Cost and Quality: How Do Surgical Site Infection Bundles Measure Up?

Introduction: Enhanced recovery after operation and surgical site infection (SSI) bundles have been implemented in hospital systems nationwide to mitigate complications after colorectal operation. These quality improvement bundles (QIB) aim to improve patient safety and should decrease healthcare costs. This study identifies the impact of QIB on SSI rate and hospital costs. Method(s): Vizient and SSI reporting data was queried from 2016- 2021, for all colorectal resections tracked by the National Healthcare Safety Network across the enterprise. The operations were linked to a financial database. Data was analyzed quarterly to identify a relationship between SSI rate, hospital cost, and implementation of SSI mitigation elements. Result(s): 4,163 patients were identified during the study period. SSIs peaked in quarter 2 of 2018 at 5.3%, after which SSI mitigation efforts were announced. A steady decrease is seen in SSI rates, until quarter 3 of 2020, when our hospital system experienced its first COVID wave. With adjustment for procedure type, hospital costs increased by 15.8% per case from 2018-Q3 forward on average with the sharpest elevation observed in quarter 3 of 2019, due to medication startup costs for our SSI bundle. Conclusion(s): We successfully reduced colon SSIs with implementation of an ERAS bundle but incurred 16% greater costs compared with pre implementation, especially during the early implementation period.

Diarrhea as an Independent Risk Factor for COVID-19 Severity and Inpatient Mortality

Introduction: Multiple meta-analyses have shown that over 15% patients with COVID-19 have at least one gastrointestinal complaint, most commonly diarrhea. The effects on the gastrointestinal system are thought to be mediated by the high expression of angiotensin-converting enzyme 2 (ACE2) and cellular serine proteases (TMPRSS2) in enterocytes, which cause altered intestinal permeability. The purpose of this study was to determine the incidence of diarrhea as it relates to COVID-19 infection and to determine if having concomitant diarrhea had a significant impact on disease course. Method(s): A retrospective chart review of 164,730 patients in a hospital system who were older than 18 years of age and had a positive SARS-CoV-2 test from March 2020 to February 2022 was completed. Diarrhea was determined using ICD code or patient's symptoms. Patients with confounding variables such as IBD, IBS, Celiac, Clostridium difficile, and pancreatic insufficiency were excluded. Demographic clinical characteristics and outcomes, including inpatient admission and mortality, were compared in patients with and without diarrhea. The Mann-Whitney test and Fisher's exact or Chi-square test was used for continuous and categorical variables respectively and multivariate logistic regression was used to evaluate for significant differences in disease outcome between the two groups. (Table) Results: Of the 164,730 patients included, 14,648 (8.89%) had diarrhea at the time of SARS-CoV-2. 6,748/33,464 (20.16%) of inpatient admissions were associated with diarrhea. On multivariate analysis, diarrhea was an independent risk factor for inpatient hospitalization (OR 2.39, CI 95% 2.28-2.51, P, 0.001) and inpatient mortality (OR 1.15, CI 96% 1.06-1.26, P= 0.001) after controlling for age, gender, race, comorbidities that could impact patient outcome, use of immunomodulators and outpatient antibiotics. Conclusion(s): These findings show that, even with controlling for comorbidities with COVID-19, diarrhea was an independent factor for predicting inpatient mortality and inpatient admission in general. Patients who had diarrhea and COVID-19 were sicker, having more comorbid conditions than those without diarrhea in our cohort. Attention should be given to not only respiratory complaints of COVID-19, but also gastrointestinal complaints, as they are an indicator of poor prognosis and mortality.

A Novel Emr-Based Care Pathway for Nephrolithiasis: Development and 1 Year Utilization

INTRODUCTION AND OBJECTIVE: Patients with acute renal colic due to stones frequently visit the ED. With limited ED resources due to the COVID-19 pandemic, we developed a best practice management pathway within our electronic medical records (EMR) to provide consistent, expeditious and appropriate care for patients with nephrolithiasis. The objective of this study is to describe the development and 1 year outcomes of our EMR Care Pathway for nephrolithiasis. METHOD(S): Our hospital system is composed of many centers. To standardize best practice care, we convened a clinical consensus group, with key stakeholders in emergency medicine, urology, interventional and diagnostic radiology to develop a pathway for the initial work up and management of acute renal colic. AUA guidelines, current literature, and expert consensus across specialties were used to develop the pathway to guide work up and management. Risk assessment tools, and criteria for specific imaging modalities, lab work, and pain protocols were outlined. Criteria for routine discharge with follow-up, including pre-populated links for referrals, indications for urology consult, hospital admission and urgent decompression (stent versus nephrostomy tube) were provided. Data was gathered through the EMR analytics team and descriptive statistics were performed. RESULT(S): The Care Pathway was utilized 944 times from August 3, 2021-September 17, 2022 at 11 different hospitals or care centers (Table 1). Usage increased overtime (r2=0.77). The majority of usage was in the ED (892, 94.4%). A total of 194 providers utilized the Pathway with the majority being residents (64, 33.0%). The pathway included care of 505 unique patients, with 106 primary diagnosis key words triggering pathway use. 139 Urology referrals were placed through the pathway with 124 new 28 day prescriptions of tamsulosin. CONCLUSION(S): An EMR-integrated care pathway has been readily utilized in our system and may augment triage and best practice management of patients presenting with stone disease. Further studies are needed to understand the full impact on outcomes.

