The use of hotels/motels to address homelessness among veterans during the COVID-19 pandemic: lessons from the supportive services for veteran families program

The objective of this exploratory mixed methods study is to assess the use of hotels/motels among Veterans experiencing housing instability during the COVID-19 pandemic to inform policy and programmatic responses to homelessness during such emergencies. We analyzed qualitative interviews conducted with national-level homeless services leadership and Supportive Services for Veteran Families (SSVF) program providers during October 2020-May 2021 and quantitative data for Veterans who enrolled in SSVF during March-August 2020. A multivariable two-part regression model identified factors associated with receiving hotel/motel-specific financial assistance and associated costs. Qualitative interviews indicated that the use of hotels/motels during COVID-19 offered protection from a contagious disease and a novel mechanism to accommodate high-need Veterans who may have previously been unsheltered or resistant to services. Quantitative analyses found that Veteran households' stays in hotels/motels increased sharply following the onset of the COVID-19 pandemic;this assistance tended to flow to a more vulnerable group (i.e. older, no income, and extensive histories of homelessness). COVID-19 and homelessness are ongoing public health concerns;strategies such as the use of hotels/motels to reduce homelessness and ensure safe options for isolation and quarantine are needed to prevent poor health outcomes for a vulnerable population.

Recruitment, clinical equipoise, patient acceptance and compliance in the UK-ANZ POSNOC trial

Background: POSNOC is a UK-ANZ multicentre, non-inferiority, randomised trial comparing systemic therapy alone with systemic therapy plus Axillary Treatment (Axillary radiotherapy or ALND) for women with <=2 macrometastases at SNB. The primary outcome is axillary recurrence within 5 years. This paper describes screening, recruitment and compliance data. Method(s): Sites were requested on a monthly basis to upload screening data and provide reasons for nonrecruitment of eligible patients into the trial. Sites entered in the online database whether the patients were compliant with their randomisation allocation. Result(s): The study opened in July 2014 and completed target recruitment of 1900 women (24% of those screened) in July 2021, at 95 sites in the UK and 20 sites in Australia and New Zealand. The reason for non-enrolment was unknown in 1300 women. Of the remaining 4774 women with known reasons, who were screened but not randomised, the most common reasons for non-recruitment were due to either patients (n=2219, 46.5%) or their clinicians (n=782, 16.4%) favouring axillary treatment, or patients (n=490, 10.3%) or their clinicians (n=170, 3.6%) not wishing to have axillary treatment. Over the course of the study, there was an increase in the proportion of patients wanting axillary treatment and declining the trial (Mean % patients declined 2015 - 17.9%, 2021 - 39.1%). Mean number of participants recruited per site per month was 0.24 (SD 0.18) overall, 0.25 (SD 0.19) in the UK, and 0.19(SD 0.15) in ANZ. The mean was < 0.3 in 79 sites and >0.9 in only one site. Recruitment rate remained consistent throughout the study (mean 25.3 per month) except for during the first 6 months of recruitment (5.7) and during the COVID pandemic Apr-Sep 2020 (7.5). Of 89 (4.8%) participants non-compliant with allocation, n=45 (50.6%) received systemic therapy alone and n=44 (49.4%) received systemic therapy plus axillary treatment. There was no fluctuation in the direction of non-compliance during the study duration. There was increasing uptake of axillary radiotherapy to treat the axilla instead of ALND over the course of the study in patients receiving axillary treatment (Number who had ART of all who had axilla treatment2014-2017 - 248/454 (54.6 %);2018-2021 - 315/449 (70.2%)). Conclusion(s): Recruitment and compliance with randomised allocation remained consistent over a seven-year period. POSNOC with in-built radiotherapy QA will provide definitive data on axillary management in patients undergoing mastectomy or BCS with <=2 macrometastases on SNB.

