Barriers to the Maintenance of COVID 19 Cross Infection Control Protocols among Medical and Dental Practitioners

Objective: To determine the barriers to the maintenance of COVID 19 cross infection control protocols among medical and dental practitioners Methodology: A cross sectional study was conducted in College of Dentistry, Sharif Medical and Dental College, Lahore from July 2021 to July 2022 on medical and dental practitioners. The sampling technique employed was convenient sampling. Medical and dental practitioners irrespective of their age, gender and specialty of practice were included in the study. Data was collected using a pre-validated questionnaire with a Cronbach alpha value of 0.7. Result(s): There was s statistically significant difference in the scores of barriers to maintenance of COVID 19 cross infection control protocols of overcrowding in the hospital (p= <=0.001), limitation of infection control material (p=<=0.001), insufficient training in infection control (p=0.05), lack of handwashing (p=0.022), not wearing a mask while examining the patient (p=<=0.001) and lack of knowledge about mode of transmission of COVID 19 (P=0.036) Conclusion(s): The barriers faced to maintenance of cross infection control protocols pertaining to the hospital administration were reported to be higher for medical practitioners in comparison to the dental practitioners. The barriers faced to maintenance of cross infection control protocols pertaining to the attitude and practices of health care workers were also higher for medical practitioners in comparison to the dental practitioners. Copyright © 2022 Lahore Medical And Dental College. All rights reserved.

Risk factors for mucormycosis in covid-19 patients

Opportunistic infections, such as mucormycosis, in coronavirus disease 2019 (COVID-19) patients has become a new health challenge. Since opportunistic infections can exacerbate COVID-19 patients' status, it is vital to identify the risk factors to prevent, diagnose, and treat them as soon as possible. Viral, fungal, environmental, and host factors may be responsible for this situation. Long hospital stays, impaired host immune system function due to viral infection, and excessive consumption of glucocorticoids in managing COVID-19 patients are the main risk factors for the increased risk of mucormycosis in COVID-19 patients. Educating health care workers and considering the association between mucormycosis of the paranasal sinuses and different strains of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as the cause of COVID-19 can help prevent invasive fungal sinusitis in COVID-19 patients. Copyright © 2021, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

Outcomes comparison of hospitalized patients with COVID-19 during the first three pandemic waves. Experience in Colombia, South America

Background. Differences in access to specialized medical care services and their overcrowding due to the pandemic could impact clinical outcomes. Availability of newer treatments, vaccination, and emergence of newer SARS-CoV-2 variants could also explain these differences. Methods. We performed a single-centered, observational study comparing clinical outcomes of COVID-19 admitted to the emergency department among the first three waves of the pandemic defined as June to August 2020, November 2020 to January 2021, and May to July 2021, respectively. The primary outcomes included intensive care unit admission, invasive mechanical ventilation requirement, hospital length of stay, and hospital mortality categorized by age groups. Effective COVID 19 antiviral therapy and monoclonal antibodies are not available in Colombia. Vaccination was available after March 2021. Results. Out of a total of 2264 patients were admitted. Fifty-six percent were male, with a median age of 58 years [IQR, 45-70]. A significant increase of patients was seen after each wave: 530 in the first, 568 in the second, and 1166 in the third-wave worsening hospital overcrowding. Patients from the third wave were significantly younger (59 vs. 62 vs. 56 years, p < 0.01). Patients from the first wave had higher proportion of intensive care unit admission (62.83% vs. 51.23% vs. 52.23%, p< 0.01), invasive mechanical ventilation (39.25% vs. 32.22% vs. 31.22%, p< 0.01), and length of hospital stay (9 vs 7 vs 7 days, p< 0.01). Overall, no difference was found inmortalityamong waves (18.4%vs 19% 18.8%, p = 0.974). However, patients of 70-79 and >= 80 had a lower mortality during the third wave (24.4% vs 33.3% vs 19%, p=0.018), (30.6% vs 29.6% vs 23.6%, p=0.018). Vaccination was very low in all the age groups but was higher in elderly patients. Conclusion. Overall mortality did not increase between infection waves, although there was an increase in cases during the third wave. We found a significant decrease in mortality among the elderly. Major efforts of medical teams succeed in containing COVID 19 mortality.

A Case-Control Study Investigating Household, Community, and Clinical Risk Factors Associated with Multisystem Inflammatory Syndrome in Children (MIS-C) after SARS-CoV-2 Infection

