Procalcitonin and D-dimer levels at baseline, but not CRP, were informative of COVID-19 hospitalization outcomes

Background. The WHO estimates 512 million cases of COVID-19 and 6.2 million deaths globally as of May 4th, 2022. In Michigan (MI), the first case was diagnosed March 10th, 2020. We describe here outcomes of COVID-19 patients cared for in a large tertiary hospital in 2020 spanning two surges based on baseline lab values for C-reactive protein (CRP), Procalcitonin (PC), and D-Dimer (DD). Methods. After IRB approval, adult patients diagnosed via PCR with COVID-19 during the two surges in 2020 and admitted to Beaumont Hospital, Royal Oak, an 1,131 beds tertiary care referral center in MI, were reviewed. Demographic, clinical and laboratory characteristics were obtained from the EMR. ICD-10 classification diagnoses were utilized to identify comorbidities, and patient BMIs were based on the admission values in the EMR. Outcomes were defined as death during current admission, transfer to nursing home or other facility, or discharge home. Using a tree-based model and the combined levels of the three labs we defined a hierarchy of four lab levels, each progressively having increased risk of death. We then analyzed the outcome for the four levels, adjusting for time period (surge), age, sex, race, BMI and comorbidities. Data was analyzed using SAS statistical software version 9.4 (SAS Institute). Results. A total of 2197 patients were identified from March through December 2020, of whom 1118 had CRP, PC and DDavailable at baseline. The mean age was 66.7 years (SD 16.1) for the cohort in first surge (March-June), and 66.4 (15.6) in the latter surge (July-December, Table1). More patients had a PC of >0.5 in the first surge (25.7%) than the second (13.2%). After adjusting for all other factors, the hierarchical lab levels are significantly associated with outcomes. Of note, baseline CRP value was not informative. Compared to the 2nd level (Table 2), the lowest level (PC < 0.1) has significantly lower odds of death [OR=0.37, 95% CI (0.19, 0.73)], while the highest level, (DD >1000 and PC >= 0.26) has significantly higher odds of death [OR=3.01, 95% CI (1.59, 5.72)]. Conclusion. Baseline PC and DD, but not CRP, were informative in determining risk of death and can assist clinicians determine possible outcomes during COVID-19 hospitalization.

Women's health care during COVID-19

Introduction: The coronavirus disease 2019 (COVID-19) pandemic is disrupting health services worldwide. Women's health care is often acute and in continual demand, with poor health outcomes seen in women's health in particular in the recent Ebola and Swine flu epidemics. Regrettably, early reports globally and in the UK have shown a rise in the stillbirth rate. We aimed to evaluate the provision of obstetrics and gynaecology services in the UK during the acute phase of the COVID-19 pandemic. Methods: We undertook an interview-based national survey of junior doctors in obstetrics and gynaecology in women's healthcare units in the National Health Service using the network of the UK Audit and Research Collaborative in Obstetrics and Gynaecology. We sought responses on general training, labour ward care, antenatal and postnatal care, benign gynaecology and gynaecology oncology services. Results: We received responses from 148/155 units (95%) contacted. Most completed specific training drills for managing obstetric and gynaecological emergencies (89/148, 60.1%) and two-person donning and doffing of personal protective Equipment (PPE) (96/148, 64.9%). The majority of surveyed units implemented COVID-19-specific protocols (130/148, 87.8%), offered adequate PPE (135/148, 91.2%) and operated dedicated COVID-19 emergency theatres (105/148,70.8%). Most units suspended elective gynaecology services (131/148, 88.5%). The 2-week referral pathway for oncological gynaecology was not affected in half of the units (76/148,51.4%), but half reported a planned reduction in oncology surgery (82/148, 55.4%) Discussion: Women's health care services have responded well to the acute phase of the COVID-19 pandemic, however further planning is required for the long term.

