Learning from an equitable, data-informed response to COVID-19: Translating knowledge into future action and preparation

Introduction: The COVID-19 pandemic revealed numerous barriers to effectively managing public health crises, including difficulties in using publicly available, community-level data to create learning systems in support of local public health decision responses. Early in the COVID-19 pandemic, a group of health care partners began meeting to learn from their collective experiences. We identified key tools and processes for using data and learning system structures to drive equitable public health decision making throughout different phases of the pandemic. Methods: In fall of 2021, the team developed an initial theory of change directed at achieving herd immunity for COVID-19. The theoretical drivers were explored qualitatively through a series of nine 45-min telephonic interviews conducted with 16 public health and community leaders across the United States. Interview responses were analyzed into key themes to inform potential future practices, tools, and systems. In addition to the interviews, partners in Dallas and Cincinnati reflected on their own COVID-19 experiences. Results: Interview responses fell broadly into four themes that contribute to effective, community driven responses to COVID-19: real-time, accessible data that are mindful of the tension between community transparency and individual privacy;a continued fostering of public trust;adaptable infrastructures and systems;and creating cohesive community coalitions with shared alignment and goals. These themes and partner experiences helped us revise our preliminary theory of change around the importance of community collaboration and trust building and also helped refine the development of the Community Protection Dashboard tool. Conclusions: There was broad agreement amongst public health and community leaders about the key elements of the data and learning systems required to manage public health responses to COVID-19. These findings may be informative for guiding the use of data and learning in the management of future public health crises or population health initiatives. © 2023 The Authors. Learning Health Systems published by Wiley Periodicals LLC on behalf of University of Michigan.

Overt and Occult Hypoxemia in Patients Hospitalized With COVID-19.

Progressive hypoxemia is the predominant mode of deterioration in COVID-19. Among hypoxemia measures, the ratio of the Pao2 to the Fio2 (P/F ratio) has optimal construct validity but poor availability because it requires arterial blood sampling. Pulse oximetry reports oxygenation continuously (ratio of the Spo2 to the Fio2 [S/F ratio]), but it is affected by skin color and occult hypoxemia can occur in Black patients. Oxygen dissociation curves allow noninvasive estimation of P/F ratios (ePFRs) but remain unproven. OBJECTIVES: Measure overt and occult hypoxemia using ePFR. DESIGN SETTING AND PARTICIPANTS: We retrospectively studied COVID-19 hospital encounters (n = 5,319) at two academic centers (University of Virginia [UVA] and Emory University). MAIN OUTCOMES AND MEASURES: We measured primary outcomes (death or ICU transfer within 24 hr), ePFR, conventional hypoxemia measures, baseline predictors (age, sex, race, comorbidity), and acute predictors (National Early Warning Score [NEWS] and Sequential Organ Failure Assessment [SOFA]). We updated predictors every 15 minutes. We assessed predictive validity using adjusted odds ratios (AORs) and area under the receiver operating characteristic curves (AUROCs). We quantified disparities (Black vs non-Black) in empirical cumulative distributions using the Kolmogorov-Smirnov (K-S) two-sample test. RESULTS: Overt hypoxemia (low ePFR) predicted bad outcomes (AOR for a 100-point ePFR drop: 2.7 [UVA]; 1.7 [Emory]; p < 0.01) with better discrimination (AUROC: 0.76 [UVA]; 0.71 [Emory]) than NEWS (0.70 [both sites]) or SOFA (0.68 [UVA]; 0.65 [Emory]) and similar to S/F ratio (0.76 [UVA]; 0.70 [Emory]). We found racial differences consistent with occult hypoxemia. Black patients had better apparent oxygenation (K-S distance: 0.17 [both sites]; p < 0.01) but, for comparable ePFRs, worse outcomes than other patients (AOR: 2.2 [UVA]; 1.2 [Emory]; p < 0.01). CONCLUSIONS AND RELEVANCE: The ePFR was a valid measure of overt hypoxemia. In COVID-19, it may outperform multi-organ dysfunction models. By accounting for biased oximetry as well as clinicians' real-time responses to it (supplemental oxygen adjustment), ePFRs may reveal racial disparities attributable to occult hypoxemia.

