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Background: Convalescent plasma (CP) has been described as a potential therapy for coronavirus disease 2019 (COVID-19). Given paucity of data, we sought to describe characteristics of CP recipients in survivors and non-survivors. Methods: We conducted retrospective review of electronic medical records which included any patient with a positive SARS-CoV-2 PCR test who received CP at an 890-bed quaternary care hospital in Southeast Michigan between March-May 2020. Data collected included: demographics, co-morbidities, mSOFA score on admission, laboratory values, and treatment. Outcomes assessed included inflammatory markers and clinical status based on an 8-point ordinal scalea. These values were recorded on admission, the date of CP (day 1), day 3, 7, and day 30 post-CP. Patient outcomes were stratified by ordinal scale score and compared using Mann-Whitney U tests to examine differences in clinical characteristics: scale of 1-4 (“meaningful survivor”), 5-7 (“survivor”), and 8 (“non-survivor”). Results: Results of our study are summarized in Table 1 and 2. Non-survivors were older than survivors (62 vs 71 years;p=0.026). There was no statistically significant difference between patient gender, race, number of days from positive PCR test to CP, treatments, and co-morbidities. There was a trend toward higher mSOFA score on admission in non-survivors (p=0.056). A lower ordinal scale score on the date of receiving CP was significantly associated with meaningful survivorship (6 vs 7, p=0.005). Conclusion: Patients who have a lower ordinal scale score on the date of CP administration are most likely to have meaningful survivorship at day 30. Future studies should evaluate optimal timing and outcomes for CP therapy in COVID-19. (Figure Presented).
ABSTRACT
Background: The clinical spectrum of the novel corona virus disease 2019 (COVID-19) ranges from mild to severe disease and death. We aim to construct a simple and novel scoring model that will predict mortality events in hospitalized COVID-19 patients. Methods: We established a retrospective cohort of 2541 patients admitted with COVID-19 from February 19, 2020 to April 28, 2020 to Henry Ford Health System, MI. Sociodemographic data, comorbidities, and clinical data were collected. Our novel SAS score was constructed using 3 easily available parameters, namely Sex, Age, and Oxygen Saturation at presentation (Table 1 and 2). Primary endpoint was mortality. Multivariate analysis with logistic regression was done and the model was assessed using receiver operating characteristic (ROC) with area under ROC (AUROC) to determine the optimal cutoff for sensitivity, specificity, and positive and negative predictive values. Results: The mean age of survivors was 61 compared to 75 years for non-survivors (standard deviation 16 vs 13.8, p< 0.0001), and 1298 (51.1%) were men. Multivariateanalysis of the SAS score adjusted for modified SOFA [Sequential organ failure assessment] score (mSOFA) showed that age (odds ratio [OR] 2.4, 95% confidence interval {CI} 2.04-2.72, p< 0.0001) and oxygen saturation (OR 1.6, 95% CI 1.27-1.98) were the most significant predictors of mortality in the model. The SAS score had an AUROC of 0.78 (95% CI 0.77-0.81) (Figure 1). A cutoff score of 3 offered the most sensitivity for predicting mortality while maintaining a negative predictive value of 95% (Table 3). Comparison of AUROC shows that SAS score adjusted to mSOFA has better diagnostic information compared to either SAS score or mSOFA alone (Figure 2). Conclusion: The easy to use SAS score at time of presentation identified hospitalized COVID-19 patients at high risk for mortality. Application of the SAS score in the emergency department may help triage patients to inpatient versus outpatient care. (Figure Presented).
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Background: Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has significantly impacted Michigan, with over 60,000 cases and 5,700 deaths to date. During the surge, Metropolitan Detroit was the epicenter of the outbreak, accounting for 80% of cases and 86% of deaths statewide. Healthcare workers (HCW) are particularly at risk;however, rates of infection based on job category has not been described previously in the United States. We describe the impact of the outbreak on our workforce. Background Michigan COVID Methods: This was a retrospective review of employees with COVID-19 at Henry Ford Health System (HFHS), a comprehensive, integrated, health care organization in Southeast Michigan includes 5 hospitals and 9 emergency departments from 3/10/2020-6/10/2020. Employees exhibiting symptoms and/or signs consistent with COVID-19 infection were referred to employee health and tested for SARS-CoV-2. All employees with positive polymerase chain reaction (PCR) of upper respiratory tract were included. Data were obtained from a dedicated analytics dashboard that tracked all testing and results for employees. Rate (number positives/total tested) of infection for each job category was determined. Results: A total 5352 (16%) of 33538 employees were tested, of whom 1036 (19%) tested positive. The number of infected workers represents approximately 3.1 % of the workforce. The sharp increase of COVID-19 admissions correlated with the rise in HCW COVID-19 positivity (Figure 1). The number of HCW tested largely correlated with the disease burden at each hospital (Figure2). Table 1 shows total population of symptomatic HCW tested and demonstrates volume of testing and positivity were higher among HCW with close patient contact. The positivity rates in specific clinical support staff are shown in Table 2. Notably, there were high rates of positivity among non-clinical business and management employees tested suggesting community-transmission. Conclusion: COVID-19 risk is highest among HCW in high volume settings with close patient contact. Community exposure may be an important factor that contributes to this risk. Strategies to minimize transmission in healthcare settings should be combined with HCW education emphasizing measures to avoid exposure within the community (Figure Presented).
