Vitamin D Levels in Hospitalized COVID-19 Patients

Background: Several studies suggest an association between serum Vitamin D levels and outcomes in patients diagnosed with COVID-19. Prevention measures for COVID-19 continue to be one of the best strategies to combat the virus but identification of individuals at high risk will help clinician's direct preventative care to reduce infections and improve outcomes. This work assesses the vitamin D levels of hospitalized COVID-19 patients at one community hospital in central Pennsylvania. Method(s): This prospective study, conducted on adult, hospitalized patients under the care of clinical nutrition services between April 2021 and April 2022. Inclusion criteria included age >18 years, COVID-19 positive by polymerase chain reaction (PCR) test with associated symptoms, and not receiving vitamin D supplementation prior to or during hospital admission (N = 122). Vitamin D 25 hydroxy laboratory values were obtained, and values were interpreted utilizing the recommended range categories: 25(OH)D level >= 30 ng/ml was representative of adequate vitamin D stores, while values between 21-29 ng/ml signified vitamin D insufficiency. A 25(OH)D value <20 ng/ml is indicative of vitamin D deficiency. Result(s): Over 77% (n = 95) of all patients included in study had vitamin D values below the recommended levels, with one half (n = 61) demonstrating vitamin D deficiency. Only 22.1% (n = 27) were found to have values consistent with a blood level deemed adequate. Conclusion(s): Many hospitalized patients with COVID-19 demonstrate vitamin D levels below acceptable ranges, many with vitamin D deficiencies. Identification of these individuals in the community will allow clinicians an opportunity to treat the vitamin insufficiency or deficiency with the goal of preventing infections and potential morbidity or mortality associated with the disease. (Figure Presented).

Renal safety of liposomal amphotericin B in critically ill mechanically ventilated patients with SARS-CoV-2 pneumonia

Introduction: Liposomal amphotericin B (L-AmB) represent a good treatment strategy for critically ill patients according to its unique pharmacological characteristics and a relatively broad spectrum of action. The aim of the present study is to asses the impact on renal function of L-AmB during the first days of ICU admission in critically ill patients. Method(s): Retrospective, single-center case series of patients with SARS-CoV-2 pneumonia admitted in ICU. Setting(s): 19-bed medical-surgical ICU of a community hospital. Time of study: 2 years. Study variables: APACHE II and SOFA at admission, clinical characteristics, oliguria and creatinine level at admission and 72 h after L-AmB treatment were recorded. Oliguria was defined as urinary output less than 400 ml per day or less than 20 ml per hour. Two groups of patients were selected according to whether or not they received anticipated antifungal treatment pending microbiologic confirmation or discarding of aspergillosis;dosage of L-AmB was 3 mg/kg/d. Statistical analysis: Data were analyzed by SPSS 18 and quantitative variables were expressed as a mean +/- standard deviation. Result(s): 160 patients were included, 102 who received 3 days of anticipated treatment with L-AmB at ICU admission or at the beginning of mechanical ventilation were compared with patients without this treatment. There were not differences in age, median 65 [57-71] years, gender with 28% female and BMI (kg/m2), 30,4 [26,6-33,2]. APACHE II at admission was higher in the treated group of patients 17 [12-23] vs 12 [9-14]. SOFA was 7 [4-8] in the treated group of patients vs 6 [3-8]. There were not differences in urinary output between groups during the three first days of ICU stay. Table 1 shows creatinine levels. Conclusion(s): According to our retrospective analysis, L-AmB is safe in the first days of treatment in critically ill patients admitted in ICU requiring mechanical ventilation.

Outcomes for Anti-CD19+ Chimeric Antigen Receptor T (CAR-T) Cell Therapy for Non Hodgkin Lymphoma (NHL) across a Large Community Transplant and Cellular Therapy Network