Overt and Occult Hypoxemia in Patients Hospitalized With COVID-19

IMPORTANCE: Progressive hypoxemia is the predominant mode of deterioration in COVID-19. Among hypoxemia measures, the ratio of the Pao2 to the Fio2 (P/F ratio) has optimal construct validity but poor availability because it requires arterial blood sampling. Pulse oximetry reports oxygenation continuously (ratio of the Spo2 to the Fio2 [S/F ratio]), but it is affected by skin color and occult hypoxemia can occur in Black patients. Oxygen dissociation curves allow noninvasive estimation of P/F ratios (ePFRs) but remain unproven. OBJECTIVES: Measure overt and occult hypoxemia using ePFR. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively studied COVID-19 hospital encounters (n = 5,319) at two academic centers (University of Virginia [UVA] and Emory University). MAIN OUTCOMES AND MEASURES: We measured primary outcomes (death or ICU transfer within 24 hr), ePFR, conventional hypoxemia measures, baseline predictors (age, sex, race, comorbidity), and acute predictors (National Early Warning Score [NEWS] and Sequential Organ Failure Assessment [SOFA]). We updated predictors every 15 minutes. We assessed predictive validity using adjusted odds ratios (AORs) and area under the receiver operating characteristic curves (AUROCs). We quantified disparities (Black vs non-Black) in empirical cumulative distributions using the Kolmogorov-Smirnov (K-S) two-sample test. RESULTS: Overt hypoxemia (low ePFR) predicted bad outcomes (AOR for a 100-point ePFR drop: 2.7 [UVA];1.7 [Emory];p < 0.01) with better discrimination (AUROC: 0.76 [UVA];0.71 [Emory]) than NEWS (0.70 [both sites]) or SOFA (0.68 [UVA];0.65 [Emory]) and similar to S/F ratio (0.76 [UVA];0.70 [Emory]). We found racial differences consistent with occult hypoxemia. Black patients had better apparent oxygenation (K-S distance: 0.17 [both sites];p < 0.01) but, for comparable ePFRs, worse outcomes than other patients (AOR: 2.2 [UVA];1.2 [Emory];p < 0.01). CONCLUSIONS AND RELEVANCE: The ePFR was a valid measure of overt hypoxemia. In COVID-19, it may outperform multi-organ dysfunction models. By accounting for biased oximetry as well as clinicians' real-time responses to it (supplemental oxygen adjustment), ePFRs may reveal racial disparities attributable to occult hypoxemia.

Adapting and responding to a pandemic: Patient and family advisory councils in children's hospitals during COVID-19

This mixed-methods study investigated the effects of the COVID-19 pandemic on Patient and Family Advisory Councils (PFACs) within children’s hospitals in the United States. Specifically, the study sought to understand how PFACs adapted operations as a result of the COVID-19 pandemic, how patient and family advisors (PFAs) were engaged in the response to COVID-19, and the intersection of the COVID-19 pandemic with PFAC diversity, equity, and inclusion. The study consisted of a survey distributed to 228 children’s hospitals, with a 73% response rate, and in-depth interviews with selected survey respondents (n=12). While COVID-19 temporarily disrupted PFAC operations and forced rapid adaptations, most children’s hospital PFACs transitioned successfully to virtual meetings, with 86% reporting that their PFAC met at least once from March to December 2020 and 84% indicating that their PFAC planned to meet as frequently or more frequently than before the pandemic. The majority of respondents (72%) reported that attendance at virtual PFAC meetings was the same as or better than with in-person meetings. Interview participants reported benefits associated with virtual meetings, including the potential ability to recruit and engage PFAs who better reflected the diversity of the patients and families served by the hospitals. Children’s hospitals are well-positioned to be leaders in the field, contributing to the development of new approaches, lessons learned, and best practices moving forward. This is especially true as hospitals continue to navigate the evolving realities of the COVID-19 pandemic, and as PFACs address challenges associated with maintaining diverse, equitable, and inclusive councils. © The Author(s), 2022.

