IMPORTANCE OF PATIENT THROUGHPUT WHEN SIMULATING CRISIS STANDARDS OF CARE: EXCLUSION CRITERIA AND TRIAGE SCORE MODIFIERS

SESSION TITLE: What Lessons Will We Take From the Pandemic? SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: COVID-19 surges due to variants continue to intermittently strain healthcare resources, highlighting the need to refine crisis standards of care (CSC) guidelines and study how they may perform in actuality. Studies to date, focusing on excess deaths or exacerbations of existing health disparities, simulate retrospective patient cohorts that synchronize patient presentation to a single point in time, rather than the reality where patients present continually throughout time. This artificial static model may not be an accurate reflection of patient throughput and dynamic resource strain, which occurs in reality, and might distort patient cohorts and mislead CSC simulated outcomes. METHODS: All intubated COVID-19 patients in a single healthcare system in New York City during the first surge (1/1/20 to 6/30/20) were included. A crisis period requiring CSC activation was defined as occurring once 95% of pre-pandemic ventilators were utilized and lasted 2 weeks in duration, consistent with prior simulated length of CSC for this cohort under the New York State Ventilator Allocation Guidelines (NY). NY, Maryland (MD), Pittsburgh (PA), Saskatchewan Canada (SAC), and California (CA) CSC policies were reviewed for exclusionary and other criteria that would affect patient triage (admission diagnosis, comorbidities, occupation, or other patient circumstances). NY, MD, SAC, and CA all use exclusionary criteria. Subsequently NY and SAC only use a SOFA score for triage whereas MD, PA, and CA all integrate tiered comorbidities in addition to a SOFA score to generate an overall triage score. Partial triage priority is provided by PA, SAC, and CA for certain occupations and by PA for those socially disadvantaged. Patient charts were reviewed to determine if they would satisfy triage criteria from any of these guidelines and if they would be relevant during the specific crisis period. RESULTS: 936 patients were included in the total cohort, of which 573 were involved during the crisis period. Those not involved during the crisis period required a ventilator when less than 95% of all ventilators were utilized and would not be relevant during a CSC simulation. NY, MD, PA, SAC, and CA would have excluded 1, 3, 0, 79, and 4 patients respectively for the entire cohort, but 0, 0, 0, 29 (36.7%), and 2 (50%) during the specific crisis period. MD, PA, & CA would have modified 49, 88, & 102 individual’s triage score due to comorbidities in the entire cohort but only 17 (34.7%), 40 (45.5%), and 41 (40.2%) during the crisis period respectively. CONCLUSIONS: CSC simulations that include patients outside the crisis period will include patients that may not be relevant to understanding how CSC might perform. CLINICAL IMPLICATIONS: Understanding CSC performance, particularly when studying excess deaths or exacerbating social disparities, requires incorporating patient throughput for an accurate real-world understanding. DISCLOSURES: No relevant relationships by Deepak Pradhan No relevant relationships by Brandon Walsh

IMPROVING ACCESS TO ADVANCED CARDIORESPIRATORY THERAPIES FOR UNDERSERVED PATIENTS AND MINORITIES WITH A MULTIDISCIPLINARY EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) PROGRAM IN A LARGE PUBLIC HOSPITAL NETWORK

