ABSTRACT
Introduction & Objective: Due to the COVID-19 global pandemic, in July 2020 we developed a same day discharge (SDD) protocol for robotic assisted laparoscopic prostatectomy (RALP) that balanced safety concerns with benefits of early discharge. In this study we present our experience and protocol. Methods: We performed a prospective analysis of patients undergoing RALP who were selected for SDD in a high-volume prostate cancer referral center. The criteria for discharge included uncomplicated surgery, stable postoperative hemoglobin, ambulation, tolerance of clear liquids without nausea or vomiting, pain control with oral medication, and patient/family comfort with SDD. We excluded patients older than 70 years, having concomitant general surgery operations, significant comorbidities (e.g. cardiopulmonary disease), and challenging procedures (e.g. salvage procedure, large prostates). We analyzed patient demographics, clinicopathologic factors, and operative outcomes and evaluated rates of SDD and factors associated with SDD failure (SDF). Results: From July 13, 2020 to January 1, 2021, 101 patients undergoing RALP were selected for SDD. Eighty patients (79%) met criteria , 73 (72%) were successful SDD, and 28 (28%) were SDF. All the SDF were discharged on postoperative day 1. Preoperative demographics were similar between the two groups with a median age of 63 (57-67) years and median BMI of 27 (25-30) kg/m2. Intraoperative characteristics were not statistically different with a median operative time of 92 (81-107) vs 103 (91-111) minutes for SDD and SDF respectively (P = 0.51). The readmission in the SDD group was due to dizziness from hematoma and ileus from urine leak in the SDF cohort (P = 0.69). Of the 28 SDF patients, the most common reasons for staying were anesthesia-related factors of nausea (35%) and drowsiness (7%), followed by patient/caregiver preference (25%), pain (14%), labile blood pressure (7%), arrhythmia (7%), and dizziness (7%). Conclusions: SDD for patients undergoing RALP can be safely incorporated into a clinical care pathway without increasing readmission rates. Coordinated care with anesthesia and nursing teams is an integral part of developing a SDD program, as is preoperative counseling to manage expectations. Future aims will be to investigate anesthesia factors leading to nausea and to expand selection to more patients.
ABSTRACT
Background: Cardiac involvement in coronavirus disease 2019 (COVID- 19) has been established. This is manifested by troponin elevation, and associated with worse prognosis as compared with patients without myocardial injury. Purpose: We sought to evaluate if the outcomes of these patients has improved as experience accumulated during the pandemic. Methods: We analyzed COVID-19-positive patients with the evidence of myocardial injury (defined as troponin elevation) who presented to our large US healthcare system in the northeast region during the Early Phase of the pandemic (March 1-June 30, 2020) and compared their characteristics and outcomes to the COVID-19-positive patients with the presence of troponin elevation in the Current Phase of the pandemic (October 1, 2020-January 31, 2021). Results: The cohort included 788 COVID-19-positive admitted patients for whom troponin was elevated, 167 during the Early Phase and 621 during the Current Phase. The cohort's mean age was 70.2±14.9 years;54.3% were men (Figure 1). Maximum troponin-I in the Early Phase was 13.46±34.72 versus 11.21±20.57 in the Current Phase (p=0.553) In-hospital mortality was significantly higher (50.3%) in the Early Phase group compared to the Current Phase group (24.6%;p<0.001). Similarly, the incidence of intensive care unit admission (77.8% versus 46.1%;p<0.044) and requirement for mechanical ventilation (61.7% versus 28%;p<0.001) were higher in the Early Phase (Figure 2). In addition, 6% of those in the Early Phase underwent coronary angiography compared to 2.3% in the Current Phase (p=0.013). Finally, 3% of Early Phase and 0.8% of Current Phase patients underwent percutaneous coronary intervention (p=0.025). Conclusions: Treatment outcomes have significantly improved since the beginning of the pandemic in COVID-19-positive patients with troponin elevation. This may be attributed to awareness, severity of the disease, improvements in therapies and provider experience.
ABSTRACT
On 2 July 2020, the governor of Kansas issued an executive order (state mandate), effective 3 July, requiring masks or other face coverings in public spaces. CDC and the Kansas Department of Health and Environment analyzed trends in county-level COVID-19 incidence before (1 June-2 July) and after (3 July-23 August) the governor's executive order among counties that ultimately had a mask mandate in place and those that did not. As of 11 August, 24 of Kansas's 105 counties did not opt out of the state mandate or adopted their own mask mandate shortly before or after the state mandate was issued;81 counties opted out of the state mandate, as permitted by state law, and did not adopt their own mask mandate. After the governor's executive order, COVID-19 incidence (calculated as the 7-day rolling average number of new daily cases per 100,000 population) decreased (mean decrease of 0.08 cases per 100,000 per day;net decrease of 6%) among counties with a mask mandate (mandated counties) but continued to increase (mean increase of 0.11 cases per 100,000 per day;net increase of 100%) among counties without a mask mandate (non-mandated counties). The decrease in cases among mandated counties and the continued increase in cases in non-mandated counties adds to the evidence supporting the importance of wearing masks and implementing policies requiring their use to mitigate the spread of SARS-CoV-2. Community-level mitigation strategies emphasizing wearing masks, maintaining physical distance, staying at home when ill, and enhancing hygiene practices can help reduce transmission of SARS-CoV-2.
