Exploratory Descriptive Analysis of Smart Speaker Utilization in the Emergency Department During the COVID-19 Pandemic.

BACKGROUND: In March 2020, the U.S. Department of Health and Human Services Office for Civil Rights stated that they would use discretion when enforcing the Health Insurance Portability and Accountability Act regarding remote communication technologies that promoted telehealth delivery during the COVID-19 pandemic. This was in an effort to protect patients, clinicians, and staff. More recently, smart speakers-voice-activated, hands-free devices-are being proposed as productivity tools within hospitals. OBJECTIVE: We aimed to characterize the novel use of smart speakers in the emergency department (ED). METHODS: A retrospective observational study of Amazon Echo Show® utilization from May 2020 to October 2020 in a large academic Northeast health system ED. Voice commands and queries were classified as either patient care-related or non-patient care-related, and then further subcategorized to explore the content of given commands. RESULTS: Of 1232 commands analyzed, 200 (16.23%) were determined to be patient care-related. Of these commands, 155 (77.5%) were clinical in nature (i.e., "drop in on triage") and 23 (11.5%) were environment-enhancing commands (i.e., "play calming sounds"). Among non-patient care-related commands, 644 (62.4%) were for entertainment. Among all commands, 804 (65.3%) were during night-shift hours, which was statistically significant (p < 0.001). CONCLUSIONS: Smart speakers showed notable engagement, primarily being used for patient communication and entertainment. Future studies should examine content of patient care conversations using these devices, effects on frontline staff wellbeing, productivity, patient satisfaction, and even explore opportunities for "smart" hospital rooms.

Health system adaptions to improve care for people living with non-communicable diseases during COVID-19 in low- middle income countries: A scoping review

Background During the COVID-19 pandemic, access to health care for people living with non-communicable diseases (NCDs) has been significantly disrupt-ed. Calls have been made to adapt health systems and innovate service delivery models to improve access to care. We identified and summarized the health sys-tems adaptions and interventions implemented to improve NCD care and their potential impact on low-and middle-income countries (LMICs). Methods We comprehensively searched Medline/PubMed, Embase, CINAHL, Global Health, PsycINFO, Global Literature on coronavirus disease, and Web of Science for relevant literature published between January 2020 and Decem-ber 2021. While we targeted articles written in English, we also included papers published in French with s written in English.Results After screening 1313 records, we included 14 papers from six countries. We identified four unique health systems adaptations/interventions for restoring, maintaining, and ensuring continuity of care for people living with NCDs: tele-medicine or teleconsultation strategies, NCD medicine drop-off points, decen-tralization of hypertension follow-up services and provision of free medication to peripheral health centers, and diabetic retinopathy screening with a handheld smartphone-based retinal camera. We found that the adaptations/interventions enhanced continuity of NCD care during the pandemic and helped bring health care closer to patients using technology and easing access to medicines and rou-tine visits. Telephonic aftercare services appear to have saved a significant amount of patients' time and funds. Hypertensive patients recorded better blood pressure controls over the follow-up period.Conclusions Although the identified measures and interventions for adapting health systems resulted in potential improvements in access to NCD care and better clinical outcomes, further exploration is needed to establish the feasibility of these adaptations/interventions in different settings given the importance of context in their successful implementation. Insights from such implementation studies are critical for ongoing health systems strengthening efforts to mitigate the impact of COVID-19 and future global health security threats for people liv-ing with NCDs.

Sickness presenteeism in healthcare workers during the coronavirus disease 2019 (COVID-19) pandemic: An observational cohort study.

Sickness presenteeism among healthcare workers (HCW) risks nosocomial infection, but its prevalence among HCW with COVID-19 is unknown. Contemporaneous interviews revealed a sickness presenteeism prevalence of 49.8% among 255 HCW with symptomatic COVID-19. Presenteeism prevalence did not differ among HCW with and without specific COVID-19 symptoms or direct patient care.