Rules of engagement: The role of mistreatment from patients in the nurse, physician and advanced practice provider experience

The objective of this study is to examine the incidence of reported stress due to mistreatment by patients toward clinicians and the role of mistreatment from patients along with organizational factors in clinician distress. A survey of clinicians was conducted at a large academic medical center, resulting in a final analytic sample of 1,682 physicians, nurses, advanced practice providers and clinical support staff. Nurses reported the greatest incidence of mistreatment by patients as a major stressor (18.69%), followed by Advanced Practice Providers (11.26%), Clinical Support Staff (10.36%), and Physicians (7.69%). Logistic regression analysis was conducted to determine the relationship of individual- and organization-level characteristics with the odds of reporting mistreatment from patients as a major stressor. Overall findings indicate that nurses and those who work in the ER and ambulatory or outpatient clinics were more likely to be stressed from mistreatment by patients than other clinicians. Stress due to mistreatment by patients was also associated with higher Well-Being Index (WBI) distress scores, rapid changes in workflows or policies, ongoing care of COVID-19 patients, under-staffing, and low perceived organizational support. Gender or sexual minorities (not identifying as male or female) and younger (18-34 years of age) healthcare workers were also more likely to experience stress from mistreatment by patients. Individual resilience was not statistically significantly associated with reported stress from mistreatment by patients. Organizations must examine expectations for patient and visitor behavior in tandem with service standards for clinicians toward patients. © The Author(s), 2022.

GAINING CONSENSUS ON EXPERT RULE STATEMENTS FOR A DIGITAL TWIN PATIENT MODEL IN THE ICU USING A DELPHI METHOD

SESSION TITLE: Optimizing Resources in the ICU SESSION TYPE: Original Investigations PRESENTED ON: 10/16/2022 10:30 am - 11:30 am PURPOSE: The COVID-19 pandemic has exposed worldwide heterogeneity in the application of fundamental critical care principles and best practices. New methods and strategies to facilitate timely and accurate interventions are needed. If built on a robust foundation of physiologic principles, a virtual critically ill patient (aka digital twin) could better inform decision making in critical care. When used in clinical practice, a digital twin may allow bedside providers to preview how organ systems interact to cause a clinical effect, providing the opportunity to test the effects of various interventions virtually, without exposing an actual patient to potential harm. Building on our previous work with a digital twin model of critically ill patients with sepsis, this current project focuses specifically on the respiratory system. METHODS: We assembled a modified Delphi panel of 36 international critical care experts. We modeled elements of respiratory system pathophysiology using directed acyclic graphs (DAG) and derived several statements describing associated ICU clinical processes. Panelists participated in three Delphi rounds to gauge agreement on 71 final statements using a 6-point Likert scale. Agreement was defined as >80% selection of a 5 (“agree”) or 6 (“strongly agree”). RESULTS: The first Delphi round included statements of pulmonary physiology affecting critically ill patients, eg pulmonary edema, hypoxemic and hypercapnic respiratory failure, shock, acute respiratory distress syndrome (ARDS), airway obstruction, restrictive lung disease, and ventilation-perfusion mismatch. Agreement was achieved on 60 (84.5%) of expert statements after completion of two rounds. After partial completion of the third round, agreement increased to 62 (87%). Statements with the most agreement included the physiology and management of airway obstruction decreasing alveolar ventilation and the effects of alveolar infiltrates on ventilation-perfusion matching. Lowest agreement was noted for the statements describing the interaction between shock and hypoxemic respiratory failure due to increased oxygen consumption and ARDS increasing dead space. CONCLUSIONS: An international cohort of critical care experts reached 87% agreement on our rule statements for respiratory system pathophysiology. The Delphi approach appears to be an effective way to refine content for our digital twin model. CLINICAL IMPLICATIONS: Expert consensus can be used to strengthen the respiratory physiology statements used to direct the ICU digital twin patient model. With a digital twin based on refined respiratory physiology statements, bedside providers may preview how organ systems interact to cause a clinical effect without exposing an actual patient to various interventions. DISCLOSURES: No relevant relationships by Ognjen Gajic, value=Royalty Removed 06/06/2022 by Ognjen Gajic No relevant relationships by Amos Lal No relevant relationships by John Litell No relevant relationships by Amy Montgomery

Unique stressors in a global pandemic: a mixed methods study about unique causes of distress among healthcare team members during COVID-19

