April 22 COVID-19 Update – Pennsylvania American College of Physicians

April 22 Pennsylvania COVID-19 Update

On Tuesday, the Department of Health reported that Pennsylvania had found another new 1,296 positive cases in the previous 24 hours, for a total of 34,528. The increase includes 981 confirmed cases and 315 probable positives. The death total rose to 1,564 deaths, an increase of 360 deaths from Monday, all in adult patients.  That number includes 1.264 were confirmed and 300 were probable.  The Health Department said the increase was due to better data collection and confirmation of cases and probable deaths will be reported in the future. 
The DoH ha now included trend animations on its website as well, for reference.
The state Health Department’s breakout of virus data for long-term care living facilities indicates 796 of the state’s deaths, about 51 percent, were nursing home residents.  There were 132,323  negative tests in PA as of midnight Monday night.
At least  1,677 are health care workers – accounting for about five percent of all positive cases; the total figure includes  572 in nursing homes. And from the department’s website, 5,026 cases – accounting for 14.5 percent of all cases- are in 396 of the state’s long-term care living facilities in 36 counties.
Two percent of hospitalizations were under 29 years of age, five percent were 30-49, nine percent were 50-64, 19% were 65-79 and 20% were 80+.  The remainder were unclassified yet per age.
Of the total through Monday, 18,332 positive cases (53%) were female and 15,482 (45%) were male. Two percent (714) were unreported or neither.  Among the deaths, 719 (54%) were males and 612 (46%) were female with 224 unreported by sex.
By race, 6,226 were Caucasian (18%), 3,097 were African-American (9%) and 321 (1%) were Asian, with 123 listed as “Other.”  The vast majority, 24,761 (72% of all cases) remained unreported on the race of the patient.
On Tuesday at noon,  2,665 were hospitalized, slightly less than 10% of those testing positive.  At that time, 672 were using ventilators or ECMO.  About 42% of beds, 36% of ICU beds are available, and 1464 of 5122 ventilators were in use (nearly 70% of ventilators were still available.) 
Of the patients who tested positive to date the age breakdown was: less than 1% are aged 0-4; less than 1% are aged 5-12; 1% are aged 13-18; 6% are aged 19-24; 39% are aged 25-49; 28% are aged 50-64; and 25% are aged 65 or older. 
See below for Tuesday’s Questions and Answers with Sec. Levine.
The Pennsylvania Department of Health (DOH) released guidance for making decisions about return to work for healthcare personnel (HCP) with confirmed COVID-19, or who have suspected COVID-19 but did not get tested for COVID-19). This HAN replaces guidance provided specifically for healthcare workers in PA-HAN-489
Details of the new guidance are available on our website here.
In summary, the Guidance says

  • Decisions about return to work for HCP with confirmed or suspected COVID-19 should be made in the context of local circumstances. Options include a test-based strategy or a non-test-based strategy.
  • A test-based strategy is preferred, where possible, for healthcare personnel (HCP) given that there is uncertainty about the length of time that a person who has recovered from COVID-19 is infectious.
  • In the presence of a shortage of testing supplies or a long turn-around-time for test results and staffing shortages, a non-test-based strategy should be employed.
  • Implement strategies described with the CDC guidance for mitigation of staffing shortages.
  • If HCP must return to work before meeting criteria, they should ideally perform non-direct care or direct care for persons who are confirmed to have COVID-19.

Decisions about return to work for HCP with confirmed or suspected COVID-19 should be made in the context of local circumstances. Options include a test-based strategy or a non-test-based strategy. 
Return to Work Criteria for HCP with Confirmed or Suspected COVID-19
Use the Test-based strategy as the preferred method for determining when HCP may return to work in healthcare settings:

The test-based strategy is preferred given that there is uncertainty about the length of time that a person who has recovered from COVID-19 is infectious. Use of a test-based approach might provide a greater level of confidence that HCP are no longer infectious compared to the non-test-based approach. This level of confidence might be particularly important for HCP who regularly come into contact with other HCP and vulnerable patients and residents.
If the Test-based strategy cannot be used, the Non-test-based strategy may be used for determining when HCP may return to work in healthcare settings

  • Non-test-based strategy. Exclude from work until
    • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
    • At least 7 days have passed since symptoms first appeared

