Metro Detroit hospitals team on treatments as outbreak strains resources
The COVID-19 pandemic has forged unprecedented cooperation between Metro Detroit health systems on potential treatments for the respiratory illness but also created tension as they coordinate how to spread patients in crowded facilities to less-filled ones across Michigan.
But health leaders say their systems are working together to push for more resources to care for thousands of sick patients overwhelming hospitals as potential cases multiply by the minute.
"We are all in it together, and we all need help, and we all need resources — three times more resources than we currently have," said Dr. Teena Chopra, chief of infectious diseases at the Detroit Medical Center, on Monday.
"Wayne County is pretty much exploding at this time."
In response, Chopra said DMC, Beaumont Health and Henry Ford Health System are "making a lot of decisions as a combined health care system in Southeast Michigan."
"We have been transferring patients elsewhere, and we are really looking forward to the arrangements being made at the (TCF) Center," said Chopra, referring to bed spaces being created at the Detroit convention center for patients with mild symptoms.
"We know that this week and the coming few weeks are going to be very tough on us — just like New York. We have asked for help, just like every other southeast Michigan hospital."
Several health systems, meanwhile, have been transferring patients to the University of Michigan health system, known as Michigan Medicine, to participate in a clinical trial of the medication Remdesivir, a general anti-viral medication. It was once contemplated as a possible treatment for SARS and MERS and tested in clinical trials as a treatment for Ebola.
Henry Ford Health System also has multiple studies underway, including one to evaluate the effectiveness of Remdesivir in treating coronavirus patients with moderate or severe symptoms, spokeswoman Kim North Shine said.
Since Henry Ford is already running trials with the drug, its transfers to Michigan Medicine are to help balance the number of patients the hospitals are treating, rather than for the university's Remdesivir study, she noted.
“In addition to the new trials, several Henry Ford patients have received Remdesivir under the compassionate use program that allows sick patients to have access to unproven treatment therapies,” North Shine said. “The patients are being monitored; however, it is still too early to tell if the medication has made a difference in their recovery.”
Recognizing there is no Food and Drug Administration-approved therapy to treat the virus, Henry Ford also is using off-label hydroxychloroquine on some hospitalized COVID-19 patients who meet certain criteria, North Shine added.
The Detroit-based hospital system is documenting its use of the product in the patient’s medical record to comply with the state Department of Licensing and Regulatory Affairs requirements.
But the effort at balancing patient loads across hospital systems “is not going smoothly,” said Beaumont Health CEO and President John Fox.
“Right now, it’s a function of luck” if another hospital will open its doors to transfers, Fox said, “or the medical directors have to ask and beg and cajole, and it’s not effective.” He blamed the problem on a combination of incomplete data being provided by some hospitals to the state and worry among relief hospitals of quickly being overwhelmed by the transfers.
The state Department of Health and Human Services and Gov. Gretchen Whitmer's office did not respond to requests for comment on the problems with the load balancing plan.
The clinical treatments are part of an effort by Wayne State University and the region's four major health systems — DMC, Henry Ford, Ascension Michigan and Beaumont — to develop best practices for treating COVID-19 and potentially conduct clinical trials of possible treatments.
"This viral pandemic has no boundaries,” said Dr. Shukri David, chair of Cardiovascular Services at Ascension Michigan, in a press release about the partnership. “By combining the resources of our medical community, we will offer research opportunities."
The university and health systems hope to receive National Institutes of Health approval to bring two specific COVID-19 trials to southeast Michigan, including Moderna’s potential COVID-19 vaccine.
Moderna's chief executive officer said the company might provide the vaccine to a few people, which could include health care workers, as early as this fall. A healthy volunteer received the first COVID-19 vaccine on March 16. The company estimates it could take 18 months to make it commercially available, if the trials prove successful.
The institutions also hope to start clinical trials on Takeda’s hyperimmune globulin, a potential treatment. Using plasma from patients who have recovered from COVID-19, the company is evaluating a treatment that’s effective on other severe acute viral respiratory infections.
“The whole idea is we want to collaborate in the region, apply for the new trials and be part of discovering best practices and treatments for COVID-19,” said Dr. William W. O’Neill, an interventional cardiologist with Henry Ford, in a press release.
Various medications being used
Many area hospitals are treating patients with hydroxychloroquine, an unproven treatment they hope will lessen the severity of COVID-19 in some patients.
The FDA in late February issued an emergency use authorization for the use of hydroxychloroquine and chloroquine for treatment of SARS-CoV-2, another name for the disease caused by the novel coronavirus. Several Metro Detroit health systems say they are using it.
The decades-old malaria drugs have been championed by President Donald Trump for COVID-19 treatment to the consternation of some medical experts because little evidence is available on their safety or effectiveness.