Background. Risk factors for MIS-C, a rare but serious hyperinflammatory syndrome associated with SARS-CoV-2 infection, remain unclear. We evaluated household, clinical, and environmental risk factors potentially associated with MIS-C. Methods. This investigation included MIS-C cases hospitalized in 14 US pediatric hospitals in 2021. Outpatient controls were frequency-matched to case-patients by age group and site and had a positive SARS-CoV-2 viral test within 3 months of the admission of their matched MIS-C case (Figure 1). We conducted telephone surveys with caregivers and evaluated potential risk factors using mixed effects multivariable logistic regression, including site as a random effect. We queried regarding exposures within the month before hospitalization for MIS-C cases or the month after a positive COVID-19 test for controls. Enrollment scheme for MIS-C case-patients and SARS-CoV-2-positive outpatient controls. MIS-C case-patients were identified through hospital electronic medical records, while two outpatient controls per case were identified through registries of outpatient SARS-CoV-2 testing logs at facilities affiliated with that medical center. Caregivers of outpatient controls were interviewed at least four weeks after their positive test to ensure they did not develop MIS-C after their infection. Results. We compared 275 MIS-C case-patients with 494 outpatient SARS-CoV-2-positive controls. Race, ethnicity and social vulnerability indices were similar. MIS-C was more likely among persons who resided in households with >1 resident per room (aOR=1.6, 95% CI: 1.1-2.2), attended a large (>=10 people) event with little to no mask-wearing (aOR=2.2, 95% CI: 1.4-3.5), used public transportation (aOR=1.6, 95% CI: 1.2-2.1), attended school >2 days per week with little to no mask wearing (aOR=2.1, 95% CI: 1.0-4.4), or had a household member test positive for COVID-19 (aOR=2.1, 95% CI: 1.3-3.3). MIS-C was less likely among children with comorbidities (aOR=0.5, 95% CI: 0.3-0.9) and in those who had >1 positive SARS-CoV-2 test at least 1 month apart (aOR=0.4, 95% CI: 0.2-0.6). MIS-C was not associated with a medical history of recurrent infections or family history of underlying rheumatologic disease. Conclusion. Household crowding, limited masking at large indoor events or schools and use of public transportation were associated with increased likelihood of developing MIS-C after SARS-CoV-2 infection. In contrast, decreased likelihood of MIS-C was associated with having >1 SARS-CoV-2 positive test separated by at least a month. Our data suggest that additional studies are needed to determine if viral load, and/or recurrent infections in the month prior to MIS-C contribute to MIS-C risk. Medical and family history were not associated with MIS-C in our analysis.

Effects of Process Changes on Emergency Department Crowding in a Changing World: An Interrupted Time-Series Analysis

Objectives: Crowding at the emergency department (ED) is a problem in many countries. Crowding research often fails to consider external influences. In this study, we aimed to evaluate the effects of various process changes on ED crowding while taking into account changing external circumstances, such as the Covid-19 pandemic and centralization of acute care. Method(s): During a six-year period, we assessed the effects of several interventions to improve patient flow, using an interrupted time-series approach. Main outcome measures were crowding measured with the National ED Overcrowding Score, length of stay (LOS) and number of exit blocks. We determined time points of the various interventions and external circumstances and built an interrupted time-series model per outcome measure. We analysed changes in level and trend before and after the selected time points using linear regression, with baseline slope variables included to control for secular trend. Result(s): Crowding decreased when medical staffing increased during peak hours, and when next-day appointments at the ED were shifted to the policlinics. However, the closure of a neighbouring ED and further expansion of beds at the remaining ED coincided with increased crowding. During the Covid-19 surge, LOS increased but we observed no changes in crowding and number of exit blocks. Some of the interventions showed paradoxical effects, such as increased crowding after installing a psychiatric team during peak hours, but decreased LOS and number of exit blocks. Conclusion(s): Our findings reflect the importance of progressive interventions in response to changing external circumstances, in the ongoing battle against ED crowding. Timely feedback on new interventions is vital to increase the success and sustainability of projects, and long-term effects corrected for changing circumstances are pivotal to decide which interventions to prioritize. Our results show that it is possible to improve ED processes, even during changing conditions in challenging times. Copyright © 2022

The Waiting Game: Emergency Department Boarding and Its Financial Costs for Patients, Hospitals, and Clinicians

Background: Emergency departments (EDs) have experienced increased patient boarding even before the pandemic which has led to significant challenges for both patients and clinicians. The COVID pandemic has only exacerbated ED crowding despite reduced ED volumes nationally. ED boarding has been erroneously attributed to inefficient ED practices but is often largely the result of hospital and systemic inefficiencies. While ED boarding is not solely an ED problem, the financial impact of boarding on the ED can be significant and the cost of ED crowding is often largely borne by already overburdened EDs. Study Objectives: There were two primary objectives;1) To quantify the number of ED beds occupied by inpatient boarding patients, 2) To estimate the financial impact of boarding on the ED in a large, academic, safety-net hospital. Method(s): A retrospective, cohort review of all ED encounters from July 1, 2020, through June 30, 2021, were identified at our large, academic, safety-net trauma center. Performance metrics were retrieved from a novel, interactive, digital data dashboard at the Zuckerberg San Francisco General Hospital (ZSFGH) including average Length of Stay (LOS) and Total Boarding Minutes. Boarding was defined as time spent occupying an ED bed beyond 120 minutes after the admit disposition was determined as defined by the Agency for Healthcare Research and Quality (AHRQ). An estimate of total missed encounters due to ED boarding time was made and total potential charges and revenue were then estimated using an institutional average of estimated charges as well as average realized reimbursement rate. Result(s): There were a total of 54,612 encounters, of which 50,980 (93.3%) were included and 3,632 (6.7%) were excluded due to alternative dispositions, such as Absent Without Leave (AWOL), Left Without Being Seen (LWBS), Left Without Being Triaged (LWBT) and Nursing Referrals (RN Referrals). Included were 11,850 (23.2%) admissions and 39,130 (76.8%) discharges and transfers. Total annual boarders were 7,410 (62.5%) with a total of 3,782,670 boarding minutes. The mean LOS for our ED patients during this period was 395 minutes (753 for admissions and 288 for discharges and transfers) resulting in an estimate of potential missed encounters of 9,576. The institutional average charge for all-comers to the ED is $780. At 9,576 missed encounters, an estimate for potential lost charges was $7.47M and at an average reimbursement rate of 23%, potential revenue loss of $1.72M [Figure 1]. During the pre-pandemic period with available data (August 1, 2019 - February 29, 2020) when boarding and nurse staffing were not as limited, the daily census was 184.1 patients, excluding LWBS, LWBT, and RN Referrals. During the pandemic period with significant ED boarding and nursing staffing shortages, the daily census was 149.6. Including the potential daily missed encounters of 26.2 would result in a total potential daily census of 175.8. Thus, we assume there would be sufficient patient volume and demand to occupy all available ED beds if boarding were eliminated. Conclusion(s): ED boarding is due to systemic health care system failures but results in significant lost ED revenue further straining already over-burdened EDs. Improving hospital patient flow can improve ED patient flow and revenues both during and after the COVID pandemic. [Formula presented] Yes, authors have interests to disclose Disclosure: FujiFilm-SonoSite Consultant/Advisor FujiFilm-SonoSite Disclosure: Inflammatix Consultant/Advisor Inflammatix Copyright © 2022

