African American Palliative Care amid the COVID-19 Pandemic

African Americans have suffered disproportionately from COVID-19. Underlying health conditions account for part of the disproportion. Exposure to the disease due to being essential workers is another part. Emotional pain resulting from infections, deaths, and other occurrences add to preexisting allostatic loads, resulting in profound amounts of stress. For many African Americans, especially those residing in congested urban or poor rural areas, such stress increases the daily concerns of communities saturated with poverty and violence. Palliative care is a healthcare paradigm designed to address physical, emotional, psychological, and spiritual needs of patients and derivative effects on family members. While the original focus of such case was on patients suffering from terminal conditions, the focus has shifted to include patients suffering from chronic conditions. Throughout that time span, spirituality has been one of the most underdeveloped aspects of the palliative care framework. That fact has been especially troubling for people of African descent, who during some of the most crucial moments in their history have relied on spirituality to overcome life's challenges associated with systemic oppression. This essay contends it is important for health delivery systems to recognize gaps in racial/ethnic justice and for faith institutions to be positioned well to bridge the gaps. © 2002 Taylor and Francis.

ESTABLISHING METRICS TO ASSESS PERSPECTIVES OF VIRTUAL LEARNING IN ADOLESCENTS WITH CANCER

Background: School absenteeism is one challenge faced by children with cancer and has been associated with declining academic performance and feelings of social isolation. Virtual learning may improve school participation and outcomes in this population. This form of instruction has gained prominence during the COVID-19 pandemic, allowing for real-time remote learning when being present at school poses health-related risks. Objectives: 1. To develop two internally reliable metrics that evaluate adolescent experiences with virtual learning. 2. To determine if adolescents with cancer have an affinity for virtual learning and if they find aspects of one learning environment easier than the other. 3. To determine if a cancer diagnosis is associated with perceptions about school. Design/Method: We conducted a cross-sectional survey of adolescent patients presenting to either the hematology oncology or primary care clinic between June and September of 2021. Exploratory Factor Analysis was used to construct and verify the internal reliability of two metrics: one to assess general affinity for virtual learning (Virtual Learning Affinity Score, or VLAS) and one to compare ease of learning between virtual and in-person school (Scholastic Comparison Score, or SCS). These metrics were compared across cancer status, controlling for demographics. Independence between cancer status and perceptions about school was also explored. Results: Of a total of 68 respondents, 54% identified as female and 25% as having cancer. The majority (60%) were in high school;grade level ranged from elementary to college. We found no significant difference in VLAS or SCS scores between those with and without cancer. In both groups, VLAS scores indicated a neutral affinity for virtual learning (no significant difference from a neutral score of 24), and SCS scores showed that respondents found in-person learning easier. We found no significant associations between cancer status and feelings of safety in regular school or elective participation in virtual learning. Conclusion: We developed two internally reliable metrics to measure virtual learning experiences in adolescents. Based on these metrics, we found that individuals with cancer feel the same way about virtual learning as their peers. Both groups neither like nor dislike virtual learning and ultimately find it easier to engage in the regular classroom. Importantly, having a cancer diagnosis may not imply that a child, or their caregiver, feels unsafe about attending school in-person. Overall, these findings suggest that efforts to improve academic outcomes may be best directed at continuing to make in-person learning inclusive and accessible to those with cancer.

PEDIATRIC OPIOID ANALGESIA SELF-INSTRUCTION SYSTEM (PEDOASIS): AN EFFECTIVE EDUCATION TOOL

Background: Many children with cancer, survivors of childhood cancer, and patients with sickle cell disease experience pain, yet receive inadequate pain management due to health care provider lack of knowledge and comfort. Pain management using opioids is a required competency for pediatric hematology/oncology (PHO) fellows, yet knowledge gaps persist. Objectives: Pediatric Opioid Analgesia Self-Instruction System (PedOASIS) is an interactive, case-based education tool for independent learning by post-graduate medical trainees which has undergone pilot testing and validity and reliability testing. The goal of this study was to evaluate its efficacy in increasing PHO fellows' knowledge and comfort with using opioids to manage pain. Design/Method: PHO fellows were recruited from 74 ACGMEaccredited US programs during the 2019-2020 academic year. Participants were randomized to receive access to PedOASIS (intervention) or usual PHO training (control). Participants completed surveys at enrollment, immediately after distribution of the tool, and 6 months later. Surveys assessed subjective comfort with prescribing opioids and objective knowledge, using a version of the questions from the tool. Results: At baseline, mean scores on the 10-question knowledge assessment did not significantly differ by level of training (first year: 5.05, second year 5.74, third/fourth year: 5.58;p = 0.410) or between groups (intervention: 5.38, control: 5.5;p = 0.795). Following intervention, mean score was significantly higher in the intervention group (8.91) vs. controls (5.38;p < .0001). Six months later, scores in both groups decreased but remained significantly higher in the intervention group (6.91) compared to baseline (p = 0.0002) and compared to controls (4.91, p < .0001). Fellows indicated comfort with selecting opioid and starting dose for an opioid-naive patient at baseline but less with rotating opioids. Intervention group reported significant increases in comfort dosing opioids after exposure to the tool (p = 0.022) and in rotating opioids (p = 0.054) following the intervention. Conclusion: Use of PedOASIS was associated with improvement in scores on validated knowledge questions and in comfort using opioids for pain management in PHO fellows exposed to the tool compared to fellows without the tool. These findings suggest that this is a valid, reliable, and effective curricular tool. The use of self-directed learning has been associated with increased knowledge gains when compared to traditional didactic methods. The asynchronous learning structure is useful in the setting of the ongoing SARS-CoV19 pandemic, which has necessitated significant alterations in medical education. Based on these results, we suggest that PedOASIS is an effective and relevant addition to the PHO fellowship curriculum.

