Telehealth and its impact on the management of type 2 diabetes

The recent Covid-19 pandemic has created many challenges and barriers in healthcare, which includes the treatment and management of patients with type 2 diabetes (Robson & Hosseinzadeh, 2021). The purpose of this Evidence-Based Project (EBP) project is to evaluate the effectiveness of type 2 diabetes management through telehealth and answers the following PICOT question: In patients with diabetes type 2 who have difficulties with medical visit compliance (P), will the telehealth platform (I), compared to patient's previous visit HbA1c (C) improve the Hemoglobin A1c (HbA1c) diagnostic marker (O) over a 12-week period(T)? An extensive literature search of five databases was performed, citation chasing, and a hand search yielded fourteen pieces of evidence ranging from level I to VI (Melnyk & Fineout-Overholt, 2019). The pieces of evidence selected for this project support the evidence that telehealth implementation is as effective as the "usual care" or in-person visits to treat type 2 diabetes. The John Hopkins Nursing Evidence-Based Practice (JHNEBP) model was selected. Patients with a HbA1c of greater than 6.7% have been asked to schedule two six-week telehealth visits. During the live video visit, a review of medications, and diabetes self-management education (DSME) will be conducted. Participants will be provided with education to promote lifestyle modifications. The visits will be conducted through an Electronic Medical Record (EMR) system that is Health Insurance Portability and Accountability Act (HIPAA) compliant. A paired t-Test will be used with the data collected from the pre-and post-HbA1c. Improve the management of type 2 diabetes with the incorporation of telemedicine in primary care. Research supports the need to further expand the use of telehealth in primary care, to improve patient outcomes and decrease co-morbidities related to type 2 diabetes.

COVID-19 Vaccination during Pregnancy: A Structured Electronic Medical Record Data Study

Objectives: To compare pregnancy loss rates, preterm birth rates and gestational age at delivery in women vaccinated against COVID-19 during pregnancy vs. those unvaccinated. Method(s): Data were captured from Dorsata Prenatal, an electronic medical record (EMR) system that captures obstetrical data for tens of thousands of pregnancies annually. Patients who delivered between February 11, 2021-June 2, 2022, were included. The vaccinated group included women who had at least one COVID-19 vaccination documented in their EMR between 30 days prior to pregnancy and delivery. The unvaccinated group included women without a COVID-19 vaccination documented. The primary outcome measure was gestational age (GA) at delivery. We analyzed the data using chi-square tests, with significance set at p<0.01. Result(s): A total of 51,994 pregnant women were identified-7,947 (15.3%) in the vaccinated group and 44,047 (84.7%) in the unvaccinated group. Vaccination rate varied by race (Asian: 19.7%;White: 17.3%;Black: 11.2%, P<0.001), ethnicity (Latino: 8.6%;Not-Latino: 18.7%;P<0.001), marital status (Married: 19.2%;Single: 8.8%;P<0.001), mother's age (>=35 years: 20.0%;<35 years 14.2%;P<0.001), and region (Northeast: 19.2%;South: 15.2%;West: 9.1%;P<0.001). The vaccinated group had significantly lower rate of preterm delivery (Gestational Age [GA]<37 weeks;vaccinated: 7.8% vs. unvaccinated: 9.6%;P<0.001), and significantly lower rates of pregnancy loss (GA<20 weeks;vaccinated: 1.1% vs. unvaccinated: 4.1%;P<0.001). Conclusion(s): This is one of the largest real-world studies to date in women who received the COVID-19 vaccination during pregnancy. Vaccination rates varied significantly across race/ethnicity. Vaccinated patients had lower preterm delivery and pregnancy loss rates compared with unvaccinated patients.Copyright © 2023

Electronic Medical Record System Use and Determinants in Ethiopia: Systematic Review and Meta-Analysis.