Addressing Workplace Violence: Health Care Staff Safety, a Culture of Caring

Background: Workplace violence (WPV) in health care is an important public health issue and a growing concern in the ED. According to the 2018 Bureau of Labor Statistics, health care and social service industries workers experience the highest rates of injuries caused by WPV;5 times as likely to suffer a WPV injury as compared to the all-worker incidence rate of 2.1, creating harm and work-related stress and burnout. According to American Nurses Association, "A health care culture that considers workplace violence as part of the job" is the number one barrier to reporting WPV. Objective(s): Define WPV, create a multidisciplinary team, increase awareness, formalize reporting process, improve database, and track actionable trends. Method(s): Study data was ed retrospectively from 1/2019-12/2021 at an 80K visits ED, 750 bed quaternary hospital;the following variables: unit/department, persons involved (employees, patients, visitors), nature of violence, and time of day. Descriptive statistics and Wilcoxon rank sum test were used. Our Health system and committee adopted the OSHA definition of WPV: any act or threat of physical violence, harassment, intimidation, verbal abuse, or other threatening disruptive behavior that occurs at work. The multidisciplinary team includes Physicians, Nursing, Security, Quality Management, Human Resources, Safety, Patient and Family Centered Care, Patient Care Services, Case Management and Social Work, as well as close collaboration with the System Workforce Safety team. Increased WPV incident reporting was encouraged by embracing a culture of transparency. WPV events were reported to Security, Quality Management, and HR, and collected in an internal database. Data collection processes were improved and drilled down on indicators that could impact the ED specifically. Result(s): From 1/2019-12/2021, there were a total of 445 WPV incidents, 85 in the ED (19%) (graph ED incidents/quarter and year). The median number of ED WPV incidents from 2019, 2020, and 2021 was significantly different across the 3 years (the Wilcoxon rank sum test p-value= 0.0317). The rate of ED WPV incidents per 1000 ED visits was: 2019, 0.13;2020, 0.27;2021, 0.76;ED volume 84,889, 66,652, and 74,121, respectively. In 2021, 243 WPV incidents reported at the hospital level, and 56 ED incidents (23%), greater than any other location in the hospital. Of the ED WPV incidents in 2021: 78.6% occurred between patients and employees, 19.6% between visitors and employees, and 1.8% between an unknown person and an employee. The nature of violence of ED WPV incidents as follows: 21.4% physical abuse, 25% physical abuse with injury, 30.4% harassment, 17.9% verbal abuse/threats/harassment, and 5.4% sexual harassment. Most WPV incidents occurred between 2am - 4am and 3pm - 11pm. Conclusion(s): There was a significant increase of ED WPV incidents reported from 2019 to 2021. We concluded this increase was a result of a combination of factors related to data collection, emphasis on reporting, and factors related to crowding, restrictive visitation policies due to Covid-19, and patient factors. The ED was identified as having a disproportionate number of WPV incidents leading to the decision to place security posts 24/7. The ED WPV committee has also developed a formal debrief process for instances of WPV as well as "Proactive Rounding" with a combination of security and clinical teams. [Formula presented] No, authors do not have interests to disclose Copyright © 2022

Emergency Department Virtual Telehealth Rounding - A Strategy for a Pandemic and Beyond

