Using the framework for reporting adaptations and modifications for evidence-based interventions (FRAME) for reporting adaptations to coordinated specialty care during the COVID-19 pandemic

Throughout the COVID-19 pandemic, OnTrackNY teams provided coordinated specialty care (CSC) in a radically shifted environment. This presentation describes adaptations to OnTrackNY's model implemented during the pandemic. Method(s): OnTrackNY providers were recruited to participate in indepth, qualitative interviews conducted using phone and video platforms. The project team co-developed the qualitative interview guides with OnTrack Central trainers for each of the six team member roles. A coding team used the FRAME to identify the top three role-based adaptations to the OnTrackNY model from transcripts of qualitative interviews. Result(s): Twenty-three providers (n = 3-4 providers per role) discussed challenges and adaptations of providing CSC services during the pandemic. Use of telehealth was a major adaptation applied across all roles. Adaptations to outreach included narrowing community outreach to inpatient and emergency settings, increasing communication with referral sources, increasing contact with newly referred participants and families. Peer specialist adaptations include conducting physically-distanced groups, discussing current events and expanding online resources for engagement. SEES adaptations included monitoring evolving employment opportunities, conducting mock job interviews remotely, and supporting online learning. Adaptations to PCP/RN roles included sending equipment home for monitoring heath, changing methods and frequency of administering medication, and providing education regarding COVID-19 and vaccination. Adaptations to the Primary Clinician role included increasing informal 'check-ins', using screen sharing to complete assessments and safety plans, and addressing increased stress due to the pandemic. Conclusion(s): Adaptations to CSC were common with providers most frequently making changes to format and setting of care delivery and content modifications. Future work will examine implications of adaptations and OnTrackNY fidelity indicators.

The integration of principles of co-creation for promoting quality improvement within a learning healthcare system providing coordinated specialty care for people with FEP

Co-creation places key stakeholders at the centre of development processes for quality improvement projects to reduce gaps between research and practice. We describe an Amplify OnTrackNY project that used principles of community-based participatory research to meaningfully partner with individuals with lived experience and describe lessons learned. Method(s): Two individuals with lived experience were hired and coled decision-making about project selection and design. The project examined OnTrackNY provider, participant, and family perspectives on the impact of COVID-19 on service delivery. To enhance the lived experience perspective, we hired two OnTrackNY graduates and a family member, and created mechanisms for team building and integration, and co-planning sessions. All team members contributed to the development of research questions, co-facilitated interviews/ focus groups, and participated in data analysis and dissemination. Result(s): Team members conducted focus groups and semi-structured interviews with 13 participants and five family members, presented results to various stakeholder groups, and are contributing to scientific publications. To ensure participation, our flexible working structure focused on promoting equity and building trust. Dedicated time ensured opportunities for meetings focused on mutual support, sharing, capacity building, and training in qualitative methods. Individuals with lived experience were in decision-making roles, created content, and led project activities embodying principles of power-sharing, reciprocity, and mutual learning. Orienting new team members to the office culture required extra effort. Conclusion(s): Provided sufficient time and infrastructure, it is feasible to meaningfully involve individuals with lived experience in quality improvement projects. Co-creation ensures that important perspectives are incorporated from the outset and procedures improve the relevance and uptake of research findings in the real world.

ACUTE ISCHAEMIC STROKE IN THE CONTEXT OF CAROTID ARTERY FREEFLOATING THROMBUS: A SINGLECENTRE OBSERVATIONAL STUDY OF CHARACTERISTICS, TREATMENT STRATEGIES AND OUTCOME

Background and aims: Optimal management of carotid artery freefloating thrombus (CAFFT) and CAFFT-related strokes remains unclear. We sought to examine the clinical characteristics, treatment strategies and patient outcomes for CAFFT-related ischaemic strokes. Methods: We conducted a single-centre retrospective observational study by extracting data from electronic patient records. We included consecutive patients admitted between 2016-2021 with ischaemic stroke and CAFFT on initial CT/MR angiogram. Results: We included 59 patients (mean age 63, 66% male). Vascular risk factors included hypertension (42%), diabetes (19%), dyslipidaemia (27%), previous stroke (10%), smoking history (56%) and alcohol excess (14%). 6 patients (10%) were COVID-19 positive. Median modified Rankin score was 0 and mean NIHSS was 11. On admission, 42% were taking antiplatelet agents, 10% were on anticoagulant, 34% had CRP >10mg/L, and 14% had eGFR <50 ml/min/1.73m2. On arrival, 27% received IV thrombolysis and 19% underwent mechanical thrombectomy. Acute antithrombotic strategies included IV heparin (49%), low molecular weight heparin (47%), oral anticoagulation (15%), and antiplatelet agents (63%). 24 patients (41%) were referred to vascular surgery, of whom 9 (38%, 15% of total) received emergency carotid endarterectomy. Neurological deterioration (<7 days) occurred in 14%. In-hospital mortality was 8% overall, but 67% for COVID-positive patients. At 6 months, recurrent stroke occurred in 12% and mortality was 3%. Conclusions: CAFFT-related ischaemic stroke is associated with significant mortality and neurological morbidity. The use of different acute antithrombotic strategies and emergency carotid endarterectomy varied significantly between patients. These major treatment options should be subjects of future clinical trials.