Management of acute genital ulcers, retrospective review of a tertiary Canadian centre and survey of North American Pediatric and Adolescent Gynecology care providers

Background: Acute genital ulcers (AGU) are painful ulcerations of the lower vagina and vulva. Lesions typically occur in adolescents and may be preceded by a viral illness such as Epstein-barr virus, cytomegalovirus and more recently, COVID-19. AGU is a diagnosis of exclusion, with limited data to guide investigations and treatment. We aim to retrospectively review the clinical course of patients presenting to our center with suspected AGU to characterize and evaluate local practice patterns. In addition, we survey pediatric and adolescent gynecology care providers to understand the work up and management of AGU across North America. Method(s): We performed a retrospective chart review between June 1, 2016 to June 30, 2021. Medical records were reviewed to capture demographic data, diagnostic work up and management. Data is presented descriptively, and time to resolution is compared for patients managed expectantly versus with corticosteroids using a Student's T-test. A cross-sectional survey created by study authors was distributed to members of the NASPAG. Data was summarized through descriptive statistics. Management practices between care providers were compared using Fisher's Exact test. Result(s): Overall, 25 patients were diagnosed and managed as AGU at our center during the study period. On average, patients were 13.2 years old (range 11 to 17 years). The majority (92%) reported prodromal symptoms. EBV and CMV were the most ordered serologies (64%);only 3 patients showed serologic evidence of acute viral infection. Conservative measures were recommended to 84% of patients. 40% of patients were prescribed corticosteroids. Average duration to resolution was 16.3 days, with no difference between patients managed supportively versus with corticosteroids (p=0.9). In total, 100 responses from NASPAG members were included. Most care providers reported seeing fewer than 10 patients with AGU per year (62%). Common diagnostic tests performed were herpes simplex virus polymerase chain reaction (82%), Epstein-barr virus serology (56%) and cytomegalovirus serology (47%). Most care providers recommended supportive management with topical analgesia (84%), NSAIDs (83%) and acetaminophen (64%). Topical steroids were considered by 67% based on the degree of accompanying inflammation. There was no difference in corticosteroid prescribing practices between types or location of providers (p > 0.05). Conclusion(s): Our retrospective review and survey capture practice patterns of AGU management amongst pediatric and adolescent gynecology care providers. Further collaboration is needed to prospectively evaluate the effectiveness of treatment modalities, and develop evidence-based guidelines to inform practice.Copyright © 2023

Antecedents to COVID-19 vaccine uptake among patients and employees in the Veterans Health Administration.

The present study sought to understand the antecedents to COVID-19 vaccination among those reporting a change in vaccine intention in order to improve COVID-19 vaccine uptake in the United States. We employed semi-structured interviews and one focus group discussion with vaccinated and unvaccinated Veterans Health Administration (VHA) employees and Veterans at three Veterans' Affairs medical centers between January and June 2021. A subset of these participants (n=21) self-reported a change in COVID-19 vaccine intention and were selected for additional analysis. We combined thematic analysis using the 5C scale (confidence, collective responsibility, complacency, calculation, constraints) as our theoretical framework with a constant comparative method from codes based on the SAGE Working Group on Vaccine Hesitancy. We generated 13 themes distributed across the 5C constructs that appeared to be associated with a change in COVID-19 vaccine intention. Themes included a trusted family member, friend or colleague in a healthcare field, a trusted healthcare professional, distrust of government or politics (confidence); duty to family and protection of others (collective responsibility); perceived health status and normative beliefs (complacency); perceived vaccine safety, perceived risk-benefit, and orientation towards deliberation (calculation); and ease of process (constraints). Key factors in promoting vaccine uptake included a desire to protect family; and conversations with as key factors in promoting vaccine uptake. Constructs from the 5C scale are useful in understanding intrapersonal changes in vaccine intentions over time, which may help public health practitioners improve future vaccine uptake.