BACKGROUND: The strategic plan of the Ethiopian Ministry of Health recommends an electronic medical record (EMR) system to enhance health care delivery and streamline data systems. However, only a few exhaustive systematic reviews and meta-analyses have been conducted on the degree of EMR use in Ethiopia and the factors influencing success. This will emphasize the factors that make EMR effective and increase awareness of its widespread use among future implementers in Ethiopia. OBJECTIVE: This study aims to determine the pooled estimate of EMR use and success determinants among health professionals in Ethiopia. METHODS: We developed a protocol and searched PubMed, Web of Sciences, African Journals OnLine, Embase, MEDLINE, and Scopus to identify relevant studies. To assess the quality of each included study, we used the Joanna Briggs Institute quality assessment tool using 9 criteria. The applicable data were extracted using Microsoft Excel 2019, and the data were then analyzed using Stata software (version 11; StataCorp). The presence of total heterogeneity across included studies was calculated using the index of heterogeneity I2 statistics. The pooled size of EMR use was estimated using a random effect model with a 95% CI. RESULTS: After reviewing 11,026 research papers, 5 papers with a combined total of 2439 health workers were included in the evaluation and meta-analysis. The pooled estimate of EMR usage in Ethiopia was 51.85% (95% CI 37.14%-66.55%). The subgroup study found that the northern Ethiopian region had the greatest EMR utilization rate (58.75%) and that higher (54.99%) utilization was also seen in publications published after 2016. Age groups <30 years, access to an EMR manual, EMR-related training, and managerial support were identified factors associated with EMR use among health workers. CONCLUSIONS: The use of EMR systems in Ethiopia is relatively low. Belonging to a young age group, accessing an EMR manual, receiving EMR-related training, and managerial support were identified as factors associated with EMR use among health workers. As a result, to increase the use of EMRs by health care providers, it is essential to provide management support and an EMR training program and make the EMR manual accessible to health professionals.

The Cost-effectiveness of the Pediatric Antimicrobial Stewardship Program in a Non-Freestanding Children's Hospital

Background. Improper utilization of antimicrobials has impacted clinical outcomes in patient care and economical costs. Pediatric antimicrobial stewardship (Ped ASP) lowers healthcare costs by promoting efficient and judicious use of antimicrobials which improves patient outcomes and amends resource utilization. The objective of this study is to evaluate the cost-effectiveness of a Ped ASP in a non-freestanding children's hospital within an adult-centered tertiary hospital. Methods. We conducted a cost-effective analysis of our Ped ASP within a 685-bed, adult-centered medical center. Impacted by the COVID pandemic, the pediatric services reduced from 21 to 14 beds with 10 general pediatrics (PED) and 4 pediatric intensive care (PICU) beds. Our Ped ASP activities include thrice-weekly chart reviews followed by handshake rounds and quarterly reviews of documented interventions. The preset values of antimicrobial-specific interventions in the Electronic Medical Record system were utilized. An average cost savings of $732 (range: $2.5 - $2,640) per patient as determined by previous studies was used to calculate the annual cost savings. Results. During years 2020 to 2021, antibiotic days of therapy per 1000 patient days (DOT) decreased from 290.4 to 100.2 in PED but increased from 433 to 569.1 in PICU. The ratio of broad to narrow-spectrum antibiotics decreased from 0.46 to 0.20 in PED and 0.69 to 0.63 in PICU. In 2020, 286 reviews were completed of 155 patients which projected an average cost savings of $113,460 (range: $387.5 - $409,200). In 2021, 256 reviews of 116 patients projected an average cost savings of $84,912 (range $290 - $306,240). An estimated overall annual cost-savings was $99,186. The total number of ASP-specific interventions in 2020 and 2021 were 172 and 146 with projected pharmacy intervention values of $26,354 and $19,170 respectively. Conclusion. Our Ped ASP effectively reduces the usage of broad-spectrum antibiotics in both PED and PICU demonstrating cost savings. Implementing antibiotic time-out reports on specific broad-spectrum antibiotics based on local susceptibility data may further enhance the safety and appropriateness of antimicrobial therapy.

Implementation of a health screening process for cystic fibrosis care during the COVID-19 pandemic

Background: Cystic fibrosis (CF) is associated with complications such as CF-related diabetes (CFRD) and bone disease. The Cystic Fibrosis Foundation advises routine screenings as the standard of care for early identification and treatment of these complications. Specifically, the foundation recommends annual completion of an oral glucose tolerance test (OGTT) and a dual-energy X-ray absorptiometry (DEXA) bone density scan at least every 5 years. In 2019, 55% of eligible patients completed an OGTT, and 68% completed a DEXA scan at UVA Health System (UVAHS). Transition of in-person clinic visits to telemedicine during 2020 and 2021 decreased completion of health screenings. The UVAHS team used quality improvement tools to design a process to maintain and increase OGTT and DEXA completion rates with the newhybrid nature of clinical care. The aim of this project is to define a replicable, reliable process for obtaining health screenings in the setting of hybrid patient care. Method(s): Quality improvement tools highilghted in the Model for Improvement methodology guided production of a simplified failure mode effects analysis (sFMEA) to identify areas for intervention. A process was developed to track patient eligibility and completion of screenings and adapted through iterative plan-do-study-act (PDSA) cycles. CF registered dietitians (RDs) documented completion of OGTTs and DEXAs in a secure Excel spreadsheet coded to flag patients due for each health screening. Two weeks before clinic, both RDs referenced the spreadsheet to determine patients due for health screenings. All identified patientswere contacted to inform them of the health screenings due. Patients and RDs then coproduced a plan for completion of the health screenings at an in-person visit, at a local lab, or in conjunction with a non-CF health care appointment. Regardless of the plan, patients were provided outpatient lab order requisitions. To ensure communication with other care team members, patients contacted about and scheduled for their screenings were denoted in the shared Health Insurance Portability and Accountability Act-compliant clinic tracking platform. Clinic nurses received outside lab results via fax and all in-house results through the electronic medical record system. Once lab results were reviewed and communicated to the patient, the health screening spreadsheet was updated. Result(s): In 2020 and 2021, 39% of eligible patients completed an OGTT, and 76% of eligible patients completed a DEXA scan. Of thosewho completed an OGTT in 2020 and 2021, 68% and 74%, respectively, indicated abnormal results consistent with impaired fasting glucose tolerance or CF-related diabetes. Most patients with up-to-date DEXA scans by the end of 2021 were positive for osteopenia or osteoporosis (53%). Conclusion(s): Through the creation of a standardized protocol using iterative PDSA cycles, patients continued to sustain routine health screenings despite reduced in-person clinic visits, allowing for identification and intervention for many patients regarding diabetes and bone health. Continuation of this protocol will enhance our ability to collect patient health screenings while providing the same high-quality care via telemedicine that we provide with in-person visits. Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