Overt and occult hypoxemia in patients hospitalized with novel coronavirus disease 2019 (preprint)

Background: Progressive hypoxemia is the predominant mode of deterioration in COVID-19. Among hypoxemia measures, the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (P/F ratio) has optimal construct validity but poor availability because it requires arterial blood sampling. Pulse oximetry reports oxygenation continuously, but occult hypoxemia can occur in Black patients because the technique is affected by skin color. Oxygen dissociation curves allow non-invasive estimation of P/F ratios (ePFR) but this approach remains unproven. Research Question: Can ePFRs measure overt and occult hypoxemia? Study Design and methods: We retrospectively studied COVID-19 hospital encounters (n=5319) at two academic centers (University of Virginia [UVA] and Emory University). We measured primary outcomes (death or ICU transfer within 24 hours), ePFR, conventional hypoxemia measures, baseline predictors (age, sex, race, comorbidity), and acute predictors (National Early Warning Score (NEWS) and Sepsis-3). We updated predictors every 15 minutes. We assessed predictive validity using adjusted odds ratios (AOR) and area under receiver operating characteristics curves (AUROC). We quantified disparities (Black vs non-Black) in empirical cumulative distributions using the Kolmogorov-Smirnov (K-S) two-sample test. Results: Overt hypoxemia (low ePFR) predicted bad outcomes (AOR for a 100-point ePFR drop: 2.7 [UVA]; 1.7 [Emory]; p<0.01) with better discrimination (AUROC: 0.76 [UVA]; 0.71 [Emory]) than NEWS (AUROC: 0.70 [UVA]; 0.70 [Emory]) or Sepsis-3 (AUROC: 0.68 [UVA]; 0.65 [Emory]). We found racial differences consistent with occult hypoxemia. Black patients had better apparent oxygenation (K-S distance: 0.17 [both sites]; p<0.01) but, for comparable ePFRs, worse outcomes than other patients (AOR: 2.2 [UVA]; 1.2 [Emory], p<0.01). Interpretation: The ePFR was a valid measure of overt hypoxemia. In COVID-19, it may outperform multi-organ dysfunction models like NEWS and Sepsis-3. By accounting for biased oximetry as well as clinicians' real-time responses to it (supplemental oxygen adjustment), ePFRs may enable statistical modelling of racial disparities in outcomes attributable to occult hypoxemia.

Impact of the COVID-19 pandemic on social and health behaviors among rural and urban cancer patients at Huntsman Cancer Institute (HCI)

Purpose: The COVID-19 pandemic has disrupted many facets of life for rural and urban patients with cancer. Here, we characterize the impact of the pandemic on social and health behaviors of rural and urban cancer patients. Methods: N=1,326 adult cancer patients, who visited HCI in the last 4 years and enrolled in either Total Cancer Care or Precision Exercise Prescription studies, completed a COVID-19 survey. The survey was administered between Aug and Sept 2020 and included questions on demographic and clinical information as well as employment status, health behaviors, and COVID-19 prevention measures. Results: The mean age was 61 (19-92) years, with 54% female, 97% non-Hispanic White, 80% stage I-III, 42% employed full or part-time, 25% living in rural counties, and 85% reporting good to excellent overall health. Cancer patients in rural compared to urban counties were more likely to be older (rural=63 vs. urban=60 years;p=0.01), retired or not employed (rural=63% vs. urban=56%;p=0.04), not have health insurance coverage (rural=4% vs. urban=2%;p=0.01), and have ever smoked (rural=35% vs. urban=24%;p=0.001). However, urban patients reported “somewhat” to “a lot” of change in their daily lives more frequently than rural patients (urban=86% vs. rural=77%;p<0.001), but there were no differences in change in social interaction or feeling lonely between populations. Changes in health behaviors namely exercise habits due to the pandemic were more common in patients residing in urban vs. rural counties (urban=51% vs. rural=39%;p<0.001), with more urban patients either exercising less (urban=23% vs. rural=17%) or more frequently (urban=12% vs. rural=8%);however, there were no significant differences with respect to changes in alcohol consumption between these groups. In terms of prevention measures, urban patients compared to rural patients were more likely to use face masks “fairly” or “very often” (urban=94% vs. rural=83%;p<0.001) and also felt they were more likely to contract a COVID-19 infection (22% vs. 14%;p=0.003), but there were no differences for other risk mitigation behaviors, such as hand sanitizer use. Conclusion: These findings suggest that the first 6 months of the COVID-19 pandemic had disparate effects on cancer patients living in rural and urban counties. Rural patients were more likely to have risk factors associated with poor health outcomes, such as not having health insurance coverage and having a history of smoking. However, urban patients were more likely to experience larger changes in their daily lives and exercise habits. Urban patients were more likely to follow preventive measures (e.g., wearing face masks) and felt they were at a greater risk of contracting the virus. Further research is needed to better characterize the pandemic's short- and long-term effects on cancer patients in rural and urban settings and appropriate interventions.