Background: The Sarah Cannon Transplant and Cellular Therapy Network (SCTCTN), which offers community access to transplant and cell therapy, implemented a coordinated approach to deliver CAR-T therapy through 5 programs. We conducted a retrospective review of clinical outcomes after FDA-approved anti-CD19+ CAR-T in B-cell NHL. Method(s): All patients referred for evaluation within SCTCTN were tracked in our prospective registry (Stafa-CT). We identified 110 patients who received FDA-approved anti-CD19+ CAR-T for NHL within the network between 12/10/2018 and 3/7/2022. All patients received care through standardized eligibility criteria, process, care pathways, toxicity management protocols, and a single quality plan. Result(s): The median age at referral was 60 years (range 23-82), 63% were male, the referral indication was diffuse large B-cell lymphoma (70%), mantle cell lymphoma (7%), follicular lymphoma (15%), or other B-NHL (8%). 35% had received a prior autologous transplant. The median time from referral to infusion was 143 days (range 89- 224), and from collection to infusion was 32 days. The infusion year was 2018 (1), 2019 (20), 2020 (31), 2021 (48), 2022 (10). The CAR-T cell products were Axi-cel (70), Tisa-cel (27), Brexu-cel (9), and Liso-cel (4). 16 patients (15%) were infused as outpatient, of which 10 patients were subsequently hospitalized at a median of 8 days (range 1-26) after infusion. Of the 94 patients (85%) infused as inpatient, the median length of stay was 15 days (range 6 to 85). Cytokine release syndrome (CRS) was observed in 78% with a median maximum grade 1. Maximum grade CRS was none, grade 1, grade 2, grade 3, grade 4, grade 5 in 22%, 36%, 32%, 7%, 2 % and <1%, respectively. The median times to onset and resolution of symptoms were day 3 and 8, respectively. Tocilizumab was administered to 39% for a median of 2 doses. Neurotoxicity was observed in 55% with a median maximum grade 1. Maximum grade neurotoxicity was none, grade 1, grade 2, grade 3, grade 4, grade 5 in 45%, 19%, 13%, 18%, 4 % and 0%, respectively. The median times to onset and resolution of symptoms were day 7 and 13, respectively. Neutropenia (<0.5/ muL) and thrombocytopenia (<20K/muL) at day 30 were reported in 11% and 12%, respectively. 18% required ICU stay. 37 deaths (34%) were reported from disease progression (23), infections (7, including 5 from COVID), CRS (2) and other causes (5).(Figure Presented) Conclusion(s): Administration of anti-CD19+ CAR-T is feasible in specialized community hospitals with outcomes similar to registrational clinical trials. Outpatient administration is feasible in selected patients, but subsequent hospitalization needs to be anticipated. CRS, neurotoxicity, cytopenias and infection remain challenges, while disease progression was the commonest cause of deathCopyright © 2023 American Society for Transplantation and Cellular Therapy

Universal Genetic Counseling for Breast Cancer Patients Mitigates Social Determinants of Health and Improves Genetic Testing Rates Across All Races

INTRODUCTION: While available since 1996, genetic testing for breast cancer patients has been limited by stigma, cost, and poor access. Many patients were not captured by traditional NCCN criteria, particularly those with healthcare barriers. Previously, genetic testing was used in high-risk screening and determining prophylactic utility, but with recent targeted therapies, has allowed personalized therapeutic benefit for patients. We expanded genetic testing counseling at a three-hospital Midwestern community hospital system from only NCCN high-risk patients to all patients diagnosed with breast cancer. METHOD(S): The implementation of universal genetic counseling to all newly diagnosed breast cancer patients began at our system in 2020. Under IRB approval, all new breast cancer patients were retrospectively reviewed from January 2019 through December 2019 (genetics based on NCCN guidelines group) and January 2021 through December 2021 (genetics offered to all group). Patient data regarding completion of genetic testing, pathologic mutations identified, stage, race/ethnicity, insurance type, primary language, and age was included in the analysis. Categorical variables were compared using Pearson's chi-square or Fisher's exact test;age was analyzed using ANOVA. RESULT(S): We reviewed a total of 973 patients, 439 diagnosed in 2019 and 534 in 2021. Demographic differences between 2019 and 2021 were similar including age, race/ethnicity, insurance, primary language. Despite the SARS CoV-2 pandemic, the stage of diagnosis between 2019 and 2021 was also similar (p=0.194). Completion of genetic testing increased significantly from 204 (48.6%) in 2019 to 338 (63.3%) (p=0.000) in 2021 with the universal access group. Across all demographic groups, genetic testing increased with significant findings in Medicare patients (p=0.005) and older patients (p=0.041) and near significant findings in non-white populations (0.059).[Table] Overall number of pathological mutations increased, 32 (7.29% of all patients) in 2019 to 39 (7.30%) in 2021, with the most common being BRCA2 (n=11), CFTR (n=9), CHEK2 (n=8), and BRCA1 (n=6). CONCLUSION(S): Implementation of universal access to breast cancer genetic counseling allowed for a significant expansion in genetic testing completion and overall increase in pathological mutations found. We saw an increase within sub-populations that may have not been targeted by NCCN guidelines previously including older patients, minority groups, and varying insurance types. (Table Presented).

Emergency Department-based monoclonal antibody therapy for patients with mild to moderate COVID-19

