Daily numbers, graphs, analysis thread 4

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Welcome to thread 4 of the daily updates.

Resource links:
Worldometer UK page
Financial Times Daily updates and graphs
HSJ Coronavirus updates
Johns Hopkins Coronavirus Resource Centre
NHS England stats, including breakdown by Hospital Trust
Covidly.com to filter graphs using selected data filters
ONS statistics for CV related deaths outside hospitals, released weekly each Tuesday

Thank you to all contributors for their factual, data driven, and civil discussions.

We clapped a lovely chap out of the unit the other day, so glad he's done well, he admitted it was terrifying.

DH watched a news segment of staff clapping a patient. He pointed out that recovery/step down can’t be a frequent occurrence if it attracts such celebration/attention. Staff looked v. emotional.

Thank you for all you do, at this unprecedented time and all the more usual times before this and those yet to come, Herman

Caveat - I am not a statistician
The linked model seems to suggest we have already run out of ICU beds but that is at odds with the data the Government is producing.
I also have a serious question about modelling eventual death rates from COVID 19 unless you model up until vaccine availability. The U.K. might have the worst outcome now but it isn’t clear if we have taken a bigger hit than we needed to or just taken our hit earlier. It may depend on next winter.

DuLANGDuLANGDuLANG

ICU in-tubation, like CPR, is an extremely invasive, high risk intervention. Very, very few people survive it, even in "normal" times, without Covid. It supports you to enable your body to recover from the trauma/infection, however, you have be pretty fit and well beforehand to enable you to come out the other side. There will always be the good news stories, which are great, but it must be devastating for the staff to see the sheer volume of people not surviving, despite their best efforts.

Some would argue that demographics work against Ireland in that over 40% of the population of the entire country live in one city, Dublin, which is experiencing the worse of the Covid 19 outbreak.

I know a lot of people are arguing that the main reason we are seeing so many deaths is because we didn't lock down soon enough. I am not so sure. I think the biggest issue is the fact that in other countries people are getting into hospital much more quickly, especially in Germany, I don't know about Ireland but there's certainly far better access to primary care in Ireland than in the UK, because you have to pay to see a GP.

Here people have to call 111, they may or may not get through and by the time they do it may be hours or even days later, by which time it will be too late for them.

It's access to care here that is the issue. Once you get care, it's excellent.

But it's no good getting excellent care if you needed that care yesterday.

The population density of Dublin is around 4.5k per km2
12 London boroughs are more than double that and 3 are triple.
Barcelona has a population density of 16k per km2.

Ireland also has a lower death rate than Scotland or Wales, and taking into consideration that Irish deaths show ALL deaths, not just those in hospital, the rates are even lower (relatively). The BAME thing has been mentioned in relation to Ireland a lot. The Irish population is still over 90% white, and proportionally many more healthcare workers are white than in London or Birmingham.

I think people are being admitted to ICU in Dublin anyway earlier than they are in London, simply because there are currently fewer cases. I personally know four people in their 50s who were in ICU for under a week each and who are all back home. I don't think any of them would have passed the criteria for critical care admission in London at the moment.

I don't think Ireland have it beaten, but having double the rate of testing and contact tracing every single person who tests positive, is really helping.

Much lower figures again from Spain today. I do hope they are over the worst.

Glass That IHME model has since received updated info about recently added beds & ventilators
So they updated their model and revised their UK prediction down to 37,000

Stil would be the highest in Europe, but not as bad as original estimate

"ICU in-tubation, like CPR, is an extremely invasive, high risk intervention. Very, very few people survive it,"

Usually survival rates on ventilators are above 50% for most respiratory diseases

COVID is a particular problem in that patients often need 2, 3 even 4 weeks on ventilators, instead of the more usual 1 week for other ailments

I think these threads have brought home to me how complex and multifactorial the analysis is. I am not sure anyone would have been factoring in issues like sex, ethnicity and BMI into their models.

I imagine there will be a multitude of analytical papers published when this is under control.

re BAME deaths:

NHS staff are about 45% BAME, especially doctors and they have suffered a tragically high death rate

BUT
in critical care hospital beds,

⅔ of COVID patients overall are white:

Testing, contact tracing and monitoring cases are key enablers
which has enabled countries like Germany and S Korea to keep death rates low.

Other enablers are well-resourced health systems with large capacity,
including public health teams for contact tracing,
so they have plenty spare when a crisis like this arises

Testing enables more infected people to be isolated early on and hence slows spread of the virus

Testing is best combined with contact tracing, to find and test more cases

Once confirmed, these cases should be closely monitored by health teams and treated as soon as deterioration starts,
which can sometimes head off more serious problems

Early hospital admission to treat respiratory problems as early as possible, also improves prospects
Contrast that to the Uk when ambulances often refuse to take people unless they are have v serious respiratory problems

Thanks @BigChocFrenzy - that's very helpful. I do recall reading somewhere that the government were viewing 20K deaths as a "success" criteria.

Let's hope the fewer the better

WhyNotMe40 the patients are incredibly ill, they don't progress as we would anticipate, reach a certain point then have setback after setback. They don't seem to respond to the usual ventilation/ fluid strategies we use with ards patients. I'm pretty certain that none of our ventilated patients have been successfully extubated and discharged to the ward. Even the ones with tracheostomies are not weaning easily off mechanical ventilation, some are still being repeatedly prone positioned after over 2 weeks and are extremely sensitive to any intervention. The ones who do well have tended to just require cpap and self proning.
The crisis is compounded because of the volume of sedation, inotropes and equipment being used nationally. Our dietician is seriously worried that we will run out of feeding pumps and we are already trying different stategies to keep patients confortable whilst ventilated rather than iv meds.
One positive is that one of our consultants has developed a cpap mask using a snorkel mask which is effective, more comfortable, and uses less o2 flow !

for everything you and your colleagues do Herman.