SESSION TITLE: Impact of Health Disparities and Differences SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Vulnerable patients, including minorities and underserved populations whose care relies on public hospitals, have limited access to advanced cardiac or respiratory care in shock centers or extracorporeal membrane oxygenation (ECMO)-capable hospitals, especially when socioeconomic or insurance barriers play a role in patient selection. Our aim is to describe the implementation of an ECMO program for cardiac and respiratory failure during the COVID-19 pandemic in the largest public health system in the country, as a strategy to mitigate healthcare disparities and improve access to care for minorities. METHODS: We collected clinical, demographic and socioeconomic data of all patients undergoing ECMO at Bellevue Hospital Center, the shock and ECMO center for New York City’s Health and Hospitals’ network. This public health system includes 11 Hospitals and provides care to 1 million New Yorkers. The decision to proceed with ECMO took place with a multidisciplinary team discussion, which was also in charge of providing longitudinal care during their hospitalization. RESULTS: A total of 49 patients were included [30 veno-venous (VV) ECMO, 19 venoarterial (VA) ECMO, including 9 extracorporeal cardiopulmonary resuscitation (ECPR)] from April 1st, 2020 to March 30th, 2022. The median age was 42.6 years, 57% were male, 38% were Hispanic, 35% African American, 14% white, 6% Asian and 8.2% had other ethnicities;33% were uninsured, 49% lived below the poverty level reported for New York City and 20% were undocumented. Level of education was 8th grade or less in 2.1%, high school in 24.5%, ≤ 2 years of college in 10.2%, >4 years of college in 12.2% and unknown in 51%. ECMO survival was 56% for VV ECMO, 44% for VA ECMO and 33% for ECPR. Survival to discharge was 56% for VV, 33% for VA and 33% for ECPR. One VV ECMO patient was bridged to lung transplant, there were no patients bridged to LVAD or heart transplant. Bleeding complications occurred in 3 patients (6%) and there were no procedural related complications. CONCLUSIONS: Our multidisciplinary ECMO program demonstrates feasibility to provide care to underserved and vulnerable populations with outcomes comparable to the national average, despite the challenges related to the potential limitations in bridging strategies for such patients. While socioeconomic and insurance status have a key role in bridging options for ECMO, they should not be a major determinant in denying patients advanced cardiopulmonary support if clinically indicated. CLINICAL IMPLICATIONS: Access to advance cardiorespiratory therapies including ECMO for vulnerable populations is a present need and is feasible with a multidisciplinary team DISCLOSURES: Speaker/Speaker's Bureau relationship with Zoll Please note: 3 years Added 04/04/2022 by Carlos Alviar, value=Honoraria No relevant relationships by Fariha Asef No relevant relationships by Sripal Bangalore No relevant relationships by Samuel Bernard No relevant relationships by Lauren Bianco No relevant relationships by Nishay Chitkara No relevant relationships by Jennifer Cruz No relevant relationships by Michael DiVita Research support relationship with Eurofins Viracor Please note: 12/1/2021 ongoing Added 12/23/2021 by Randal Goldberg, value=Grant/Research Support No relevant relationships by Kerry Hena No relevant relationships by William Howe No relevant relationships by Norma Keller no disclosure on file for Ma-Rosario Mertola;no disclosure on file for Thor Milland;No relevant relationships by vikramjit mukherjee No relevant relationships by Kayla Nunemacher No relevant relationships by Mansi Patel No relevant relationships by Radu Postelnicu No relevant relationships by Deepak Pradhan No relevant relationships by Vito Stasolla no disclosure on file for Amit Uppal;No relevant relationships by Susan Vlahakis No relevant relationships by Kah Loon Wan no disclosure on file for Victoria Yunaev;

Change in Disease Dynamics and Health Care Utilisation in Children during COVID 19 in a Tertiary Care Hospital of Eastern India

Introduction: The direct and indirect impact of SARS COVID 19 on the health of children was unprecedented. This study was conducted to compare the changing pattern of pediatric disease dynamics and the use of healthcare system before and after the SARS-CoV2 outbreak in a tertiary care hospital. Methodology: This retrospective, observational study was conducted by collecting data from medical records during COVID 19 pandemic from March 2020 till August 2020. This was compared with the data of 2019 during similar months. The impact of COVID 19 on use of paediatric health care service units like outpatient department, casualty, intensive care and immunization clinic were assessed. Results: There was a significant decline in routine OPD (68%) attendance during the COVID 19 period as compared to pre-COVID period. Paediatric ward admissions and PICU admissions were decreased by 55% and 42% respectively. We also observed a significant 43% decline in the number of children attending immunization clinic in the year 2020. Conclusion: The fear of COVID 19 pandemic and the measures taken to control the pandemic has affected the health seeking behaviour of patients. This evaluation of trends in healthcare use may help in planning the delivery of healthcare service delivery in future. @ The Journal retains the copyrights of this article.