Objectives: To describe the implementation of an ED-based program to offer monoclonal antibody therapy to patients with mild-moderate COVID-19 disease. Background(s): Monoclonal antibody therapy (MOAB) has recently emerged as a treatment for mild to moderate COVID-19, potentially preventing those with underlying conditions from progressing to severe illness and hospitalization. Further, as EDs are the primary point of health care access for many at-risk individuals, offering MOAB in the ED may increase availability of treatment options for patients from traditionally underserved communities. Method(s): A retrospective chart review was conducted of patients 12 years and above who received treatment in our urban, academic, community hospital. Patients 12 years and older were screened for eligibility during ED visits or during follow-up calls providing positive test results. Staff was trained on specific consent, infusion, monitoring, and documentation procedures adherent to MOAB administration under the Emergency Use Authorization. Patients were contacted following MOAB and queried regarding symptom resolution and healthcare utilization. Data regarding patient demographics, ED course, and 7-day unscheduled visits were collected. Result(s): In this ongoing quality improvement initiative, from December 2020 to March 2021, there were 26,229 patient encounters at the pilot ED site. 84 patients were provided MOAB, 87% Bamlanivimab and 13% Bamlanivimab/Etesevimab. Patients had a mean age of 52.3 years (SD 24.4);21% were 12-17 years of age and 37% were >65 years old. 52% were male. 33% self-reported as Caucasian, 19% Black, 18% Asian/Pacific Islander, 21% as other, and 9% were unknown. 17% identified as Latinx. 19% of patients were insured by Medicaid, 36% Medicare, 39% commercially insured, and 6% were uninsured. Patients had symptoms a median of 3 days prior to MOAB. After age (46%), the most commonly reported eligibility criteria was obesity (20%), followed by hypertension (11%) and immunocompromised state (11%). 74% of infusions were administered during nights and weekends. No infusion reactions occurred. 8% returned to an ED within 7 days of MOAB, 5% were hospitalized. No patients required ICU admission or died. Conclusion(s): ED-based MOAB has been safely implemented and may be an effective treatment for patients with mild to moderate COVID-19. Health-system wide expansion of this program may provide opportunities to offer this life-saving therapy to underserved populations with poor access to care.Copyright © 2023

Fluid balance as an independent prognostic indicator of in-hospital mortality in heart failure patients with Covid19

Introduction: Fluid resuscitation confers protection against in-hospital mortality in heart failure (HF) patients with severe sepsis. SARS COV-2 infection leads to cytokine storm that is clinically similar to severe sepsis. We aim to evaluate if positive fluid balance is associated with in-hospital mortality in HF patients with Covid-19. Method(s): This single center retrospective cohort study was conducted in patients admitted in the ICU for Covid 19 from 10/2020 to 3/2021 in a community hospital in Newark. The primary outcome was survival to discharge. Clinical SAS 9.4 was used to obtain summary statistics, perform chi-squared test and multivariable logistic regression analysis. Result(s): We included 91 patients admitted in the ICU with covid 19, of which 33 were diagnosed with HF. Out of 33 people, majority were males. Most of the patients were hispanic. Diabetes and hypertension were the most common comorbidities. 60.61% of HF patients had multiple comorbidities. Odds of negative survival outcome in those with positive fluid balance after adjusting for HF as compared to those with negative fluid balance in patients of COVID 19 was 12.958 (P value= 0.0183). Conclusion(s): Positive fluid balance in HF patients admitted with Covid 19 may be associated with adverse outcomes. Larger, prospective studies are needed to investigate the correlation between covid 19 and fluid balance in HF patients.

Comparison of STEMI Door-To-Device Time During the COVID-19 Crisis in a New Jersey Inner City Community Hospital.

As the novel COVID-19 pandemic was on the rise, its impact on the healthcare system was devastating. Patients became more reluctant to present to the hospital and elective procedures were being postponed for patient safety. We wanted to assess the effects of the COVID-19 pandemic on the door-to-device time in our small community hospital in the heart of Trenton, New Jersey. We created a retrospective study that evaluated all STEMI cases that presented to our institute from January 2018 until the end of May, 2021. Our primary outcome was the door-to-device time. Secondary outcomes were the length of hospital stay, ICU admission, length of ICU stay, cardiac arrest, and death during the hospitalization. We studied 114 patients that presented with STEMI to our emergency department, 77 of these patients presented pre-COVID-19, and 37 presented during the pandemic. Our median door-to-device for STEMI cases pre-COVID-19, and during the pandemic were 70 min (IQR 84-57) and 70 min (IQR 88-59) respectively with no significant difference found (P-value 0.55, Mann Whitney Test). It is, however, interesting to note that the number of STEMI admissions significantly decreased during the pandemic era. There are limitations to our study, most noticeably the number of STEMI cases at our small community hospital which limits its generalizability. Moreover, we did not assess other comorbidities which might have confounded our outcomes and we were also unable to follow patients post-discharge to assess the long-term sequela of their STEMI admission. Therefore, more dedicated studies of this clinical conundrum are required to further assess and implement guidelines for the future.

Correlates of Coronavirus Disease 2019 Inpatient Mortality at a Southern California Community Hospital With a Predominantly Hispanic/Latino Adult Population.