HCP with laboratory-confirmed COVID-19 who have not had any symptoms should be excluded from work until 10 days have passed since the date of their first positive COVID-19 diagnostic test assuming they have not subsequently developed symptoms since their positive test.
If HCP had COVID-19 ruled out and have an alternate diagnosis (e.g., tested positive for influenza), criteria for return to work should be based on that diagnosis.
The guidance also provides restrictions and allowed practices for HCPs upon return to work and  outlines strategies to mitigate Health Care Personnel staffing shortages,
Return to Work becomes Issue for Wolf and Businesses
On Tuesday, Wolf reiterated that May 8 was his “target date” for the start of a phased reopening of the state. Between now and then, he said, specific guidelines will be issued. He said Tuesday that Pennsylvania’s comeback would be tied to its own profile during the virus, and not the experiences of other states.
In Pennsylvania, Wolf said, parts of the state less affected by the COVID-19 pandemic might see a more “robust” reopening than other areas. He used Philadelphia as an example of the latter category. There, 9,391 people have tested positive for the virus and 363 people have died.
On Monday, Governor Wolf had responded to a question from the news media  regarding unemployment benefits during Monday’s press briefing. The question was, “If we have employees that are currently laid off and we call them back to work and they tell us that they don’t or won’t come back because they’re getting paid more with unemployment and the $600 bonus, what can we do? Can their unemployment be revoked?”
Wolf had responded, “No, and as a former business owner, if you ever face that kind of situation, there’s one really simple thing you can do as a business owner and that is raise the compensation of your employees.”
The response created confusion and some pushback, and on Tuesday, the Governor and a press aide clarified that a person may not refuse work solely because they are making more on unemployment claim.  However, during the COVID-19 emergency, an employee at high risk of complications of the virus could seek a review if their employer cannot make reasonable accommodations for them, or if they were being asked to return to work at reduced hours that result in them earning less than they did before the pandemic.
“The governor’s point was that we all depend on those workers now more than ever and they deserve a safe work environment and living wage, which is why he has proposed a minimum wage increase each year he has been in office, among many other proposals to improve working conditions for workers,” said Penny Ickes, communications director with the Department of Labor and Industry. 
Gene Barr, President and CEO of Pennsylvania Chamber of Business and Industry, said, if you say ‘I’m not going back to work just because I don’t feel like it, I can make more money not working’ — that’s fraud, because you have to certify that you’re out of work through no fault of your own.”.
UPMC and DoH and resuming surgeries
UPMC said Tuesday that the coronavirus surge ‘simply hasn’t happened’, and that it will resume elective surgeries.  But during her Q/A period Tuesday afternoon, Health Secretary Dr. Rachel Levine said that, while the state has begun talking to hospitals including UPMC about resuming some surgeries, “we’re not there yet.”

