The compound risk of heat and COVID-19 in New York City: riskscapes, physical and social factors, and interventions

Climate change is disrupting the fundamental conditions of human life and exacerbating existing inequity by placing further burdens on communities that are already vulnerable. Risk exposure varies by where people live and work. In this article, we examine the spatial overlap of the compound risks of COVID-19 and extreme heat in New York City. We assess the relationship between socio-demographic and natural, built and social environmental characteristics, and the spatial correspondence of COVID-19 daily case rates across three pandemic waves. We use these data to create a compound risk index combining heat, COVID-19, density and social vulnerability. Our findings demonstrate that the compound risk of COVID-19 and heat are public health and equity challenges. Heat and COVID-19 exposure are influenced by natural, built, and social environmental factors, including access to mitigation infrastructure. Socio-demographic characteristics are significant indicators of COVID-19 and heat exposure and of where compound vulnerability exists. Using GIS mapping, we illustrate how COVID-19 risk geographies change across the three waves of the pandemic and the particular impact of vaccinations before the onset of the third wave. We, then, use our compound risk index to assess heat interventions undertaken by the City, identify neighborhoods of both adequate and inadequate coverage and provide recommendations for future interventions. © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

Palliative care education in a pandemic

BackgroundThe COVID-19 pandemic and increased home deaths has highlighted the need for rapid, scaleable and cost-effective education on palliative and end of life care for health and social care staff in community settings.MethodsDuring COVID the Cardiff University MSc in Palliative Medicine team rapidly developed and delivered webinars on end-of-life care aimed at staff managing patients dying at home or in nursing and residential care from COVID, frailty and other conditions. They were delivered through the Zoom digital platform and made interactive by the Q&A facility, chat function and polls. Sessions were free to attendees as part of Cardiff University's ‘Civic Mission.' All sessions were recorded and uploaded to a Cardiff University YouTube channel without time restrictions. A second series of webinars with expanded content was funded by Cardiff and Vale University Health Board and delivered by local clinicians. Electronic feedback was collected via Likert scales on content, delivery and organisation.ResultsOn evaluation, more than 90% of respondents gave scores of ‘very good, or ‘excellent' for all domains. Data taken 2–4 weeks after the end of series 1 and the more locally targeted series 2 showed means of 182.6 and 89.4 registrations respectively per session, 49.4 and 33.2 live attendees and 126.6 and 38.6 YouTube viewings. However, re-analysis of YouTube data 22 months after completion of series 1 and 7 months after completion of series 2 showed viewings continuing to rise with more than 180 and 100 viewings respectively for the most popular sessions.Discussion and ConclusionValuable and interactive education can be produced and delivered efficiently via virtual platforms and at minimal cost. Good quality digital recording of sessions provides an ongoing and sustainable resource that continues to be accessed regularly approaching 2 years after some live events.

Remdesperate for Stewardship: Impact of a Remdesivir Stewardship Strategy on the Care of Patients with COVID-19 Admitted to a Community Teaching Hospital

Background. The use of remdesivir (RDV) in patients hospitalized with COVID-19 has resulted in a significantly shorter time to recovery, especially in patients receiving low flow oxygen. Despite the shortened time to recovery, concerns have been raised regarding the $3,120 cost of a five-day course. This price was originally justified by the suggestion that RDV would save hospitals approximately $12,000 per patient by shortening hospital length of stay (LOS) by four days, however, this has not been consistently demonstrated in clinical practice. A preliminary review of RDV orders at our facility revealed hospital discharges were being delayed to complete a five-day course of treatment in patients otherwise medically ready to discharge. Methods. This single-center, retrospective, comparative study was conducted at AdventHealth Orlando, a 1,368-bed community teaching hospital in central Florida. In January 2021, the campus stewardship committee devised a RDV stewardship strategy including targeted education and escalation of orders not meeting institutional criteria at time of order verification. This study compared pre-intervention patients who received RDV from December 1, 2020, to January 7, 2021, to post-intervention patients who received RDV from January 8, 2021, to February 28, 2022. The primary objective of this study was to assess the impact of a pharmacist-driven RDV stewardship initiative on the duration of therapy in hospitalized patients with COVID-19. Results. A total of 2104 remdesivir orders were included in the study (209 preintervention and 1895 post-intervention). Overall, patients had a median age of 59 years and 49% were male. Majority of patients in both groups required low flow supplemental oxygen at the time of RDV initiation. Significantly more orders in the intervention group aligned with institutional criteria at the time of order entry (47% vs 84%, p< .001). Patients completing the full 5-day course of remdesivir therapy decreased from 79 to 53% (p< .001). A decreased duration of therapy and length of stay were observed in the intervention group. Conclusion. Pharmacist-driven RDV stewardship increased adherence to the institutional algorithm and reduced duration of therapy.