Background: Amid the COVID-19 pandemic, healthcare systems experienced significant challenges, including lower revenues from elective procedures, limited supplies, a massive influx of patients and psychologically distressed employees. National reports of well-being showed striking rates of burnout among healthcare workers. Prior research depicted how the pandemic affected all categories of healthcare workers, yet there is little evidence showing what specific factors hinder each type of employee. Methods: Employees from a large medical center in the Southeastern United States (US) (n=1,130) participated in an online survey, responding to a series of questions about their daily stressors, working conditions, and distress as measured by a 9-item Well-Being Index (WBI), and providing open-ended responses about additional stressors and positive changes in their work. With an analytic sample of 1,037, we used stepwise analysis for each employee group to identify which stressors have a significant association with their overall distress. Using a convergent mixed methods approach, we corroborate our quantitative findings with qualitative themes from the open-ended responses. Results: Among all types of employees i.e., physicians, nurses, Advanced Practice Providers (APPs), Clinical support staff and Non-clinical staff, moral distress was associated with higher WBI distress. Qualitative themes showed employees were mainly concerned with quality of and access to care for patients. Stress triggered by heavy workload in the setting of increased pandemic-related responsibilities and decreased personnel was associated with a high level of WBI distress among all types of employees, whereas other significant stressors differed by role. Conclusions: The COVID-19 pandemic created a myriad of work and non-work-related stressors hindering all healthcare workers' psychological well-being differently. Working conditions and responsibilities for each role are unique. Institutional policies must contemplate the distinctiveness of stressors and distress across employee sub-groups to properly mitigate psychological distress. © 2022 Journal of Hospital Management and Health Policy.

Gaps in Documented Assessments at the Time of Intensive Care Unit Admission

RATIONALE During this unprecedented COVID-19 pandemic intensive care units (ICU) need efficient ways to deliver patient care. As hospital workload increases, so does the risk for medical error and delays in care. A systematic initial approach and timely documentation is important to provide an efficient and thorough assessment and to facilitate communication within the interprofessional team. We aimed to evaluate documentation of key assessment elements at ICU admission. METHODS The Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) is a validated tool that reduces errors in the initial assessment and ongoing care of critically ill patients. With Mayo IRB approval, electronic medical records (EMR) of a convenience sample of ICU patients admitted to medical, surgical and mixed ICUs at our institution during October 2021 were reviewed to assess documentation of the CERTAIN primary survey, including assessment of airway, breathing, cardiac, disability, and exposure (ABCDE);vital signs;intravenous access;point of care labs and ultrasound (POCUS);differential diagnosis;and plan by systems including code status and goals of care. Patients admitted for post-operative monitoring and those who declined the use of their medical records for research were excluded. RESULTS Forty patient EMRs were reviewed. Median age was 65 years, 47.5% were female, and respiratory failure was the most common reason for ICU admission. Documented frequency of airway assessment was 32.5%, breathing 92.5%, cardiac 70%, disability 42.5%, and exposure 85%. Thorough vital sign review including temperature was documented in 47.5% of ICU admissions. A comment or plan for intravenous or intraosseous access was documented in 75% of patients. Completion or review of same day point of care labs was documented in 55%. Cardiac POCUS was documented in 9 of 40 ICU admissions. No patients had documented lung or abdominal POCUS. 80% had a differential diagnosis documented as part of their initial assessment. All patients had a complete plan by systems. 85% of patients had a documented code status, although it was unclear if it had been actively re-addressed on ICU admission. CONCLUSION EMR documentation of key findings at the time of ICU admission leaves significant opportunities for improvement, with particularly large gaps in primary survey and POCUS assessment. The results of this study, combined with ongoing direct observation of ICU admissions using the CERTAIN checklist, will inform future recommendations to improve the performance and documentation of key assessment elements during the “golden first hour” of ICU admission.