Do hospitals need to establish multiple hospital districts? A hospital-based perspective on the benefits of scale.

Background: During the fight against COVID-19, China's public hospitals played the main role in taking on the most urgent, dangerous and arduous medical treatment and work. Therefore, in order to promote the high-quality development of hospitals, it is necessary to support some potential public hospitals to build and develop a "One Hospital with Multiple Campuses System" (OHMC) based on controlling the size of single hospitals, and to quickly convert their functions in the event of a severe epidemic. Methods: The Cobb-Douglas production function and log-transformed production function were used to measure the appropriate hospital size for 22 public hospitals in a region of China. Results: The eight OHMC hospitals that planned to be build are basically qualified to handle the conditions and potential of multi-districts from the perspective of economy of scale. The OHMC hospitals in operation appear to have weakened incremental scale rewards, because they are in the process of development, but they are still higher than the overall level of single-campus hospitals. Conclusion: The expansion of hospital scale may bring the advantages of group development, but it may also bring about problems including rising hospital cost, increasing management and operation cost, inefficient allocation of medical resources and unbalanced development.

Logistical challenges with an emphasis on organizing specialized triage in the conditions of a newly emerging, epidemiologically significant infectious pathogen for humans -SARS-CoV2

Background: UMHATEM N.I. Pirogov" Sofia, is one of the largest and busiest hospitals for emergency medical care in Bulgaria. It is the legal successor of the former Institute of Emergency Medicine N.I. Pirogov", and it can be said that at the moment it is the only diagnostic-therapeutic, prophylactic and scientific-educational structure of this type within the Bulgarian healthcare system. The concept of adequate functioning and development of this type of hospital does not consider structuring an Infectious Diseases diagnostic-treatment unit. This reality makes necessary the formation of a radically different organization for the admission and treatment of patients in the hospital, both for those with symptoms of Covid 19 and for all other emergency patients. The organization created in this way must absolutely guarantee safety for both streams of patients. In the conditions of a pandemic, in case of a real threat to public health, the main task of triage in the Emergency Department is to establish indications for urgent hospitalization, or to refuse it in the absence of indications. The characteristic course of the disease, the prolonged treatment, the manifestations within the so-called post-Covid syndrome", require serious planning not only of the diagnostic-treatment and rehabilitation period, but also adequate monitoring in the first months after the patient's discharge. Within the national reorganization measures, during the determined periods, the main changes concerning the MED (Multi-profile emergency department) of Pirogov are implemented, with an emphasis on the formation of a specialized triage for the diagnosis and clinical evaluation of patients with a coronavirus infection. The main goal is the adequate diagnosis, treatment and follow-up of patients with coronavirus infection who have passed through the organized Covid-triage in a period of extreme pressure on the emergency structures and on the hospital system in the country as a whole. Objective(s): For a MED, which at the time of declaring an epidemic situation does not have a concept for the diagnosis and treatment of infectious diseases, to systematize the main urgently implemented organizational and structural changes, which turned out to be absolutely necessary to meet a newly emerging epidemiologically significant infectious disease. Aim(s): To systematize the organizational changes imposed by the situation and urgently implemented in the MED (multi-profile emergency department). To systematize the structural changes imposed by the situation and urgently implemented in the work of the MED. To analyze the organizational and structural changes carried out in this way and to differentiate the main difficulties caused by the regulations existing at the time of the announcement of the epidemic situationCopyright © Pantileeva D et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Implementing and managing nurse led reviews of patient outcomes at 3 and 6 months following mechanical thrombectomy for acute ischaemic stroke

Introduction: 90% of patients undergoing mechanical thrombectomy (MT) require collection of a 90-day outcome (Sacks et al, 2018). This paper presents the development and operation of a Stroke clinical nurse specialist (CNS) led, telephone thrombectomy outcome clinic at a Comprehensive stroke centre (CSC). The clinic was funded and included within the CNS role. The CNS completed formal mRS training. Service managers created a template for the clinic e.g., appointment duration, frequency, and volume. The CNS curated appointments at 90days & 6 months +/- 14 days. Clinics operated weekly (10-20 patients/month) in structured 15-minute appointments. Multiple 'Did not attend's' (DNA) outcome data was obtained via GP and next of kin. Method(s): Outcome completion and DNA rates were compared from 2019- 2021 from hospital systems. A survey for stroke consultants captured perceived benefits and challenges. Result(s): Outcome completion for 2019 was 97.6% (n=164), 2020 86.9% (n=145) and 2021 99% (n=101). 2020 data was temporarily impacted by stroke CNS staffing change and the coronavirus pandemic. DNA rates reduced between 2019 - 2021 for 3 month (18% to 17%) and 6-month reviews (19% to 11%). 100% of stroke consultants agreed outcome data is vital for the service (6/6). Perceived benefits were quality assurance, standardisation, governance, and clinical continuity. Practical challenges included room availability, following up DNA's and the use of interpreters. Conclusion(s): CSC's can achieve >90% of MT case outcomes with mRS trained CNS led clinics. They provide standardised, reliable, and vital patient outcomes for improving MT services.