In this study of the Veteran and VA employee population, we aimed to understand what factors led to a decision to receive a COVID-19 vaccine. As part of a quality improvement project, we interviewed individuals at three Veterans' Affairs sites in the first six months of 2021. We then used a smaller sample of 21 participants who reported a change in their intentions to receive a COVID-19 vaccine to analyze for this study. This analysis utilizes constructs from the 5C scale, which was developed to understand the conditions required for an individual to decide to receive a vaccine (confidence, collective responsibility, complacency, calculation, constraints). The coding process revealed a number of recurring themes across the interviews falling under each of the five constructs, but concepts relating to vaccine confidence (i.e., level of trust in those developing and disseminating the vaccine) were most common, and constraints (i.e., psychological and structural barriers that stand in the way of vaccination) appeared least frequently in our interviews. We found that significant motivators to receive the vaccine included a desire to protect family and conversations with trusted clinicians, particularly mental healthcare providers. Our study was unique in using the 5Cs to understand changes in vaccine changes over time. Findings show that change in vaccine attitudes is possible even in the presence of concerns and shed light on approaches that public health providers could use to improve vaccine and booster rates.

Staff and Veteran Perspectives on Residential Treatment Programs' Responses to COVID-19: A Qualitative Study Guided by the WHO's After Action Review Framework.

Healthcare must rapidly and systematically learn from earlier COVID-19 responses to prepare for future crises. This is critical for VA's Mental Health Residential Rehabilitation and Treatment Programs (RRTPs), offering 24/7 care to Veterans for behavioral health and/or homelessness. We adapted the World Health Organization's After Action Review (AAR) to conduct semi-structured small-group discussions with staff from two RRTPs and Veterans who received RRTP care during COVID-19, to examine COVID-19's impact on these programs. Six thematic categories emerged through qualitative analysis (participant-checked and contextualized with additional input from program leadership), representing participants' recommendations including: Keep RRTPs open (especially when alternative programs are inaccessible), convey reasons for COVID-19 precautions and programming changes to Veterans, separate recovery-oriented programming from COVID-19-related information-sharing, ensure Wi-Fi availability for telehealth and communication, provide technology training during orientation, and establish safe procedures for off-site appointments. AAR is easily applicable for organizations to debrief and learn from past experiences.

SOCIAL CONNECTION IN OLDER ARKANSANS DURING COVID-19: CHANGES AND SATISFACTION

Social support is important to the health and well-being of older adults. Changes in social support (both frequency and satisfaction with) and barriers to social support during the pandemic remain unknown. During Spring 2021 an automated phone survey of adults 65 and older in Arkansas was completed. Calls were placed to 27,296 households where 8,745 individuals answered, and 867 (N=723 White, non-Hispanic) older Arkansans completed the 18 question self-report survey. Results indicated that: 41% had curtailed their in-person interactions significantly;61% continued to engage in in-person social interactions outside of their home once a week or more;and social group activities decreased from 52% to 41%. Additionally, it was reported that 88% used technology for social interactions once a week or more and 60% reported technology interactions made them feel socially connected. Despite this, only 67% reported being satisfied with their social connection during the pandemic compared to 93% prior to the pandemic. While many participants continued in-person social interactions, social activity and satisfaction decreased during the pandemic. Social technology alternatives were used by many and for some, social connection was reported to be satisfactory. The value of what was learned from this survey has application outside pandemic times. Understanding and acknowledging that social isolation exists for older adults in normal times and improving technological access to social activities has great value. This knowledge can be used to substantiate the expansion and improvement of older adult friendly virtual platforms therefore contributing to reducing social isolation.

Organizational Readiness for Patient-Facing Mobile Teledermatology to Care for Established Veteran Patients in the United States.