BOOZE, BETAS, AND A FATTY SOLUTION TO SPARE PANDEMIC WOES

SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: The COVID-19 pandemic raised economic strife, social isolation, fear from contagion, and anxiety to a level where 45% of surveyed U.S. adults report a detriment to their mental health. With U.S. suicide rates up from 10 to 14 cases per 100,000 over the past 20 years, the health and safety of a vulnerable mental health population becomes more of a concern. We report a case of an individual with depression who was resuscitated after severe toxicity from alcohol and beta-blocker ingestions. CASE PRESENTATION: A 58-year-old woman with prior suicide attempts was found in an obtunded state after finishing a 20-pack of beer and swallowing a propranolol 20 mg pill bottle. On admission, she presented with bradycardia, hypotension, and alteration to a Glasgow Coma Scale of 9 with emesis residue on her face. Her blood gas revealed an anion-gap metabolic acidosis with a pH of 7.26, lactate of 2.53, normal potassium and calcium, and glucose of 134 mg/dL. Toxicity labs were notable for an alcohol of 199 mg/dL. Her EKG demonstrated a junctional bradycardia with a p-wave complex after the QRS consistent with retrograde depolarization of the atrium (Image 1). She was intubated to protect her airway. She subsequently developed cardiac arrest secondary to pulseless electrical activity. She underwent CPR for 33 minutes with boluses of intravenous epinephrine, glucagon, insulin, calcium gluconate, and sodium bicarbonate prior to return of spontaneous circulation. Due to failure of transcutaneous pacing, a transvenous pacer was placed. In concert with Poison Control, she was started on an a euglycemic insulin drip and an intralipid infusion. Her hemodynamics improved, and she was weaned off pacing and ICU interventions within 24 hours. She was discharged a week after admission with no residual morbidities. DISCUSSION: Overdose from nonselective beta-blockers can result in bradycardia, hypotension, seizures, QRS widening, QTc prolongation with ventricular tachy-arrhythmias, hyperkalemia, and hypoglycemia. Understanding the pharmacodynamics of beta-blocker toxicity enables targeted interventions to improve: chronotropy with epinephrine, glucagon, and pacing;inotropy with insulin, calcium, glucagon, and phosphodiesterase inhibitors;QRS widening with sodium bicarbonate;and QTc prolongation with magnesium or lidocaine. The high lipid solubility of propanol allows for intravenous lipid infusions to aid in drug elimination for patients in refractory cardiogenic shock. CONCLUSIONS: Despite a lack of labs for monitoring beta blocker toxicity, our case demonstrates successful resuscitation in a severe overdose. Perhaps an absence of hyperkalemia, hypoglycemia, QRS and QTc changes, and tachy-arrhythmias in this incident portended to a decreased morbidity and mortality. Ultimately, we reaffirmed the role of intralipid infusions as a critical treatment adjunct for recovery from cardiogenic shock secondary to beta blockade. Reference #1: Sher L. The impact of the COVID-19 pandemic on suicide rates. QJM. 2020;113(10):707-712. Reference #2: Kerns W 2nd. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am. 2007;25(2):309-viii. Reference #3: Anderson AC. Management of beta-adrenergic blocker poisoning. Clin Pediatr Emerg Med. 2008;9(1):4–16. DISCLOSURES: No relevant relationships by Jackie Hayes No relevant relationships by Andrew Salomon

Staff and patient experience of the implementation and delivery of a virtual health care home monitoring service for COVID-19 in Melbourne, Australia.