Perception of Dental Students of Karnataka on Effectiveness of e-Learning during Covid-19 Pandemic - A Questionnaire Based Survey

Aim: E-learning has currently been used as a medium of education due to the COVID-19 pandemic. This survey was conducted to evaluate the effectiveness of e-learning class among the dental students of Karnataka and adding a note on their concerns regarding their future plans. Materials and Methods: A questionnaire was created with questions aiming at the effectiveness of e-learning and the concerns of the students regarding their future plans using the Google docs. It was circulated among the dental students of Karnataka using various social media platforms. Results: A total of 406 students completed the survey and nearly half of the respondents (51.1%) were glad to attend online mode of digital learning (73.3%). Of all the respondents, accessibility (88%) and problems related to poor internet connection (55.1%) was not reported as an issue. However, the state of mind of the students (79.9%), psychological stress (72.6%), and the lack of confidence in the clinical/ practical work (83.6%) seemed to be a major concern. A significant concern regarding their future plans was observed in terms of getting a job (58.3%), overseas studying (87.5%), and majority of them felt the requirement of additional training (85.5%). Conclusion: Despite good acceptance and adaptation to this new learning environment, the pandemic has shown to influence the future plans of the students.

Classification of Corona Virus Infected Chest X-ray using Deep Convolutional Neural Network

The coronavirus 2019 is a worldwide pandemic declared by the world health organization (WHO). It starts in China, Wuhan in November 2019 and spread all over the world. As time passed, the detection and clinical treatment of COVID-19 is developed by the researchers. COVID-19 is detected using a reverse transcription-polymerase chain reaction (RT-PCR) test, which is precise but requires two days to complete. Hence, the researchers proposed many classification models, which are mainly based on artificial intelligence. Mainly these classification models are using chest X-ray images for the detection of COVID-19. In this paper, we proposed a deep convolutional neural network model architecture to classify chest X-ray images. We called this model the base model, which is the first train to classify normal and abnormal chest X-ray images. Using the transfer learning technique, we retrained this model for four-classes classification (i.e., Normal, COVID-19, Pneumonia, and Pneumothorax). We obtain 73.9% accuracy for the base model (i.e., binary classification) and 83.2% accuracy for fine-tuned model (i.e., four-classes classification). © 2021 IEEE.

Evaluation of the airway viral load in acute sars-cov2 infection as a predictor of clinical outcome

Rationale: Throughout recent studies, data suggests high viral load in the plasma and nasopharynx of patients with severe SARS-CoV2 infection is associated with disease severity (mortality, length of hospitalization, and risk of intubation). Here, we evaluated whether viral load in the airway is associated with poor clinical outcomes in patients with SARS-CoV2. Methods: Lower airway samples in 148 patients from an academic center that were admitted to the ICU (dates: March 10th to May 10th, 2020) with severe respiratory failure requiring mechanical ventilation and underwent bronchoscopy for airway clearance and/or tracheostomy. Clinical outcome was defined as ≤ 28 Day mechanical ventilation vs. > 28 Day mechanical ventilation vs. death. Post-admission followup time was 232 [IQR 226-237] days. RNA was isolated in parallel using zymoBIOMICS™ DNA/RNA Miniprep Kit (Cat: R2002) as per manufacturer's instructions. Viral load was measured by quantitative real-time reverse transcription polymerase chain reaction (rRT -PCR) targeting the virus nucleocapsid (N) gene and an additional primer/probe set to detect the human RNase P gene (RP). Results: Among this bronchoscopy cohort, n=58 39% of the subjects were successfully extubated within 28 days of initiation of mechanical ventilation, n=56 38% required prolonged mechanical ventilation and n=34 23% died. We evaluated the viral load by rRT-PCR for SARSCoV2 N gene adjusted by human RP gene throughout the respiratory tract using supraglottic samples and bronchoalveolar lavage (BAL) samples obtained during bronchoscopy. Paired analysis of upper and lower airway samples shows that there is a subset of subjects (n=31, 21%) where there is greater viral load in the BAL than in the supraglottic area supporting topographical differences in viral replication (Fig 1A). BAL samples from subjects that died had higher viral load in their lower airways than patients that survived, even after adjusting for confounders such as age, gender, BMI and timing of sample collection (Fig 1B magenta dots (deceased) vs. yellow/green dots (alive)). Conclusions: Using samples obtained via bronchoscopy we identified that in a subset of subjects with acute SARS-CoV2 infection, the lower airways are the predominant site for viral replication. From our study, it is unclear if the higher viral load reflects host co-morbidies (e.g., diabetes or immunosuppression) or viral factors favoring higher replication. High viral load can be used as a predictor for disease severity upon hospital admission as viral load in the lower airways correlated with poor outcomes.

