ABSTRACT
Background: A need was identified to streamline and expedite assessment of cardiac patients presenting to the Gold Coast University Hospital Emergency Department (ED). The Emergency Cardiology Coordinator (ECC), a senior nursing role, was implemented 14 April 2020 to 15 September 2020. Evaluation of the ECC role focussed on patients’ presenting problems and time from triage to cardiology consult (TTCC). Methods: ED and cardiology data were extracted from electronic medical records for the period from 2/9/2019 to 1/3/2021. The TTCC for each presenting problem was compared between patients seen by the ECC and those not on the days the ECC worked by the rank sum test. The effect of COVID-19 on TTCC was assessed by an interrupted time series analysis. Results: The ECC saw 378 patients;112 had a cardiology consult. The effect of COVID-19 was increased TTCC (0.13 hrs/mo;p=0.027). For all presenting problems, median TTCC was 2.07 hours (IQR 1.44, 3.16) for patients seen by the ECC compared to 2.58 hours (1.73, 3.80;p=0.007) for patients not seen by the ECC. Chest pain (1.94 cf. 2.41 hrs;p=0.06) and non-obvious cardiac presenting problems (1.77 cf. 3.05 hrs;p=0.004) were seen quicker when the ECC was involved. Presentations with palpitations, respiratory distress and altered level of consciousness had similar TTCCs. Conclusions: The ECC role resulted in an overall decrease in TTCC despite the role coinciding with the emergence of COVID-19. Further analyses involving patients’ risk factors and presenting problems will clarify the optimal strategy for the ECC role.
ABSTRACT
Background: Pediatric patients with short bowel syndrome (SBS) have complex medical needs that may impact their quality of life (QoL). Research has generally found children with SBS/intestinal failure (IF) to have impaired health-related QoL, but the mechanisms by which SBS shapes QoL for these patients remain unclear. Methods: A disease-specific mixed-methods pilot survey investigating wellbeing for children with SBS and their families was developed collaboratively by community stakeholders and clinicians and distributed via convenience sampling. The survey included fourteen diseasespecific items (e.g., PN, EN, toileting, eating, medical procedures), each scored on a 5-point Likert scale (1=no negative impact on child's wellbeing, 5=high negative impact on child's wellbeing);a not applicable option was additionally included for each item. Upon completion of the matrix, respondents were prompted to explain their response for each item scored with a 4 or 5 (indicating a high negative impact on child QoL). An option to describe any additional items perceived as negatively impacting their child's QoL was provided. Descriptive analyses of closed-and open-ended responses were conducted to investigate parent-perceived impact of disease-specific items on child wellbeing. Results: A total of 21 parents completed the survey. Items least frequently reported by parents as having a strong negative impact on their child's wellbeing were pain/discomfort or vomiting (23%) and utilization of PN (29%). Items related to absorption, including oral eating (33%), output-related issues (38%), and enteral feeds (41%), were more frequently reported by parents as strongly negatively impacting their child's wellbeing. Half of survey respondents (50%) perceived sleep or fatigue to have a strong negative impact. Items outside of the medical/physical domain were reported by 62% of parents as having a strong negative impact on their child's wellbeing: 39% of parents perceived their child's social life (independent of the impacts of the COVID-19 pandemic) to have suffered because of the condition;39% highlighted the impact of medical procedures on their child's mental health. Over half of respondents (53%) perceived two or fewer items to have a strong negative impact on their child's overall wellbeing. An additional 29% of respondents perceived 3-6 items, while 19% reported 7 or more items as having a strong negative impact on their child's wellbeing. Qualitative analyses of open-ended responses revealed no additional SBS-related items were perceived by parents as negatively shaping child wellbeing, suggesting the survey reached thematic saturation. Conclusion: These exploratory data provide insights into the parent-perceived factors shaping wellbeing for children with SBS. Better understanding how- and to what extent- these factors impact child QoL longitudinally is central to providing whole-person, patient-centered care. The conceptualization of overall wellbeing as a measurable outcome may provide members of the care team with important information to consider along with clinical factors and offer opportunities to discuss goals of care with children and their families. Future research should investigate the validity and reliability of a disease-specific child QoL measure.