Multifactorial Benefits of Radial Access in Endovascular Interventions to Treat Peripheral Arterial Disease-Critical Limb Threatening Ischemia

Background A paradigm shift appears to be occurring with overwhelming evidence of trans-radial access (TRA) being a safe and feasible approach for peripheral interventions compared to trans-femoral access (TFA). Our study explores the additional, multifactorial benefits of TRA regarding perioperative times, radiation, contrast administration, and cost-savings for patients and hospitals during Covid era. Methods A retrospective review of all peripheral interventions were performed over two years to outline the advantages and limitations of TRA compared to TFA approach. Patient demographics, procedural time, contrast usage, and radiation dose were recorded and analyzed. Hospital discharges and bed utilization were also studied. Results Total of 170 procedures performed via radial access were evaluated and compared to a control population of n=20 femoral access procedures. Procedural success rate for all interventions was 100% with 10% of cases presenting with acute limb ischemia and 90% presenting with chronic limb ischemia. A two-fold decrease in procedural time for TRA was evident in our analysis compared to the procedures conducted via TFA (81 +/- 43 mins vs. 164 +/- 36 mins, respectively). Furthermore, contrast usage and radiation absorption in TRA procedures decreased dramatically, adding to the potential cost-saving and safety measures for the patient and hospital system. Conclusion While current TRA limitations include operator experience, length of devices, and sheath sizes, the overall benefits of TRA over traditional TFA management cannot be ignored. TRA approach is undoubtedly a safe, feasible, efficient, and cost-saving route for peripheral interventions. It is here to stay as the present and future of diagnosing and treating peripheral arterial disease.Copyright © 2023 American College of Cardiology Foundation

SARS-CoV-2 and Stroke in a New York Healthcare System

Background and Purpose: With the spread of coronavirus disease 2019 (COVID-19) during the current worldwide pandemic, there is mounting evidence that patients affected by the illness may develop clinically significant coagulopathy with thromboembolic complications including ischemic stroke. However, there is limited data on the clinical characteristics, stroke mechanism, and outcomes of patients who have a stroke and COVID-19. Method(s): We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 15, 2020, and April 19, 2020, within a major health system in New York, the current global epicenter of the pandemic. We compared the clinical characteristics of stroke patients with a concurrent diagnosis of COVID-19 to stroke patients without COVID-19 (contemporary controls). In addition, we compared patients to a historical cohort of patients with ischemic stroke discharged from our hospital system between March 15, 2019, and April 15, 2019 (historical controls). Result(s): During the study period in 2020, out of 3556 hospitalized patients with diagnosis of COVID-19 infection, 32 patients (0.9%) had imaging proven ischemic stroke. Cryptogenic stroke was more common in patients with COVID-19 (65.6%) as compared to contemporary controls (30.4%, P=0.003) and historical controls (25.0%, P<0.001). When compared with contemporary controls, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale score and higher peak D-dimer levels. When compared with historical controls, COVID-19 positive patients were more likely to be younger men with elevated troponin, higher admission National Institutes of Health Stroke Scale score, and higher erythrocyte sedimentation rate. Patients with COVID-19 and stroke had significantly higher mortality than historical and contemporary controls. Conclusion(s): We observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability, and mortality was increased. Studies are needed to determine the utility of therapeutic anticoagulation for stroke and other thrombotic event prevention in patients with COVID-19.Copyright © 2020 Lippincott Williams and Wilkins. All rights reserved.

A community intervention for increasing screening through engaging primary care providers (I-STEP)

Background: While lung cancer is a leading cause of death in the U.S., annual lung cancer screening (LCS) rates remain low at 12.7%. The WUSTL research group began a community intervention to increase LCS called I-STEP (Increasing Screening Through Engaging Primary Care Providers) to address this quality gap. A customizable Toolkit was administered to a collaborative of six hospital systems in Missouri and Illinois, encompassing LCS eligibility and follow up guidelines, navigating LCS referral, and smoking cessation. The COVID-19 pandemic prompted brief suspension of screening, with lingering effects on LCS delivery and I-STEP implementation. Method(s): This was a step-wedged cluster randomized control trial from January 2019 - March 2021. Six hospital systems sequentially entered a three-month training phase, followed by I-STEP implementation into primary care settings. Primary outcomes were mean number of screenings and mean percent change in LCS from baseline. Data were collated into a dashboard. Analyses compared outcomes within I-STEP sites pre- and post- intervention. To investigate whether I-STEP sites recovered screening numbers during the pandemic, we compared I-STEP sites to six comparator hospitals within the collaborative that did not participate in the intervention. Result(s): Mean LCS increased by 63% amongst I-STEP sites (130.8 to 212). Mean screenings increased significantly from pre- to post-intervention phases within I-STEP sites (p = 0.0272). Across I-STEP sites and comparator hospitals, mean LCS increased significantly following emergence of the pandemic in March 2020 (p = 0.0002, LSM difference -72.0, 95% CI [-100.9, -43]) - data adjusted for the three-month period in which LCS was suspended. Findings were similar for mean percent change in LCS. There was no difference in outcomes between I-STEP and comparator sites. Conclusion(s): I-STEP implementation successfully increased mean LCS from pre-intervention baseline. Findings suggest a possible effect of the I-STEP intervention in promoting increased LCS amidst the pandemic.