A New Chapter in an Evolving Pandemic: Successful Pediatric Liver Transplantation with COVID+ Donors

Purpose: We report the first two pediatric liver transplants utilizing allografts from COVID+ donors, infected at time of organ procurement, demonstrating a pivotal step toward donor pool maximization amid a viral pandemic with poorly understood transmissibility in the pediatric patient. Method(s): This is a prospective and retrospective review of two pediatric liver transplants and their donors who tested positive for SARS-CoV-2 at time of procurement. Data was obtained through the electronic medical record system and UNet DonorNet platform. Result(s): The first donor is a 3-year-old male succumbing to head trauma. 1 of 5 nasopharyngeal swab RT-PCR tests demonstrated COVID-19 positivity while 1 of 3 bronchoalveolar lavage RT-PCR tests indicated SARS-CoV-2 infection. Preceding procurement in the second donor, a 16-month-old male with unknown etiology of cardiorespiratory arrest, 2 nasopharyngeal swab RT-PCR tests and 1 bronchoalveolar lavage RT-PCR test failed to detect SARS-CoV-2 infection. Diagnosis was not made until the Medical Examiner's office repeated a nasopharyngeal swab RT-PCR and archive plasma RT-PCR which were both positive for SARS-CoV-2. The two 2-yearold pediatric liver recipients underwent transplantation in November 2021. Continued follow-up demonstrates successful transplant void of viral transmission or hepatic artery thrombosis as liver chemistries have anticipatorily normalized with excellent graft function. One recipient experienced early portal vein thrombosis treated by interventional radiology with discharge on postoperative day 20. Conclusion(s): This report is the first to describe successful pediatric liver transplants from COVID+ donors. This data reinforces case reports in the adult transplant population of successful use of COVID + donor organs and further supports the judicious use of COVID+ donors for extrapulmonary pediatric organ transplant. The concern for donor-derived transmission must now be weighed against the realized benefit of successful, life-saving transplantation for end stage liver disease in the pediatric patient. (Figure Presented).

INCREASING USE OF AGE-ADJUSTED D-DIMER

SESSION TITLE: Quality Improvement SESSION TYPE: Original Investigations PRESENTED ON: 10/17/22 1:30 pm - 2:30 pm PURPOSE: Age adjusted D-dimer is a well validated method by which to rule out pulmonary embolism in patients with low to intermediate pretest probability. The specificity of the traditional D-dimer cutoff (500 mcg/L) decreases with age and leads to false-positive results and unnecessary imaging tests. When an age-adjusted cutoff is used (age x 10 mcg/L), specificity improves, and excessive testing is avoided. METHODS: We began by collecting retrospective data for all patients who underwent D-dimer testing over the course of a 29-month period (from October 2017 through February 2020) within our 400 bed community hospital. We determined how many of these patients underwent further imaging with either a CT angiogram (CTA) or ventilation-perfusion (VQ) scan. We then implemented a messaging system within the hospital’s electronic medical record (EMR) with the purpose of reminding providers to consider age-adjusted D-dimer values prior to ordering imaging. Post-intervention data was collected over a period of six months (August 2021 – January 2022). Patients who tested COVID positive were excluded from analysis. RESULTS: A total of 1054 patients were included in the pre-intervention group, while 371 patients were included in the post-intervention group. There was no significant difference in age between the two groups (p = 0.241). A total of 13.6% (n = 143) of the patients in the pre-intervention group underwent CTA or VQ scan despite having a D-dimer below the age-adjusted cutoff, indicating that the patient did not require any imaging. Post-intervention, a total of 9.2% (n = 34) of patients underwent CTA or VQ scan despite having D-dimer values below the age-adjusted cutoff. Using a chi-square test for association, there was a statistically significant decrease in unnecessary testing (χ2(1) = 5.343, p = 0.021). CONCLUSIONS: Despite high quality evidence that suggests the use of age-adjusted D-dimer is safe and effective for ruling out pulmonary embolism, many imaging tests are ordered based upon standard cutoff values. Implementing a reminder message within our hospital’s EMR system produced a significant reduction in inappropriate imaging. This ultimately resulted in less radiation for patients, as well as an estimated cost savings of $33,758 over a six-month period. Although statistically significant improvement was seen, further interventions, such as automatically adjusting D-dimer cutoff values within the EMR, may further reduce unnecessary imaging and avoid pop-up message fatigue. CLINICAL IMPLICATIONS: Built-in EMR reminders to use age-adjusted D-dimer cutoff values may decrease unnecessary CTAs and VQ scans. This may translate into reduced patient irradiation and decreased overall healthcare costs without sacrificing patient care. DISCLOSURES: No relevant relationships by Naren Bhupatiraju No relevant relationships by Meagan Mayo No relevant relationships by Katherine Reano

