As the number of COVID-19 hospitalizations on Long Island continues to rise, doctors and nurses see one bright spot: The patients they’re treating today are more likely to survive than the ones they cared for during the spring coronavirus surge.
Improved treatments, a better understanding of the disease and months of experience caring for COVID-19 patients has led to the decline in death rates, doctors said.
"It’s definitely less frustrating and it’s less scary now," said Dr. Sahar Ahmad, a critical and pulmonary care specialist and director of critical care and ultrasound education at Stony Brook Medicine.
Dr. David Battinelli, chief medical officer at New Hyde Park-based Northwell Health, said that, unlike in March and April, "We know the natural history of the disease. We know how to treat the patients because we know what to expect. That will always make care better."
A New York University study of patients at the three NYU Langone hospitals, including NYU Langone Hospital-Long Island in Mineola, found a dramatic increase in survival for COVID-19 patients.
The study of 5,121 hospitalizations, published Oct. 23 in the Journal of Hospital Medicine, found that mortality dropped from 25.6% in March to 7.6% in August, even when adjusted for age and other characteristics.
Researchers can’t be sure which factors were most important, said Dr. Leora Horwitz, lead author of the study and director of NYU Langone’s Center for Healthcare Innovation and Delivery Science. But experience was key.
"In March, we had no idea what to expect," she said. "We had never seen this disease before. We didn’t know COVID caused blood clots. We didn’t know it caused kidney failure. We didn’t know we didn’t need to rush people onto ventilators, which we thought we had to do … . Now we can watch for and prevent complications earlier."
Ventilators can save the lives of people who have trouble breathing. But doctors learned that COVID-19 causes more damage to the lungs than most respiratory illnesses, making lungs more fragile and susceptible to further harm from ventilators pushing air into them, said Dr. Frank Coletta, chief of critical care medicine at Mount Sinai South Nassau hospital in Oceanside.
They also discovered that COVID-19 patients can tolerate lower oxygen levels than most other patients, so they now try to avoid ventilators if possible, instead using devices such as high-flow nasal cannulas, which are tubes that deliver oxygen through the nose, Coletta said.
In addition, nurses and doctors now know that proning — turning patients on their stomachs, which can help with breathing — can in some cases forestall the use of ventilators, Ahmad said.
Different medications are used today than in the spring. For example, there were early indications that the anti-malaria drug hydroxychloroquine might help coronavirus patients.
"In April, all the patients I was seeing would get five days of hydroxychloroquine plus azithromycin, and they would often get a course of antibiotics — things we don’t do now," said Dr. Jessica Justman, an associate professor of epidemiology at Columbia University and an infectious disease specialist.
Steroids, which reduce the coronavirus-triggered inflammation that can damage multiple organs, have been used since early on, she said. But, she said, "We didn’t really know the best way, the best dose, the best timing, how often it should be repeated. We were doing our best with incomplete information. We now have a much better understanding of how and when to use steroids."
In March and April, patients with COVID-19 symptoms arriving at hospitals were on average more severely ill than those arriving in recent months, making their odds at survival lower, said Dr. Sarun Thomas, director of the medical intensive care unit at NYU Langone Hospital–Long Island.
Many people who were sick but unsure if they had COVID-19 avoided hospitals as long as possible for fear of contracting the coronavirus there, Thomas said.
Research shows older COVID-19 patients are more likely to die than younger ones. Coronavirus patients today are on average younger, because "they are the cohort who are exposing themselves" the most to the coronavirus, Battinelli said.
The median age of patients in the NYU study dropped between March and August from 63 to 49. But researchers adjusted the mortality numbers for age and other factors, such as severity of illness, meaning the study assumed for statistical purposes that patients in March and August were similar — and there still was a large drop in death rates, Horwitz said. Survival rates improved for people of all ages, the study found.
Another factor in reduced mortality may be that many March coronavirus patients were infected before Gov. Andrew M. Cuomo shut down much of the state’s economy and before social distancing was common, Horwitz said. Experts theorize that lower doses of the virus may lead to less severe COVID-19 illnesses, and with masks and social distancing common by the summer, many people infected then likely had a lower amount of coronavirus in their bodies, possibly improving the possibility of survival, she said.
In the spring, many hospitals were far over their typical patient capacity and short-staffed.
"Everybody was getting pulled in to do things they don’t normally do," which can affect patient care, Horwitz said.
"ICU care in particular is very specialized," but with so many coronavirus patients in intensive care, ICU nurses needed assistance from non-critical-care nurses, she said.
Crowded hospitals also meant "less flexibility moving patients to where they needed to be, because there were fewer beds open," and strains on supplies and materials, she said.
"In general, it’s just not good to have an overwhelmed, overcrowded hospital," Horwitz said. "Even if everybody were perfectly experienced, and you had a highly trained ICU nurse at every bed, still you wouldn’t want to overwhelm the hospital."
Horwitz cautioned that the improved survival rates "are not written in stone." If New York hospitals again are filled over capacity, gains could be reversed, she said. That’s why it’s critical that mask-wearing, social distancing and other precautions continue.
"I know it’s really hard, and it’s been a long time, and people are tired of it," she said. "But the hard work they’re doing really is saving lives."