Purpose: To improve patient access to skin care, the Department of Veterans Affairs (VA) developed a patient-facing asynchronous mobile teledermatology application (app), which allows patients to follow up remotely with dermatologists. To understand how the app would be received in VA, we examined Organizational Readiness for Change (ORC), an important prelude to effective implementation, which includes the shared resolve and collective ability of organizational members to implement a change. Methods: We used a mixed-methods multiple case study approach to assess ORC at three VA facilities. Data derived from a site process call, surveys, and semistructured telephone interviews of VA staff, field notes, and administrative data. Results: Participants at all three facilities supported the intervention and recognized the value of using the app to increase patients' access to dermatologists, but expressed concerns largely related to disruption of the pre-existing clinical workflow. Participants at the facility most actively using the app had the highest overall ORC score and reported the most facilitators. Facility leadership support when guided by a clinical champion minimized barriers by recognizing the complexities of health care provision at specialty clinics. Discussion: While provider buy-in remained a barrier, leadership, guided by the clinical champion, played a critical role instituting implementation strategies. The strong association between the ORC survey score and the presence of facilitators and barriers suggests that the ORC survey may be a rapid, convenient, and effective tool for health care systems to identify favorable sites for wider implementation of mobile telehealth care. Clinical Trials Identifier: NCT03241589.

COVID-19 surge readiness: use cases demonstrating how hospitals leveraged digital identity access management for infection control and pandemic response.

BACKGROUND: Surging volumes of patients with COVID-19 and the high infectiousness of SARS-CoV-2 challenged hospital infection control/safety, staffing, care delivery and operations as few crises have. Imperatives to ensure security of patient information, defend against cybersecurity threats and accurately identify/authenticate patients and staff were undiminished, which fostered creative use cases where hospitals leveraged identity access and management (IAM) technologies to improve infection control and minimise disruption of clinical and administrative workflows. METHODS: Working with a leading IAM solution provider, implementation personnel in the USA and UK identified all hospitals/health systems where an innovative use of IAM technology improved facility infection control and pandemic response management. Interviews/communications with hospital clinical informatics leaders collected information describing the use case deployed. RESULTS: Eight innovative/valuable hospital use cases are described: symptom-free attestation by clinicians at shift start; detection of clinician exposure/contact tracing; reporting of clinician temperature checks; inpatient telehealth consults in isolation units; virtual visits between isolated patients and families; touchless single sign-on authentication; secure access enabled for rapid expansion of personnel working remotely; and monitoring of temporary worker attendance. DISCUSSION: No systematic, comprehensive survey of all implemented IAM client sites was conducted, and other use cases may be undetected. A standardised reporting/information sharing vehicle is needed whereby IAM use cases aiding facility pandemic response and infection control can be disseminated. CONCLUSIONS: Clinical care, infection control and facility operations were improved using IAM solutions during COVID-19. Facility end-user innovation in how IAM solutions are deployed can improve infection control/patient safety, care delivery and clinical workflows during surges of epidemic infectious diseases.

