first heard of omicron, and hospital staff are still eagerly awaiting to see how the coming weeks unfold.

As of Tuesday morning, the Houston Methodist had 630 inpatients with the virus at its eight hospitals, said Musser, the vast majority of whom most likely have omicron. That figure remains below the system’s peak delta – in which there were 850 to 900 patients hospitalized with the virus at a time – but the number of new cases continues to rise, he said.

“How high will he go?” he said. “I can’t tell you. I do not know. We are all watching it, obviously, very, very closely.

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