Objective: Telehealth in the ED seems counterintuitive. However, COVID-19 surges have led to crowding and increases in patients leaving without being seen (LWBS). This study evaluated the impact of a novel virtual telehealth initiative (virtual telehealth rounding or VTR) in the ED on the prevalence of LWBS dispositions during the pandemic and its effect on mortality and patient safety. Method(s): We conducted a cross sectional study on adult patients presenting to a level 1 trauma and tertiary referral center who were triaged to the waiting room. The trial of VTR took place for 107 days in December 2021-April 2022 and was operational for 65 days (8-hours a day). The remaining 42 days without VTR served as a comparison group. During VTR patients were triaged per usual care on arrival to the ED. Those patients with triage acuity categories II to V who were triaged to the waiting room were then evaluated virtually by a remote clinician (advanced practice providers such as physician assistants, advanced nurse practitioners, and third year emergency medicine residents) after their initial screening examination using a secure virtual health platform in a private cubicle in the ED waiting room. Patients were then reevaluated at 1-2 hour intervals if necessary. ED paramedics were available onsite to take vital signs, transport patients, and communicate directly with the onsite nurses and ED physicians. Patients were evaluated virtually via an iPad by the virtual clinician and provided an initial assessment. They expedited care by ordering labs, radiography, changing the patient's triage category and determining early disposition according to usual clinical practice. Patients were then either left to wait in the waiting room, taken for radiography and/or blood work, or taken back to a room in the ED where they were seen by an onsite ED physician. The main outcome was the LWBS rate, including LWBS before and after triage, patients leaving against medical advice and elopements. Secondary patient outcomes included in-hospital mortality and improved patient safety via "great saves" defined as care that was urgently/emergently escalated by the virtual rounding provider. Result(s): There were 19,958 patients in the analysis, 6,953 (35%) were evaluated via VTR and 13,006 (65%) received standard of care. Mean patient age was 50 years (SD20), 48 (95% CI 48-49) in the VTR group and 50 (95% CI 50-51) in the standard group. Females were 49%, with 3,489 (50%) females in the VTR group and 6,204 (48%) in the standard care group. Overall acuity levels at triage were II 24%, III 54%, IV 22%, and V 1%. Mean triage levels were 2.95 (95% CI 2.94-2.97) in the VTR group and 3.07 (95% CI 3.06 - 3.09) in the standard group. The proportion of LWBS was 565 (8%) in the VTR group and 3,246 (25%) in the standard care group (p<0.001). Overall, 27 (0.1%) of patients did not survive to hospital discharge, 7 (0.1%) in the VTR group and 20 (0.2%) in the standard care group (p=0.421). VTR clinician documented "great saves" in 5% of their patient encounters. Conclusion(s): This novel approach to triage in the ED significantly reduced the proportion of patients with LWBS dispositions by 17%. Although in-hospital mortality was lower in the VTR group it was not statistically significant. Furthermore, VTR clinicians documented rapid escalations in care that may have otherwise been delayed or missed. This approach has the potential to improve patient care and provide relief from crowding. No, authors do not have interests to disclose Copyright © 2022

Major Cancer Surgery during Covid- 19 Pandemic - Experience of Central India

World faced a biggest challenge on health care system during Covid-19 pandemic and has become the focus of attention worldwide. The challenge faced by surgeon treating cancer patient is different, because most of the cancer surgeries are elective but cannot be delayed beyond a period of time due to biology of cancer and adverse effect on survival. A prospective database of elective cancer surgeries was analyzed from May 3rd 2020 to august 30th 2021 by group of surgeons in Jabalpur Madhya Pradesh. In symptomatic patient RT PCR testing was advised and HRCT chest was performed. During the study period 350 elective major cancer surgeries was performed. Median age of our cohort was 53 years and 52.5% patients were male. Head neck surgeries constituted 41.6 % followed by breast 22%, Gynae-oncology (10.2%) and gastrointestinal (10 %). In 8 patients the RT PCR test was positive. Additional 12 patients were advised quarantine in view of clinical suspicion even with a negative RTPCR report. None of the patients undergoing surgery had clinical suspicion for COVID-19 infection. 43% patients were having associated comorbid illness among them 11.7% of the patients were ASA class-3. There was no postoperative mortality in our cohort across all cancer sub sites. Our lower rate of complication and zero mortality over 8 weeks not only reflect our case selection policy, screening strategies, adopting best surgical practices, judicious use of personal protective equipment(PPE), best operating team members and using the basic protocol by using a triple layer/ N-95 mask with physical distancing and avoid overcrowding. Relevant clinical history and examination about COVID infection was the most critical factor before proceeding to surgery during pandemic. RT PCR should be done only in selective patients. Our result possibly represented the largest published series of central India on cancer surgery during COVID pandemic. Copyright © 2022 Necati Ozpinar

The epidemiological situation in Ukraine in terms of the implementation of preventive vaccinations according to the Protective Vaccination Program

The level of immunization of children and adolescents under the Protective Vaccination Program in Ukraine is lower than in Poland, and, due to the outbreak of the war in Ukraine, many people now live in conditions that are often unsanitary. Centers for refugees are also places of increased risk of outbreaks of infectious diseases. This risk is increased by the low percentage of the vaccinated, limited access to healthcare (including diagnostics) and overcrowding. The paper presents the state of vaccination in Ukraine against poliomyelitis, measles, diphtheria, tetanus and pertussis, the most important problems in the field of infectious diseases, as well as the resulting risks and the need to prevent them.