An audit on the delivery of bristol royal children's hospital paediatric orthopaedic services in response to BOAST COVID-19 guidance

Introduction: The COVID-19 pandemic raised concerns regarding the spread of infection by asymptomatic children. Guidance from the British Orthopaedic Association Standards for Trauma (BOAST) for the 'management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic', helped structure our service in response to the pandemic. We assessed our compliance with 'BOAST COVID-19 standards' pertaining to children to determine whether it is possible to run a safe and effective paediatric orthopaedic service. Methods: Between the 16th March and 30th April 2020, we performed a prospective audit of clinic and theatre data from the paediatric orthopaedic department at the Bristol Royal Children's Hospital against the 'BOAST COVID-19 standards'. We also performed a retrospective audit between 16th March and 30th April 2019 for comparison. Results: Patients booked into acute fracture clinic (AFC) and fracture clinic follow-up (FFO) reduced by 40% and 48% respectively from 2019 to 2020. A virtual fracture clinic (VFC) was implemented with increasing trend in VFC consultations. From 2019 to 2020, the number of patient initiated follow-up appointments increased in AFC and FFO from 16% to 75% and 12% to 35% respectively. Radiography was reduced;only 17% and 39% of AFC and FFO patients respectively required radiographs. On-call referrals and trauma cases reduced by almost 50% with a similar case mix year-on-year. All elective operating was cancelled in 2020. Conclusion: By reducing clinic admissions and theatre throughput, it was possible to run an effective paediatric orthopaedic service in a busy tertiary referral centre. Our aim now is to determine the longterm efficacy.

An audit of the delivery of paediatric orthopaedic services at the bristol royal children's hospital in response to the british orthopaedic association standards for trauma (BOAST) covid-19 guidance

Introduction: Guidance from the BOAST helped structure our paediatric orthopaedic service n response to COVID-19. We assessed our compliance with 'BOAST COVID-19 standards', whether it is possible to run a safe and effective paediatric orthopaedic service. Method: We performed a prospective audit of clinic and theatre data (16th March to 30th April 2020), from the paediatric orthopaedic department at the BRCH against the 'BOAST COVID-19 standards'. We also performed a retrospective audit. Results: Patients booked into acute fracture clinic (AFC) and fracture clinic follow-up (FFO) reduced by 40% and 48% respectively from 2019 to 2020. A virtual fracture clinic (VFC) was implemented with an increasing trend seen. The number of patient initiated follow-up appointments increased in AFC and FFO from 16% to 75% and 12% to 35% respectively. Radiography was reduced;only 17% and 39% of AFC and FFO patients respectively required radiographs. On-call referrals and trauma cases dropped by 50% with similar case mix year-on-year. All elective operating was cancelled in 2020. Conclusions: By reducing clinic admissions and theatre throughput, it was possible to run an effective paediatric orthopaedic service in a busy tertiary referral centre. Our aim now is to determine the longterm efficacy, cost, and sustainability of our COVID-19 service.

Molecular SARS-CoV-2 testing during the COVID-19 outbreak: Experiences of a hospital in Southeast Michigan, USA

Background: The novel Coronavirus SARS CoV-2 (COVID-19) outbreak was complicated by the lack of diagnostic testing kits. In early March 2020, leadership at Beaumont Hospital, Royal Oak Michigan (Beaumont) identified the need to develop high capacity testing modalities with appropriate sensitivity and specificity and rapid turnaround time. We describe the molecular diagnostic testing experience since initial rollout on March 16, 2020 at Beaumont, and results of repeat testing during the peak of the COVID-19 pandemic in MI. Methods: Beaumont is an 1100 bed hospital in Southeast MI. In March, testing was initially performed with the EUA Luminex NxTAG CoV Extended Panel until March 28, 2020 when testing was converted to the EUA Cepheid Xpert Xpress SARSCoV- 2 for quicker turnaround times. Each assay was validated with a combination of patient samples and contrived specimens. Results: During the initial week of testing there was > 20 % specimen positivity. As the prevalence grew the positivity rate reached 68% by the end of March (Figure 1). Many state and hospital initiatives were implemented during the outbreak, including social distancing and screening of asymptomatic patients to increase case-finding and prevent transmission. We also adopted a process for clinical review of symptomatic patients who initially tested negative for SARS-CoV-2 by a group of infectious disease physicians (Figure 2). This process was expanded to include other trained clinicians who were redeployed from other departments in the hospital. Repeat testing was performed to allow consideration of discontinuation of isolation precautions. During the surge of community cases from March 16 to April 30, 2020, we identified patients with negative PCR tests who subsequently had repeat testing based on clinical evaluation, with 7.1% (39/551) returning positive for SARS- CoV2. Of the patients who expired due to COVID-19 during this period, 4.3% (9/206) initially tested negative before ultimately testing positive. Conclusion: Many state and hospital initiatives helped us flatten the curve for COVID-19. Our hospital testing experience indicate that repeat testing may be warranted for those patients with clinical features suggestive of COVID-19. We will further analyze these cases and clinical features that prompted repeat testing. (Figure Presented).