Improving Enrollment and Adherence to the Lung Transplant Home Spirometry Program

In May 2020, we implemented a home spirometry program (HSP) to facilitate remote monitoring of lung function in lung transplant recipients in response to the COVID-19 pandemic. We found enrollment and adherence rates were below the program goal of 75%. We developed a quality improvement project to optimize the HSP enrollment and onboarding in order to improve enrollment and adherence rates. Gap analysis was performed through observation and qualitative interviews of patients, nurses, and physicians. A fishbone analysis found three main opportunities to improve adherence including a variable onboarding process, no foreign language offerings, and suboptimal educational material. We developed and launched a standardized workflow, a new educational video, and educational materials in 5 languages. In-process metrics were tracked through the use of an EMR "smartphrase" and QR code to indicate use of the new workflow and educational video. Enrollment and adherence were measured by the % of patients submitting more than one FEV1 value in the first 30 days after discharge. After implementation in August 2022, we found the new onboarding process, as indicated by the use of our"smartphrase", and the new educational video, as indicated by the use of the QR code, were utilized for 100% of new patients over the first two months. We found an absolute increase of 85% of patients submitting an FEV1 value in the first month following discharge from lung transplantation (Figure 1). We were able to improve the process of onboarding and education through the development of a new standardized workflow and video. This was found to be reliably executed and resulted in an improvement in patient enrollment and adherence. Moving forward we will track the impact of our new onboarding and video educational tool on long-term adherence. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

COVID-19 in CHILDREN: WORSENING OUTCOMES during DELTA VARIANT WAVE

Background: Pediatric cases of COVID-19 surged in the summer/fall of 2021 coinciding with the SARS-CoV-2 Delta variant. It is unclear whether the Delta variant caused more severe illness among pediatric patients. We leveraged the Children and COVID-19 in Colorado database to determine whether differences exist in demographics, underlying comorbidities, and outcomes among children requiring hospital admission due to the SARS-CoV-2 Delta variant vs. wild type virus. Methods: We performed a retrospective review of children <21 years with symptomatic COVID-19 and detectable SARS-CoV-2 NAAT hospitalized at Children's Hospital Colorado during pre-Delta (Mar-Nov 2020) and Delta (Jun-Sep 2021) periods. We compared variables using Fisher's exact or Pearson's chi square tests for categorical variables and Wilcoxon rank sum tests for continuous variables. Results: There were 119 children hospitalized with symptomatic COVID-19 during the pre-Delta and 137 in the Delta period. There was a slight male predominance in both periods. Children hospitalized during the Delta period were younger, with median (interquartile range) age of 5.9 (1.0-14.5) vs. 12.2 (1.5-16.9) years, p=0.02;and were less likely to identify as Hispanic and Spanish-speaking, compared to the pre-Delta period (Table). There was a trend toward decreasing proportions of hospitalized children with underlying comorbidities in the Delta vs. pre-Delta period (59.1% vs. 69.8%;p=0.07). The most prevalent types of comorbidities were similar between periods;but the proportion of hospitalized immunocompromised patients was lower in the Delta vs. pre-Delta period (p=0.005). Half of all children were overweight/obese in both periods. Similar proportions of hospitalized children required respiratory support in both periods, but more children required intensive care in the Delta vs. pre-Delta periods (36.5% vs. 23.5%, p=0.03). Conclusion: Children hospitalized with the Delta variant of COVID-19 were younger, less likely to be Hispanic, and had fewer comorbidities than children hospitalized with wild type SARS-CoV-2. Children hospitalized with the Delta variant were more likely to require ICU admission compared to children hospitalized with wild type SARS-CoV-2, which may indicate increased severity of the Delta variant in the pediatric population. Close monitoring of pediatric outcomes is needed as new SARS-CoV-2 variants emerge.

Respiratory disease, and treatment / thematic poster session mortality rate in lung transplant recipients infected with COVID-19

Rationale: The emergence of the novel SARS-CoV-2 has caused a global pandemic costing the lives of thousands of people. In the US, COVID-19 is now the third leading cause of death among those aged 45 through 84. Lung transplant (LTx) recipients may be at increased risk for fulminant novel SARS-CoV-2 COVID-19 infection due to their immunosuppressed state. Within solid organ transplant (SOT) recipients, the reported mortality rate has ranged from 5% to 40%. Observational studies of LTx recipients have noted a mortality rate of 10% to 34%. To further understand the mortality rate in LTx recipients, we retrospectively evaluated LTx patients at our center with COVID-19. Method: We identified LTx recipients infected with COVID-19 by nasopharyngeal swab at our institution in the Bay Area. Baseline demographics and clinical data were obtained through review of the electronic medical record (EMR) from 3/20/2020 to 12/18/20. Results: Eighteen LTx recipients were diagnosed with COVID-19 infection. The mean age was 55.1 years (SD ± 3.0) and the majority were male (Table 1). Eightynine percent of patients had 2 or more comorbidities, which included hypertension, diabetes, coronary artery disease, and chronic kidney disease. Clinical presentation ranged from mild to severe, 11% of patients were monitored at home and 89% required hospitalization. Of those hospitalized, 50% were treated in the intensive care unit (ICU). The survival rate of COVID-19 in this population was 94%. One patient who recovered from COVID-19 later died in hospice care related to other comorbidities. Conclusion: Lung transplant recipients infected with COVID-19 were mostly male and most had two or more comorbidities. Most patients had severe infection requiring hospitalization and of these, half necessitated ICU level care. The overall survival rate, however, was higher than has been reported in LTx recipients at other centers. Favorable survival outcomes may be due to disease education and prompt access to healthcare in this LTx population. Additionally, during this study period, the Bay Area did not experience the same overwhelming surge of COVID-19 cases that has been seen in other regions of the United States. Further studies are needed to evaluate factors affecting COVID-19 mortality rate in LTx patients. .