How would new york ventilator reallocation policies perform during a COVID-19 surge? An observational cohort study

COVID-19 has created significant strain on the supply of healthcare resources and, during the spring surge in New York City, many hospitals prepared resource allocation policies should the demand for ventilators exceed supply. In such circumstances, resources should remain allocated to patients most likely to survive. Understanding how these guidelines perform is an important consideration in disaster planning. Numerous allocation guidelines exist however nearly all utilize a Sequential Organ Failure Assessment (SOFA) score. We sought to evaluate the performance of ventilator reallocation by applying the New York State Ventilator Allocation Guidelines (NYVAG) to a large cohort of COVID-19 patients. Our retrospective cohort included 895 intubated COVID-19 patients admitted to an academic system in New York City. SOFA scores were calculated for every day of mechanical ventilation. Per NYVAG, patients would have their ventilator reallocated at 48 hours if their interval SOFA score increased, did not change from an initial SOFA of 8-11, or was greater than 11. At 120 hours it would be reallocated if their SOFA score worsened or was greater than 7. At 168 hours and every subsequent 48 hours it would be reallocated if their SOFA score worsened. Ventilator reallocation was simulated and no reallocation was made for any patient. The average SOFA (n=895) at the time of intubation was 7.1 ± 3.6. At the 48-hour reassessment (average SOFA 8.2 ± 3.6, n=759), 436 (57%) patients would have their ventilator reallocated, 145 (33%) of whom would later survive to discharge. At the 120-hour reassessment (average SOFA 7.8 ± 3.6, n=264) 173 (66%) of the 264 remaining simulated ventilated patients would have their ventilators reallocated, 83 (48%) of whom would later survive to discharge. At the 168-hour reassessment (average SOFA 7.8 ± 3.6, n=80) 66 (83%) of the 80 simulated remaining ventilated patients would have their ventilators reallocated. Overall, 685 patients (77%) of the starting cohort would have had their ventilator reallocated at some time during the first 168 hours of mechanical ventilation, 268 (40%) of whom survived to discharge. Our simulated study found that the application of NYVAG to the COVID-19 surge at one academic system would have resulted in a significant portion of ventilated patients having had their ventilators reallocated. This may be deeply concerning as a significant portion of patients ultimately survived to discharge. These results call for further confirmatory studies and have implications for optimal resource allocation strategies during pandemics.

Evaluation of the lower airway microbiota in patients with severe sars-cov2

RATIONALE:Secondary infections with bacterial pathogens are thought to be responsible for poor outcomes in the 1918 Spanish and H1N1 pandemics. We postulate that poor prognosis in patients with SARS-CoV2 may be associated with uncontrollable viral replication, co-infection with a secondary pathogen, and over exuberant host immune response. We seek to evaluate whether there is an association between distinct features of the lower airway microbiota and poor clinical outcome in patients with SARS-CoV2. METHODS:We collected lower airway samples in 148 patients from NYU admitted between 3/10/2020 and 5/10/2020 with severe respiratory failure requiring mechanical ventilation and that underwent bronchoscopy for airway clearance and/or tracheostomy. Clinical outcome was defined as dead vs alive. DNA was isolated in parallel using zymoBIOMICS™ DNA/RNA Miniprep Kit (Cat: R2002) as per manufacturer's instructions. The V4 region of the 16S rRNA gene marker was sequenced using Illumina MiSeq. Sequences were analyzed using the Quantitative Insights into Microbial Ecology (QIIME version 1.9.1) pipeline. Total bacterial load was evaluated in lower airway samples using digital droplet PCR targeting the 16S rRNA gene. RESULTS:Of the 148 patients included, 114 survived (77%) and 34 (23%) died. Among those with poor clinical outcome, there was a non-statistically significant trend towards higher age and BMI. Patients who died more commonly had chronic kidney disease and prior cerebrovascular accidents, and more often required dialysis. There was no statistically significant difference in the rate of positive bacterial respiratory or blood cultures among those that survived vs. those that died (75 vs. 73% and 43 vs 38%, respectively). Topographical analysis of the 16S RNA microbiome shows compositional differences between the upper and lower airways based on β diversity comparisons. When comparing across clinical outcomes, the α diversity was lower in the dead group but there was no statistically significant difference in overall community composition (β diversity). Taxonomic differential enrichment analysis using DESeq analysis showed that oral commensals were enriched in the group that survived. Patients that died had a higher bacterial load in their lower airways than those who survived. CONCLUSION:Using samples obtained via bronchoscopy we identified lower airway microbiota signatures associated with mortality among critical patients infected with SARS-CoV2. Taxonomic signals identified as associated with poor prognosis did not reveal bacterial taxa commonly classified as respiratory pathogens. This data is not supportive of the hypothesis that secondary untreated bacterial co-infections are responsible for increased mortality in patients with severe SARS-CoV-2.