Background: Studies of inpatient coronavirus disease 2019 (COVID-19) mortality risk factors have mainly used data from academic medical centers or large multihospital databases and have not examined populations with large proportions of Hispanic/Latino patients. In a retrospective cohort study of 4881 consecutive adult COVID-19 hospitalizations at a single community hospital in Los Angeles County with a majority Hispanic/Latino population, we evaluated factors associated with mortality. Methods: Data on demographic characteristics, comorbidities, laboratory and clinical results, and COVID-19 therapeutics were abstracted from the electronic medical record. Cox proportional hazards regression modeled statistically significant, independently associated predictors of hospital mortality. Results: Age ≥65 years (hazard ratio [HR] = 2.66; 95% confidence interval [CI] = 1.90-3.72), male sex (HR = 1.31; 95% CI = 1.07-1.60), renal disease (HR = 1.52; 95% CI = 1.18-1.95), cardiovascular disease (HR = 1.45; 95% CI = 1.18-1.78), neurological disease (HR = 1.84; 95% CI = 1.41-2.39), D-dimer ≥500 ng/mL (HR = 2.07; 95% CI = 1.43-3.0), and pulse oxygen level <88% (HR = 1.39; 95% CI = 1.13-1.71) were independently associated with increased mortality. Patient household with (1) multiple COVID-19 cases and (2) Asian, Black, or Hispanic compared with White non-Hispanic race/ethnicity were associated with reduced mortality. In hypoxic COVID-19 inpatients, remdesivir, tocilizumab, and convalescent plasma were associated with reduced mortality, and corticosteroid use was associated with increased mortality. Conclusions: We corroborate several previously identified mortality risk factors and find evidence that the combination of factors associated with mortality differ between populations.

Elevated Risk of Recurrent Ablation in Black Compared to White Patients With Atrial Fibrillation: Another Paradox of Atrial Fibrillation in Blacks

Introduction: Lower prevalence of atrial fibrillation (AF) despite a higher prevalence of risk factors in blacks compared to whites (AF paradox) has been reported. However, less information is available about recurrent ablation events in blacks compared to whites. Method(s): Demographic characteristics and one-year recurrent ablation events were analyzed in AF patients admitted to a community hospital from 2018 to 2021. Result(s): Recurrent AF ablation occurred in 3.7% (16/435) of the study population and was significantly higher in black compared to white patients [9/86 (10.5%) vs. 7/349 (2.0%), respectively, p=0.0001]. Black race and history of atrial flutter were predictors of recurrent AF ablation (p<0.05) within one year of initial ablation. Black patients were younger (p=0.03) with a significantly higher prevalence of hypertension, diabetes, cardiomyopathy/heart failure, thyroid disease, renal disease, sleep apnea, COVID-19, pacemaker/AICD placement, and history of Ventricular tachycardia (Table). Concomitant medications were similar between races besides higher use of antihypertensive medications in black patients (Table). Conclusion(s): In our community hospital setup, black patients with AF had a higher prevalence of comorbidities and significantly higher incidence of one-year recurrent ablation events despite similar therapy compared to white patients. These observations should be explored in a larger prospective study to understand the differential association of comorbidities in black AF patients and associated higher risk for recurrent events.

Evaluation of Bivalirudin Anticoagulation in Patients on Ecmo Due to Covid-19 Respiratory Failure

INTRODUCTION: Patients supported on extracorporeal membrane oxygenation (ECMO) due to COVID-19 are at an increased risk of both thromboembolic complications and thrombocytopenia. Bivalirudin, a direct thrombin inhibitor, is increasingly being utilized for anticoagulation in the ECMO patient though there is largely a lack of literature within the COVID-19 population. The objective of our study was to evaluate the safety and efficacy of alternative anticoagulation with bivalirudin in patients on ECMO with COVID-19 respiratory failure. METHOD(S): This was a non-interventional retrospective chart review conducted at a single center large community hospital between January 2020 - November 2021. We included both venovenous (VV) and venoarterial (VA) adult ECMO patients anticoagulated with bivalirudin that tested positive for COVID-19. Patients were excluded if their duration of ECMO cannulation was less than 48 hours. Descriptive statistical analyses were performed utilizing median with interquartile range and frequency with percent as appropriate. RESULT(S): Overall, 180 ECMO patients were included in the study. The duration of ECMO cannulation was 29 (9-54) days and our cohort experienced a 42% mortality rate. The rate of thrombotic events including in-circuit thrombosis, arterial and venous thrombotic events was 22%. The median initial platelet count on ECMO was 206 (157-274) and the median nadir was 85 (48-121). ELSO defined major bleeding occurred at a rate of 53% within this cohort. CONCLUSION(S): To our knowledge, this study describes the largest number of patients anticoagulated with bivalirudin for ECMO secondary to COVID-19. Our results suggest similar rates of thrombotic events compared to ELSO registry data. While the half-life of bivalirudin is short, clinicians should still be cautious of bleeding due to lack of a specific reversal agent. Retrospective studies with a comparator cohort, as well as randomized trials are warranted to further evaluate the selection of intravenous anticoagulants in the ECMO population with and without COVID-19.

