Virtual Hospital Medicine

Telemedicine is a rapidly expanding field. This is due in part it today's climate of advancing technology, combined with increasing demand for contactless communication in the context of the novel coronavirus disease 2019 (COVID-19). Much has been written on the role of telemedicine in outpatient medical settings, with its ability to reach both rural areas without access to specialists and people at risk of contracting COVID-19. This chapter will examine its in patient role. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Updates in Nephrology for the Hospitalist

This chapter gives a broad overview of nephrology as it affects hospitalists while also hoping to answer a few of the essential questions hospitalists may ask their nephrology colleagues. Evaluation and treatment of both acute and chronic kidney disease is constantly evolving as the small but tight-knit community of hospital-nephrologists continue to collect, review, and research data. The majority of the chapter will be focused on discussing a few new updates in the field of nephrology and how these updates could potentially change hospital care. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Clinical Approaches to the COVID-19 Pandemic

SARS-CoV-2 is a highly contagious virus that can affect almost any system in the body. New developments in understanding its transmissibility, management, and sequelae are unfolding almost daily. However, no medical publication in 2021 would be complete without a snapshot of the current status of this pandemic. The virus continues to mutate to more contagious, and therefore more dangerous, strains. The best path forward through this pandemic is vaccination against SARS-CoV-2 for all those who are eligible. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Milrinone-induced platelet inhibition in patients supported on veno-aterial extracorporal membrane oxygenation: a case series

Case Report: Purpose: Milrinone is an inodilator that is used in the treatment of cardiogenic dysfunction and shock. It causes increased cardiac output by stimulating myocardial contractility, enhancing cardiac relaxation, and reducing afterload via phosphodiesterase III inhibition, preventing cyclic adenosine monophosphate (cAMP) degradation. Increased cAMP concentrations are known to inhibit platelet aggregation. Veno-arterial-extracorporeal membrane oxygenation (VA-ECMO) is an extracorporeal treatment option for inotrope-refractory cardiogenic shock and is often used in conjunction with inodilators. Often, patients supported on ECMO require systemic anticoagulation to prevent clotting complications. Therefore, thromboelastography (TEG) with platelet mapping is used to help gauge a patient's clotting status and gives clinicians information about the degree of platelet inhibition present. We present the case of two patients, both supported on VA-ECMO, who developed platelet inhibition with clinically significant bleeding while on milrinone, requiring the cessation of the milrinone infusion. Cases: First, we present an adult female in her fourth decade of life who required VA-ECMO for Covid-19 ARDS and cardiogenic shock. TEG platelet mapping was obtained for clinically significant bleeding from her trachea and gastrointestinal tract. Ten days after starting milrinone, adenosine-5'-diphosphate (ADP) inhibition was elevated at 67.4% and arachidonic acid (AA) inhibition normal at 1.8%. Twenty days after starting milrinone, ADP inhibition was 93.3% and AA inhibition was 76.4%. Milrinone discontinued and repeat TEG platelet mapping (10 days after discontinuation) showed ADP inhibition of 76.8% and AA inhibition of 0%. Her lowest ADP inhibition was 41.9%, approximately 1 month after milrinone discontinuation. Milrinone again attempted and ADP inhibition was 87.9% and AA inhibition 89.2% within 24 hours of initiation. No data available for platelet inhibition prior to starting milrinone. Next, we present a 9 year old female with acute myeloid leukemia who required VA-ECMO for septic shock. Initial TEG platelet mapping, obtained 2 days after milrinone initiation, showed ADP inhibition of 43.6% and AA inhibition of 98.7%. Two days after discontinuation of milrinone, her ADP inhibition was 19.6% but AA inhibition remained elevated at 91.9%. However, after 4 days off milrinone, her ADP inhibition was normal at 15.5% and AA inhibition mildly elevated at 33.6%. No data available for platelet inhibition prior to starting milrinone. Conclusion(s): Milrinone is a known platelet inhibitor due to increased intracellular cAMP concentrations. For patients on ECMO and milrinone, care should be given to the degree of platelet inhibition and potential risk of clinically significant bleeding. Further studies are needed to further investigate the correlation between milrinone, platelet inhibition, and clinically significant bleeding in ECMO patients. Copyright © 2023 Southern Society for Clinical Investigation.