ABSTRACT
RATIONALE: Several studies have identified risk factors for increased mortality due to the COVID-19 infection. However, few have assessed whether these risks have changed between each wave of the pandemic, particularly with the introduction of new treatment options. We analyzed the differences in risk factors associated with mortality in each individual surge of the pandemic. METHODS: A single center retrospective chart review of COVID-19 positive patients (n=310) treated at the University of Louisville Hospital was performed from March 2020. Surge periods were divided March 1st - May 31st (wave 1) and June 1st - August 31st (wave 2) to identify risk factors for outcomes between periods. A spearman correlation analysis was performed, and odds ratios were calculated using the Fisher-exact test (p ≤ 0.05). Partial Least Squares and Random Forest classification models were trained using mortality as the primary outcome and validated with 100 resampling iterations of 5-fold cross validation. RESULTS: This analysis included 124 patients for wave 1 and 152 patients in wave 2. During the first wave, significant risk factors that predicted mortality included patients treated with convalescent plasma or hydroxychloroquine, a prior history of hyperlipidemia, or type 2 diabetes mellitus. Significant odds ratios for mortality included the same variables in addition to the presence of altered mental status, on admission, a history of hypertension, and treatment with azithromycin for COVID-19. In the second wave of infections, initial blood pressure and sex were the most predictive variables for mortality. Significant odds ratios were a prior history of neoplastic disease in the previous year and, again, the presence of altered mental status. CONCLUSION: Comparison between these two periods show a possible epidemiological transition from adults less than 65 years with multiple comorbidities to patients greater than 65 years, nursing home residents, and with immunocompromised states. Predictive factors for mortality in the first wave appear to be related to the use of experimental therapies and comorbidities, while clinical symptoms were more pertinent during the second wave. These results show that predicting overall mortality may have changed over the course of the pandemic. This may be due to the availability of novel treatment options and a better understanding of the approach to supportive care. As hospitals continue to be overwhelmed by the rising incidence and mortality related to COVID-19, identifying patients at a higher risk of mortality may improve overall healthcare cost and utilization by appropriately triaging therapy.
ABSTRACT
The SARS-CoV-2 virus is a public health emergency. Social distancing is a key approach to slowing disease transmission. However, more evidence is needed on its efficacy, and little is known on the types of areas where it is more or less effective. We obtained county-level data on COVID-19 incidence and mortality during the first wave, smartphone-based average social distancing (0-5, where higher numbers indicate more social distancing), and census data on demographics and socioeconomic status. Using generalized linear mixed models with a Poisson distribution, we modeled associations between social distancing and COVID-19 incidence and mortality, and multiplicative interaction terms to assess effect modification. In multivariable models, each unit increase in social distancing was associated with a 26% decrease (p < 0.0001) in COVID-19 incidence and a 31% decrease (p < 0.0001) in COVID-19 mortality. Percent crowding, minority population, and median household income were all statistically significant effect modifiers. County-level increases in social distancing led to reductions in COVID-19 incidence and mortality but were most effective in counties with lower percentages of black residents, higher median household incomes, and with lower levels of household crowding.
ABSTRACT
AIMS & OBJECTIVES: Multisystem inflammatory syndrome in children (MIS-C) is a severe Kawasaki-like disease seen in a fraction of children with SARS-COV-2. The syndrome's sequelae are still being defined. We present a 17-year-old female with MIS-C and acute biventricular heart failure (BVHF). We highlight her presentation, clinical course, management, and outcomes. METHODS: Design: Case report Setting: Pediatric intensive care unit (PICU) in an academic hospital Participant: 17-yearold female with MIS-C and BVHF RESULTS: A 17-year-old overweight female with asthma was admitted to the PICU with MIS-C. A history of SARS-COV-2 infection was confirmed with positive nasopharyngeal swab and IgG antibody and borderline IgM antibody. She presented with hypotension, fevers, abdominal pain, myalgias, and headache, but no chest pain. Initial diagnostic studies were notable for troponin I 2.572 ng/ml, BNP 386 pg/mL, ECG with sinus tachycardia, and echocardiogram with normal function. Over two days her hypotension worsened despite increasing vasoactive therapy. Repeat echocardiogram revealed LVEF 30% and moderate right systolic dysfunction consistent with acute heart failure. She received intravenous immune globulin (400 mg/kg) once, dexamethasone (6 mg daily), and Tocilizumab. Within 48 hours of these treatments she was weaned off all vasoactive therapies and extubated. Repeat echocardiogram near time of discharge showed improved LVEF 55%. She was discharged home after 8 days. CONCLUSIONS: MIS-C is a severe hyperinflammatory disease in a fraction of pediatric patients with COVID-19. Acute heart failure is a known, but uncommon, devastating complication of MIS-C that may resolve with prompt and aggressive treatment of the underlying hyperinflammatory syndrome.
ABSTRACT
This report describes random sample testing of persons aged ≥12 years in Indiana to assess the prevalence of active COVID-19 infection and SARS-CoV-2 antibodies.