Role of Virtual Ward in COVID-19 Pandemic in a developing country: Our experience of first 100 patients

Objective: To assess the role of virtual ward in COVID-19 Pandemic in a developing country and to describe our experience with first 100 patients admitted in virtual ward. Methodology: This retrospective study is chart review of first 100 patients who presented consecutively to our service in virtual ward. The data were captured from the electronic medical record system, which was secure and password protected. We used Microsoft excel for data analysis. Results: Out of 100 patients, there were 63 males and 37 females and with age range of 50 – 60 years. Majority had no comorbidities while 20% had diabetes, another 24% with cardiac disease and 4% with pulmonary disease. Off all patients, 90% were discharged from the service and 10% were admitted to the hospital. One person died during the stay in service. Feedback on the quality of service showed majority patients were satisfied with the service with the score of 4.8 on the scale of 1 to 5. Conclusion: In pandemic era, there is increasing need for safer and coordinated care through virtual ward. It increases the level of patient's satisfaction and lowers the inpatient burden for the hospital.

COST ANALYSIS OF MINIMALLY-INVASIVE SACROCOLPOPEXY COMPARED TO NATIVE TISSUE VAGINAL REPAIR IN THE ERA OF ERAS

Introduction: Minimally invasive sacrocolpopexy (SCP) is the gold-standard treatment for patients with apical prolapse and is increasingly used as a primary intervention in women with uterovaginal prolapse. There is a lack of comparative data evaluating costs between SCP versus native tissue vaginal repair in the post-ERAS implementation era. Objective: The primary aim was to determine the cost difference between performing hysterectomy and minimally-invasive sacrocolpopexy as compared to vaginal hysterectomy with native tissue vaginal repair for uterovaginal prolapse. We hypothesized that minimally-invasive sacral colpopexy has a higher cost when compared to native tissue repair but when failure rates of native tissue repair approach 15%, costs equilibrate. Methods: This was a retrospective cohort study at a tertiary care center. The electronic medical record system was queried for women who underwent native tissue vaginal repair or minimally invasive SCP with concomitant hysterectomy for uterovaginal prolapse in calendar year 2021 (post-COVID enhanced recovery after surgery implementation). We excluded all patients who had concomitant colorectal procedures and where billing was not complete or re-imbursement was not received. Hospital charges, direct and indirect costs and operating margin (net revenue minus all costs) were obtained from Strata Jazz and were compared using R statistical program. Net revenue (reimbursement) was directly obtained from the record as the total payment received by the hospital from the payor. Results: A total of 81 women were included, (33 SCP (25 robotic and 8 laparoscopic) versus 48 native tissue). Payor mix included 27% Medicare, 5% medicaid, 61% employer-based and 7% private insurance. Demographic and surgical data is presented in Table 1. The mean total charge per case for services was higher in the SCP group compared to the vaginal repair group ($119,863 vs. $82,205, P < 0.01). Cost of supplies was more in the SCP group ($4429 vs. $2108, P < 0.01), but the cost of operating room time and staff was similar ($7926 vs. $7216, P = 0.06). Controlling for surgeon, age and BMI, the direct and indirect costs were also higher in the SCP group ($13,649 vs. $10,168, P < 0.01 and $5068 vs. $3685, P < 0.01, respectively). Net revenue was lower for the vaginal repair group compared to the SCP group ($14,614 vs. $31,618, P < 0.01). The operating margin was significantly higher in the SCP group ($11,770 vs. $ 517, P < 0.01). Additionally, there were no significant differences in the net revenue between different payors (P = 0.8997). Same-day discharge and EBL were similar among both groups with operative time being higher in the SCP group (204 vs. 161, P < 0.01). Using the means of the direct costs between groups, a re-operation rate of 25.5% would be needed for the native tissue repair costs to equilibrate to the SCP group. From a hospital perspective, due to the low operating margins experienced with native tissue vaginal repair, 227 native tissue vaginal repairs would need to be performed for the same net return as 10 minimally-invasive SCP's. Conclusions: Vaginal hysterectomy with native tissue repair had lower direct and indirect costs compared to minimally-invasive SCP. However, operating margins are significantly higher for SC P due to net revenue received. (Table Presented).