Impact of Covid-19 Wave 3 Paediatric Inpatient Unit Closures on Transfers to Tertiary Care Paediatric Hospital

BACKGROUND: During Wave 3 of the COVID-19 pandemic, 15 community hospital paediatric inpatient units (comprising 167 beds) in Toronto were directed to close by the Greater Toronto Area (GTA) Hospital Incident Management System (IMS) Command Centre to increase adult inpatient bed capacity. All paediatric patients from closed inpatient units were redirected to a single tertiary care paediatric hospital, which increased capacity to accommodate these additional patients through activation of surge plans, while community hospitals redeployed resources to fill much needed gaps in adult care. OBJECTIVE(S): The objective was to describe patient characteristics of all transfers during the closure to explore the impact of community paediatric inpatient unit closures on transfers to the tertiary hospital. DESIGN/METHODS: A chart review of all transferred patients was conducted during the mandated closure and subsequent reopening. Transfers excluded ICU-level transfers as these were not impacted by IMS mandated closures. All transfers were categorized as requiring tertiary care (i.e. would typically be transferred) or not requiring tertiary care (i.e. only transferred due to the closure). Variables collected included sending hospital, admitting diagnosis, patient age, hospital disposition, and length of stay. Data was collected until the last paediatric unit reopened. Quality improvement project approval was granted by the institution. RESULT(S): A total of 858 patients were transferred to the tertiary hospital during the 67 day closure;of those, 530 were transferred solely to increase adult bed capacity (i.e. were categorized as patients requiring non-tertiary care). The majority of patients were admitted to general paediatrics (52%), and 39% went to a surgical inpatient unit. Most patients (68%) admitted had a length of stay between 24 and 72 hours. A third of patients admitted were under 2 years old, and a third were over 12 years old. The top three diagnoses for admission were infections, gastrointestinal issues, and general surgery. Two-thirds (60%) of transfers from closed sites came from three sites. CONCLUSION(S): More than half of the transfers occurred solely due to the mandated closures, and transfers returned to a stable volume once all sites re-opened. The GTA hospital system was able to respond to the mandated closure effectively through clear high-level communication, escalation processes and structures as well as responsive, real-time problem solving. Closures increased potential adult inpatient capacity by 6740 bed days and demonstrated an unprecedented system-wide approach to the provision of integrated paediatric care across the region.

COVID-19 Reinfection and Disease Severity in the New York City Health + Hospitals System

Background. Though reinfection with SARS-CoV-2 is well documented, there remains uncertainty about the potential for more severe symptoms with reinfections compared to index infections. Methods. Patients who received SARS-CoV-2 PCR testing between March 1, 2020 and March 1, 2021 at New York City Health and Hospitals (NYC H+H) facilities and had two positive tests>=90 days apart were included in the analysis. Clinical and demographic data were extracted from the electronic medical record. Manual chart review was done to confirm symptomatology, assess COVID-19 related hospital admissions, and determine WHO disease severity. Patients were then classified as unlikely reinfection, possible reinfection, or probable reinfection based on symptomatology, PCR and antibody testing, and lack of alternative diagnoses. Patients were classified as 'unable to be assessed' if symptomatology could not be assessed for both episodes of PCR positivity. Results. During our study timeframe, 1,255,584 unique patients received at least one SARS-CoV-2 PCR test, 265 of whom had two positive tests>=90 days apart. We categorized 20 patients as unable to be assessed, 28 as unlikely reinfection (1 persistent PCR positivity, 27 unlikely true infection at index or second PCR-positive episode), and 217 as possible or probable reinfection. Of the 217, at their index episode 79 had an asymptomatic infection (36.4%) and 17 were severe or critical (7.8%). At their second episode, 162 patients had an asymptomatic infection (74.7%), and 5 were severe or critical (2.3%). Only 24 patients with possible/probable reinfection had a more severe COVID reinfection than index infection, and 20 of the 24 had asymptomatic index infections. Three patients were hospitalized at both episodes, and two deaths possibly attributable to COVID-19 reinfection were noted in this cohort. Figure 3: Change in WHO disease severity classification from index to second infection among probable/possible reinfection cases (n=217) Red indicates increase in disease severity from index to reinfection (n=24), blue indicates decrease in disease severity from index to reinfection (n=100), white indicates no change (n=74) and gray indicates unable to assess disease severity at index or second infection (n=19). Conclusion. COVID-19 reinfection was rare in a high incidence setting among patients tested at NYC H+H facilities. Disease severity was generally milder in reinfection, although severe and critical disease occurred in a small number of patients.These findings from earlier in the pandemic (presumably wild-type and alpha variant) provide data for comparison in understanding how reinfection is evolving with newer variants.