BACKGROUND: Provision of virtual health care (VHC) home monitoring for patients who are experiencing mild to moderate COVID-19 illness is emerging as a central strategy for reducing pressure on acute health systems. Understanding the enablers and challenges in implementation and delivery of these programs is important for future implementation and re-design. The aim of this study was to explore the perspectives of staff involved with the implementation and delivery, and the experience of patients managed by, a VHC monitoring service in Melbourne, Australia during the COVID-19 pandemic. METHODS: A descriptive qualitative approach informed by naturalist inquiry was used. Staff interviews were analysed using the Consolidated Framework for Implementation Research (CFIR). Patient experience was captured using a survey and descriptive statistics were used to describe categorical responses while content analysis was used to analyse free text responses as they related to the CFIR. Finally, data from the interviews and patient experience were triangulated to see if patient experience validated data from staff interviews. RESULTS: All 15 staff were interviewed, and 271 patients were surveyed (42%). A total of four final overarching themes emerged: service implementation enablers, service delivery benefits for patients, fragmentation of care, and workforce strengths. 19 subthemes aligned with 18 CFIR constructs from staff and patient data. CONCLUSION: Rapid implementation was enabled through shared resources, dividing implementation tasks between senior personnel, engaging furloughed healthcare staff in design and delivery, and having a flexible approach that allowed for ongoing improvements. Benefits for patients included early identification of COVID-19 deterioration, as well as provision of accurate and trustworthy information to isolate safely at home. The main challenges were the multiple agencies involved in patient monitoring, which may be addressed in the future by attributing responsibility for monitoring to a single agency.

A follow-up on quantitative and qualitative olfactory dysfunction and other symptoms in patients recovering from COVID-19 smell loss.

BACKGROUND: Sudden smell loss is a specific early symptom of COVID-19, which, prior to the emergence of Omicron, had estimated prevalence of ~40% to 75%. Chemosensory impairments affect physical and mental health, and dietary behavior. Thus, it is critical to understand the rate and time course of smell recovery. The aim of this cohort study was to characterize smell function and recovery up to 11 months post COVID-19 infection. METHODS: This longitudinal survey of individuals suffering COVID-19-related smell loss assessed disease symptoms and gustatory and olfactory function. Participants (n=12,313) who completed an initial survey (S1) about respiratory symptoms, chemosensory function and COVID-19 diagnosis between April and September 2020, were invited to complete a follow-up survey (S2). Between September 2020 and February 2021, 27.5% participants responded (n=3,386), with 1,468 being diagnosed with COVID-19 and suffering co-occurring smell and taste loss at the beginning of their illness. RESULTS: At follow-up (median time since COVID-19 onset ~200 days), ~60% of women and ~48% of men reported less than 80% of their pre-illness smell ability. Taste typically recovered faster than smell, and taste loss rarely persisted if smell recovered. Prevalence of parosmia and phantosmia was ~10% of participants in S1 and increased substantially in S2: ~47% for parosmia and ~25% for phantosmia. Persistent smell impairment was associated with more symptoms overall, suggesting it may be a key marker of long-COVID illness. The ability to smell during COVID-19 was rated slightly lower by those who did not eventually recover their pre-illness ability to smell at S2. CONCLUSIONS: While smell ability improves for many individuals who lost it during acute COVID-19, the prevalence of parosmia and phantosmia increases substantially over time. Olfactory dysfunction is associated with broader persistent symptoms of COVID-19, and may last for many months following acute COVID-19. Taste loss in the absence of smell loss is rare. Persistent qualitative smell symptoms are emerging as common long-term sequelae; more research into treatment options is strongly warranted given that even conservative estimates suggest millions of individuals may experience parosmia following COVID-19. Healthcare providers worldwide need to be prepared to treat post COVID-19 secondary effects on physical and mental health.

Should I stay or should I go? An exploration of the decision-making behavior of acute cardiac patients during the COVID-19 pandemic.

BACKGROUND: During the SARS-COV-2 (COVID-19) pandemic efforts to reduce virus transmission resulted in non-emergency patients being deterred from seeking help. The number of patients presenting with acute cardiac conditions reduced, significantly OBJECTIVES: To explore the decision-making process, and influential factors in that process, of patients and their family during an acute cardiac event. METHODS: A qualitative research design was employed using purposive sampling of patients who experienced an acute cardiac event during the social containment mandates. Semi-structured interviews were conducted, with thematic analysis of interview transcripts. RESULTS: Twenty-five participants were recruited from three UK hospitals. Themes identified were reliance on informal support network, lack of awareness of cardiac symptoms leading to delayed help-seeking, and an indirect COVID-19 effect (e.g. avoiding treatment). CONCLUSIONS: These results highlight the need for informed public health messages, targeting patients and their support networks, that allow those in need of treatment to access care.