Correlation between Chest CT Severity Scores and Clinical Parameters in Patients with COVID-19 Pneumonia: A Comparative Study between 1st and 2nd Wave

Aim and objective: To correlate a chest CT score in COVID-19 pneumonia with clinical severity and inflammatory biomarkers and overall patient's outcome. Materials and methods: In this retrospective single-center analysis, we collected data of 200 patients admitted to Fortis hospital during the peaks of the two waves of the COVID-19 pandemic. Data for 1st wave were collected between July and September 2020 (100 patients) and 2nd wave from March to April 2021 (100 patients). We collected clinical and laboratory data for analysis, derived from the electronic medical record system for the above durations. Only symptomatic patients within 10 days of onset of symptoms who had CT imaging done at admission were included in the study. A team of experienced radiologists analysed the images to determine the CT severity score based on the extent of lobar involvement. Each lung lobe was visually scored from 0-5, 0-no involvement, 1: <5% involvement, 2: 5-25% involvement;3: 26-50% involvement;4: 51-75% involvement;5: >75% involvement. The total CT score was the sum of individual lobar scores ranging from 0 (no involvement) to 25 (maximum involvement). The results of the chest HRCT images were collected and evaluated using the picture archiving and communication systems (PACS). Patient's chest CT score, P/F ratio, O2 requirement, and need for ventilatory support and mortality were compared. Descriptive statistics of patients demographics, clinical, and laboratory results were reported as numbers and relative frequencies. Frequencies of CT scores were calculated and compared with other clinical variables. The Pearson correlation coefficient test was used for correlations, considering p < 0.05 statistically significant. Results: Our study highlights the clinical implication of initial CT findings as a prognostic indicator in patients with COVID-19. In terms of demographic distribution median age was 57.5 and 58 years, respectively, and both the waves had a median male predominance of 65%. Wave 1 had more patients with lower CT scores and higher P/F ratio, whereas wave 2 had a significant lower P/F ratio for the same CT scores as compared to wave 1, especially at higher CT scores. CT score of >18/25 is associated with increased probability of ventilatory requirement and hence increased mortality in both the waves which was found to be statistically significant with p = 0.005. Also, higher CT scores were found to be positively correlated with lymphopenia, increased serum CRP, d-dimer, and ferritin levels. Conclusion: Chest CT imaging has played an important role in monitoring disease progression and predicting prognosis during the COVID-19 pandemic. They can be pivotal in assisting clinicians in diagnosing the severity, predicting the outcomes and most of all, in the management plan for the concerned patient. In our analysis of one of the largest single-centre studies conducted during the two waves of the COVID-19 pandemic in India, CT severity score was directly proportional with inflammatory lab markers, length of hospital stays, and oxygen requirement in patients with COVID-19 infection. CT Chest score of >18/25 on admission is associated with poor prognosis and increased mortality.

Improving the Care of Newly Arrived Immigrant Patients in Two Primary Care Clinics