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Background: During the coronavirus disease 2019 (COVID-19) surge, there was a sharp increase of blood cultures (BC) performed at Henry Ford Health System (HFHS). However, the epidemiology and outcomes of bloodstream infections (BSI) in COVID-19 patients (pts) remains undefined. We report the utilization of blood cultures, risk factors and mortality associated with BSI in a large cohort of COVID-19 pts. Methods: A retrospective analysis was performed of all COVID-19 pts that had BC performed during hospitalization at HFHS, a 5-hospital system in southeast Michigan. BSI was defined using NHSN criteria. Demographics, comorbidities, severity of illness, and outcome of pts with and without BSI were compared. Results: From 3/10/2020 to 4/28/2020, 2541 pts were hospitalized with lab-confirmed COVID-19. 1393 (55%) of these pts had BC performed and 80 (5.74%) met criteria for BSI. Of the 84 pathogens identified, Staphylococcus aureus was most common (Figure 1). As compared to 1313 COVID-19 pts without BSI, those with BSI were older (70.1 vs 64.5 years, P = 0.0024). Other factors significantly associated with BSI included chronic kidney disease, higher mSOFA score, ICU stay and mechanical ventilation (all P < 0.0001) (Table 1). Multivariate analysis revealed age (OR, 1.07 CI [1.06-1.08]), ICU stay (OR, 7.91 [CI: 5.75-10.87]) and mSOFA score (OR, 1.29 [CI: 1.13-1.47]) were independent risk factors associated with mortality. BSI was not associated with increased mortality (Table 3). Conclusion: Although more than half of hospitalized COVID-19 pts had BC done, the number of BSI were low suggesting overutilization of BC. BSI was associated with older age and disease severity. Mortality was not affected by BSI but was primarily driven by age and severity of illness. (Table Presented).
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Background: Michigan was one of the severely impacted regions during the initial COVID-19 surge. An institutional protocol with early methylprednisolone (MP) to treat COVID-19 patients requiring supplemental oxygen was implemented. We sought to study characteristics of these patients who were readmitted with infectious and non-infectious diagnoses. Methods: A retrospective analysis of 21 COVID-19 readmitted patients initially admitted between 3/10/2020 and 4/20/2020 (early 0-7, late 8-30 days) was done. Total of 455 COVID-19 patients, confirmed by a positive nasopharyngeal RT-PCR were admitted during this time period. Demographic data, clinical characteristics, laboratory and radiographic results and treatments were compared among the early and late readmission groups. Univariate and logistic regression analysis were performed to study the risk factors associated with early readmission and worsening of COVID-19 pneumonia. Secondary analyses were performed comparing worsening COVID-19 pneumonia with other readmission diagnoses. Results: 4.6% (21/455) were readmitted, 14 early vs 7 late (median age 75 vs 65 yrs). Most early readmissions were COVID-19 related and 8 out of 14 had worsening COVID-19 pneumonia based on clinical picture, laboratory and imaging findings. Readmitted patients with worsening COVID-19 related pneumonia had significantly elevated CRP and lower ALC compared to last discharge value (Table 1). None of the late readmissions required MP. A total of 8 readmissions had bacterial coinfections (1/8 COVID-19 related) (Table 2). Bacterial infections unrelated to COVID-19 were aspiration pneumonia (2), urinary tract infection (2), enterococcal bacteremia from stercoral colitis (1), sacral osteomyelitis (1), and infected BKA stump (1). Each increasing day of MP duration during the first admission reduced the likelihood of early readmission by approximately 10% (OR 0.90, 95% CI 0.63-1.2, p=0.56) (Table 3). 1/14 and 0/7 patients died amongst early and late readmissions respectively. Conclusion: Early MP in COVID-19 pneumonia was not associated with increased risk of early secondary bacterial infections in the readmitted patients. Optimal duration of MP in patients with COVID-19 pneumonia needs to be defined.