Identifying Factors that Contribute to Joy and Gratitude for Emergency Medicine Healthcare Workers Amidst the COVID-19 Pandemic

Study Objective: During COVID-19, emergency medicine (EM) providers have labored to protect the health of their patients, often at the expense of their own well-being. Increased demands imposed on providers without intentional efforts to evaluate and improve wellness can lead to burnout, attrition, and compromise patient care. Practices that promote mindfulness, reflection and gratitude have been shown to reduce burnout. The Institute for Healthcare Improvement (IHI) Framework for Improving Joy In Work provides an approach to restore joy and engagement by first identifying elements that "matter most” to healthcare workers. The objective of this study was to identify common themes and associations that contribute to EM provider and staff (1) joy in work, (2) gratitude, and (3) personal wellness. Methods: This descriptive study used an electronic survey tool with open-ended questions adapted from the IHI framework to assess what matters most. Q1: What brings you joy in your work? Q2: Thinking back to what matters most, what are you grateful for? Q3: What do you do to maintain your personal wellness? In Nov. 2020, email listservs were used to recruit a voluntary sample of emergency physicians, advanced practice providers (APPs), residents, fellows, nurses and staff from 10 academic and community hospitals. Data were managed in Qualtrics and Excel. Qualitative analysis used inductive thematic coding by two authors independently, with verification by a third. Information redundancy signaled saturation for common themes. Pivot tables examined themes across demographics, and associations were analyzed with 2x2 contingency tables using chi-square, Fisher’s exact tests, and odds ratios (95% CI). Results: Of 254 respondents, 63% were female and 89% identified as White. Roles were 32% physicians, 8% APPs, 16% residents/fellows, and 44% nurses/staff. Response rates were 39-54% for providers. Common themes for joy in work were patient care (47%) and teamwork/camaraderie (43%), followed by feeling valued/appreciated (13%), making a difference (13%), and teaching/mentoring (9%). EM providers at academic sites were more likely to find joy in teaching/mentoring than those in the community (p=0.01;OR 10.5, 95% CI 1.3-82.6). For gratitude, themes were teamwork/ camaraderie (13%), family (12%), health (7%), and supportive work environment (7%). Themes for maintaining personal wellness were physical exercise (46%), time with family and friends (32%), hobbies (15%), and self-care (13%). Conclusions: Results of this study reveal common themes for EM providers and staff surrounding joy, gratitude, and wellness. By identifying elements that matter most, systems can take the next steps in the IHI framework to support and rejuvenate their healthcare team. Implications from our findings suggest that practices and future research to remove barriers and encourage meaningful provider-patient interactions, team camaraderie, teaching/mentoring, physical activity, and time with family/friends could increase joy and fulfillment for frontline healthcare workers.

Identifying Factors that Contribute to Joy and Gratitude for Emergency Medicine Health Care Providers Amidst the COVID-19 Pandemic

Study Objectives: During COVID-19, emergency medicine (EM) providers have labored to protect the health of their patients, often at the expense of their own well-being. Increased demands imposed on providers without intentional efforts to evaluate and improve wellness can lead to burnout, attrition, and compromise patient care. Practices that promote mindfulness, reflection and gratitude have been shown to reduce burnout. The Institute for Healthcare Improvement (IHI) Framework for Improving Joy In Work provides an approach to restore joy and engagement by first identifying elements that "matter most” to health care workers. The objective of this study was to identify common themes and associations that contribute to EM provider and staff (1) joy in work, (2) gratitude, and (3) personal wellness. Methods: A descriptive study used an electronic survey tool with open-ended questions adapted from the IHI framework to assess what matters most. Q1: What brings you joy in your work? Q2: Thinking back to what matters most, what are you grateful for? Q3: What do you do to maintain your personal wellness? In Nov. 2020, email listservs were used to recruit a voluntary sample of emergency physicians, advanced practice providers APPs, residents, fellows, nurses and staff from 10 academic and community hospitals. Data were managed in Qualtrics and Excel. Qualitative analysis used inductive thematic coding by two authors independently, with verification by a third. Information redundancy signaled saturation for common themes. Pivot tables examined themes across demographics. Associations were analyzed using chi-square, Fisher’s exact test, and odds rations (95% CI). Results: Of 254 respondents, 63% were female and 89% identified as White. Roles were 32% physicians, 8% APPs, 16% residents/fellows, and 44% nurses/staff. Response rates were 39-54% for providers. Common themes for joy in work were patient care (47%) and teamwork/camaraderie (43%), followed by feeling valued/appreciated (13%), making a difference (13%), and teaching/mentoring (9%). EM providers at academic sites were more likely to find joy in teaching/mentoring than those in the community (p=0.01;OR 10.5, 95% CI 1.3-82.6). For gratitude, themes were teamwork/camaraderie (13%), family (12%), health (7%), and supportive work environment (7%). Themes for maintaining personal wellness were physical exercise (46%), time with family and friends (32%), hobbies (15%), and self-care (13%). Conclusions: Results of this study reveal common themes for EM providers and staff surrounding joy, gratitude, and wellness. By identifying elements that matter most, systems can take next steps in rejuvenating their health care team. Implications from our findings suggest that practices and future research to remove barriers and encourage meaningful provider-patient interactions, team camaraderie, teaching/mentoring, physical activity, and time with family/friends could increase joy and fulfillment for frontline health care workers.

