A Comparison Among Adult Patients Receiving Extracorporeal Membrane Oxygenation With and Without Continuous Renal Replacement Therapy at an Integrated Healthcare System

Background: Extracorporeal Membrane Oxygenation (ECMO) is being increasingly used among critically ill patients some of whom have multiple organ failure and need concurrent use of continuous renal replacement therapy (CRRT). Limited data are available regarding outcomes among such patients. Method(s): We report retrospective data on patients who were treated with ECMO with or without CRRT over a period of 36 months (Jan 2019 - Mar 2022) at hospitals within a single integrated healthcare system in Pennsylvania. Patients with end stage renal disease were not eligible to receive ECMO within this system. Result(s): 166 patients were treated with ECMO of whom 50 (30.1%) received CRRT during the course of their treatment. Mean age of patients on ECMO was 52.1 years (interquartile range 43-64), 68.1% were male;and 23.5% had Covid-19. Reasons for ECMO included cardiac arrest (43%), post cardiac surgery (18%), acute respiratory distress syndrome (38%) and transcatheter aortic valve placement (2%). Patients received either Venoarterial (VA) ECMO (45.8% patients;mean age 60.0) and its variant extracorporeal cardiopulmonary resuscitation (eCPR) (9.6%;mean age 50.9) or Venovenous (VV) ECMO (44.6%;mean age 44.4). A comparison among patients who needed CRRT versus those who did not is provided in figure 1. 38% patients who received CRRT survived to discharge compared to 62.9% who did not receive CRRT (p=0.003) Conclusion(s): Nearly 1 in 3 patients treated with ECMO needed CRRT at some point during their care. Patients who needed CRRT on ECMO were significantly less likely to survive to discharge. Nephrology service was involved in the care of ECMO patients from the beginning in some cases. However, there remains a need for early multi-disciplinary care for critically ill patients requiring ECMO therapy. (Table Presented).

Telemedicine for nephrology outpatient care in a large integrated health system during the COVID-19 pandemic

Background: The COVID-19 pandemic has necessitated increased use of telemedicine for outpatient care. Understanding factors impacting access to telemedicine is important to optimize care delivery during the pandemic. Methods: We examined trends in telemedicine use during the COVID-19 pandemic using data from Geisinger, a large, integrated, predominantly rural health system in central and northeast Pennsylvania. We also examined the association between patient characteristics (age, sex, patient portal status, Charlson Comorbidity Index [CCI]) and use of televideo nephrology visits. Results: From 3/15/20-5/29/20, nephrology was the top adult specialty using telemedicine at Geisinger in terms of proportion of office visits using telemedicine (televideo or telephone) with 1911 (94% of all outpatient visits). The proportion of nephrology visits using telemedicine increased rapidly from <1% pre-COVID-19 crisis to 21% (week of 3/15/20) to consistently ≥95% each week from (3/22/20-5/29/20). Visit completion rate during this time was 84% with 8% same-day cancellations and 8% noshows/ left prior to being seen. The majority of nephrology clinic patients were ≥65 years old (63%), had severe CCI score 5+ (70%), and had active patient portal status (65%). The proportion of telemedicine visits using televideo was 42% overall with large differences by age, CCI score, and patient portal status (Figure). For example, the proportion of telemedicine visits using televideo was as low as 10% (65+ year old patients, CCI 5+, non-user of patient portal) and as high as 86% (<50 year old patients, CCI score 0-4, active patient portal users). Conclusions: Telemedicine may serve an important role in providing nephrology care to elderly patients with many comorbidities who are particularly susceptible to ill effects from COVID-19. Patient portal users were much more likely to use televideo for telemedicine visits. Further investigation into the digital divide (e.g. broadband internet access) is needed to optimize care delivery during the COVID-19 crisis.

Challenges as Opportunities: Adapting Tele-Education for Physicians Collaborative Response to COVID-19 Pandemic

COVID-19 pandemic challenge provided us with impetus to innovate and provide rapid solutions. We have successfully launched multiple tele-education online learning programs through a Pakistani diaspora and local physician collaborative that have been extremely effective. The programs were launched form the platform of Association of Physicians of Pakistani Descent of North America (APPNA) and include Daily COVID-19 Webinars, Weekly Case Discussions, online discussion groups, themed webinars on psychosocial health of physicians, ventilator management, critical care nursing and primary care. So far 40 webinars have been hosted for over 1800 physicians with multiple institutional partners and are developing online short courses on these topics. We have used this as a learning opportunity, creation of new collaboration with Pakistani institutions and diaspora organization. We take this challenge as an opportunity to rapidly learn successful ways and avenues of collaborating in future with our Pakistani physician partners in Pakistan.