Experiences of staff working in a mental health trust during the COVID-19 pandemic and appraisal of staff support services

Purpose The health and well-being of healthcare staff came into focus during the coronavirus disease-2019 (COVID-19) pandemic as already strained workforces responded to new and additional challenges. Organisational support services made efforts to adapt staff support provision. However, most literature and recommendations are centred on surveys of medical and clinical staff. The present study included staff across clinical and non-clinical workforces within a mental health trust over the course of the COVID-19 pandemic to date, and aimed to understand workforces' access to and experiences of organisational support. Design/methodology/approach The current study was a qualitative one using convenience and purposive sampling. Semi-structured individual and group interviews were conducted using a topic guide. Reflexive thematic analysis was used in a phenomenological framework to analyse data. Findings 35 staff, broadly representative of the trust workforce, were recruited. Six global themes summarised the experiences of staff in relation to work practices, personal well-being and support access over the first year of the COVID-19 pandemic: COVID-19 disease, interpersonal relationships, individual considerations, change, working environment and support. Practical implications The findings from the study have implications for organisational support provisions for healthcare workers and the dissemination of these services. Originality/value Acknowledging the multi-various experiences of different workforces within National Healthcare Service organisations and how these change over time will facilitate innovative changes to staff support provision.

The effect of rapidly discharging psychiatric inpatients from Mental Health Act section during COVID-19: a cohort study.

AIMS: In March 2020, the UK government ordered mental health services to free up bed space to help manage the COVID-19 pandemic. This meant service users detained under the Mental Health Act were discharged at a higher rate than normal. We analysed whether this decision compromised the safety of this vulnerable group of service users. METHODS: We utilised a cohort study design and allocated service users to either the pre-rapid discharge, rapid discharge or post-rapid discharge group. We conducted a recurrent event analysis to assess group differences in the risk of experiencing negative outcomes during the 61 days post-discharge. We defined negative outcomes as crisis service use, re-admission to a psychiatric ward, community incidents of violence or self-harm and death by suicide. RESULTS: The pre-rapid discharge cohort included 258 service users, the rapid discharge cohort 127 and the post-rapid discharge cohort 76. We found no statistical association between being in the rapid discharge cohort and the risk of experiencing negative outcomes (HR: 1.14, 95% CI: 0.72-1.8, p = 0.58) but a trend towards statistical significance for service users in the post-rapid discharge cohort (HR: 1.61, 95% CI: 0.91-2.83, p = 0.1). CONCLUSIONS: We did not find evidence that service users rapidly discharged from section experienced poorer outcomes. This raises the possibility that the Mental Health Act is applied in an overly restrictive manner, meaning that sections for some formally detained service users could be ended earlier without compromising safety.

AI based impact of COVID 19 on food industry and technological approach to mitigate

The food industry or the restaurant business has always been one of the most profitable and growing businesses. As technology is evolving day by day and to sustain itself in the food industry the restaurant needs to come up with new and innovative services which they can provide to the customers. Pandemic has made a major impact on the business of the restaurant industry in 2020. This paper will help to understand how technology can help in food ordering, while taking care of the COVID-19 pandemic guidelines. The purpose of this paper is to analyze the impact of COVID-19 in the food industry and suggest methods that would help restaurants to adapt to challenges that originate from COVID-19. One of the ways would be to automate the food ordering process. Our Project 'Contactless food ordering system' is a mobile application operated by a voice assistant. That the client (The Restaurant Customer) can use to scan through the restaurant menu and view various food categories and items like 'Starter' 'Drinks' etc. and place their order through the Application. They can modify and confirm their order, as well as make their payment. The aim of the study is to reduce the point of contact during COVID-19 and automate the ordering and billing process, simplifying the work. Thus, providing a totally computerized, automated, and scalable food ordering system that will assist the business by reducing their workload, provide better management and smooth operation. The restaurant can also use various other means to increase their presence as a business. © 2021 IEEE.