Outcomes of Covid-19 Infection among Hospitalized Patients by Their Stage of Chronic Kidney Disease

INTRODUCTION: Chronic kidney disease (CKD) is an important risk factor for severe COVID-19 disease associated with increased intensive care unit (ICU) admission and mortality. Studies demonstrate an increased mortality rate among advancing CKD stages in patients without COVID-19 infection. However, it is unknown whether a graded association exists between the stages of CKD and COVID-19 mortality. We aim to compare the rates of ICU admission, mechanical ventilation (MV), and survival amongst COVID-19 patients with Stage IIIb -V CKD. METHOD(S): We conducted a retrospective cohort study on non-dialysis adults with Stages IIIb, IV, and V CKD without previous renal transplant hospitalized for COVID-19 infection in a community hospital. Patients were categorized into two groups, Stage IIIb CKD and Stages IV&V CKD, based on their pre-admission glomerular filtration rate (GFR 30-44ml/ min vs < 30ml/min). The primary endpoints were rates of ICU admission, MV, non-invasive mechanical ventilation (NIMV), and survival. The Mann-Whitney U test for continuous variables and the chi-square test for categorical variables were used for analysis. RESULT(S): We screened 228 patients and 153 met the inclusion criteria. Baseline demographics were distributed equally between the two groups. There were statistically significant differences in the ICU admission rate (45.2% vs 25.3%,p-0.01), MV rate (37.1% vs 16.5%,p-0.004) and NIMV rate (50% vs 28.6%,p-0.007) in patients with Stage IIIb versus Stages IV&V CKD respectively. However, there was no significant difference in the survival rates (79.1% vs 67.7%,p-0.1128) between the two groups. CONCLUSION(S): The association between reduced baseline eGFR and increased risk of severe COVID-19 infection has been established with multiple studies evaluating the prognostic impact of pre-existing CKD in patients with COVID-19. Our study illustrates the greater incidence of adverse outcomes, such as ICU admission rate, MV rate, and NIMV rate, in patients with Stages IV&V CKD versus Stage IIIb CKD. With recent guidelines recommending management of COVID-19 infection based on the presence of risk factors, these results will aid in risk stratification among CKD patients with COVID-19, and encourage future prospective studies to explore disease-modifying treatments for the vulnerable CKD population.

Spike in Critical Care Admissions for Severe Hyponatremia in Patients Receiving Paxlovid

INTRODUCTION: Paxlovid (nirmatrelvir-ritonavir) received Emergency Use Authorization (EUA) for mild to moderate COVID-19 among those at high risk for severe disease. Hyponatremia is not yet listed as an adverse reaction to either Paxlovid or ritonavir alone in UpToDate. The package insert lists hyponatremia if Paxlovid is administered with finerenone, due to the increased concentration of finerenone caused by a drug-drug interaction. The EUA lists one case of mild hyponatremia in a patient with 10 other adverse events, none of which thought to be related to Paxlovid. The Liverpool COVID-19 website allows review of concomitant medications for drug interaction prior to prescribing, although it is unclear how widespread its use is among prescribers. The objective of this case series is to review 4 cases of severe hyponatremia in patients receiving Paxlovid that required intensive care unit (ICU) admission. DESCRIPTION: During a 6-week period from June to July 2022, our community hospital treated 7 adult patients in the ICU for severe hyponatremia, defined as sodium (Na) less than 120 mEq/L. Of those 7, three patients did not have COVID-19. The remaining four patients had been prescribed and were taking Paxlovid for COVID-19, with Na levels upon admission ranging from 112 to 115 mEq/L. Weakness, nausea and dehydration were all common side effects upon presentation. Use of the Liverpool COVID-19 interaction checker revealed a potential weak interaction in only 1 of 4 patients that venlafaxine concentrations could potentially be increased and venlafaxine has been associated with hyponatremia. With cessation of the drug and conventional treatment measures for severe hyponatremia including hypertonic saline, the hyponatremia corrected appropriately in all four cases. DISCUSSION: COVID-19 itself has been associated with hyponatremia of unclear mechanism, however two large studies of 1099 & 5700 patients hospitalized for COVID-19 showed average Na levels of 138 & 136 mEq/L, respectively. We admitted 4 patients to the ICU in a 6-week period for severe hyponatremia while taking Paxlovid. Although the mechanism is unknown, this could be a signal that warrants further investigation. Vigilant review of concomitant medications when prescribing Paxlovid using the Liverpool interaction checker is needed.