LUNG ULTRASOUND B-LINES CORRELATE WITH STATIC COMPLIANCE IN MECHANICALLY VENTILATED PATIENTS

SESSION TITLE: Insights into the Care of Patients with Respiratory Failure SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Lung ultrasound is a quick, non-invasive, and widely available tool used to assess for a multitude of disease processes. Recently, a quick point assessment of B-lines (B-line score) has been shown to be an accurate marker of extra-vascular lung water. In mechanically ventilated patients, static lung compliance is calculated as Cstat = VT/(Pplat-PEEP), with VT meaning tidal volume, Pplat plateau pressure, and PEEP positive end expiratory pressure. A limitation of this technique is that patients need to be passive on the ventilator to accurately measure PPlat, something which is difficult given efforts to reduce sedation. Other techniques, such as esophageal manometry, have been used to estimate transpulmonary pressures, but is limited by being invasive and subject to error. Our study sought to determine if the B-line score correlates with lung compliance in mechanically ventilated patients. We hypothesized that the B-line score would inversely correlate with static lung compliance. METHODS: This was a prospective observational study performed in the medical intensive care units of NYU Langone Health and Bellevue Hospital Center. Inclusion criteria included all adult patients requiring mechanical ventilation. Exclusion criteria included reasons to have reduced respiratory system compliance from an extrapulmonary etiology: BMI > 35, abdominal hypertension, significant pleural effusions, or pneumothorax. Lung ultrasound was performed at 4 points over the anterior chest. Each image was independently scored by two intensivists. The number of B-lines seen in each window were counted and added together to create the B-line score. Static lung compliance was determined using the formula above;inspiratory hold maneuvers were used to obtain plateau pressures. RESULTS: A total of 99 observations were performed. The mean B-line score was 4.73 +/- 0.60 with a range score from 0 to 25.5. Ultrasound B-line score inversely correlated with static lung compliance (Spearman's r = -0.60, p<0.001), net fluid balance in the 24 hours prior to the scan (Spearman's r = -0.26, p=0.02), and P/F ratio (Spearman's r = -0.37, p<0.001). CONCLUSIONS: Ultrasound B-line score correlates with for static lung compliance in mechanically ventilated patients. CLINICAL IMPLICATIONS: Our study demonstrates that an assessment of B-lines on lung ultrasound is an effective marker of important clinical characteristics in mechanically ventilated patients. In patients where assessments of these factors are limited, use of this quick and simple B-line score may be clinically useful. This is especially true in the recent COVID-19 pandemic, where imaging tests and monitoring may be limited given isolation precautions. Whether serial B-line scores in the same patient correlate with clinical improvement in the above-mentioned markers is yet to be determined. DISCLOSURES: No relevant relationships by Andrew Lehr, source=Web Response No relevant relationships by Vikramjit Mukherjee, source=Web Response, value=Consulting fee Removed 04/27/2020 by Vikramjit Mukherjee, source=Web Response No relevant relationships by Deepak Pradhan, source=Web Response No relevant relationships by Bishoy Zakhary, source=Web Response

The Emergence of novel SARS-CoV-2 (COVID-19) a triple reassortant corona virus immunogenicity and reactogenicity in human

Presently, the emergence of a novel human corona virus, Severe Acute Respiratory Syndrome (SARS)-CoV-2, has lead to a global health concern. It causes severe respiratory tract infections in humans. WHO on March 11, 2020, declared COVID-19 (Corona Virus) as a pandemic. There have been more than 3,842,000 confirmed COVID-19 cases in the world. The reports have shown sharp increase in the number of infections reported in recent days from Italy, Iran, South Korea, Spain, Germany, United States, and other parts of the world, with the most dramatic increase recorded in China where more than 80,000 cases were reported in a very short duration. Since no potential medication nor vaccines are available in the market and the presence of corona virus in different form both in symptomatic and asymptomtic in human system makes the chances of cure less effective. This article enlightens about the Corona virus, its modes of infection, and prevention measures.