An Outbreak of Covid 19 Infection at the Massey Street Children's Hospital, Lagosisland, Nigeria

Aims 1) To review the admissions into the emergency unit of children with pneumonia and other uncommon presentation of Covid from October2020 to January 2021 2) To highlight leadership role in managing a hospital Outbreak Conclusion There was a high number of admission of pneumonia cases into the emergency unit in December 2020 and some children with uncommon symptoms of Covid. The testing rate in children was almost zero. The belief was, these contributed significantly to the source of outbreak in the hospital as Lagos state is also the epicenter of the disease. With more than 60% of the workforce testing positive to the virus, the morale of staffs was low, mortality worsened during this period as there were fewer staff available to work. Leadership instituted alternate day shifts for staffs, and resolved to strengthen the adherence to Covid protocols by providing more PPEs, continued to train and retrain staff in management of Covid infection and IPC. No crowding allowed in call rooms, lounge and library, restriction of visitors to the hospital and regular cleaning of surfaces. Virtual meetings replaced physical meetings. Staffs who tested positive but not needing admission received a home based treatment pack for free and self-isolated at home for 14days. 3 staffs were admitted in the central isolation unit in the state. Thankfully, no death was recorded among the staff and by March the infection had reduced drastically. The staffs' mental health issues were addressed, there were zoom sessions with mental health experts. Today, we have a workforce that is fully vaccinated against Covid 19 (received booster dose).

Health Rights of Prisoners and Prison Law Reforms during COVID-19 Pandemic in India

Background: The National Crime Record Bureau and the Prison Statistics India, 2020 report on the overcrowding and occupancy in jails has ripple effect on the spread of the COVID-19.The protection to health freedoms of detainees and prisoners reflected in the World Health Organization (WHO) Guidance on COVID-19 for Prisons and Detention, 2020. The Indian jails have congestion and inhabitance and prone to contagion disease. The COVID-19 has an expanding transmission among detainees in prisons, jails and detention homes. Objectives: The WHO Guidance on COVID-19 for Prisons and Detention, 2020 standardizes the essential instrument to manage the COVID-19 difficulties in penitentiaries and confinement homes. The direction secures the strength of detainees and convicts living in encased conditions. The ostensible purpose is to contain the COVID-19 disease from spreading to general population and release the under trials for the safe healthy conditions. Methodology: The methodology applied the canons of statutory interpretation of United Nations Principles of the Protection of Prisoners, 1982 and Basic Principles for the Treatment of Prisoners, 1990 alongside the Moscow Declaration on Prisons and Health, 2003 and Nelson Mandela Rules, 2015 in fostering the health equity and criminal justice during COVID-19 pandemic. The mandate of the WHO Interim Guidance on COVID-19 in Prisons and Other Places of Detention, 2020 is straight out in preventive and medicinal measures for the penitentiaries and confinement homes in the virus of COVID-19. Results: The paper tracks the salubrious results of the international legal norms and national precedents of High Courts and Supreme Court in heralding systemic prison reform. The compliance of WHO Interim Guidance on Preparedness, Prevention and Control of COVID-19 In Prisons and Other Places of Detention, 2020 cultivated robust criminal administration during COVID-19 pandemic and the lockdown in India.Conclusion: The judgment of High Courts and Supreme Court on prison reform during the COVID-19 pandemic in India has resulted in Health Rights of Prisoners and Prison Law Reforms during COVID-19 Pandemic in India. It also refurbished the medical services in correctional facilities and confinement homes in criminal justice system.

Challenges of implementing nonpharmaceutical- interventions to prevent COVID- 19 in an urban-slum in Lagos-Nigeria

Introduction/ Background: Non-pharmaceutical interventions are important public health measures targeted at behavioral changes to interrupt the transmission of coronavirus in humans. This study evaluated the challenges of implementing non-pharmaceuticalinterventions, assessed adherence, and identified requirements to the successful control of the spread of COVID-19 among individuals living in an urban-slum setting in Lagos-Nigeria. Methods: A cross-sectional study conducted among resident of an urban-slum in Makoko, Lagos-Nigeria. Adult members of households aged 18 years and above were selected via convenient sampling. An interviewer administered semi-structured questionnaire was used to obtain information on sociodemographic characteristics, living conditions and adherence to non-pharmaceutical interventions over a period of five-months from May to September 2020. Adherence to nonpharmaceutical intervention was determined by calculating an adherence index from 10 evidence based protective behaviors and a self-report of adhering to the measures. Descriptive-statistics and multiple-logistics regression model were used to determine challenges and factors associated with adherence to COVID-19 preventive measures. Results: A total of 357 participants with a mean-age of 45.8 ± 12.9 years were included in the analysis. Majority were males (62.2%) and married (83.8%). Most participants (93.8%) had no space for selfisolation as majority lived in a one-roomapartment (72.8%), shared toilets/kitchen-space (63.6%) with other families and had no constant source of water-supply (61.9%). About 98.8% are aware of the pandemic but only 33.9% adhered to the preventive-measures. The ability to afford facemasks/hand-sanitizers (aOR:6.7;95% CI:3.8-11.6), living-alone (aOR:3.7;95%CI:1.3-10.6), and ability to buy-water (aOR:0.3;95% CI:0.1-0.5) were found to be associated with adherence to the preventivemeasures after adjusting for covariates in a multilogistic- regression-model. Impact: This study gives insight on the realities/challenges of implementing non-pharmaceutical-intervention against COVID-19 disease in a setting of economically disadvantaged individuals who are at a great risk of being a hub for circulating the virus. This will aid the government in addressing cogent factors that might fuel re-occurrence of the pandemic waves. Conclusion: Implementation of non-pharmaceutical interventions for COVID-19 prevention was a challenge as only a quarter of residents adhered to national guidelines. Government should prioritize vaccinating these cohort of individuals and address factors like poor housing, overcrowding and lack of public water supply that affects adherence to public health measures in this setting.