Of 5,500 beds in the UPMC hospital system, only 2% are occupied by COVID-19 patients, as are 8% percent of intensive care beds, according to Donald Yealy, MD, UPMC’s head of Emergency Medicine.  He said UPMC has strong supplies of protective equipment such as masks, shields and gowns and that the 118 patients hospitalized with COVID-19 at UPMC hospitals are “not a significant increase from last week,” he said. He noted the rate of positive coronavirus tests through UPMC hospitals has dropped from 12 percent to 6.6 percent.
UPMC has been hearing from patients who delayed surgeries related to things such as heart conditions or cancer, and is “not comfortable with the disruption in care this has caused for people who don’t have COVID-19,” he said.  He said the surgeries that will be resumed might be called non-urgent because they are done on a scheduled rather than emergency basis, but are “essential” to people waiting for them.
Yealy said the expansion of surgeries is within federal guidelines and UPMC has notified Gov. Tom Wolf and Levine.  But it’s not clear whether UPMC’s plans will conflict with the priorities of Wolf and Levine, who continue to cite potential for an overwhelming surge and shortages, and to urge people not to relax social distancing and other steps to prevent spread of the disease.
Yealy said he couldn’t speak for the business side of UPMC, but the impetus toward resuming some elective surgeries “came from doctors and patients and not in response to a business concern.”
Insurers Covering Telehealth
Independence Blue Cross announced last night they will cover well visits via Telehealth: http://medpolicy.ibx.com/policies/mpi.nsf/6eeddf656d983ec98525695e0068df68/edb9b64528c16eb0852585500043c735!OpenDocument&Highlight=0,telehealth 
Cigna has been on board with telehealth payments as well. https://static.cigna.com/assets/chcp/resourceLibrary/medicalResourcesList/medicalDoingBusinessWithCigna/medicalDbwcCOVID-19.html  
And Aetna has provided the following:
What services can providers deliver virtually and what will they get reimbursed?
Any service that is currently on a provider’s fee schedule can be provided virtually.* This means that if a provider has a code on their fee schedule today that is reimbursable, they can offer that same service virtually and bill us using the same code (plus the GQ, GT, or 95 modifier), and be reimbursed the full face-to-face amount, at least until May 31, 2020. We will closely monitor and audit claims for inappropriate services that cannot be performed virtually (e.g., surgical codes). 
We expect to get more info from United Health Care this week.
General Assembly takes on Telemedicine, more
Telemedicine legislation passed, but headed for a veto
The State Senate today passed SB 857, the telemedicine bill, by a 29-21 vote, and the bill now goes to the Governor.  PA-ACP had supported the bill when it first passed the Senate, but opposed language the House put in that restricted telehealth prescription of products on the FDA REMS list.  The House has said it would not consider the bill without that provision, which includes 12 medicines that require an in person evaluation.
Shortly after its passage, Lt. Governor John Fetterman tweeted “Elections have consequences.” And “Another assault on women’s reproductive freedoms in Pennsylvania goes to die under Governor Wolf’s veto pen.”  Wolf’s spokespersons later confirmed that the Governor would veto the bill.
Senate Majority Leader Jake Corman said that if the bill is vetoed, he does not have another plan to address the situation with telemedicine.
Small business, health care bills moving in the House.
The House set up legislation for consideration next week that would provide for COVID-19 disaster emergency business interruption grants for small businesses.  This legislation provides grant eligibility requirements, grant amounts, application procedures, conditions, and for rules and regulati
ons to be established by the Department of Community and Economic Development. The House Insurance Committee next week will be taking up several other health related bills which now cover pre-existing conditions, essential health benefits, lifetime coverage insurance limits, mental health parity and addiction treatment.  These bills have been in the committee, some for a year, and the Democrats this week presented Discharge Resolutions which mandate action by the House if they are not considered by the Committee.  We expect amendments to all of these bills.
Q/As with Sec. Levine.
Sen. Casey secured a commitment to release names of nursing homes with COVID cases.  Does this require you to do that and when will you?  LEVINE: We will strongly consider that and need to figure out the right way to do that and we’ll look at that
Antibody testing in California shows their prevalence may be 50-80 times greater than we know.  What is PA doing?  LEVINE: We’re looking at that and can get an antibody test through Quest, we’ve looked at that study but have some concerns about it.  That’s how science works.  We look at it and other studies and compare.  The American Public Health Laboratory Association and CDC had a webinar yesterday, looking at random blood samples in several states including PA.  We’ll do that when it fits our platforms, but will be a surveillance test.
If you recover after testing positive will you be immune, and for how long?  LEVINE: We don’t really know the answer to that question.  With Chicken Pox, you knew you’d be immune.  With others, sometimes it’s partial and sometimes it’s not very long lived.  That remains to be seen, and for how long. S. Korea has studies, but science takes time.
Can you speak to testing in PA and what’s an adequate level?  LEVINE: We’ve done a good job and one of the top ten states, but not where we want to be.  We want more and want to expand and do mass testing more .Might consider other mass testing sites. Viral tests with nasal swabs, but need more information.
What’s the status on number of ICU beds, and are there counties with problems?  LEVINE: 41% are available, but in specific areas they are more challenged – in Phila and suburban counties.  We have opened up alternative care sites where that is a problem, for example at Temple. 