Children and COVID-19 in Colorado: The children's hospital Colorado experience

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that causes coronavirus disease of 2019 (COVID-19) and has been reported in > 98,000 children in the U.S (5% of reported cases) as of early June 2020. Most published literature focuses on adults with COVID-19, but little is understood on the impact of SARS-CoV-2 in children. We created a database for children with COVID-19 at Children's Hospital Colorado (CHCO), a large tertiary care pediatric hospital, to better understand the epidemiology and clinical outcomes of this disease in children. Methods: We retrospectively reviewed the medical records of all pediatric and youth patients with positive SARS-CoV-2 PCR test results from March-May 2020. Univariate logistic regression models were used to identify predictors of hospital admission, need for critical care, and need for respiratory support among symptomatic patients, with p-values < 0.05 considered statistically significant. Results: We identified 246 patients with SARS-CoV-2 (age range: 17 days- 25 years). We noted a Hispanic predominance with 68% of all patients with SARSCoV- 2 identifying as Hispanic or Latino, compared to 29% among all CHCO visits in 2019 (Figure 1). The most common symptoms at presentation were fever, cough, or shortness of breath in 94% of symptomatic patients. Sixty-eight patients (28%) were admitted, of which 7 (10%) required admission to the pediatric intensive care unit (PICU) for symptomatic COVID-19 disease (Figure 2). Age 0-3 months, certain symptoms at presentation, and several types of underlying medical conditions were predictors for both hospital admission and need for respiratory support (Figure 3). Initial and peak C-reactive protein (CRP) values were predictors for PICU admission with median peaks of 24.8mg/dL vs. 2.0mg/dL among PICU vs. non-PICU patients (OR 1.27, p=0.004). Conclusion: There is a wide spectrum of illness in children with SARS-CoV-2, ranging from asymptomatic to critical illness. Hispanic ethnicity was disproportionately represented in our cohort, which requires further evaluation. We found that young age, comorbid conditions, and CRP appear to be risk factors for severe disease in children.

COVID-19 Disease in Lung Transplant Recipients: A Case Series

Purpose Lung transplant (LTx) recipients may be at increased risk for fulminant novel SARS-CoV-2 COVID-19 infection due to their immunosuppressed state. Additional risk factors, outcomes, and optimal management of COVID-19 in LTx recipients is unknown. Methods We identified LTx recipients infected with COVID-19 by nasopharyngeal swab in our institution. Baseline demographics and clinical data were obtained through review of the electronic medical record (EMR) from 3/20/2020 to 10/25/2020. Results Ten LTx recipients were diagnosed with COVID-19 infection. Disease course and management details are described in Table 1. Mean age was 57.5 ± 8 years, 50% were women (n = 5), and 70% self-identified as Latinx, 66% had a high school diploma or lower education. Medicare or Medicaid was the primary insurance in 60% (n = 6). Mean household size was 3.2 ± 1.5 persons. Forty percent (n = 4) had mild symptoms that progressed to fulminant hypoxemic respiratory failure at 9-10 days from symptom onset. Ninety percent (n = 9) required hospitalization with an average length of stay 14.8 ± 12. Sixty percent (n = 6) were treated in the intensive care unit (ICU), 40% (n = 4) requiring mechanical ventilation. COVID-19 specific therapies included remdesivir (80%, n = 8), dexamethasone (60%, n = 6), and convalescent plasma (50%, n = 5). Mycophenolate mofetil (MMF) was reduced or held in 60% (n = 6) of recipients. One recipient who recovered later died in hospice care from other comorbidities. Conclusion Most LTx recipients infected with COVID-19 had severe complications, with a high proportion requiring ICU admission and mechanical ventilation. Though, mortality was relatively low. Adjustments to immunosuppression included reduction in MMF and steroid augmentation. Similar to the general US population, there is a disproportionate impact of COVID-19 infection in Latinx LTx recipients that may be related to social factors such as residing in multi-generational households.

Implementation of a Chatbot Mobile Health Intervention with Home Spirometry to Monitor Lung Transplant Recipients Remotely

Purpose The COVID-19 pandemic accelerated the need to develop remote monitoring of graft function in lung transplant (LT) recipients. While home spirometry has been used previously in LT, long-term engagement has been poor. We aimed to improve engagement and allow efficient data and symptom collection using Bluetooth enabled home spirometers coupled with a digital chatbot. Methods We implemented an automated, chat-based mobile health intervention via text message or email paired with Bluetooth-enabled hand-held spirometers. The chatbot engaged LT recipients weekly in a personalized, automated chat with symptom assessment, education modules, and spirometer data collection. Clinical team members received automatic notification of concerning symptoms or FEV1 declines of >10%. The correlation between home spirometry FEV1 values and lab-based values were assessed with Pearson's coefficient. Results We mailed home spirometers to 424 patients. Between 5/4/2020 and 10/21/2020, 311 patients enrolled in the automated chat and, of these, 273 patients submitted ≥1 FEV1 measure, (median 13;IQR 6-23) over 24 weeks. The largest drop in FEV1 engagement came after the first week in each patient's chat experience;65% of those that submitted an FEV1 at baseline entered a value at week one and 72% at week two. However, after this initial decline, engagement remained stable through 24 weeks (57-72%, Figure 1.A). Home spirometry FEV1 correlated closely with in-lab spirometry (rho = 0.94) (Figure 1.B) Conclusion