Purpose/Objectives: 1) To design and implement a clinical pathway that delineates evidence-based recommendations of screening for newly arrived immigrant children in an academic primary care setting. 2) To improve adherence to recommended biomedical and infectious screening by providers caring for newly arrived immigrant children. 3) To evaluate the effectiveness of the clinical pathway and adjunct tools to support uptake and adherence to the pathway with a goal of achieving 90% adherence to key indicators in 18 months. Design/Methods: A clinical pathway for primary care of newly arrived immigrant children was developed and implemented based on existing evidence from immigrant and refugee populations, delineating recommended psychosocial, developmental, biomedical, and infectious screenings by region of origin. Adjuncts to support uptake were implemented, including an EMR order-set and note template. Faculty and resident education to the pathway was conducted in person and with pre-recorded educational presentations. Indicators of adherence were defined as the percentage of patients who obtained the recommended screening tests according to their world region of origin. Results: A total of 301 newly arrived immigrant patients were seen at the clinics during our observation period (from Dec 2018-May 2021);190 (63%) were seen after the rollout of our main interventions in August 2019, and 70 (23%) were seen after the onset of the COVID-19 pandemic in March 2020. We observed an improvement in the % of patients who obtained lead level, Complete Blood Count (CBC) with differential, Strongyloides, and Tuberculosis screening on their first visit in the U.S. following the introduction of the clinical pathway and order-set (Images 1 and 2). There have been six consecutive points above the mean in the case of lead level and Tuberculosis screening. In the case of Strongyloides screening, a mean shift was observed months after the implementation of the pathway. On average, 74% of the ordered screening tests for these patients were entered using the order-set. The COVID-19 pandemic impacted the number of new patients in both clinics from April 2020-Sep 2020. Periodical reminders and continuous education to providers also have proved beneficial to our goals. Conclusion/Discussion: Implementation of a clinical pathway for the care of newly arrived immigrant children resulted in improvements in adherence to region-specific recommendations for biomedical and infectious screenings;specifically for lead, CBC with differential, Strongyloides, and Tuberculosis screening. Implementation of an order-set embedded in the electronic medical records system was a successful strategy to facilitate adherence. Drastic reductions in the number of new immigrant children seeking care during the initial months of the COVID-19 pandemic raised concerns about access barriers for this vulnerable population and required strategies to remind clinicians about the use of the pathway as numbers of new immigrant patients return to baseline.

IMPROVING ANNUAL DIABETIC RETINAL SCAN SCREENING RATES IN A PRIMARY CARE CLINIC DURING THE COVID-19 PANDEMIC

STATEMENT OF PROBLEM/QUESTION: How can systems-based changes increase the rate of diabetic retinal scan (DRS) completion in a primary care clinic during the COVID pandemic with decreased in-person visits? DESCRIPTION OF PROGRAM/INTERVENTION: The intervention was based in a primary care clinic associated with a public county-based health system. During the COVID-19 pandemic, in-person clinic visits were drastically reduced to prevent transmission, leading to a significant decrease in DRS completion rates. Additional barriers to completion of DRS screening included the following: (1) patients needed a separate, scheduled visit in our electronic medical record system (EPIC) for the DRS exam, (2) DRS clinic had limited hours during the primary care visit day, (3) many of our underserved patients could not afford consecutive clinic visits within a short period of time, and (4) providers signed the orders for DRS at the end of the visit;thus, nursing staff could not start scheduling patients an appointment until the end of the primary care visit. The intervention included two Plan-Do-Study-Act (PDSA) cycles. The first PDSA cycle involved a physician manually screening all patients due for DRS on a weekly basis if they were scheduled for a clinic visit in the upcoming week. For those identified, our nursing staff scheduled and completed a separate DRS appointment for the same day as the patient's clinic visit to minimize multiple visits. The second PDSA cycle involved using an EPIC tool, SlicerDicer, to automatically identify patient charts with overdue DRS screenings and upcoming clinic visits. The list of identified patients were then sent over to our nursing staff in order to schedule patients for their DRS on the same day as their clinic visit. MEASURES OF SUCCESS: We recorded diabetic retinal scan completion rate each month for one year from September 2020 to August 2021 to assess if rates would improve after our interventions. Monthly completion rates were measured on a rolling basis and based on the completion of the annual DRS for all clinic patients within the last 12 months. FINDINGS TO DATE: The percent of completed annual diabetic retinal exams for all clinic patients increased from 32.4% in September 2020 to 70.9% in August 2021 after implementation of our interventions. KEY LESSONS FOR DISSEMINATION: We identified system-based barriers that were negatively impacting our patients' ability to complete an important health maintenance screening such as the DRS exam. After identifying these barriers, we utilized existing tools and technology within our electronic medical record system to help patients complete their annual DRS exams and drastically increased overall clinic DRS completion rates.

What Pediatric Primary Care Providers Need to Support Gender Diverse Youth: Perspectives on Consultative Support for Gender-Affirming Care