Investigation of a Cluster of COVID-19 among Factory X Workers, Buikwe District, Uganda, 2020

Introduction/ Background: In September 2020, a cluster of SARS-COV-2 infections was reported among workers at a factory in Uganda. The factory had already introduced COVID-19 risk reduction measures for all employees, including face mask use. We investigated the cluster to determine exposures associated with transmission and inform evidence-based control measures. Methods: We defined a case as positive RT-PCR test for SARSCOV- 2 in a Factory X worker during August- September 2020. We conducted a case-control study using a randomly selected subset of case patients. A control was a Factory X worker with a negative RTPCR test for COVID-19 during August-September 2020, selected randomly from Factory X departments with cases. Case-patients and controls were interviewed using a standardized questionnaire, asked about possible exposures. We analysed data using logistic regression to obtain an adjusted odds ratio (AOR) with confidence interval (CI). We interviewed facility staff on preventive measures and conducted an observational assessment for ventilation and crowding. Results: Among 163 case-patients (factory attack rate=11%), none died. The index case-patient was a 27-year-old employee with infection confirmation on August 10. In the case-control study with 75 cases and 75 controls, lack of self-reported mask use (AOR=14, 95% CI 2.4-76), and working in the engineering (AOR=5.9, 95% CI 2.3-16) or old garments (AOR=2.4. 95% CI 1.1- 5.5) departments were associated with infection. Engineering and old garments departments lacked windows, while other departments all had open windows. We observed workers on production lines spaced closely together. Impact: Based on the findings, Integration of tracking mechanisms for local infections at workplaces and enhanced focus on preventive measures, including periodic worker monitoring to ensure adherence to preventive measures, may be warranted during higher-risk times to prevent such outbreaks in the future. Conclusion: This SARS-COV-2 cluster was associated with inadequate mask use and poor ventilation, likely exacerbated by congestion. We recommended enforcement of factory risk reduction measures including mask use, increased spacing on production lines and provision of adequate windows and doors in all departments.

Redesigning emergency department for a safer surge capacity during COVID-19 pandemic

Background and objectives: The COVID-19 pandemic has proved itself to be the greatest global health disaster and overwhelm any healthcare system. Hence, it is paramount that we consider our approach in the management and distribution of resources in light of this pandemic. The aim of this project was to draw up a modified surge capacity plan, to facilitate patient's admission, and ensure safety of patients and healthcare workers. In view of that, a Surge Capacity Preparedness and Response Plan For COVID Pandemic Emergency Department Hospital Selayang was implemented due to an increase in patients' volumes and access block. All patients shall be triaged according to severity based on Malaysian Triage Category and the probability of COVID infection based on recent Case Definition of Clinical Criteria and Epidemiological by Ministry of Health, Malaysia. Methods: A Quality Improvement Project was conducted in the Emergency and Trauma Department, Hospital Selayang (ETDHS). Using a driver diagram, we were able to focus on the multiple key areas that includes reducing non-emergency visits, expanding and utilizing all available space, proper clean and dirty zoning system, and improving the work flow employed in facilitating patients' review, treatment, and admission. Results: The emergency department (ED) overall admission volume increased by 50% compared to before the pandemic. New zoning system showed there was increase in critical zone patients and reduction in total number of patients in non-critical zones (MDSU/fever center/COVID tent/green zone) from 78% to 76% with proper triaging and workflow system. Before the implementation of the new zoning system, there were eight confirmed COVID-19 cases with majority (87.5%, n=7) who were initially triaged to "clean" zones and caused cross-contamination. However, after the implementation of the new system, it was found that all the patients who were tested positive for COVID-19 (100%, n=6) were successfully isolated during the initial triage stage to the respective respiratory/"dirty" zones. Conclusion: The implementation of new zoning system in the ED during COVID-19-associated patient surge successfully improved patient flow, reduced over-crowding and non-emergency visits, decreased cross-contamination, increased the awareness and knowledge, and subsequently prevented transmission of COVID-19 among healthcare staffs.

Collaborative Care in Acute Settings: An Integrated Approach to Psychiatric Care within an Academic Emergency Department