Patient information videos on SACT to improve patient experience and access to information: A North/NE London collaboration

Background: Prior to the COVID-19 pandemic, oncology patients attended in-person educational sessions to understand the practicalities and side-effects of their planned systemic anti-cancer treatments (SACT). These were halted during the pandemic to minimise hospital attendances. Moreover, patients were unable to bring family or friends for support at consultations. Providing this key treatment information in a digital format using videos was proposed with these aims: 1. Improve accessibility of information. 2. Improve patient experience. 3. Improve staff experience and efficiency. Method(s): A network collaboration with the Royal Free London and North East London Cancer Alliance enabled consistency of information and increased exposure of the videos. A patient-centred approach was taken in developing the videos: 1. A baseline patient survey assessed current and proposed methods of communicating: patients received written and verbal information, but some felt they had been given 'too much' or 'not enough' information and 33% of patients reported a video would be helpful. 2. A patient focus group guided content: cannulation, real patient experiences and images of staff/facilities were identified as important. 3. The videos were translated into four languages to meet the needs of the local patient population. A multiprofessional team of doctors, nurses, managers and communications staff were involved in the development and production of the videos. Between November 2020 and September 2021, several Plan Do Study ACT (PDSA) cycles were undertaken to create, edit and review content in the production process, with patient and production team feedback throughout. Intervention(s): Three videos were produced covering an overview of treatment and the side-effects of chemotherapy and immunotherapy. These were disseminated via trust websites, YouTube and QR codes on posters. Learning outcomes of the videos were assessed by separate patient and staff feedback surveys. Result(s): 15 patients were approached prior to starting SACT to complete a questionnaire prior to and after watching the videos. Prior to watching the videos, 60% of patients felt they had not received enough SACT information, 73% were anxious about treatment. After watching the videos, 100% reported understanding of the common side-effects of treatment and how to contact the hospital for advice. 87% would recommend the videos to others, 73% would watch them again. 100% of staff surveyed agreed that the videos improved accessibility to key patient information. The videos answered common questions patients asked staff prior to starting treatment. Over six months, there have been >300 YouTube views. [Formula presented] Conclusion(s): Multilingual patient information videos are an effective way to deliver key information about SACT, improve patient experience and reduce anxiety. Next steps are to intensify signposting by increasing stakeholder exposure, and consider adapting the videos for national use. YouTube views will be counted to continue to monitor the use and sustainability of this intervention. Keywords: systemic anti-cancer therapy, digital, videos, patient education, patient experience, patient information, multilingual, staff experience, network collaboration, SACT, chemotherapy, immunotherapy Copyright © 2022

At the Touch of a Button: Creating Real-Time ECMO Specialist Education and Training

Introduction: In 2019, our ECMO department transitioned from a core group of full-time specialists to a larger prn team. Anticipating challenges with this transformation, the ECMO education team created a department webpage. By utilizing the webpage, specialists had access to online educational resources. In 2021, the COVID-19 pandemic created a workload that was difficult to manage with newer specialists, and experienced primers were stretched thin due to higher patient census. More readily accessible, real-time visual education and training was required. Method(s): Identifying that current educational modalities were no longer meeting the busy department's needs, and we created a novel educational platform for ECMO specialists. In 2022, we developed succinct in-depth, real-life educational content that was then linked to QR codes. These videos provide specialists with easy-to-navigate, point-of-care resources for ECMO education. With this technology, any ECMO team member can easily access educational material in a timely manner. For each topic, step-by-step instructions are verbalized and demonstrated. Result(s): Prior to this educational platform initiative, our ECMO department page was too cumbersome to access expeditiously. Now, just-intime training and education can be accessed in a timely fashion with our QR codes. This training decreases specialists' anxiety associated with high-stress procedures. Conclusion(s): With this educational innovation, ECMO specialists have a resource that is easily accessible. They are taken directly to a website that allows them to see tasks and procedures role-modeled by senior team members. In the future, we anticipate expanding to include family brochures and teaching for non-ECMO bedside staff.