Comparative Surge Data on SARS CoV-2 Variants in a Rural Community - A Virtual Hospital Experience

Background. UNC Health Blue Ridge is a nonprofit community teaching hospital with 145 staffed beds. The COVID-19 pandemic has challenged rural hospitals like ours with high occupancy and periodic surges. UNC Health Blue Ridge COVID Virtual Hospital (CVH) created a home monitoring program for enrolled patients with severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) infection utilizing disease risk stratification and pulse oximeter readings to dictate nurse and clinician follow-up. We report raw data that compare surge levels in our community for the Alpha (B.1.1.7), Delta (B.1.617.2) and Omicron (B.1.1.529) surges. Methods. From April 2020 to present, the CVH enrolled patients diagnosed with COVID-19 based on FDA approved PCR tests. For this , we defined any surge as an outpatient CVH census of greater than 50 patients or an inpatient census of >10 patients. We defined the maximum intensity of the surge as >20% outpatient SARS CoV-2 positivity and a CVH census >100 patients or >20 inpatients with SARS CoV-2 infection. Results. For the outpatient setting, days of surge and maximum intensity were 144 / 98 days for Alpha, 92 / 71 days for Delta, 74 / 47 days for Omicron, respectively. Average daily CVH admissions during surges were 17.7 for Alpha, 26.15 for Delta, and 27.15 for Omicron. Total emergency department (ED) and urgent care visits were 12,765 and 23,696 for Delta, and 9701 and 16102 for Omicron. In the inpatient setting, days of surge and maximum intensity days were 102/76 days for Delta and 78/48 days for Omicron. Our peak inpatient COVID-19 daily census was 51 and 50 patients for Delta and Omicron. Conclusion. Our CVH has enrolled over 8700 patients, and our hospital has not been on diversion during the COVID-19 pandemic, unlike many surrounding hospital systems of similar size. More importantly, the CVH has helped create a sustainable model that gathers local data to aid predictive algorithms and facilitate proactive rather than reactive resource allocations. This virtual model can be adapted for multiple other health conditions in the outpatient setting to improve patient safety and quality care.

Planning feasible and efficient operational scenarios for a university hospital through multimethodology.

The COVID-19 pandemic required managerial and structural changes inside hospitals to address new admission demands, frequently reducing their care capacity for other diseases. In this regard, this study aims to support the recovery of hospital productivity in the post-pandemic context. The major challenge will be to make use of all the resources the institution has obtained (equipment, beds, temporarily hired human resources) and to increase production to meet the existing repressed demand. To support evidence-based decision-making at a major university hospital in Rio de Janeiro, hospital managers and operations research analysts designed an approach based on multiple methodologies. Besides multimethodology, one important novelty of this study is the application of a productivity frontier function to future scenario planning through the quantitative DEA methodology. Concept maps were used to structure the problem and emphasize stakeholders' perspectives. In sequence, data envelopment analysis (DEA) was applied, as it combines benchmarking best practices and assigns weights to inputs and outputs. To guarantee that the efficiency measurement considers all inputs and outputs before any inclusion of expert judgment, the scope was redirected to full dimensional efficient facet, if any, or to maximum efficient faces. The results indicate that production scenarios proposed by stakeholders based on the Ministry of Health parameters overestimate the viable production framework and that the scenario that maintains temporary human resource contracts is more compatible with quality in health provision, teaching, and research. These findings will serve as a basis for decision-making by the governmental agency that provided temporary contracts. The present methodology can be applied in different settings and scales.

A COVID-19 Clinical Management Committee to Standardize Care in a 2-Hospital System

Objective: The COVID-19 pandemic has been a challenge for hospital medical staffs worldwide due to high volumes of patients acutely ill with novel syndromes and prevailing uncertainty regarding optimum supportive and therapeutic interventions. Additionally, the response to this crisis was driven by a plethora of nontraditional information sources, such as email chains, websites, non-peer-reviewed preprints, and press releases. Care patterns became idiosyncratic and often incorporated unproven interventions driven by these nontraditional information sources. This report evaluates the efforts of a health system to create and empower a multidisciplinary committee to develop, implement, and monitor evidence-based, standardized protocols for patients with COVID-19. Method(s): This report describes the composition of the committee, its scope, and its important interactions with the health system pharmacy and therapeutics committee, research teams, and other work groups planning other aspects of COVID-19 management. It illustrates how the committee was used to demonstrate for trainees the process and value of critically examining evidence, even in a chaotic environment. Result(s): Data show successful interventions in reducing excessive ordering of certain laboratory tests, reduction of nonrecommended therapies, and rapid uptake of evidence-based or guidelines-supported interventions. Conclusion(s): A multidisciplinary committee dedicated solely to planning, implementing, and monitoring standard approaches that eventually became evidence-based decision-making led to an improved focus on treatment options and outcomes for COVID-19 patients. Data presented illustrate the attainable success of a committee that is both adaptable and suitable for similar emergencies in the future. Copyright © 2022 Turner White Communications Inc.. All rights reserved.