Geospatial Factors Interact with Baseline Health to Impact Covid-19 Mortality (Community Hospital)

INTRODUCTION: Social determinants of health have been under-reported in critically ill patients during the pandemic. We hypothesized that geospatial factors and baseline health status in our community would significantly impact outcomes from Covid-19 infection. METHOD(S): We conducted an urban, single-center, observational study of patients with Covid-19 infection admitted to our adult ICU over ten months (March 23, 2020 to January 21, 2021, after approval by our hospital's Institutional Review Board. Weekly prospective data on the Covid-19 study population were entered in our ICU's quality assurance database. Data specific to test our hypothesis-zip code of residence, functional status, and Canadian Frailty Score (1-7)-were collected from retrospective chart review. The studied population was dichotomized to access patients who resided in long-term care facilities or home residence. Five zip code regions based on sample size and the distance from the patient's residence to the hospital allowed random sampling. Statistical significance was determined using ANOVA and T-test as indicated. RESULT(S): A total of 300 patients were enrolled. Across the designated cohort-based zip code regions, the mean frailty score of patients who resided at home differed significantly (2.9+/- SE.98 vs. 3.8+/- SE. 1.28, p< 0.01). Favorable frailty scores of 1-2 had a combined death and hospice rate of 23%. Of the survivors, 30% were transferred to skilled nursing facilities (SNF) and 26% were discharged to home. Patients with frailty scores of 6-7 had a final mortality rate of 83%. Of the survivors, only 2% were transferred to a SNF and 6% were discharged to home. Compared to admitting frailty scores between 1-3, a frailty score of 4 or greater (which represented 35% of all Covid ICU patients admitted from home) had a 1.8 relative risk of death (p< 0.0001). CONCLUSION(S): In our adult Covid-19 population, geospatial factors were associated with significant variances in frailty determined on ICU admission. Worsening frailty scores were associated with marked differences in both survival and final disposition, with combined death and hospice rates as high as 80%. We recommend that these metrics be added to routine data reporting to help better characterize ICU populations and stimulate efforts to improve frailty in vulnerable populations.

Babesiosis and Red Blood Cell Exchange Transfusion: Consider It Early

INTRODUCTION: Babesiosis, or Babesia microti in the blood, is a rare tickborne parasitic illness. It is endemic to the Northeast and upper Midwest regions of the United States, in warmer summer months, and is a reportable disease. Babesia is transmitted by the bite of an infected Ixodes scapularis nymph tick (black-legged or deer tick). Many people remain asymptomatic, while others experience life-threatening illness. even with low parasite index, such as the case described. Cases are rising in Pennsylvania overall since 2010, but since the start of COVID-19 pandemic, our small community hospital in rural Northeastern Pennsylvania (NEPA) has seen 12 cases. DESCRIPTION: A 63-year-old male presented with severe illness due to persistent Babesiosis parasitemia in a NEPA community hospital, with history of recent COVID-19 infection. He presented with fever, rigors, myalgias, diarrhea, and weakness. He reported history of tick bite two weeks prior to presentation. Initial exam was unremarkable. He was admitted to the hospital with hyponatremia, acute liver and kidney injury, anemia, thrombocytopenia, and elevated bilirubin. Babesia microti red blood cell (RBC) parasite index initially was 2%. He then became lethargic and hypotensive and parasite index escalated to 5% with worsening febrile illness, confusion, rapid atrial fibrillation, worsening acute kidney injury, and evidence of hemolysis and consumptive coagulopathy, despite standard-of-care antimicrobial regimen. He was fluid resuscitated and transferred to a higher level of care for urgent RBC exchange, which he obtained, and recovered after prolonged intensive care unit stay. DISCUSSION: Babesiosis can present indolently or acutely with flu-like and hemolytic illness. Those at higher risk of illness are elderly, and those with asplenia, baseline liver or kidney dysfunction, or immunocompromised status. Babesia cases are rising all over the country. Our single small hospital has seen 12 cases in the past 3 years. It is a possibility that the recent COVID-19 infection created a relative immunocompromised and pro-inflammatory state leading to susceptibility to the parasite. Illness can be life-threatening. Even with low parasitemia index, early RBC exchange should be considered if end organ dysfunction is present and clinical course is not improving.

Observational Cohort Study of Mayo Clinic Virus Registry Covid-19 Inpatients

INTRODUCTION: Several state-based and single center studies have demonstrated evidence of higher COVID-19 exposure rates, infection rates, and worse morbidity and mortality outcomes among minorities. Furthermore, challenges with vaccine access, hesitancy, distrust of the medical system further influenced who was protected from COVID-19.This study combines databases to conduct a multisite study across diverse states during the pandemic. METHOD(S): We conducted an ancillary study using the VIRUS (Viral Infection and Respiratory illness Universal Study) registry data supplemented by electronic medical record data from Mayo Clinic enterprise to assess demographics and outcomes among hospitalized patients with severe COVID-19. We included hospitalized adult patients admitted in five participating sites between April 2020 and January 2022 including academic hospitals in MN, AZ, and FL and two community hospitals in MN and WI. Selfidentified race and ethnicity data was categorized as White, Black, Asian, and Other;Hispanic and non-Hispanic. Other baseline characteristics, disease severity, and vaccination status were included in the analyses. The primary outcome was hospital mortality, the secondary outcomes were length of stay and healthcare utilization. Multivariable regression models were developed to analyze the interactions of relevant variables to predict outcomes. RESULT(S): 6904 patients were included. 3398 (57.8%) were male and 86.9% White,3.6% Black,3.3% Asian,6.2% Other. The mean age of Whites was 64.9 years v.53.8, 58, 52.8 respectively (p< 0.0005). Whites had higher Charlson comorbidity scores-5.2 v.4.0,3.6,3.0 respectively (p< 0.005). Vaccination rates were low in cohort, but higher among Whites 11.2% v.5.4%,4.6%,5.0% respectively (p< 0.0005). Mortality outcomes between different racial groups did not differ (p=0.41). Non-Hispanics were older than Hispanics- mean age 64.5 years v.53 (p< 0.005) and had higher Charlson comorbidity scores-5.2 v.3.4 (p< 0.005) Vaccination rates among non-Hispanics were 10.7 v 3.4% (p< 0.005)). Mortality outcomes between ethnic groups did not differ(p=0.86). Mortality outcomes between vaccinated and unvaccinated patients did not differ (p=0.9). CONCLUSION(S): Despite differences in risk factors between demographic groups, outcomes did not differ significantly in this cohort.