HUMORAL AND T CELL RESPONSES TO COVID-19 VACCINATION IN INFLAMMATORY BOWEL DISEASE

BACKGROUND: The characteristics of SARS-CoV-2 vaccine-induced immunity in inflammatory bowel disease (IBD) patients on immune modifying agents has not been clearly defined due to their exclusion in vaccine trials. Emerging results suggest infliximab impairs antibody response compared to vedolizumab. However there has not been direct comparison to controls. We evaluated this with both humoral and T cell response in IBD patients. METHODS: Antibody and T cell response were analysed in IBD patients who received BNT162b2 (Pfizer–BioNTech) or ChAdOx1 nCoV-19 (Oxford–AstraZeneca) vaccination from a single Australian centre. The control group were healthcare workers (HCW) without IBD. Blood samples were taken at 4 time points: at baseline V0 (before vaccination);V1 (7- 14 days after vaccine 1);V2 (7-14 days after vaccine 2);V3 (21-42 days after vaccine 2). Antibodies to the S1/2 IgG subunit and receptor-binding protein (RBD) were measured and reported here. RESULTS: 88 (28 ulcerative colitis, 50 Crohn's disease) IBD patients were included and compared to 53 healthy controls (Table 1). IBD patients medications included 6 5ASA (6.8%), 6 immunomodulator monotherapy (6.8%), 14 anti-TNF monotherapy (15.9%), 32 anti-TNF combination therapy with immunomodulator (36%), 16 IL12/23 (18%) and 13 vedolizumab (14%). Pre-vaccine baseline sera showed absence of anti-RBD antibodies in all participants. 84 patients (87%) received BNT162b2 and 4 (4.5%) received ChAdOx1 nCoV-19 vaccines. Geometric mean [SD] anti-S1/2 antibody concentrations at 4 weeks after second vaccination (V3) were significantly lower in IBD TNF treated patients (162.6[1.7]) compared to IBD non TNF treated patients (325.2[1.3]), and healthy controls (325.2[1.3]), p<0.0001 (Figure 1). There was no difference between non-TNF treated patients including those on vedolizumab or IL12/23 compared to controls. Similarly there was a significant difference between anti-RBD IgG titres between TNF and non-TNF IBD patients at V3 but not when compared to controls. There was no difference in RBD IgG and anti-S1/2 antibodies between anti-TNF monotherapy and combination therapy. All healthy controls and most IBD patients seroconverted at V3. 2 patients that failed to seroconvert were on steroid. CONCLUSION: TNF agents influence SARS-CoV-2 vaccine-induced antibody response in IBD patients, with lower anti-S1/2 IgG concentrations compared to non-TNF IBD patients and healthy controls. However, there was no difference in RBD IgG concentrations. It is unclear whether these subtle differences in antibody response in IBD patients on TNF agents is biologically meaningful, as most seroconverted after second dose vaccination. They may translate to differences in antibody longevity, but this is yet to be demonstrated. Neutralising antibody and T cell (CD4+/CD8+/follicular T cell) data from this study to come. (Table Presented) (Figure Presented)

SUPPORTING PSYCHIATRY WORKFORCE THROUGH COVID-19: INITIATIVES AT VICTORIAN BRANCH, RANZCP

Background: The COVID-19 pandemic posed significant challenges for all and particularly for healthcare workers. Psychiatrists, affiliates and trainees stepped up to support their patients as well as their colleagues. Objectives: During the difficult phase of COVID-19 with far and wide, known and unknown impacts on mental health and well-being, especially on healthcare workers, the Victorian Branch, Royal Australian and New Zealand College of Psychiatrists, decided to prioritise supporting the membership of psychiatrists, trainees and affiliates. Methods: Direct initiatives at the Branch level included regular newsletters, COVID-19 well-being survey, member-support webinar series as an effort to engage with and support the wider membership. The Branch also worked with the Department of Health and Human Services (DHHS) to consider practical measures to support the psychiatry workforce during these unprecedented, challenging times of COVID-19. The Branch negotiated a funding approval worth more than A$50,000 from DHHS, which was then offered as COVID-19 Member Support Grants to fund projects that aimed at supporting the well-being of the psychiatry workforce in Victoria. A total of 10 projects were successfully funded to support members' well-being. These projects were creative with clear goals of well-being during COVID-19 and had wide uptake from trainees, affiliates and psychiatrists. Findings: To be discussed, including snapshot details on various initiatives and projects, attendance and uptake, findings and feedback.

MAKING CONNECTIONS: MENTAL HEALTH MEDICAL EDUCATION LEADS AUSTRALIA AND NEW ZEALAND (MHMELANZ)

Background: The mental health (MH) curriculum within undergraduate and postgraduate medical programmes in Australia and New Zealand is fundamental to MH competencies in graduate doctors. Despite a shared professional practice, there is an absence of a community of MH lead educators in medical degrees. Objectives: To develop a community of practice network, to enhance the quality, consistency and delivery of the MH curriculum and to enhance standards, resource development, teaching learning and assessment methodology. Challenges to consider include space in the curriculum, online learning during the COVID-19 pandemic and approaches to curriculum delivery posed by lived experiences of students. Methods: Development of the Mental Health Medical Education Leads Australia and New Zealand (MHMELANZ) Mental Health Educators network will be presented. Findings: MH medical education leads from a range of universities bi-nationally, representing graduate and undergraduate courses, will present an overview of the MH curriculum and current challenges and areas of focus for the MHMELANZ. Conclusion: There will be opportunity for discussion, and further development of a network, and a future special interest group with the Royal Australian and New Zealand College of Psychiatrists.