Attitudes Regarding COVID-19 Vaccine and Vaccine Hesitancy in an Inner-City Kidney Transplant Recipients (KTRs)

Purpose: KTRs comprise a high-risk group for COVID-19 infection due to comorbidities and immunosuppression. Studying how vaccination hesitancy in inner-city KTRs has changed since the onset of the pandemic and their attitudes towards the vaccine in general is integral in the advancement of a successful vaccination effort. Method(s): A random sample of 30 KTRs in 2020 and 9 recipients in 2021 were surveyed about attitudes towards and history of vaccines. Respondents who received both doses, one dose, or were planning on doing so were recorded as VACYES while those who were unsure or refused were recorded as VACNO. Respondents were also asked their top reasons for receiving or not receiving the vaccine. Result(s): Mean age in 2020 was 57.8 +/- 10.6 yrs, time since transplant was 8.9 +/- 6.6 yrs with18 (60%) men, 20 (71.4%) identified as black. Mean age in 2021 was 50.9 yrs +/- 9.1 yrs, time since transplant 6.8 yrs +/- 8.6 yrs with 3 (33.3%) men. There was no significant difference between the two samples for time since transplant, age sex, race, or percent with diabetes or hypertension. Prior to vaccine availability in 2020 only 36.7% indicated they would accept a COVID-19 vaccination. By 2021, the number had increased to 66.7% who had either received or were planning on receiving the vaccine (p < 0.001). Among the pts who were VACNO in 2020, the most commonly cited reason was concern about vaccine safety (53%). Between VACYES and VACNO patients in 2021, there were no statistically significant differences with respect to time since transplant, sex, race, education or comorbidities but VACYES pts were older (58.8+/-2.3 vs 47.0+/-8.7 yrs, p=0.021). Among VACYES, the most commonly cited reason for vaccine acceptance was that it was recommended for people with underlying conditions (80%). 100% of VACYES felt confident about the safety and efficacy of the COVID-19 vaccines compared to 33% of VACNO. 100% of VACYES believed it is okay for the government to mandate vaccinations compared to 0% of VACNO. 100% of VACNO pts felt COVID-19 was preventable vs 100% of VACYES who stated they did not know (p<0.05). 86% of both VACYES and VACNO believe that the hospital system could take care of them if sick with COVID-19. Conclusion(s): In our population: 1. Vaccine hesitancy has decreased in our inner-city KTR sample compared to the previous year, but almost 40% remain unvaccinated. 2. The most important reason cited for receiving the vaccine was because it was recommended for patients with underlying conditions. 3. Pts who received the vaccine were older, feel more confident about its safety and efficacy, and believe a government mandate is ok. 4. Pts who refused were more likely to believe that COVID-19 is preventable. 5. Regardless of vaccination status, pts believed that the healthcare system could help them if sick with COVID-19. 6. Understanding the motivation for acceptance and reasons for refusal in underserved KTR populations will be important in increasing vaccine acceptance.

