By Dr. Anthony Policastro

There are some processes in the medical care system that are more frustrating than they are helpful. One of those is the admission of patients to the Emergency Department.

This is not something new. It has gone on for many years. One prime example occurred during my pediatric residency in the early 1970s.

I was working in the outpatient clinic. I had a patient with sickle cell disease come to see me because of a fever. She looked well. However, infections in sickle cell patients can be serious. Therefore, the treatment was to admit her to the hospital for IV antibiotics until we were sure the blood cultures showed no infection.

I wrote that admission order at 11 a.m. They proceeded to go through the admission process. At 1 p.m. one of my fellow residents passed by her room. The admission process was still taking place. He looked in and thought she did not look very good. He started the treatment and she promptly went into cardiac arrest. The resuscitation was unsuccessful.

The underlying issue is that there is a procedure for formally admitting patients to the hospital. Most of it involves paperwork. Some of it involves assessment by the admitting team. Some of it involves arranging for treatment to get started.

There are times when this process is not an issue. A patient that is being admitted for further monitoring can be monitored properly anywhere in the hospital. A patient who is being admitted for a surgical procedure needs preparation before the procedure.

There are other times when the process impairs treatment. This is often true in pediatrics. Many of the pediatric patients admitted to the hospital require IV antibiotics. The faster the antibiotics are started the quicker the treatment works.

As was the case with the girl I admitted during my residence, delays in getting the first dose of antibiotics into the patient can be fatal.

I had an approach that sometimes made the staff unhappy. When I was called to the ER for an admission, I would tell the ER physician to go ahead and admit the patient. I would then travel to the hospital. I would examine the patient to make sure that admission was correct. That process usually took 45 minutes.

At that point, I would walk the patient to the inpatient unit. That often did not allow the slow admission process to take place. The staff would tell me that I was doing it wrong. My response was that the only wrong thing would be to delay the antibiotics that the patient needed. 

They could take care of the rest of the process after that happened. If a patient was sick enough to be in the hospital, they were sick enough to be treated that way. My way was not always popular. However, more often than not, it was right.

COVID update- The national number of new cases this week was 480,000. Sussex County had 328 new cases. Both of those numbers are back to where they were before both the Delta and Omicron surges. Therefore, we have achieved baseline once again.

However, for the reasons recounted below, it appears that total numbers of new cases are no longer a yardstick to measure. New cases in vaccinated individuals tend to be so mild that they don’t really need to be counted. 

We now have ready access to at-home tests. Those are often not reported when positive. For example, states: “Over-the-counter rapid antigen tests do not require result reporting to the Division of Public Health.”

For those reasons, last week the CDC issued new guidance on mask wearing. They indicated that 62.6 percent of U.S. counties had low or medium risk levels of infections. Therefore, masks were no longer necessary for that group. As might be expected from the media purely looking for headlines, the guidance appeared confusing.

For that reason, I felt it might make sense to explain it in more detail to show the logic of it. In the past, I put out the list of the CDC criteria for threat levels by county. It was published by them in September 2020.

It broke each county into four risk categories (high, substantial, moderate and low). Sussex County recently has a case rate of about 175 cases/100,000 people. That would put it into the high category for that. Test positivity rate is only at 5.9 percent. That would be in the moderate range. Therefore, under the Sept. 2020 criteria we would be considered high because of the high number of cases.

Last week the criteria changed entirely. They no longer looked at just the total number of cases and percent of positive tests. They are now focused on severity of infection. That is logical since that is more meaningful (I have included a copy of a new chart showing both the old and new criteria for review).

They broke number of infections into two levels. One was where there were more than 200 new cases/100,000 people. The other was where there were less than 200 new cases/100,000 people. Those areas where the statistics fell into the low or medium range no longer had to wear masks.

Under the new criteria, Sussex County has less than 200 cases per 100,000 people (175/100,000 as noted above). The inpatient COVID population of 16.7 cases per 100,000 people puts us in the medium risk level. COVID patients take up 12.29 percent of total hospital beds. That percent is also in the medium range. That means that the CDC would not recommend masks for Sussex County residents at this point because of the medium risk level.