Impact of Covid-19 Pandemic: A New Approach to Global Health, Critical Care Education for the Future

INTRODUCTION: The Covid-19 pandemic affected the operations of Global Health Missions. We describe the experience of providing critical care support internationally, finding alternatives for the Pediatric Fundamental Critical Care Support (PFCCS) course to adapt to these constraints. A group of PFCCS consultants, directors, and instructors from Pediatric Life-Saving Effort (PULSE) conducted courses in New York and Nigeria. METHOD(S): A pilot PFCCS course was scheduled for December 2021 at a registered center in NYC, USA, with the "online-hosted" option for the lectures. A "hybrid" (virtual and in-person) virtual modality on Zoom for the skills stations facilitated the training of pediatric residents and nurses from 2 community hospitals: 14 participants, 2 local, and 4 remote instructors. Two "break out" rooms were assigned for a specific skills station. The audio-visual display of the remote instructor was via a monitor screen augmented with an external microphone. Webcams were connected to the computer for remote instructors to visualize the skill station as a volunteer manipulated the vital sign simulator. We used the "side by side: speaker" option in the "view" feature to display the remote instructor simultaneously. Remote instructors used a chat application to advise changes on the digital monitors while following a scripted scenario. Local instructors acted as facilitators. This course was replicated in Nigeria to support a project spearheaded by Health Place for Children Initiative to establish the first PICU at The University of Nigeria Teaching Hospital. n candidates became PFCCS certified. Feedback from course experiences was gathered by email and standardized surveys. RESULT(S): Remote instructors in Italy, Mexico, and Texas effectively engaged virtually to conduct the skills stations. Their experience was similar to their vast experience conducting live skills stations. There was positive feedback about the quality of the skill stations. Their experience was similar to other scenarios of crisis resource management conducted regularly at TBHC. CONCLUSION(S): The pandemic significantly reduced PULSE's activity in international educational missions. The "hybrid" model of PFCCS courses can reduce the logistical and financial burden of international courses.

Impact of the COVID-19 Pandemic on Healthcare-Associated Infections (HAI) by Race and Ethnicity in a Large Network of Community Hospitals: A Call to Action

Background. Inequities in healthcare among racial and ethnic minorities are globally recognized. The focus has centered on access to healthcare, equitable treatment, and optimizing outcomes. However, there has been relatively little investigation into potential racial and ethnic disparities in HAI. Methods. We performed a retrospective cohort analysis of select HAI prospectively-collected by a network of community hospitals in the southeastern US, including central line-associated bloodstream infection (CLABSI), catheterassociated urinary tract infection (CAUTI), and laboratory-identified Clostridioides difficile infection (CDI). Outcomes were stratified by race/ethnicity as captured in the electronic medical record. We defined the pre-pandemic period from 1/1/2019 to 2/29/2020 and the pandemic period from 3/1/2020 to 6/30/2021. Outcomes were reported by race/ethnicity as a proportion of the total events. Relative rates were compared using Poisson regression. Results. Overall, relatively few facilities consistently collect race/ethnicity information in surveillance databases within this hospital network (< 40%). Among 21 reporting hospitals, a greater proportion of CLABSI occurred in Black patients relative toWhite patients in both study periods (pre-pandemic, 49% vs 38%;during pandemic, 47% vs 31%;respectively, Figure 1a), while a higher proportion of CAUTI and CDI occurred in White patients (Figures 1b-c). Black patients had a 30% higher likelihood of CLABSI than White patients in the pre-COVID period (RR, 1.30;95% CI, 0.83-2.05), which was not statistically significant (Table 1). However, this risk significantly increased to 51% after the start of the pandemic (RR, 1.51;95% CI, 1.02-2.24). Similar trends were not observed in other HAI (Tables 2-3). Conclusion. We found differences in HAI rates by race/ethnicity in a network of community hospitals. Black patients had higher likelihood of CLABSI, and this likelihood increased during the pandemic. Patient safety events, including HAI, may differ across racial and ethnic groups and negatively impact health outcomes. (Figure Presented).