MENTAL HEALTH MEDICAL EDUCATION LEAD: UNIVERSITY OF MELBOURNE, MELBOURNE - MENTAL HEALTH EDUCATION IN A TIME OF COVID-19

Background: During COVID-19 in 2020, medical students at The University of Melbourne were withdrawn from clinical sites, leading to challenges in delivery of curriculum and assessment. Objectives: To describe the development of the Mental Health Medical Education Leads Australia and New Zealand (MHMELANZ) community of practice network. To outline the adaptations to teaching mental health (MH) in the medical doctorate (MD) at The University of Melbourne in 2020 and 2021, and future redesigned learnings and challenges. Methods: To outline the MH curriculum within the MD and MH during 2020 and 2021. Findings: Reduction in MH curriculum space, inequity in opportunity, adaptation of teaching to online (asynchronous to enhance clinical contact) and the need to address learning outcomes over 2 years. Presentation of governmental advocacy for essential worker status, while enhancing near-peer and well-being supports, is included. Conclusion: The capacity to adapt the curriculum and strong liaison between the university, hospitals and state government, has ensured delivery of the MH curriculum during 2020 and 2021. Future redesign of the MD will incorporate learnings through this experience and the MD will have an opportunity to be enhanced with the MHMELANZ network.

Perceptions and Use of Telehealth Among Mental Health, Primary, and Specialty Care Clinicians During the COVID-19 Pandemic.

Importance: Clinician attitudes toward telehealth may impact utilization rates, and findings may differ based on specialty. Objective: To determine whether clinician beliefs regarding telehealth quality and ease of use were associated with the proportion of care delivered via video, phone, and in-person across specialties. Design, Setting, and Participants: This survey study used a voluntary, anonymous survey conducted from August to September 2021 in the Department of Veterans Affairs New England Healthcare System (VANEHS). Mental health (MH), primary care (PC), and specialty care (SC) clinicians were invited to participate. Data were analyzed from October 2021 to January 2022. Exposures: Participation in a 32-item survey. Main Outcomes and Measures: The main outcomes were clinicians' views on relative quality of video, phone, and in-person care; factors contributing to clinicians' modality choice; telehealth challenges; and clinician modality preferences and utilization when treating new and established patients. Results: There were 866 survey respondents (estimated 64% response rate); 52 respondents reported no video or phone telehealth use in the 3 months prior to survey completion and were excluded, resulting in a final sample of 814 respondents. Respondents were divided among MH (403 respondents [49.5%]), PC (153 respondents [18.8%]), and SC (258 respondents [31.7%]). Compared with PC and SC clinicians, MH clinicians rated the quality of video care the highest (eg, compared with in-person care with masks when treating new patients: χ2 = 147.8; P < .001) and were more likely to prefer video over phone when treating both new (χ2 = 26.6; P < .001) and established (χ2 = 100.4; P < .001) patients remotely. PC and SC clinicians were more likely to rate phone care as being at least equivalent in quality to video for both new (χ2 = 26.3; P < .001) and established (χ2 = 33.5; P < .001) patients. PC and SC clinicians were also more likely to endorse challenges of video care, including patient barriers and the inability to conduct a physical examination (χ2 = 292.0; P < .001). Most PC and SC clinicians either had no preference (46 PC respondents [36.2%]; 59 SC respondents [28.4%]) or preferred phone (36 PC respondents [28.3%]; 67 SC respondents [32.2%]) for remote care of established patients. Findings aligned with utilization rates within VANEHS, with MH clinicians conducting significantly more of their encounters via video (36 734 encounters [40.3%]) than PC (3201 encounters [3.9%]) and SC (1157 encounters [4.9%]) clinicians. Conclusions and Relevance: These findings suggest that clinician attitudes regarding telehealth quality and ease of use were associated with utilization rates. Moving forward, clinician use of telehealth may be impacted by additional data regarding the relative effectiveness of modalities as well as improvements in video telehealth workflows.