COVID-19 infections among minority patients with gastrointestinal malignancies in urban safety net academic medical centers

Background: COVID 19 infection has worse outcomes and is more severe among frail patients and with co-morbidities. Additionally, it was suggested by Mehta et al that gastrointestinal malignancies may have worse outcomes. Based off these findings, we have evaluated outcomes and potential predictors of these outcomes in patients with gastrointestinal malignancies and COVID 19 infection. Methods: We conducted a retrospective evaluation of 69 cases of patients between February 2020 to February 2021, that had both COVID 19 infection and a gastrointestinal malignancy, including: gastric, colon, pancreatic, biliary, and hepatic. We studied population general characteristics, most common tumors, oxygen requirements, management and death frequencies, at two urban safety net hospitals. Results: The median age of patients with gastrointestinal malignancies and COVID-19 infection was 68 (33 to 87), it was more frequently seen among males (N = 46, 67%);patients had on average 1-7 other comorbidities (N = 55, 80%), hypertension being the most common (N = 43, 62%). All patients in this study were minorities, the majority being Hispanics (N = 32, 46%), followed by African Americans (N = 21, 30%), the rest of patients were minorities such as Asians, Native Americans, and others (N = 16, 23%). We noted that more than half of patients were obese (N = 24, 35%), or overweight (N = 19, 28%), with a mean BMI of 26.24. Most patients were non-smokers (N = 39, 57%). The performance status among these patients was excellent in the large majority (ECOG 0-2;N = 62, 90%). The majority of malignant tumors were adenocarcinomas (N = 63, 91%);others included neuroendocrine tumors (N = 4, 6%) and gastrointestinal tumors (N = 2, 3%), the majority were advanced stage disease between stage III to stage IV disease (N = 38, 55%). The most common malignancy was colon cancer (N = 44, 64%), and also was the most reported deaths were among patients those patients with colon cancer (N = 13, 57%). Among patients that needed to be hospitalized (N = 43, 62%), needed some sort of oxygen supplementation (N = 36, 84%), a small number of patients required ICU admission (N = 8, 19%). When hospitalized, patients were mostly treated with hydroxychloroquine (N = 30, 70%) and steroids (N = 7, 16%). Inflammatory markers such as D-dimer, ferritin, C-RP were not reported in the majority of cases. Overall, the case fatality rate across all gastrointestinal malignancies was noted to be substantial (N = 22, 32%), 35% in males and 26% among females (p = 0.46). Conclusions: During the first year of the COVID-19 pandemic, patients with gastrointestinal malignancies who were infected, seemed to have a high chance to be admitted to the hospital (62%), once hospitalized the majority required some sort of oxygen supplementation (84%) and had a high case fatality rate from the COVID-19 infection (32%).

PERCEPTIONS OF TELEHEALTH BARRIERS AND BENEFITS DURING COVID AMONG AN INTERDISCIPLINARY GROUP OF CARE PROVIDERS OF OLDER ADULTS WITH CANCER

Introduction Caring for older adults with cancer is more demanding than ever. A key challenge during the COVID-19 pandemic has been the transition of care provision to telehealth. Methods Surveys were developed and distributed in April 2020 and summer 2021 by the Cancer and Aging Research Group Advocacy Committee and Association of Community Cancer Centers. Data on telehealth and demographics presented will be analyzed using descriptive statistics and chisquares. Results Most of the respondents in both cohorts were physicians, APPs, and social workers, and predominately US-based. More than 80% used telehealth during COVID compared to only 28.4% before COVID. In 2020 and 2021, respectively, the top barriers to telehealth were patient technology challenges (90.5%, 95.7%), patient access to technology (91.2%, 95.7%), patient perception (44.2%, 87.8%), treatment inappropriate for telehealth (31.4%, 81.3%), and patient impairments (e.g., auditory acuity, which was not included in 2020) to technology use (96.5%). In 2021, benefits noted included: lower need for transportation (81.9%), decreased patient exposure (78.5%%), caregiver availability (68.1%%), healthcare worker safety (66.7%%), and ease of scheduling (45.6%). Conclusions A year into the COVID crisis, cancer care providers face consistent barriers to providing telehealth to older adults with cancer. Further studies are needed to evaluate telehealth's long-term impact and determine if patients' perceptions are congruent with their healthcare providers.