DIFFERENCES IN CLINICAL CHARACTERISTICS, TREATMENT, AND OUTCOME OF PULMONARY EMBOLISM ACCORDING TO COVID-19 STATUS

SESSION TITLE: Expanding Considerations in Management of Pulmonary Embolism SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Patients with COVID have an increased risk of thrombotic events including pulmonary embolism (PE). The primary objective of this study was to understand the differences in risk factors, clinical presentation, treatment modalities, and outcomes in patients with PE who were COVID positive at time of admission compared to those who were not. METHODS: Patients diagnosed with PE and activated by the Pulmonary Embolism Response Team (PERT) at Spectrum Health hospital system between November 2019 through January 2022 were included. Clinical, demographic, laboratory, and therapeutic characteristics were compared between patients with COVID and without COVID. Continuous variables were evaluated by t-test and categorical variables by Chi square. Survival after PE was evaluated using Kaplan Meier survival analysis. RESULTS: Of the 479 PERT-activated patients at our institution, 84 (17.5%) were diagnosed with COVID upon admission. Demographics such as age, gender, BMI, and race were similar between patients with and without COVID (all p>0.05). Patients with COVID were less likely to have PE risk factors such as recent surgery (4.8% vs 16.2%, p=0.011), recent trauma (0% vs 8.1%, p=0.014), and reduced mobility (10.7% vs 26.6%, p=0.003) although they were more likely to be recently hospitalized (19.1% vs 8.9%, p<0.001). Patients with COVID were more likely to have a fever (7.1% vs 2.5%, p=0.045), hypoxia (60.7% vs 29.9%, p<0.001), tachypnea (high respiratory rate/min of 28.2 vs 24.8, p<0.001), and lower O2 saturation (low O2 mean of 87.3 vs 90.5, p<0.001) upon presentation. Compared to non-COVID patients, mean troponin (116.5 vs 83.6 ng/ml, p=0.033) was higher in patients with COVID. There was DVT in 36.9% of COVID patients and 30.63% of non-COVID patients (p=0.321). Severity of PE was similar between COVID and non-COVID patients (massive: 18% vs. 15%;sub-massive: 70% vs. 75%, p=0.661). COVID and non-COVID patients had similar rates of thrombolysis (4.7% vs 2.3%) and catheter-based interventions (56% vs 59%). Patients with COVID had longer ICU (10 vs 5.2 days, p=0.001) and hospital stays (10 vs 6.1 days, p=0.006) compared to non-COVID patients. Major bleeding in the follow-up period was higher in the COVID group (10.7% vs 3.5%, p=0.01). There was no difference in mortality between COVID and non-COVID patients at 30 days, (11.9% vs 7.6%), 90 days (15.5% vs 10.4%), or 1 year (16.7% vs 13.7%). CONCLUSIONS: Patients who presented with PE and COVID had less traditional risk factors for PE and were more hypoxemic and tachypneic at the time of PERT activation. They received similar treatment to non-COVID patients but had increased risk for major bleeding. There were no differences in short or intermediate term survival between COVID and non-COVID patients. CLINICAL IMPLICATIONS: Similar severity, treatment, and mortality show promise for PE patients with COVID but bleeding complications require further investigation. DISCLOSURES: no disclosure submitted for Wael Berjaoui;Speaker/Speaker's Bureau relationship with Bristol Myers Squibb Please note: 2015 to present Added 04/17/2022 by Trevor Cummings, value=Honoraria Speaker/Speaker's Bureau relationship with Pfizer Please note: 2015 to present Added 04/17/2022 by Trevor Cummings, value=Honoraria Speaker/Speaker's Bureau relationship with Inari Medical Please note: 2020 to Present Added 04/16/2022 by Trevor Cummings, value=Honoraria No relevant relationships by Catherine Kelty Consultant relationship with Inari Medical Please note: July 2020 - present Added 04/02/2022 by Michael Knox, value=Consulting fee No relevant relationships by marzia leacche no disclosure submitted for Renzo Loyaga-Rendon;No relevant relationships by James Morrison No relevant relationships by Joseph Pitcher No relevant relationships by Nabin Shrestha Consultant relationship with Inari Medical Please note: 1/2021 to current Added 04/08/2022 by Erin VanDyke, value=Consulting fee No relevant relationships by Glenn VanOtteren

The end is just the beginning: Involving bereaved next of kin in qualitative research

Introduction: Almost half the UK population die in hospital and more than two thirds of these are aged 75 years or more.1 Older people make up an increasing proportion of patients admitted to critical care and often have poorer outcomes, especially in the context of COVID-19.2 Loved ones are an essential support network for older patients but their ability to provide support was compromised by visiting restrictions during COVID-19. Little is known about the experiences of older patients in ICU and there is limited literature on the experiences of bereaved relatives.3 Bereaved relatives may be the only way to access the experiences of patients who do not survive, but there are a number of barriers to including bereaved relatives in research. Researchers may feel inhibited from imposing what might be seen as an additional burden on families during the aftermath of a bereavement. The ongoing ESCAlation of the eLderly (age >65years) to criTical carE with COVID-19) (ESCALATE) study includes semi-structured interviews with bereaved loved ones as well as patients and NoK of survivors in the UK. Objectives: To describe successful involvement of bereaved next of kin in critical care-based research Methods: This qualitative research uses semi-structured interviews and thematic analysis. Patient and public involvement from an intensive-care focused charity and local palliative care team advice was sought in order to develop recruitment strategies such as detailed, sympathetically worded participant information packs.4 In keeping with the literature,5 the window for recruitment and interview was approximately one year following bereavement. Following ethical approval, participants were recruited via postal invitations with follow up telephone calls if no response after a minimum of one week. Results: Recruitment was limited by only 40% of bereaved NoK (next of kin) having postal addresses recorded on the hospital systems. 9 /40 bereaved NoK contacted by letter responded and as well as completing a questionnaire, consented to be interview. A further 5/11 contacted by follow-up telephone call agreed to participate (consistent with response rates for patients and NoK of survivors). All of the interviewed bereaved participants completed the interview according to the interview topic guide, with each interview lasting around 45 minutes. More than half were female, and three quarters were Black, Asian or Minority Ethnic. Bereaved relatives were keen to share their experience and some even volunteered additional information with the interviewers, such as resources they had created for their local community and personal diaries. Participants reported that they were happy to be interviewed if it would help others in a similar position. Conclusion: Bereaved relatives of critical care patients are willing to engage in qualitative research. Recruitment is challenging due to practical constraints, but we suggest could be improved through meticulous documentation of contact details and involvement of bereavement services in research. By seeking the views of bereaved loved ones, we can improve care for critically unwell patients at end of life.