Reduction in Health Care Facility Onset Catheter-Associated Urinary Tract Infections: A Resident-Led Quality Improvement Initiative

Background. Hospital-acquired catheter-associated urinary tract infection (CAUTI) was estimated to cause 19,700 cases in 2020 across the United States per the Centers for Disease Control and Prevention (CDC). While this is a 25% decrease in reported incidence rates since 2015, ad-hoc changes in care practices and limitations of surveillance definitions brought on by the giant burden of COVID-19 on the healthcare system possibly resulted in underreporting of CAUTIs. In a 290-bed tertiary, community hospital in the Detroit metropolitan area, there was a 200% increase CAUTIs from 2020 (5 CAUTIs) to 2021(16 CAUTIs). A multidisciplinary, resident-led team was assembled to reduce hospital-acquired CAUTIs. Methods. A multi-pronged quality improvement initiative was conducted from January 1, 2021, through March 31, 2022. CAUTIs were identified and reviewed via electronic health records using predefined criteria related to CDC surveillance definitions, urinary catheter insertion indications, laboratory data, and antibiotic use. Plan-Do-Study-Act (PDSA) Cycle model was used to guide the initiative. Thus far one PDSA cycle has been completed. The initial intervention bundle was designed by the multidisciplinary team and led by internal medicine and transitional year residents. The intervention bundle included 1. Provider (including physician and RN) education, 2. Design and implementation of an appropriate urinary catheter practice algorithm, and 3. Expert review of positive urine cultures and CAUTI cases. Results. Baseline data collected from January to December 2021 showed 16 CAUTIs. Post-implementation of the intervention bundle from January to March 2022 resulted in a 75% reduction in CAUTI incidence (1 CAUTI flagged). Conclusion. A targeted intervention bundle improved CAUTI incidence by reducing inappropriate urinary catheter insertion and prolonged removal. Ongoing local initiatives focused on hospital-acquired infections, such as this one, are paramount to the persistent optimization of infection prevention despite national trends.

Understanding the Impact of COVID-19 Pandemic on Central Line-Associated Bloodstream Infections (CLABSIs): Expanding Analysis to the Microbiologic Level

Background. Increases in central line-associated bloodstream infection (CLABSI) rates have been reported in association with the COVID-19 pandemic, particularly among Candida species and coagulase-negative Staphylococcal species (CoNS). We sought to further validate the impact of the COVID-19 pandemic on CLABSI trends and perform a microbiologic analysis. Methods. This is an IRB-approved retrospective analysis of CLABSIs across a network of 38 community hospitals in southeastern United States. CLABSI rates were compared between pre-pandemic (1/1/2018-3/30/2020) and pandemic periods (4/1/2020-12/31/2021). Regression models were developed to evaluate CLABSI incidence over time. Likelihood ratio tests were used to compare models that were exclusively time-dependent to segmented regression models that also accounted for the COVID-19 pandemic. Results. A total of 1,167 CLABSIs over 1,345,062 central line days were analyzed (Table 1). The mean monthly CLABSI rate per hospital increased from 0.63 to 1.01 per 1,000 central line days (p< 0.001) in the pandemic period (Table 1). CLABSIs secondary to Candida (0.16 to 0.33, p< 0.001), CoNS (0.09 to 0.22, p< 0.001), and Enterococcal species (0.06 to 0.18, p=0.001) increased, while Escherichia coli CLABSIs decreased (0.04 to 0.01, p< 0.001). Upon regression modeling, the COVID-19 pandemic was associated with increases in monthly CLABSI rates by Candida and Enterococcus species (Figure 1). In contrast, the changes in CoNS and Escherichia coli CLABSI rates were better explained by exclusively timedependent models (Figure 1;Table 2). Non-sustained changes in Staphylococcus aureus and Klebsiella pneumoniae CLABSI rates were also noted (Table 2). Gray areas denote COVID-19 pandemic period. Statistically significant level changes in CLABSI rates were observed among Candida and Enterococcus spp. (RR=1.92, CI 1.16-3.20 and 2.42, CI 1.09-5.38). Staphylococcus aureus CLABSI rates had a non-sustained but significant increase at the onset of COVID-19 (RR 2.20, CI 1.16-4.20). CoNS and E. coli rate changes occurred independent of COVID-19 (see Table 2). Conclusion. The COVID-19 pandemic was associated with substantial increases in CLABSIs, driven in part by Candida and Enterococcus species across this network of hospitals. However, the observed increase in CoNS CLABSIs and decrease in Escherichia coli CLABSIs appear to have occurred independently of COVID-19, which only became apparent upon regression analysis. Interpretation of pre-post statistics without assessment of pre-existing trends should be done cautiously. Additional analyses may help elucidate other factors influencing these CLABSI trends by organism.