Thanks as always to Dr. Mike Silverman, Chair of the Department of Emergency Medicine at the Virginia Hospital Center in Arlington, for these superb updates!
Friday Night Update from the ER in Arlington, VA
The COVID numbers are back where they belong. I reported a pretty substantial increase in COVID cases diagnosed in the ER when I wrote last Friday. This week, the COVID numbers look much better. The total this week of COVID-positive patients that were tested because of “covid symptoms” was the lowest we have seen in quite some time. And the positive numbers among all patients tested in the emergency department were more in line with early October than the week that ended last Friday. The number of patients hospitalized with COVID remains pretty steady. It’s higher than two Fridays ago but similar to last Friday. You may recall that we had a pretty big bump last Friday compared to the week before, but we’re generally in the ballpark of where we’ve been for months and far from our peak numbers.
But the emergency department is pretty much as busy as we have ever seen it. Our volume this week (and actually last week) is 20+% higher than our typical volume. We are definitely seeing this with the flu and RSV numbers. We’re also seeing this in the increased number of pediatric patients coming to the ER. I worked our lower acuity side during my last shift. During that shift, I see my own patients and I supervise two advanced practice providers (APP) that are working in the unit with me. We had two families check-in within minutes of each other to get seen for flulike symptoms which brings me back memories of our omicron surge last winter, when we routinely had families check in throughout the day. One of the APPs I was supervising that day told me he thought he diagnosed 10 people with the flu. I also had a solid handful of people with the flu that day. I do not recall seeing anyone with COVID but it’s certainly possible I did. There is a lot of influenza A going around. The overwhelming majority of these patients have not been vaccinated. Also, the overwhelming majority of these patients do not require hospitalization. Rather they just need supportive care—fluids, Tylenol, and ibuprofen.
With that said, just like with COVID, the elderly and immunocompromised are at high risk. We’re also seeing an uptick in pediatric hospitalizations with flu. The CDC released data and a statement recently that “flu season is making an early comeback as flu-related hospitalizations are the highest in over a decade for this point in the season,” according to CDC. “There have been an estimated 880,000 cases of lab-confirmed influenza illnesses, 6,900 hospitalizations and 360 flu-related deaths nationally this season.”
The flu tests that we used in the emergency prior to COVID were generally not very good. Because of that, it was very uncommon to ever test people for the flu when it was not flu season. We always knew that if you tested enough people, we would find a little bit of flu even in the summer but given the accuracy of the older flu test, the sensitivity and specificity of the tests limited their usefulness outside of flu season. And whether you had a positive or negative flu test in a patient with a presumed viral illness, lack of testing generally did not change management.
For quite some time, we’ve had access to a test called a respiratory viral panel. This is a very accurate but extremely expensive test that can identify numerous different viruses (but far from all viruses). It takes a while for the lab to run it and historically the benefit of the results does not outweigh the cost or the time needed to get results for the typical emergency department patient who is going to be discharged. This test was often reserved for patients with respiratory infections who required admission to the hospital. This panel does test for flu as well as RSV and is very accurate. Therefore, we always knew we had a little bit of flu and RSV around.
The primary PCR COVID test that we have used for the last couple of years tests for both COVID and flu with the same swab. This was incredibly helpful last winter during the omicron surge and flu season, so we knew which one we were dealing with. (As it turned out, there has been very limited flu since the pandemic began.)
I cannot say enough good things about our hospital lab team, reports team, and our business intelligence team when it comes to providing data for the me (and others) since the start of the pandemic. I realize some of you want more details than I provided through the last couple of years. Some of those details were very challenging to come by and would have required chart reviews. For example, in the first 6 months after vaccinations were available, the percent of patients admitted with COVID that were either vaccinated or not was really interesting. This is a great question and one that was being studied in other centers, but not one that was clinically relevant for your typical community hospital. And unfortunately, it wasn’t practical to hire someone to do chart audits and track that kind of data.
With that said, I asked the lab for some updated flu data and they sent me a fantastic graph. Between our dual COVID/flu test and our respiratory viral panel, we generally test for flu and RSV about 1600 times a month. However, in January of this year and last month (October), we performed more than 2000 of these tests. Last January during our COVID surge, we had 11 positive flu tests and 3 positive RSV test. Last month, October, we had 160 positive flu test and 59 positive RSV test. I’m willing to bet that the overwhelming majority of those were in the second half of October and probably in the last week of October. For comparison, the number of flu positive tests in the summer is typically in single digits as is the number of RSV positive tests throughout most of the year.
Coronavirus is not quite done with us yet.
Science matters. Get vaccinated (or your booster). Keep a mask handy.