"We have it on our formulary, and we’re treating our patients with hydroxychloroquine at the DMC," said Chopra, noting they're are not using it with the antibiotic azithromycin, a combination that's being tested in clinical trials.
"We don’t know at this point if the combination works, but we do know that hydroxychloroquine works, and we have actually successfully discharged several patients (who received the treatment)."
Dr. Nasir Husain, director of the Infection Prevention Program at Henry Ford Macomb Hospital, said doctors have been using hydroxychloroquine to treat COVID-19 patients but are exercising caution.
"We do have some patients on that," Husain said. "The thing to understand is that these drugs have not been shown in proper, vetted clinical trials to have different outcomes.
"Unfortunately, there's nothing out there in terms of good academic literature to show that either alone or in combination with either hydroxychloroquine or azithromycin it works," he said.
"It doesn't mean nobody's doing it — everybody's doing it, including us. But I'm quite skeptical, and I'm making sure we're not causing any harm to the patients."
Researchers are racing to learn more about the coronavirus, and the information available is changing every day. A study published Monday in the journal Physician's Weekly found chloroquine and hydroxychloroquine to be efficient in treating Chinese COVID-19 patients, though the sample of patients studied was small.
The state last week warned prescribers and dispensers against “stockpiling” hydroxychloroquine or chloroquine or prescribing them “without further proof of efficacy for treating COVID-19.”
There had been allegations physicians were prescribing the drug to themselves, friends or family “without a legitimate medical purpose” and the practice could create a shortage for those who take the drug for other illnesses, such as rheumatoid arthritis or lupus, according to the letter from state Bureau of Professional Licensing Director Deb Gagliardi.
“Reports of this conduct will be evaluated and may be further investigated for administrative action,” Gagliardi wrote last Tuesday. “Prescribing any kind of prescription must also be associated with medical documentation showing proof of the medical necessity and medical condition for which the patient is being treated. Again, these are drugs that have not been proven scientifically or medically to treat COVID-19.”
In follow-up correspondence last week, the department clarified that physicians and pharmacists should “adhere to the standards of practice and exercise the professional judgment applicable to their professions.”
Several medical, physician and pharmacy associations supported the department’s Thursday letter, noting that the medicine, when used for COVID-19, should be reserved for the state’s “sickest and most vulnerable patients” and physicians should avoid “excessive, anticipatory orders.”
Whitmer on Monday defended the policy and reiterated the need for an approach that balanced the demand between COVID-19 patients and those who were using the drug before COVID-19 to treat other conditions.
“We obviously want to be nimble in this crisis, and I think that we have a duty to make sure that we’re making educated policies that reflect the needs of the people of our state,” she said.
Henry Ford has moved some patients within its hospitals and sent others to the University of Michigan, according to Henry Ford's North Shine.
UM confirmed it had accepted transfers from different hospitals but did not say which ones or how many patients.
As of Monday, hospitals statewide had a total of 12,741 beds available, including 661 adult intensive care unit beds, according to state data. A total of 1,488 ventilators were available. The totals represent an 85% response rate from hospitals supplying data to the state.
In north and south segments of southeast Michigan’s Region 2, there were a total of 4,908 beds available Monday and 230 adult ICU beds. Region 2 had 778 ventilators available.
Including beds already occupied, the state has roughly 27,000 beds overall and 1,622 ventilators.
Beaumont's Fox said efforts to balance patients among hospitals are lagging because the data hospitals are supposed to be supplying to the state about their bed and patient numbers do not appear to be complete, causing the regional medical directors to “fly blind” when determining where there might be openings.
And even if hospital bed and patient data were complete, regional medical directors lack authority to demand hospitals take overflow, he said.
For example, on Saturday, the emergency department at Beaumont’s Farmington Hills hospital was “slammed” with coronavirus cases, Fox said. Even excluding those waiting in the emergency room, the hospital’s census was comprised of about 90% COVID-19 patients.
When the medical director for southeast Michigan’s Region 2, where Beaumont’s hospitals are located, asked other hospitals to accept patients from the Farmington Hills hospital, the director was turned down due to worries over personal protection equipment, known as PPE, or the prospect of taking on coronavirus patients, Fox said.
“Some hospitals simply said they’re not taking COVID-19 patients from an ER,” Fox said. “Others say they don’t have PPE. We’ve offered to send patients with PPE. … I think that everybody is maybe scared and worried about what it might be like next week.”
Eventually, Michigan Medicine agreed to take the patients, but the distribution should be balanced within the region, Fox said. And hospitals should not have to send a patient to an outstate location three hours away when there are openings within the region, he said.
“The hotspot in Michigan right now is Region 2,” Fox said. “You have some hospitals on total overload and some on less.
“The purpose of the state, from an emergency management standpoint, is to even it out.”