Establishing a Post-Acute Covid-19 AHP Led Rehabilitation Clinic

Aim We assessed the effectiveness of an AHP-led rehabilitation service for patients with Covid-19 respiratory failure post-discharge from Cavan Hospital. Methods Of the 140 patients discharged from Cavan hospital with Covid-19, from March to June 2020, 3.6% required MV or HFNC. Using BTS guidelines a pathway was established. Patients underwent a 6 week post discharge telephone assessment. Of the 12 eligible patients only four agreed to participate. Assessments included mMRC dyspnoea score, Nijmegen questionnaire and HADS score. Patients completed an 8 week program including aerobic and endurance training with interval training at 10 stations. Focussed strength exercise was added as required. Results All three patients who completed the program had a real (> 20%) improvement in 6MWT, mMRCC dyspnoea score (1.0) and HADS. No change was seen in O2 saturation. All patients improved on IMSTS (68%, 11% and 41%). Conclusion An AHP led clinic is a safe and cost effective means of providing pulmonary rehabilitation for patients following Covid-19 pneumonitis.

Measured olfactory dysfunction and dietary intake: Results from the 2013-2014 national health and nutrition examinationsurvey (NHANES)

We identified associations between measured olfactory dysfunction (OD) and dietary parameters in a nationally representative sample of US adults. In NHANES 2013-2014, 3,206 adults 40 and over completed a measured smell exam (8-item odor identification test) as well as a 24-hour dietary recall interview administered by trained interviewers. OD was defined as incorrect identification of 3 or more (out of 8) odors;severe OD was defined as incorrect identification of 5 or more odors. Diet quality was assessed using the Healthy Eating Index 2015 (HEI-2015), where higher scores indicate higher diet quality. Other dietary variables included 24-h energy intake, and % energy from fat, added sugar, and alcohol. Survey-weighted multiple linear regression models estimated independent associations between OD and dietary variables. Models were stratified by sex, and adjusted for age, race/ethnicity, education, income, smoking and chronic disease status. The prevalence rates of OD and severe OD were 12.8% (95% CI: 10.8%, 15.2%) and 2.5% (95% CI: 1.9%, 3.5%), respectively;the average HEI-2015 score was 52.9 (0.7 SE). In men, severe OD was associated with lower energy intake with an adjusted mean difference of -403.9 (95% CI: -710.4, -97.3) between those with and without severe OD. In women, severe OD was associated with lower % of energy intake from alcohol with an adjusted mean difference of -1.71 (95% CI: -2.5, -0.95). No significant associations were observed with other dietary variables. These findings are generally consistent with the broader view that disrupted olfactory function often has meaningful dietary implications, a concern with increased public health relevance given the transient and persistent olfactory disruption observed with COVID-19 infections.

Quality improvement project: Bereavement follow-up in an acute hospital during COVID-19 and beyond

Background: Bereavement support is an important facet of palliative medicine. Many patients who receive end of life care in our hospital are not known to the hospice or hospital social workers. As a result, their families and carers do not avail of bereavement follow-up. This is particularly relevant as Covid-19 restrictions have interrupted the traditional community orientated bereavement process. Aim and objectives: The goal is to quantify this cohort and facilitate a collaborative MDT quality improvement approach to acknowledge and address bereavement follow-up in the context of Covid-19 and beyond. Methods: We quantified the weekly average number of families or carers who would not avail of bereavement follow-up prior to and during the Covid-19 surge. We reviewed the advice regarding bereavement support as per the Irish National Clinical Program for Palliative care 2018. The palliative team discussed this service gap with different stakeholders including the hospice, cancer care west, medical social work and the bereavement officer. A number of quality improvement methods were employed;such as stakeholder map, fishbone analysis, driver diagrams and the 5 whys. Results: The average weekly number of families/carers who did not avail of bereavement follow-up prior to Covid-19 was 3 and during the Covid- 19 surge was 10. Quality improvement methodologies revealed that the gap in bereavement follow-up was due to a lack of a palliative care social worker. To address this gap short-term a bereavement information leaflet was designed which will promote self-recognition of prolonged grief and signpost options available for support. Conclusion: Bereavement support is an important component of palliative care, which is often lacking. This project utilised a multidisciplinary quality improvement approach to improve this service gap with a bereavement information leaflet in the short-term and a long-term plan aimed at funding a palliative care social worker. P Posters Volunteering.