ICU in-tubation, like CPR, is an extremely invasive, high risk intervention. Very, very few people survive it, even in "normal" times, without Covid.

I know! It’s why I’m so involved in this thread - my daughter had a bad reaction to a (common) virus BACK IN 2018 and was ventilated for several days. Took her almost a whole year to go back to primary school full time.

She had the absolute best care imaginable (PICU was like being on a space ship, calm, quiet, terrifying but having absolute faith that the nurses would land us safely back on earth) but no organised clapping on exit from PICU (not a complaint in any way, shape or form, just an observation. She had a small honour guard when she ‘rang the bell’ 10 months later).

I have massive respect for ICU nurses and Intensivists (and all the staff involved in DDs longer term treatment and follow up). I can’t imagine what it’s like trying to do that job in full PPE, worried for their own health, with an overflowing unit and redeployed, unfamiliar staff, unable to even reassure fellow team members with facial expressions, unable to have family members at the bedside, who in turn cannot benefit from the usual extended support ICU team.

I sat with my DD pretty much all day everyday, sleeping for just a few hours at Ronald McDonald house. I knew exactly who was my daughter’s 1:1 nurse while I was gone, and the nurses would often come in for the shift change and rearrange the allocation between themselves to give the patients and families as much continuity as possible. They plaited my sedated daughter’s hair and brushed her teeth and sang her songs. For those days, they truly felt like part of our family.

I can never repay what the NHS gave us

I worry about them everyday, even though they are not on the COVID frontline (but are instead tasked with caring for non-COVID critical care adults who have been moved to the paediatric unit for their own safety and to free up beds for COVID patients). Still, the hospital itself is obviously a contagion risk (and with all the hoo-ha around test accuracy and delayed test results, there are undoubtedly going to be patients with the virus who have been hospitalised for other reasons and either develop symptoms after admission or who become infected after admission).

Anyway, I digress (extremely emotive topic! Love our NHS hospital).

Back to data (ish) - is anyone else dreading the next couple of weeks of ICNARC reports and what they might begin to tell us about the patients who have been ventilated for 2-3 weeks before ‘resolution’? It’s long-established that the longer a patient is ventilated, the harder it is to get them breathing independently again (and there is no evidence to suggest that this isn’t also the case with CV19 patients).

CV19 is said to be unprecedented in terms of how many critical patients are requiring longer-than-average periods of ventilation - Italian doctors have said this on TV weeks and week ago, and NHS staff are saying it now. Andrew Cuomo mentions it often in his daily press conferences - the ventilator shortage (and the associated necessary drug shortages) are because the cumulative number of critical care patients is going up due to admissions happening more frequently than discharge.

Weeks of mechanical breathing support is one of the reasons why we are seeing a lag between hospitalised cases and ‘resolution’.

ICNARC data is an incomplete picture for now, but with all of the above in mind, the current 50/50 discharge/death figures are likely to get worse before they get better (and when they get better it might be because intensivists have a rapidly increasing knowledge base re: the clinical features of good candidates for intense medical intervention and the impact on overall deaths may be minimal).

At the moment the average ICU stay of resolved CV19 patients is broadly similar to that of historical non-COVID pneumonia patients. In the coming weeks I’m expected the gap between the two figures to widen, and potentially widen again, before settling into a more stable difference.

www.icnarc.org/DataServices/Attachments/Download/c31dd38d-d77b-ea11-9124-00505601089b

Wow kudos to that consultant!
That sounds incredibly scary , and must be very hard to deal with.

I remember reading early on before it took hold here, that the Chinese were finding better results if they put patients on oxygen and cpap early, which lowered the need for ventilation. But I understand here we are trying to get patients to stay at home until their condition is bad. Obviously we only hear things as filtered through the press. But I am scared the UK is not responding adequately in all sorts of areas.

I read that Germany does early oxygen also. We hear a lot about ventilators, but it's the amount of none invasive oxygen delivery masks that I would like to hear about

@Moomoomoomin I can't see if anyone has answered your question about underweight patients. That is where there is some early positive data - if you look at the ICNARC reports, patients with a BMI under 18.5 actually had similar or better outcomes statistically as a group than even the 'healthy weight' group. This is unusual as being underweight would normally mean worse outcomes from flu-related viral pneumonia (you can see the comparison in the columns).

Dulang lovely post and exactly why we love working on ICU.
Re snorkel masks they were from a well known french sports company beginning with ‘d’ They are aware and have taken them off the open market ! A local company who has a 3 d printer has made the connectors for the o2 supply.

I don't think Ireland have it beaten, but having double the rate of testing and contact tracing every single person who tests positive, is really helping.

Damn right. We missed that boat!

Some of the differences in outcome between countries will be demographic, or difficulties due to sheer population numbers...

but much of it will be swift, decisive, effective action by national and local governments,

Our lot did far too much fannying about at the beginning and are now chasing their own tails, rewriting health and safety protocols (and laws!) to try and disguise their incompetence.

Thank you QuarrantineQueen My BMI has always been 16.8. I was really ill with flu last year and was briefly hospitalised. I’ve been stressing that this would affect me worse because of my weight.

Yes and I think that is what Boris Johnson shows that early oxygen is key.

So how does that problem get solved because its a vicious circle - we dont want to overload the system so we get people to wait, they wait too long and then come in and need more care therefore further loading the system meaning there isnt space for those who need oxygen.

How do we change the model so that people come in earlier get oxygen sooner and then get to leave without ventalation?