Prolonged ECMO Support of an Adult with SARS-CoV-2 ARDS and Right Heart Failure in a Children's Hospital

ECMO has become a widely recognized support modality for patients with severe cardiac or respiratory failure, and has been increasingly utilized in the ongoing severe acute respiratory syndrome due to coronavirus-2 (SARS-CoV-2) pandemic. Long-term support on ECMO for acute respiratory distress syndrome (ARDS) is also becoming more commonplace with eventual lung recovery, obviating the need for lung transplantation. However, long-term ECMO support has not been well studied for SARS-CoV-2 ARDS patients. We report the case of a 39-year-old female with severe SARS-CoV-2-induced ARDS successfully supported on venovenous ECMO (V-V ECMO) for 5,208 hours (217 days) in a high ECMO-volume, quaternary care children's hospital in 2021. At the time of this writing, this is the longest reported patient successfully supported on ECMO for SARS-CoV-2 ARDS. Our patient was initially cannulated at our children's hospital with dual-site V-V ECMO, via the right internal jugular vein (RIJ) and right common femoral vein. Bedside tracheostomy was performed on ECMO day 40, for early mobility, oral feeding, interaction, and pulmonary rehabilitation planning. Unfortunately, during her course she suffered multiple complications including bacterial co-infections, bleeding requiring anticoagulant changes from unfractionated heparin (UFH) to bivalirudin, multiple ECMO circuit changes due to blood product consumption and coagulopathy, and pneumothoraces requiring thoracostomy tube placements. Approximately 1.5 months into her ECMO course, she suffered acute hypoxemia and echocardiography revealed indirect evidence of pulmonary hypertension with right heart failure. Initial right heart catheterization while on V-V ECMO revealed elevated right ventricular end-diastolic pressure (RVEDP=15-20 mmHg) and severe systemic desaturation with main pulmonary artery (MPA) pressure of 30 mmHg. Pulmonary hypertension and right heart support was initiated in the form of inhaled nitric oxide (iNO), inotropes, phosphodiesterase inhibitors, nitrates, angiotensin-converting enzyme inhibitors, and diuresis. Ultimately, due to necessity of right-heart decompression and support, on ECMO day 86 she was transitioned to single-site V-V ECMO utilizing a 31 Fr dual-lumen venovenous cannula (ProtekDuo (LivaNova, UK)) placed via her RIJ through her right atrium (RA) into the MPA in the cardiac catheterization laboratory. Subsequent heart catheterization more than 2 months later revealed severe right ventricular (RV) diastolic dysfunction (RVEDP=35 mmHg) and moderate left ventricular (LV) diastolic dysfunction (pulmonary capillary wedge pressure (PCWP=24 mmHg)). During her course, multiple trials off ECMO were attempted with varying lengths of time off ECMO support, but ultimately required ongoing ECMO support. She developed evidence of end-organ dysfunction from her cor pulmonale, including oliguric renal failure requiring renal replacement therapy (RRT), hepatic injury with elevated transaminases and hyperammonemia leading to depressed mental state, feeding intolerance, and coagulopathy. Additionally, due to long-term nasogastric enteral tube placement for caloric supplementation and enteral medication administration, she developed concerns for invasive sinusitis with erosion into ethmoid and maxillary sinuses. As she was an adult patient being cared for in a free-standing academic children's hospital, multiple adult medicine consultants were involved in her care. Specifically, adult nephrology, cardiology, cardiothoracic surgery (for ProtekDuo cannula placement), and gastroenterology/ hepatology were integral into her care, along with our pediatric critical care medicine and ECMO teams. Notably, this was the first patient supported on ECMO to receive tracheostomy, RA-MPA dual-lumen VV cannula, and full autonomous mobility outside of the ICU at our well-established ECMO program, which has served as the index patient leading to future advances in the care of our ECMO patients. Over time and with multiple therapies to alleviate her cor pulmonale, the patient's echocardiograms evealed improved, half-systemic right-sided cardiac pressures. She was ultimately decannulated from ECMO at our center before being transferred back to the referring adult facility, and discharged to home 8 months after her initial presentation with acute respiratory failure.