RISK AND PROTECTIVE FACTORS ASSOCIATED WITH MENTAL HEALTH DIFFICULTIES FOR CHILDREN WITH ADHD OVER THE COVID-19 PANDEMIC: A LONGITUDINAL STUDY

Background: A growing number of studies have reported both positive and negative outcomes associated with COVID-19 in children with attention-deficit/hyperactivity disorder (ADHD) and their families. However, very few longitudinal studies have examined outcomes over multiple time points over the pandemic. Objectives: To examine COVID-19-related mental health (MH) impacts for children with ADHD and their families over a 12-month period over the pandemic. Methods: The parents of 213 Australian children (5-17 years) with ADHD were recruited in May 2020 when COVID-19 restrictions were in place. Parents completed surveys at repeated time points assessing MH (CoRonavIruS Health Impact Survey [CRISIS] - mood states subscale) and predictors. Latent profile analyses were used to examine the patterns of MH difficulties over the pandemic using the first four waves of data collected from May to August 2020, and the fifth wave of data collected in May-July 2021. Numerous baseline predictors of MH patterns were examined. Findings: Using the first four waves of data, three groups were identified comprising: (1) children with unchanging (36%), (2) increasing resolved (30%) and (3) increasing persistent (34%) MH difficulties. The most robust predictor of increasing persistent MH difficulties was stress related to COVID-19 (e.g. stress associated with restrictions related to COVID-19). Analyses are being updated to include our fifth wave of data collection (May-July 2021) (70% retention rate). Conclusion: A subgroup of children with ADHD appears to be struggling with MH, which is related to the stress associated with COVID-19 restrictions.

Trends in Substance Use in Two United States Communities during Early COVID-19 Lockdowns Based on Wastewater Analysis

The COVID-19 pandemic provoked community anxiety and stress-related disorders and increased drug-related emergency admissions and overdose deaths. The unprecedented disruption in transportation and stay-at-home orders caused a global disruption in the supply and distribution of drugs that impacted both prescription and illicit drug users. In this study, the trend in consuming 10 major illegal drugs and 19 prescription drugs of potential abuse was determined during the early four months of the COVID-19 pandemic in two communities in western Kentucky and northern Tennessee using wastewater-based epidemiology. The hydrocodone consumption rate increased by 72% (up to 430 mg/d/1000 people) in both communities that aligned with convenient opioid access through teleprescription-approved refills. However, a limited supply and a consequent increase in the cost of drugs significantly curtailed the consumption of illicit stimulants (methamphetamine, 16%;cocaine, 42%). Moreover, the increased use of benzodiazepines and antidepressants suggests elevated community anxiety that overall warrants robust neuropsychiatric screening and treatment programs. To the authors' knowledge, this is the first study to determine trends in consumption of diverse illicit and prescription drugs during the stay-at-home early months of the COVID-19 pandemic in United States communities. © 2021 American Chemical Society.

The COVID-19 lockdowns: a window into the Earth System

The COVID-19 pandemic has caused substantial global impact. This Perspective provides insight into the environmental effects of the pandemic, documenting how it offers an opportunity to better understand the Earth System. Restrictions to reduce human interaction have helped to avoid greater suffering and death from the COVID-19 pandemic, but have also created socioeconomic hardship. This disruption is unprecedented in the modern era of global observing networks, pervasive sensing and large-scale tracking of human mobility and behaviour, creating a unique test bed for understanding the Earth System. In this Perspective, we hypothesize the immediate and long-term Earth System responses to COVID-19 along two multidisciplinary cascades: energy, emissions, climate and air quality;and poverty, globalization, food and biodiversity. While short-term impacts are dominated by direct effects arising from reduced human activity, longer-lasting impacts are likely to result from cascading effects of the economic recession on global poverty, green investment and human behaviour. These impacts offer the opportunity for novel insight, particularly with the careful deployment of targeted data collection, coordinated model experiments and solution-oriented randomized controlled trials, during and after the pandemic.

Spontaneous hemopneumothorax in an adolescent with COVID-19.

As coronavirus disease 2019 (Covid-19) continues to spread world-wide, new symptoms associated with the disease continue to appear. Common manifestations include fever, shortness of breath, and gastrointestinal illness. In addition, COVID is known to induce coagulopathy. Here, we present the case of a 17-year-old male who presented with a massive hemopneumothorax and was found to incidentally be positive for Covid-19. We suspect that he had a primary pneumothorax from a bleb and the hemothorax could've been induced by the coagulopathic state induced by COVID infection.

Correction to: European Hernia Society (EHS) guidance for the management of adult patients with a hernia during the COVID­19 pandemic.

The originally published article: The surname and given name of authors, M. Pawlak and A.C. de Beaux has been incorrectly published.