Purpose: The demand for pediatric gender-affirming care has increased throughout the COVID-19 pandemic, highlighting the need for telehealth-based specialist-to-primary care provider (PCP) consultative support. Accordingly, the purpose of this study was to identify PCPs’ perspectives on receiving training and consultation in pediatric gender-affirming care using three telehealth modalities, with the larger goal of informing the development of future consultative support offerings. Methods: PCPs who had previously reached out to the Seattle Children’s Gender Clinic for a gender care consultation were invited to participate in a semi-structured, one-hour Zoom interview. During the interview, three different telehealth modalities (tele-education, electronic consultation, telephonic consultation) were described and participants were asked to share their perspectives on 1) the benefits and drawbacks of each modality, 2) which modality would be most effective in supporting them in providing gender-affirming care in the primary care setting, and 3) factors that would make a consultation platform successful. Interviews were transcribed and analyzed using an inductive thematic analysis framework by two authors using Dedoose qualitative analysis software. All participants provided informed consent and all study procedures were approved by the Seattle Children’s Institutional Review Board. Results: Interviews were completed with 15 PCPs. For the tele-education platform, PCPs most often identified continuing medical education (67%) and the community or network it creates (47%) as benefits and the commitment required (73%) and scheduling difficulties (40%) as drawbacks. For the electronic consultation model, timeliness of response (67%) and convenience (53%) were cited as benefits and electronic medical record system requirements (60%) and difficulty conveying the message electronically (53%) were considered the main drawbacks. For the telephonic consultation, PCPs identified the ability to have a conversation (80%) and the timeliness of response (60%) as the main benefits and phone-tag (87%) and finding time to make the initial call (40%) as the main drawbacks. Regarding the most effective platform, responses were mixed: 27% endorsed the electronic consultation, 27% the tele-education platform, and 20% the telephonic consultation, with the remaining 27% suggesting a hybrid of the three models. Finally, responses regarding what would make a platform successful were much more varied across participants, with the most common responses including being non-judgmental and supportive (33%) and flexible with the ability to pivot to other platforms as needed (27%). Conclusions: With the increasing demand to provide gender-affirming care in the primary care setting, further training and support is necessary for pediatric PCPs to deliver this time-sensitive care. The results of this study indicate the need for a more flexible suite of gender-focused specialist-to-PCP telehealth-based consultative services to facilitate the provision of pediatric gender-affirming care. Sources of Support: This project was supported by the Seattle Children's Research Institute and AHRQ (K12HS026393-03;PI: Sequeira) and a grant from Pivotal Ventures.

Effects of Waterpipe Smoking on the Course of COVID-19 Infection

Objective: Smoking, and also water pipe smoking (hookah), is a common method of tobacco use in Southwest Asia and Middle East countries. Although the relationship between coronavirus disease-2019 (COVID-19) infection and smoking has been evaluated in many studies, no study has been conducted to evaluate the relationship between COVID-19 infection and water pipe smoking. Methods: We enrolled 150 in-hospital patients. The severity of disease classified as mild, moderate, severe, and critically ill. The relationship between waterpipe smoker, smoker and non-smoker patients and severity of disease statistically evaluated. Results: Patients with minimal involvement (1-25%) on thorax computed tomography were found to be higher in the smoker and cigarette-hookah smoking group compared to the non-smoking group, and the patients with moderate involvement (51-75%) were found to be less in the smoking-hookah group. in terms of disease degree;It was found that there were more mild and moderate smokers in the smoking and smoking-hookah group than the non-smoking group. The C-reactive protein and sedimentation values of cigarette-waterpipe tabocco smokers were found to be lower than non-smokers. Conclusion: Waterpipe smoking does not aggravate the course of the disease in the young population, but new studies are needed for its effects on the elderly population.

A single-center prospective observational study evaluating telemedicine for kidney transplant patients in the Coronavirus disease-19 pandemic: Breaking the access barrier

Introduction: The coronavirus pandemic has restricted access to health-care services for kidney transplant patients because of concerns of COVID-19 infection. This single-center prospective study was done to assess the feasibility, acceptability, and effectiveness of telemedicine services for regular follow-up of kidney transplant patients as well as for triaging patients for admission. Methods: The study was undertaken during the lockdown period in India from March 23, 2020 to June 30, 2020. A formatted message seeking all relevant information was sent before teleconsultation. WhatsApp/email using smartphones and Electronic Medical Records system were used to provide telemedicine services. At the end of the e-consult, the patient was asked to rate his experience on a scale of 0-10. Results: A total of 296 consults for 122 patients were given. Of these, 239 (80.7%) consults (96 patients) were for domestic patients and 57 (19.3%) consults (26 patients) were for international patients. The mean age of the patients was 43 ± 15 years. The mean patient satisfaction score for e-consults was 9.5 ± 0.7. Four (3.3%) patients were seen for the first time after transplant via teleconsultation. Nine (7.4%) patients were advised admission and the rest were advised follow-up teleconsultation. Among those admitted, 6 (4.9%) were COVID positive and 1 (0.8%) patient died of COVID-19 pneumonia. Conclusions: Telemedicine offers a viable modality for health-care delivery when access to health care is restricted for transplant patients. Our model of telemedicine can be replicated easily without the burden of high cost for infrastructure.