COVID-19 ARDS with Concurrent Methicillin-Sensitive Staphylococcus aureus Bacterial Infection Requiring Extracorporeal Membrane Oxygenation

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that causes the disease entity COVID- 19. Initially, reports showed children had generally mild disease, with few requiring hospitalization. However, as of December 2021 in Arkansas, USA, children and young adults aged 24 years and younger accounted for approximately 166,000 cases with over 1,800 hospitalizations and 27 deaths (3 deaths under age 17). Comparatively, there have been over 6 million cases nationally in children and young adults, with over 1,000 deaths. Bacterial, viral, and fungal co-infections are known complications of viral respiratory illnesses that can lead to increased mortality. There have been multiple reports in adults on the incidence and type of co-infections seen with COVID-19, but few in pediatric patients. Adult data shows that co-infections are present in approximately 13-45% of patients with COVID-19, most commonly with bacterial pathogens of Mycoplasma pneumoniae and Haemophilus influenzae. Methods: We describe four patients with acute SARS-CoV-2 infection, requiring intubation, mechanical ventilation, and extracorporeal membrane oxygenation (ECMO), all of whom had methicillin-sensitive Staphylococcus aureus(MSSA) infections discovered within 24 hours of escalating respiratory support. This case series was determined as exempt by the Institutional Review Board at our institution. Results: Our cohort includes 4 patients with a median age of 18 years (range 16-19 years), all of whom required ECMO for acute respiratory distress syndrome (ARDS) secondary to SARS-CoV-2 pneumonia. The median time from intubation to ECMO cannulation was 139 hours (range 3-319 hours). All patients received targeted COVID-19 therapy with dexamethasone, remdesivir, and either tociluzimab or baricitinib during their hospitalization. These patient also all had culture positive MSSA infections from blood and mini-BAL cultures. Three of the four patients had a positive culture within 24 hours of requiring ECMO and one patient had a positive culture within 24 hours of requiring intubation. All of the patients were initially placed on venovenous (V-V) ECMO and three (75%) later required transition to venoarterial venous (VA-V) ECMO for worsening hemodynamics. All were initially cannulated with dual site femoral-internal jugular configuration. Femoral arterial cannulas were used for the transition to VA-V. Complications encountered during ECMO for these patients included GI bleeding (n=1), atrial flutter requiring cardioversion (n=1), lower extremity compartment syndrome (n=1), and dislodgement of a venous ECMO cannula (n=1). One patient received a tracheostomy while on ECMO. The median ECMO duration was 19.35 days (range 11-48.5 days). All patients were successfully decannulated from ECMO and all were discharged from the hospital alive, except one who is still requiring inpatient rehabilitation services. Discussion: We describe 4 pediatric patients with acute SARS-CoV-2 respiratory infections who were found to have MSSA co-infection within 24 hours of escalating respiratory support, all of whom eventually required ECMO support. In a recently published study, Pickens, et al reported that 25% of recently intubated adult COVID-19 patients have a bacterial co-infection. Limited data is available in pediatric patients. Staphylococcus aureus infections are among the most common bacterial infections worldwide. They are responsible for over 100,000 infections in the United States each year and lead to increased morbidity and mortality. All of our patients received immunemodulating therapies with either tociluzimab or baricitinib, which carry the risk of secondary infections due to immunosuppressive effects. Clinicians should maintain a high index of suspicion and be aware of the possibility of secondary bacterial infections in COVID- 19 patients, especially in those treated with immune-modulators. MSSA co-infection can lead to increased morbidity and mortality in patients with SARS-CoV-2, as seen in our cohort. More investigation s needed to further describe co-infections in patients with COVID- 19 and to identify risk factors for the development of co-infections.