Facilitated Peer Support Model Offers Promising Mental Health Intervention for Emergency Physicians During the Post-Pandemic Period

Study Objective: The COVID-19 pandemic has placed an unprecedented psychological burden on emergency medicine (EM) providers who have experienced anxiety, depression, isolation, burnout, and poor self-care. ACEP along with 44 medical organizations issued a statement in support of clinician health in the post-pandemic period calling for the removal of barriers to mental health care and using non-clinical mental health support, specifically peer support, to foster resilience and recovery. While physicians prefer to seek support from colleagues, formal peer support interventions are not well studied. The objectives of the study were to determine feasibility, receptivity, and effect of physician peer support groups on symptoms of acute distress, anxiety, depression, and burnout. Methods: A quasi-experimental design was used to determine pre-post intervention changes in anxiety and depression (primary outcomes) using the Patient Health Questionnaire (PHQ-4);provider burnout using the Maslach Burnout Inventory;and distress symptoms (fatigue, trouble sleeping, nervousness, feeling down, anger, helplessness, guilt, difficulty concentrating) using the SPADE Symptom Screener and PROMIS measure. The Participant-rated Global Impression of Change was used to monitor whether feeling better at the end of each session compared to the beginning. Receptivity was assessed using a net promoter score question. The study population was emergency physicians serving 10 academic and community hospitals who self-identified as having any mental health challenge during the pandemic. Three groups of 8 providers were recruited via departmental email listservs to participate in eight 1-hour virtual, peer support group sessions via Zoom Health. The visit structure was based on the National Alliance of Mental Illness (NAMI) peer support model and adapted for use in the clinician population. Three physicians were trained to cofacilitate with a NAMI support group leader. Data were collected using the Zoom polling function. Change analysis was conducted using dependent t-tests in SPSS. A sample size of 16 clinicians was needed to provide 80% power for two-sided tests at an alpha of 0.05 to detect a large effect size of 1.0 (3-point absolute change) for the PHQ-4. Results: Of the 24 participating physicians, the majority were faculty physicians, white, female, and in practice 5 years or less. Average attendance was 6.5 sessions with 83% of physicians reaching the attendance goal of 6 out of 8 sessions. On average, participants reported feeling better at the end compared to the beginning of each session. Eighty six percent of physicians reported they would recommend peer support groups to a friend or colleague. Positive effect sizes showed improvement in 8 of 11 distress symptoms, and marginal significance (p<.10) for guilt and anxiety. Conclusions: High levels of attendance, feeling better at the end of sessions, and willingness to recommend peer support groups to friends or colleagues demonstrate high physician receptivity to peer support and feasibility of implementation. Positive effect sizes show promising signs of improvement in the majority of anxiety, depression, distress, and burn out symptoms in this pilot study. Attention is needed to tailor strategies to male providers who may be hesitant to participate. Further research of this model with a larger samples and more robust design is planned. [Formula presented]

Presentation of pediatric type 1 diabetes in Melbourne, Australia during the initial stages of the COVID-19 pandemic

Introduction: Since the commencement of social isolation in the COVID-19 pandemic, pediatric diabetes centres across Australia have voiced concerns about an apparent reduction in new presentations of Type 1 Diabetes Mellitus (T1DM). Objectives: We aimed to assess new presentations of T1DM across the 2 largest treating centers in Melbourne between February-May (inclusive) in 2020, compared to the last 3 years. Methods: Data was collected on new presentations of T1DM and severity (including presentation in diabetic ketoacidosis [DKA] and admission to intensive care [ICU]) from February-May from 2017-2020 (inclusive). Results: The absolute number of new presentations of T1DM in 2020 was similar to previous years. DKA severity and ICU admissions were similar for all years. Conclusions: Concerns regarding increased severity at presentation with pediatric T1DM (due a perceived reduction in access to health care services and broader community fear in the setting of the pandemic) have not been borne out in this data.