Avoidable admissions in gynecology oncology patients undergoing minimally invasive hysterectomy (520)

Objectives: To determine the rate and identify factors associated with potentially avoidable admissions following a minimally invasive hysterectomy. Methods: Patients who underwent a minimally invasive hysterectomy for a suspected or known gynecologic malignancy between January 2019 to July 2021 were identified in our institution's prospectively curated quality improvement surgical database. Preoperatively, patients were assessed for planned same-day discharge versus a planned admission. Reasons for those who were admitted despite a planned same-day discharge were characterized as the following: anesthesia-related, comorbid conditions, intraoperative factors, social factors, system issues, and uncontrolled pain. For planned admissions, reasons for admission were categorized as necessary and potentially unavoidable. Descriptive statistics were used to summarize the cohort. Results: A total of 380 patients were identified, of which 267 (70%) patients had a planned same-day discharge, and 113 (30%) had an anticipated admission. Same-day surgery discharge rates increased over time (Figure 1). Two hundred and thirty-five patients (88%) were successfully discharged the same day. Of these patients, 17 (7%) presented to the emergency department (ED) within 30 days, and the re-admission rate in this group was 12% (n=2). Thirty-two patients did not successfully discharge on the same day, and five patients (15%) presented to the ED for evaluation within 30 days. Most unplanned admissions were anesthesia-related (n=15, 47%), followed by system issues (n=7, 22%), such as failure to recognize comorbid conditions in the preoperative period, intraoperative factors (n=5, 16%), postoperative pain (n=3, 9%), and social factors (n=2, 6%). Among the 113 anticipated admissions, 78 (69%) patients were deemed necessary due to multi-factorial comorbid conditions or surgical complexity. However, 35 (31%) patients could have been optimized for same-day discharge;reasons for which included patients with comorbid conditions that could have been optimized preopera- tively, such as poorly controlled diabetes (n=13, 12%), system issues, (n= 8, 7%), social factors (n= 7, 6%), anesthesia-related (n= 4, 4%), and surgical complexity (n=3, 3%). [Formula presented] Conclusions: Most patients were successfully discharged the same day, and of those who were deemed unsuitable for same-day discharge, nearly half could have been optimized for same-day discharge. Unplanned admissions in the anticipated same-day discharge cohort were primarily due to anesthesia-related concerns in the immediate postoperative period and where patient comorbid conditions could have been better optimized in the preoperative period. Recognizing potential areas for improvement and further optimizing same-day discharge will allow hospital systems to continue providing care for gynecologic oncology patients during COVID-19 surges.

Implementing proven methods in a community-based health system to improve breast cancer screening rates during the COVID-19 pandemic

Background: There are reduced screening rates across the United States secondary to the COVID-19 pandemic;the additional anticipated deaths from breast and colorectal cancer, secondary to reduced screening, is approximated at 10,000 people. A study of thirty-two health systems in Georgia noted an 8% decrease in screening mammography compared to pre-pandemic rates. To help reverse the decline, Northeast Georgia Medical Center (NGMC) participated in the “Return to Screening” initiative, in conjunction with the American Cancer Society (ACS). A quality improvement project was performed at the community-based hospital system to increase breast cancer screening rates, using a multidisciplinary approach with a focus on health care disparities. Methods: The initial goal was to increase screening mammograms by 10% (n = 14,364) from June 1st to December 1st 2021. Interventions were selected by a multidisciplinary team of NGMC researchers, clinical providers, and oncology administrators. Interventions varied in category, encompassing unique patient and provider-specific approaches. The evidence-based interventions were tailored to address health care disparities in the local population. This included identification and quantification of cultural groups in the community to ensure quality patient access. Integrative collaboration consisted of intermittent meetings to certify consistent communication, project reflection and identification of barriers. The selected interventions were executed monthly, with simultaneous data tracking of mammography rates. Results: From June 1st to December 1st 2021, a total of forty evidence-based interventions were successfully implemented. Analysis of screening rates demonstrated a 15% increase across the allotted time period, corresponding to an average of 1,302 mammograms monthly (n = 15,284). This exceeded the initial anticipated goal of increasing screening by 10% (n = 14,364). Analysis of mammography results identified 331 new cases of breast cancer diagnosed within the allotted period, a 7% mean diagnosis rate increase. Certain planned interventions were unable to be conducted and required modification due to limitation of the ongoing pandemic;however, this solidified the use of social media and virtual participation as effective methods of community outreach. Conclusions: We identified key methods to engage the local community and successfully increased rates of screening mammography. Interventions were tailored to the local population, ensuring patient-centered tools and a personalized approach to medicine. The multidisciplinary, consistent collaboration with stakeholders ensured quality of care for the local patient population. This project demonstrates the importance of local community engagement to impact national cancer screening rates, and thus, ensure earlier detection of breast cancer. .