Given that it’s common knowledge about congregate care being an issue, why wasn’t there more concentration on testing at these facilities last month?  LEVINE: We are aware of that and have prioritized the vulnerable population, and prioritized getting PPE to those sites and doing everything we can in terms of consultations, National Guard, and all we can to protect those vulnerable seniors and staff there.
Will you require universal testing in those LTCs now?  LEVINE: No, a negative test only proves you don’t have active f=virus on that day – we can’t test every patient and staff person every day.  And testing once won’t give us the information we need.
Do you Compare PA to other states with less restrictions?  LEVINE: We have compared ourselves to other states and other countries – some more restrictive, like Italy.  We took a progressive, iterative phased approach from the beginning and that’s the way we’ll go now.
What does Positive redacted 1-4 in zip code reports mean?  LEVINE: If less than five cases we don’t report patient
Elective surgeries, – UPMC is ready to resume despite your orders. What’s the status?  LEVINE: We have had discussions with UPMC, and they are fully on board in terms of our current order, to allow more urgent if not elective surgery when the time is right.  The time is not right yet.  Will probably start in areas where we’re less affected by COVID.
What will it take to loosen the restrictions – is there a challenge to residents who need these surgeries? LEVINE: There is a risk and risk of infection by patients with COVID.  We need to preserve ICU’s PPEs and we’re prioritizing those. Working with hospitals, health systems and HAP, in Philadelphia, UPMC, Penn State, Geisinger and we’re pleased with that Prioritizing the pandemic, but the other part is true too.  Working to find a balance to find when urgent procedures can go forward.
A specific probably type is now being included without being listed.  Are there other types of probables that don’t appear in the official death counts?  LEVINE: No but that is not unusual. This is how infectious disease deaths are always reported.  We’re presenting our data in a robust transparent way for the public. Epidemiologists are disease detectives.
Do you believe the number of deaths caused by COVID are being underreported?  LEVINE: They are not, and especially now that we’re reporting deaths and probables.  Sometimes differences with timing of reporting.  If they collect data at 9-10 am will be discordance. Johns Hopkins as well.
State reported huge increase for second time in three days.  What’s the reconciliation?  LEVINE: We’re not actually seeing that many more deaths, it’s a collection of reports over weeks.  Data sources are NEDDS, and also those through vital records office and the electronic data system from coroners.  Difference today is adding probable deaths.
In the NY Times a doctor suggested COVID is sneaky and compromises lung functions – suggested pulse oximeters would help minimize cases needing ventilators.  Do you agree?  LEVINE: Not sure I’d use sneaky, that’s for a person and motivations.  Virus doesn’t have motivations.  Some are very vulnerable and can have serious complications. It IS complex and new, so it causes significant lung damage and other organ damage as well, brain, heart, kidneys, etc.  Measuring oxygen level can be very important but I think it should be under doctors’ care reporting electronically or by phone to a doctor about going in to seek care.  Someone – physician CRNP, PA should be monitoring.
A number of State lawmakers were at yesterday’s protest – would you suggest they be tested? LEVINE: We can’t test asymptomatic people, so with mean incubation period of five days, if they did not practice social distancing, shaking hands, not wearing a mask, in five days, they should contact their health care provider.  Should isolate, rest and watch their symptoms.  I expressed before that my main concern was that they would not social distance and would contribute to spread of the coronavirus.
Deaths are rising rapidly, but today hospitalizations were lower today than yesterday at noon.  Would a continuing decline in hospitalizations be a sign the virus is petering out? LEVINE:  We have been noting hospitalization trends over time and that would be a really good sign.
People want to be tested  in the Northeast, but Internet is only way to schedule a test.  Many have no access to website – can family or friends log on for them?  LEVINE: We weren’t satisfied with that system, and we are working with PEMA to find another way to register by phone, and hope to have more info later this week.  I don’t think that would be a problem if someone registered a loved one.
Are you truly serving everyone if people CAN’T register?  LEVINE: We’ll have an answer later this week.
Local appliance store is shut down, but Home Depot is selling appliances, and it looks like Black Friday at Lowes! Why is this?  LEVINE: I didn’t have anything to do with those decisions, but I know they are open so people can do repairs on their houses.  The Governor knows the economy is struggling and people and businesses are suffering.  Small Business Loans are available, that’s why May 8 will be aspects of the state will have more recovery with businesses and job
s – we will have more details later.  Those economic, business and job considerations have to be balanced with public health.
What percentage of the  population has been tested?  LEVINE: We know how many and with the general population we can do that.  But we need more testing and want to expand wherever possible.  Need reagents and chemicals and that’s been challenging.
Why did the state decide to use probable death NOW?  Who determines this?  LEVINE: Part of the work of our epidemiologists and how they usually report.  It’s just taken time to do this reporting.
Contact tracing will be really important to decisions on reopening.  No budget though – will the financial and testing inability hamper our ability to reopen?  LEVINE: We’ll be able to do that, and we have federal funds for it. we’re discussing what, how many personnel will be needed.  I have complete confidence in our disease detectives in doing that.