Retrospective analysis of phenobarbitone prescribing in palliative patients in the acute hospital setting

Background: Phenobarbital is classed as a sedative anti-epileptic that has an overall effect of depressing the central nervous system. It has a dual action of prolonging the opening of chloride channels on GABA receptor complex as well as inhibiting glutamate transmission at non- NMDA receptor channels. Phenobarbitone is licenced for treatment of epilepsy. In palliative care phenobarbitone is considered in patients with seizures and those with terminal agitation not responding to high dose benzodiazepines and anti-psychotics. Aims and objectives: To identify the frequency, duration of treatment , dosing regime and goal of phenobarbitone prescribed by specialist Palliative Care team in the acute hospital setting and identify demographics of this cohort. Another aim to identify whether it was used as an adjuvant or a single agent and establish any side effects. Method: A Retrospective analysis of patients prescribed phenobarbitone between May 2020 and February 2021 was carried out. We identified initial dose prescribed, titration to effect, duration of treatment, PRN requirements pre and post introduction. We recorded each diagnosis and response in the first 24 hours. Side effects were also analysed. Results: 46 phenobarbitone prescriptions were issued in the 9 month period. 25 were female and 21 were male. Majority of the patients had a malignant diagnosis or covid. The most common indication for phenobarbitone prescription was management of agitation at end of life not responding to high dose benzodiazepine/ anti-psychotics. All patients received stat dose of phenobarbitone 100mg followed by initiation of continuous subcutaneous infusion. Conclusion: Phenobarbitone is a valuable and effective drug in management of terminal refractory agitation in selected cohort of patients.

Reworking the post-covid waiting list-the patient experience of implantable loop recorder explantation

Introduction The Covid-19 pandemic has put a considerable strain on procedural waiting lists, with the majority of elective outpatient work cancelled during the pandemic. With the vaccination programme and reducing infection levels, attention is turning to addressing these waiting lists. One procedure that was affected was the removal of implantable loop recorders (ILRs). Manufacturers recommend that ILRs are removed at the point of battery depletion (usually 3-4 years), if they have not already been removed due to a positive finding or patient preference. There is little evidence in the literature regarding late complications with ILRs, and we therefore wished to examine what patients' thoughts would be about keeping the ILR in for a longer period of time. Methods Patients awaiting ILR explantation and those who had undergone explantation, were identified. A retrospective review of the notes was used to get demographic and clinical data. Both groups of patients were contacted, and a questionnaire used to gain an understanding of patients' experience and expectations. Results Prior to the Covid-19 pandemic, 60 patients who had undergone ILR explantation were identified. A total of 22 responded to our questionnaire (table 1). The majority (86%) were happy to have their ILR removed, although a smaller majority (59%) would also have been happy to have had the device kept in, were it felt to be safe. Very few patients felt a tangible difference as a result of having the ILR removed (14%) and no patients were worried about the waiting time prior to Covid-19. Of 77 patients currently awaiting explant, 30 responded to our questionnaire (table 1), with 70% not being concerned by the wait for removal. This is likely aided by the fact that 80% of patients had no day to day symptoms as a result of the ILR. Half of the patients however, would be concerned about not having the ILR removed, predominantly due to mild discomfort or concerns regarding the presence of a battery. Across both groups (n=52) only 8 patients were concerned about the risk of coming into the hospital for the procedure, with patients commenting that the stringent regulations that hospitals had employed combined with the vaccination programme, gave them significant confidence in attending for outpatient procedures. Conclusions This study found that if patients are reassured about the safety of keeping an implantable loop recorder in, and do not suffer any discomfort or symptoms as a result of the device, they are happy both to wait longer for device removal, or even not have it removed at all. In the context of the current pandemic, more thought should perhaps be given to patient guided removal times, especially in cases of removals performed for battery depletion.