ABSTRACT
INTRODUCTION AND OBJECTIVE: Due to the COVID-19 global pandemic, in July 2020 we developed a same day discharge (SDD) protocol for robotic assisted laparoscopic prostatectomy (RALP) that balanced safety concerns with benefits of early discharge. In this study we present our experience. METHODS: We performed a prospective analysis of patients undergoing RALP who were selected for SDD in a high-volume prostate cancer referral center. The criteria for discharge included uncomplicated surgery, stable postop hemoglobin, ambulation, tolerance of clear liquids without nausea or emesis, pain control with oral medication, and patient/family comfort with SDD. We excluded patients older than 70 years, having concomitant general surgery operations, significant comorbidities (e.g. cardiopulmonary disease), and challenging procedures (e.g. salvage procedure, large prostates). We analyzed patient demographics, clinicopathologic factors, and operative outcomes and evaluated rates of SDD and factors associated with SDD failure (SDF). RESULTS: From July 13, 2020 to January 1, 2021, 101 patients undergoing RALP were selected for SDD. Eighty patients (79%) met criteria, 73 (72%) were successful SDD, and 28 (28%) were SDF. All the SDF were discharged on postop day 1. Preoperative demographics were similar between the two groups with a median age of 63 (57-67) years and median BMI of 27 (25-30) kg/m2. Intraoperative characteristics were not statistically different with a median operative time of 92 (81-107) vs 103 (91-111) minutes for SDD and SDF respectively (p=0.51). The readmission in the SDD group was due to dizziness from hematoma and ileus from urine leak in the SDF cohort (p=0.69). Of the 28 SDF patients, the most common reasons for staying were anesthesia-related factors of nausea (35%) and drowsiness (7%), followed by patient/caregiver preference (25%), pain (14%), labile blood pressure (7%), arrhythmia (7%), and dizziness (7%). CONCLUSIONS: SDD for patients undergoing RALP can be safely incorporated into a clinical care pathway without increasing readmission rates. Coordinated care with anesthesia and nursing teams is an integral part of developing a SDD program, as is preoperative counseling to manage expectations. Future aims will be to investigate anesthesia factors leading to nausea and to expand selection to more patients.
ABSTRACT
Many Americans fail to get life-saving vaccines each year, and the availability of a vaccine for COVID-19 makes the challenge of encouraging vaccination more urgent than ever. We present a large field experiment (N = 47,306) testing 19 nudges delivered to patients via text message and designed to boost adoption of the influenza vaccine. Our findings suggest that text messages sent prior to a primary care visit can boost vaccination rates by an average of 5%. Overall, interventions performed better when they were 1) framed as reminders to get flu shots that were already reserved for the patient and 2) congruent with the sort of communications patients expected to receive from their healthcare provider (i.e., not surprising, casual, or interactive). The best-performing intervention in our study reminded patients twice to get their flu shot at their upcoming doctor's appointment and indicated it was reserved for them. This successful script could be used as a template for campaigns to encourage the adoption of life-saving vaccines, including against COVID-19.
ABSTRACT
Background: The coronavirus pandemic led to a rapid transition to telemedicine across medical specialties.Dermatologists can utilize digital images to remotely manage skin diseases, including determining the urgency withwhich patients need to be seen in person. Accurately triaging urgent cases can be impacted by imaging modality.Dermoscopy is the examination of the skin with polarized light, which for some providers can increase theirdiagnostic accuracy and confidence in managing potential skin cancers. It has been increasingly viewed as astandard adjunct for examining skin lesions. Dermoscopic photographs have been shown to improve providers'abilities to correctly diagnose telemedicine consults. However, this has only been studied with a limited subset ofskin neoplasms and is limited to a workflow involving a photographer with a dermatoscopic imaging capability. In thepandemic, the ability of patients to access dermoscopy is exceedingly limited. This study aims to assess the impactof dermoscopy on decision-making by dermatologists, including confidence, diagnostic accuracy, and triagingurgency. Our premise is that if dermoscopy is impactful, innovative means to increase accessibility to dermoscopywould be valuable for cancer management during COVID. Methods: Twenty sets of clinical and dermoscopic photographs were selected as representative of commonly seenskin pathologies in our teledermatology consults. Study participants were first shown a clinical photograph andasked to determine their diagnoses, management decisions, level of urgency, and confidence in their triagedecisions. The responses were scaled ranging from non-neoplastic to malignant, 0-100% confidence, and non-urgent (1) to emergent (3), respectively. They were then asked to answer the same questions after viewing theassociated dermoscopic image. Results: Twenty-six physicians participated in the study: 16 dermatology attendings and 10 residents. The majorityreported using dermoscopy in ≥25% of their clinical practice. Fifty-nine percent rated themselves as “somewhatconfident” in their dermoscopic abilities. Providers correctly diagnosed 45.3% of study cases using clinical imagesalone. This increased to 53.6% after viewing the associated dermoscopic images (p=0.02). The greatest increase was for malignant neoplasms (31% vs. 54%, p=0.0007). Dermoscopy significantly reduced triage urgency scores forboth non-neoplastic (mean 1.6 vs. 1.2, p<0.001) and benign neoplastic (mean 1.43 vs. 1.35, p=0.01) pathologies.Dermoscopy significantly increased urgency scores for malignant neoplasms (mean 1.47 vs. 1.64, p=0.01). There was a 7.6% increase in providers' confidence in their management decisions with dermoscopy (p<0.0001). Conclusions: Dermoscopic photographs improve providers' abilities to correctly diagnose and prioritize skinlesions. In the COVID-19 era, innovative means to make dermoscopy available to patients at risk for skin cancerwould be valuable.