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Background: In Michigan, 44,964 (68%) of the 66,269 COVID-19 patients have recovered. However, there is concern that COVID-19 infection may lead to long-term sequelae, including pulmonary defects, cardiac complications, blood clots, and neurocognitive impairment. This study describes the 30-day outcomes of patients who had recovered. Methods: From 3/16/2020 to 5/19/2020, a follow-up was attempted for patients who were discharged alive from Henry Ford Hospital in Detroit and had recovered. Recovery was defined as being alive 30 days post symptom-onset. A telephone survey was conducted 30 days post-index admission and recorded in electronic medical records. Oxygen (O2) requirements, symptoms, readmissions and the need for antibiotics for secondary bacterial infections were evaluated. Results: 585 patients met inclusion criteria and were contacted by phone;303 answered their phone (Table 1), but only 266 (45%) completed a full telephone encounter and were included in the final analysis (Table 2). The majority were female (53%), black (80%), and discharged to home (84%). The clinical characteristics of those who completed the survey were as follows: 11% presented with O2 saturation < 90%, 16% had underlying lung pathology, and 57% had a BMI above 30. Patients' average age was 61 ± 14.3 years. At 30 days post-index admission, 49% were still symptomatic. Of the symptomatic patients, 86% had dyspnea on exertion and 15% required O2 supplementation. 18% of patients were readmitted within 30 days, and 9% developed a secondary infection prior to the phone encounter. No statistically significant differences in demographics or comorbidities were found between symptomatic and asymptomatic cohorts (Tables 1, 2). Conclusion: In our study, almost half of the discharged patients remained symptomatic after 30 days with a substantial proportion experiencing pulmonary symptoms. A better understanding of the long-term pulmonary sequelae following COVID-19 infection is needed to design interventions to reduce post-infectious morbidity.
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Background: The surge of COVID-19 cases overwhelms hospital systems necessitating rapid learning of the disease process and management. During the course of a novel pandemic, multiple interventions are rapidly implemented to improve patient outcomes. When evaluating efficacy of individual interventions, one should account for the simultaneous improvements in knowledge and experience of healthcare providers (HCP), known as the maturation effect. We hypothesized that multiple processes rapidly implemented, along with the maturation effect would result in improved survival of COVID-19 patients hospitalized over the course of the pandemic. Methods: This retrospective study was done at Henry Ford Hospital (HFH), a 900-bed tertiary care facility in Detroit, Michigan. The first COVID-19 patient was hospitalized on March 10, 2020 followed by a rapid surge of cases. We evaluated the trends of in-hospital case fatality rate of COVID-19 PCR positive patients through April 28, 2020. Time-points of sequential implementation of key measures for the management of COVID-19 patients were recorded. Results: A total of 1023 COVID-19 patients were hospitalized during the study period with 165 deaths (16 %). Case fatality rate during week one was 42% and down trended over time (Figure 1). Key measures were sequentially implemented over the course of the study period as shown in Figure 1. These included development and implementation of in-house PCR testing, dedicated infectious diseases COVID-19 rounding teams, treatment guidelines and algorithms, and early steroid use in hypoxic patients. Figure 2 demonstrates that despite the surge of COVID-19 admissions, mortality continued to improve over time. Conclusion: Maturation effect takes into consideration that regardless of individual interventions, HCP improve their knowledge of the disease process and treatment over time leading to better outcomes. Our study shows the possibility of the maturation effect leading to improved survival in hospitalized COVID-19 patients. The maturation effect should be accounted for when evaluating the effect of specific interventions for COVID-19. (Table Presented).
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Background: The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is recommended for all adults over the age of 65 to reduce S. pneumoniae pneumonia. Our institution follows a standing order for nurses to vaccinate adults who meet the Advisory Committee on Immunization Practices (ACIP) criteria. During the COVID-19 pandemic surge, the pneumococcal vaccine and influenza vaccine nurse-driven protocol was determined to be non-essential on 3/23, and 4/2 respectively. Our study aims to characterize missed vaccine opportunities among patients hospitalized with COVID-19 during this surge. Methods: A retrospective cross-sectional study of PCR-positive COVID-19 patients admitted to an inner-city hospital and discharged alive between the dates of 3/23 and 4/21/2020. Patients under the age of 65 were excluded. Data collected included patient age, gender, race, length of stay, co-morbidities that would indicate a vaccine opportunity, prior vaccinations, and whether there was a vaccine opportunity for PPSV23 and influenza defined by ACIP indications. Vaccine history was evaluated using the electronic medical record (EMR) and Michigan Care Improvement Registry. If there was a vaccine opportunity, we documented whether a vaccine was given before hospital discharge. Total numbers of vaccines given for time periods in 2019 and 2020 were collected from EMR for comparison. Results: 100 patients over the age of 65 were included. The average age was 72.8 years, and most patients (66%) were of African American race. The mean length of stay was five days. 52 patients were identified as having an opportunity to receive PPSV23, and 0 patients received the vaccine. 67.3% had more than one indication for PPSV23. 37 patients were eligible to receive influenza vaccine, and 0 received the vaccine. Results are summarized in table 1. Figures 1 and 2 display the number of pneumococcal and influenza vaccines given per EMR, respectively. Conclusion: Due to prioritization of potential staffing shortages and clustering nursing care, an opportunity to vaccinate patients with pneumococcal and influenza vaccines was missed. It is important for health care providers to be aware of this potential opportunity for vaccination of high-risk patients in order to promote primary prevention in future waves of pandemics.