Background/Significance: Nationwide, the number of hospital emergency department (ED) visits has steadily increased over the past decade;since 2009, ED volumes have increased over 11%.1 The proportion of ED visits primarily involving psychiatric concerns (including substance use) has also been on the rise, from 6.6% of all visits in 2007 to 10.9% of all visits in 2016.2 A recent retrospective analysis of ED visit data from the National Emergency Department Sample examining the years 2010 through 2014 identified mental health concerns (including substance use) as the second-most frequent ED presentation, with abdominal pain ranking as the most frequent.3 Challenges to caring for patients with prominent psychiatric concerns in EDs include: prolonged lengths of stay (LOS),4 boarding and overcrowding,5 increased restraint use,6 financial sequelae,7 and safety implications for patients and staff.5 Many EDs have limited access to psychiatric expertise. Unique features of our innovative ED-based Psychiatry service line include: 1) joint administration by academic departments of Emergency Medicine and Psychiatry, and 2) concurrent, rather than consecutive, evaluations conducted by Emergency Medicine physicians and Psychiatrists for optimal efficiency and collaboration. Methods: The ED Psychiatry Program at Froedtert Hospital was implemented in 2019 to improve patient care, systems-based processes, and cross-specialty education. IRB approval was granted on 4/7/2020 to review data collected on all patients seen in the ED by the new ED Psychiatry service and compare metrics with primary psychiatric patients seen in the ED prior to program implementation. Patient care metrics from the first 12 months has been analyzed;cases in which the ED psychiatrist was involved total 382 (data from 5 patients seen during this period could not be reviewed due to erroneous recording of identifying information). 754 charts were reviewed in total—377 post-implementation (9/1/2019-8/31/2020) and 377 pre-implementation (9/1/2018-8/31/2019). The following metrics were recorded and analyzed using basic summary statistics: ED LOS, disposition, psychiatric diagnosis at discharge, medication class recommended, medication class administered, medication route recommended, and medication route administered. Statistical analysis was performed both on the 12-month groups in aggregate, as well as separately in 6-month groupings to assess for any COVID-19 related confounding effect. Results: Analysis of the first 12 months of data (n = 377 control and intervention patients) demonstrates statistically significant results across a number of domains, including disposition (decrease in hospital admissions and increases in transfers and ED discharges post-implementation), psychiatric diagnoses (increases in personality, intellectual developmental, and anxiety spectrum disorders post-implementation), and medication classes and administration routes utilized (decrease in benzodiazepine use and increases in both atypical antipsychotic use, as well as oral route of administration post-implementation). There were also notable decreases in ED LOS for patients being admitted and transferred from the ED;however, these differences were not statistically significant. Discussion: Analysis of the first year of service data suggests program efficacy and overall value to the health system, with relevant metrics including shorter ED LOS, improved diagnostic accuracy, increased provision of pharmacological treatment interventions in the ED setting and upon discharge, and more resource-appropriate dispositions for patients presenting to the ED with psychiatric concerns. Future directions for further study include: 1) review of the total data set, numbering over 1300 patients in 2 years;2) de-duplication of the data set to eliminate repeat patient encounters as a potential source of confounding;3) collaboration with a faculty biostatistician team for further statistical analysis;and 4) collection and analysis of additional relevant metrics, including restraint use (both f equency and duration), utility of 1:1 observers, patient insurance status (to aid in quantifying possible financial impact), additional patient demographic data (including age, race, gender, ethnicity), and time of patient presentation to the ED. Conclusion/Implications: Integration of psychiatric care into medical settings has been widespread in outpatient environments, but acute models are lacking. Complex psychiatric presentations impede ED workflows and often lead to inadequate care for this vulnerable population. Our jointly administered program that embeds CL Psychiatrists into our academic ED care team has improved and enhanced the care of ED patients presenting with psychiatric concerns as well as operational efficiencies within the department. References: 1. Agency for Healthcare Research and Quality. (2021, April). HCUP Fast Stats. Retrieved from Healthcare Cost and Utilization Project (HCUP): www.hcup-us.ahrq.gov/faststats/national/inpatienttrendsED.jsp 2. Theriault, K., Rosenheck, R., & Rhee, T. (2020). Increasing Emergency Department Visits for Mental Health Conditions in the United States. J Clin Psychiatry, 20m13241. 3. Hooker, E. A., Mallow, P. J., & Oglesby, M. M. (2019). Characteristics and trends of emergency department visits in the United States (2010-2014). J Emerg Med, 344-351. 4. Ding, R., McCarthy, M., Desmond, J., Lee, J., Aronsky, D., & Zeger, S. (2010). Characterizing waiting room time, treatment time, and boarding time in the emergency room using quantile regression. Acad Emerg Med, 813-823. 5. American College of Emergency Physicians. (2014). Polling Survey Results. 6. Zeller, S., Calma, N., & Stone, A. (2014). Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med, 1-6. 7. Nicks, B. A., & Manthey, D. M. (2012). The impact of psychiatric patient boarding in emergency departments. Emerg Med Int.

TACKLING THROMBO-LYSO-PHOBIA: USING SIMULATION TO IMPROVE CONFIDENCE IN STROKE THROMBOLYSIS IN GENERAL INTERNAL MEDICAL REGISTRARS

Background: In the South-West, the majority of out-of-hours stroke thrombolysis calls are lead by the general internal medical (GIM) registrars, not neurology/stroke specialists. There are local variations in the availability of senior and nursing stroke support to support these decisions and significant colloquial fear of carrying out stroke thrombolysis affecting medical registrar confidence and willingness to thrombolyse. This in turn may affect the door-to-needle (DTN) time and patient outcomes. Method: Following positive feedback from a successful IMT3 stroke simulation scenario, a three-scenario course was devised and lead by the neurology team at Derriford and, supported by deanery funding was rolled out to include the entire deanery. Scenarios included thrombolysis, thrombectomy and hypertension control. Results: Feedback from participants identified key pre-course questions and confidence, and usefulness of each scenario and overall confidence post-course. Feedback showed a progressive improvement in each participants confidence in carrying out stroke thrombolysis and there was positive written comments. 100% of participants would recommend this training to a friend. There has been yet to show a clear improvement in door-to-needle time however this is likely compounded by the current pressures facing the NHS with COVID-19 pressures and over-crowding. Conclusion: Stroke simulation has improved participants confidence at carrying out stroke thrombolysis out-of-hours for the GIM registrar. The authors feel that it should be included routinely in the induction and continued education of the general internal medical registrar and there is much potential to spread out to the MDT assessing stroke thrombolysis. Scenarios and learning points available on https://www.plymouthhospitals. nhs.uk/stroke.