LARGE VESSEL OCCLUSION STROKE IN A 17 YEAR OLD MALE WITH PAEDIATRIC INFLAMMATORY MULTI-SYSTEM SYNDROME ASSOCIATED WITH SARS-COV-2

Background: Paediatric Cov-2 infections have been less severe than in adults, however some have developed a newly defined syndrome, Paediatric Inflammatory Multisystem Syndrome associated with CoV-2 (PIMS -TS). Its presentation is variable and can cause multi-system involvement. It belongs to the common spectrum of pathogen-triggered hyperinflammatory states, including atypical Kawasaki disease. Case summary: 17 year old male of Ghanaian origin, with no significant past medical history, presented with a one-week history of general malaise, fevers and sore throat. He developed severe chest pain and cardiogenic shock, with a CRP of 200, raised troponin and global hypokinesia on echocardiogram with an ejection fraction of 20%. He was positive for SARS-CoV-2 antibodies (though PCR-antigen negative at admission) and fit the criteria for myocarditis secondary to PIMS-TS. He was treated for sepsis, commenced on IV methylprednisolone and needed intubation, sedation and cardiothoracic ICU level care. On weaning sedation after 3 days, he was found to have left middle cerebral artery syndrome with NIHSS 16. CT head and CT angiogram showed a left MCA ischaemic stroke, and a thrombus in the Sylvian MCA branch. This was treated with antiplatelets. His disease markers and motor deficits improved significantly, however he has cognitive impairment and low mood. Conclusion: PIMS-TS related LVO anterior circulation infarct is rare. It necessitates urgent recognition and multi-specialty involvement as currently management is not standardised. Axial DWI (A), ADC (B) MRI demonstrate large left MCA territory infarct. Axial MRA (C) shows occlusion of the left M2 branches, signal drop-out on SWI (D).

Straight to Test (STT) vs. Traditional Colorectal Target Investigations Pathway - A Local Audit

Aims: The STT pathway was borne out of the National Cancer Strategy 2015 and faster diagnosis standard to rule in, or out, cancer within 28 days of referral. We aimed to review local target standard of practice, including comparison of STT vs Traditional pathways towards reaching the national standards. Methods: The Somerset Database for all target referrals to the department was accessed. We chose October 2019 as a period unaffected by COVID-19. Time to investigation, results and treatment were reviewed. SPSS v.16 was used to perform an unpaired T-test of Traditional vs. STT time to diagnosis. Results: 212 patients were referred for target investigations. 53 declined, DNA-ed or were unfit. 159 proceeded to investigations of which 7 cancers were diagnosed: 4 colorectal, 1 gastric and 2 lung. Time to diagnosis averaged 45.8 days and only 47/159 (29.6%) had their definitive diagnosis in 28 days. 52 patients were streamed to STT and 107 traditional pathways. STT patients were diagnosed at 36.3 days (95% CI 28.1- 44.6) and traditional patients 50.5 days (95% CI 45.4-55.7) (P=0.005). Cancer treatment was received median day 59 (range 27-189) and 4/7 received this within 62 days. Conclusion: Target investigations have low pick up rates of cancers with ever increasing referrals. Our centre did not meet aspirational national targets of time to treatment or diagnosis, although STT patients were diagnosed significantly faster. With COVID-19, rationalisation of patient contact with maintained diagnosis rates must be strategised. Stricter FIT testing with risk stratification and STT expansion is one strategy.

COVID-19-Associated Cytotoxic Lesions of the Corpus Callosum.

There are very limited published data on the neurologic complications associated with coronavirus disease 2019 (COVID-19) in the pediatric population. Here we present the first 2 pediatric cases of presumed COVID-19 related cytotoxic lesions of the corpus callosum. Similar to reports in adults, these cases suggest that the COVID-19 infection in children may rarely mediate a hyperinflammatory response that can cause CNS pathology. As the pandemic continues further, the presentation of cytotoxic lesions of the corpus callosum should prompt radiologists to consider COVID-19, among other known causes.