Internally displaced people in Lagos: environmental health conditions and access to healthcare in the context of COVID-19

The paper documents environmental health conditions and healthcare access challenges faced by internally displaced people (IDPs) from Borno State living in informal settlements in Lagos, Nigeria, in 2020, during the early stages of the COVID-19 pandemic. This qualitative study with 32 IDPs suggests a high vulnerability to COVID-19. Their accommodation often lacked basic sanitation including water and toilet facilities;overcrowding and high population density restricted ability to adhere to social distancing;and IDPs experienced serious consequences from lockdown, as the majority depended on daily wages, and did not receive food packages or other support from the State. Finally, there were obstacles to accessing healthcare. We highlight the importance of an integrated approach, consolidating the efforts of communities, non-governmental organisations, environmental and public health, and international organisations to address the health and well-being issues of IDPs in urban informal settlements.

Isolated Hypoglossal Nerve Palsy: Two Case Reports

Objective: NA Background: Although extremely rare, hypoglossal nerve palsy(HNP) can occur in isolation causing dysphagia, dysarthria, and tongue deviation. Documented cases of isolated hypoglossal nerve palsy(IHNP) were found to be caused by various etiologies, which include: tumor, trauma, surgery, (post)infection, sarcoidosis, atlanto-occipital dislocation, aberrant ectatic vessel in the hypoglossal canal, and stroke. We report 2 cases of IHNP, one of which had an etiology yet to be reported before. Design/Methods: NA Results: Case 1, a 78-year-old male with history of arthritis who awoke to find he had slurred speech, difficulty swallowing, and tongue deviation to the right. No tongue tumors, edema, or tenderness on exam. No recent history of infection, cancer, neck surgeries, or COVID-19. MRI head and neck revealed erosive arthritis at the C1-C2 articulation, hypertrophic pannus surrounding the atlantoaxial articulation. Pannus seen extending into the spinal canal and foremen magnum, displacing the medulla and crowding the right hypoglossal nerve at the canal. No reported cases of infiltrative pannus causing IHNP was found in literature review. Surgery was scheduled to resect the infiltrating tissue. Case 2, an 18-year-old female who presented to an urgent care for slurred speech, tongue deviation, and only being able to swallow if she shifts her jaw and food to the left side of her mouth. Stroke work-up was negative. Laboratory and imaging studies were within normal limits. She later reported that she had a sinus infection 2-3 weeks prior which required antibiotics. With a post-infectious etiology, she was treated with prednisone 60 mg daily for 7 days with a short taper after. Conclusions: IHNP is a rare disorder stemming from a variety of causes, here we have reported 2 cases demonstrating the wide ranges of age, etiologies and interventions. With increasing etiologies, it is important clinicians recognize that IHNP requires targeted intervention whether medical or surgical.

MATERNITY STAFF PERCEPTIONS OF EFFECTS ON ANTENATAL SCREENING AND SERVICES FOR MENTAL HEALTH AND DOMESTIC VIOLENCE DURING THE COVID-19 PANDEMIC: A SURVEY STUDY

Background: Domestic and family violence (DFV) and mental health screening are core components of antenatal care. However, the COVID-19 pandemic both increased the prevalence of DFV and mental health issues and resulted in many antenatal visits becoming telehealth. DFV and mental health screening were consequently often delayed, potentially resulting in insufficient time to establish support systems before birth. This study assessed pandemic effects on DFV and mental health screening from the perspective of local maternity service providers. Methods: Maternity staff (midwives, doctors, allied health) at three Sydney metropolitan hospitals were surveyed regarding perceived impact of COVID-19 on the delivery, timeliness, and quality of overall pregnancy care, DFV and mental health screening and care, and their telehealth perceptions. Responses by hospital and maternity care provider subtype were compared. Results: Of 109 respondents, most felt the pandemic negatively impacted overall pregnancy care (60%), DFV screening/care (57%), and mental health screening/care (57%), significantly more believing COVID-19 'extremely' negatively impacted DFV screening (p = 0.02). Staff at the hospital with highest sociodemographic diversity were significantly more concerned about DFV screening/ care. Nominated telehealth advantages e.g. reduced travel (69%) and clinic overcrowding (62%) were fewer than disadvantages including no physical examinations (90%), difficulties picking up non-verbal cues (84%), and certain questions unsafe (62%). Fiftysix percent believed telehealth should be used for some antenatal care for select women (low-risk, multiparous). Conclusions: Telehealth may have an ongoing limited role in maternity care in Australia for low-risk women. Staff considered those high-risk for physical and/or psychosocial reasons unsuited to telehealth care.