Multimodal Quality Initiatives In Sepsis: Impact On Core Measures And Outcomes

RATIONALE: The Center for Medicare and Medicaid requires hospitals to report compliance with a sepsis treatment bundle as part of its Inpatient Quality Reporting Program. Cleveland Clinic Foundation (CCF) Fairview hospital reported a Sepsis Core Measure Compliance (SEP-1) of 25% and a mortality averaging 20% in 2017. Both were very dismaying. METHODS: Starting in 2018 a sepsis committee was convened with a plan for several quality initiatives. Real-time audits and peer to peer education were provided to caregivers on the failed cases. A sepsis alert in the Electronic medical record system and a sepsis checklist were initiated. In 2020 a Code sepsis team was created with 24 hours response and follow-up on all sepsis alerts. As the CCF enterprise decided in 2020 to focus on mortality reviews, our hospital adopted rather a hybrid model reviewing all failed compliance cases of the one hour antibiotic in addition to mortality cases reviews. Several educational and awareness sessions were entertained with the residents, advanced practice providers, hospitalists, intensivists and nursing teams. Seventy Registered Nurses received training in 2018 and forty-three in 2021. Sepsis Champions were designated encompassing all stakeholders. Collaboration with Emergency Room caregivers to provide hand-off communication on sepsis alert patients to the medical-surgical providers ensured continuity of care. A sepsis order set was revised and went live in September 2021. Beginning of 2022, A dedicated full time quality coordinator and program manager for sepsis was appointed. RESULTS: Despite the Coronavirus 19 infection (COVID 19) pandemic where Cleveland Clinic Fairview Hospital was designated as the tertiary referral academic center for northwestern Ohio and despite the inclusion of COVID 19 mortality within the sepsis mortality data, comparing 2017 to 2021, SEP-1 measures compliance improved from 25% to 60.4% and sepsis mortality decreased from 20% to 15.38%. The one hour antibiotic compliance averaged 78.89% in 2021. With the above performance and impact on survival, Cleveland Clinic Fairview Hospital was leading the CCF Hospitals both in compliance and Mortality. Several of the above Fairview hospital quality initiatives and approaches were later adopted across the Cleveland Clinic Hospitals. CONCLUSION: A sepsis dedicated committee, quality/program manager and a code sepsis team with a focus on the evidence base components of the sepsis core measures, all helped improve compliance and decrease mortality. Future research is needed to highlight the impact of each of those quality and educational initiatives on outcomes and performance. Word Count: 400 (Figure Presented).

A CASE SERIES OF RHEUMATIC DISEASE PATIENTS DIAGNOSED WITH COVID-19 FEB 2020 TO MARCH 2021 AT THE HOSPITAL THAT REPORTED LONDON'S INDEX CASE OF COVID-19

Background/Aims The aim of this study is to describe demographics features and outcomes of patients with rheumatic diseases diagnosed with COVID- 19 in a single hospital. Methods Patients with rheumatic diseases and COVID-19 were identified via rheumatology outpatient and inpatient hospital admissions between February 2020 and March 2021. Data was collected retrospectively using the electronic medical records system and in-person and telephone consultations. The data was entered into the COVID-19 Global Rheumatology Alliance (GRA) Registry. Data collected included age, gender, ethnicity, smoker status, rheumatic disease, co-morbidities, drug history and vaccine status. Patient outcome was recorded as mortality, recovered (including days to recovery) or symptoms persisting over 90 days (>90). Requirement for hospital admission was also recorded. Comparison was made to the published GRA Registry data. Results Forty-three patients were identified;33 Female (77%),10 (23%) male. Median age 52. 22 Caucasian, 12 Black, 3 mixed race, 2 Asian, 2 Hispanic and 5 unknown. Rheumatoid arthritis (14 patients;33%) was the most common disease. Other diagnoses included psoriatic arthritis (6;14%), systemic lupus erythematosus (4: 9%), Sjogrens syndrome (4: 9%) and ankylosing spondylitis (4;9%). The most common disease modifying antirheumatic drug (DMARD) was methotrexate (35%) followed by hydroxychloroquine (33%). Eight patients were taking steroids (19%). Factors associated with hospitalisation were older age (57% age ≥ 52 vs 40% < 52), multiple co-morbidities (71% ≥ 2 comorbidities vs 35% < 2 co-morbidities) and black ethnicity (75% black vs 26% of caucasian). These risk factors for morbidity are similar to the UK background population and published COVID-19 GRA data. There was no increased risk of hospitalisation between different DMARDs (53% on methotrexate required admission vs 50% on hydroxychloroquine). 71% of patients on steroids required admission. The overall study cohort had a 49% hospital admission rate. Similar risk factors were identified for persistence of symptoms > 90;27% of black patients vs 5% of caucasian and 24% of patients with > 2 comorbidities vs 10% of patients with < 2 co-morbidities. Age did not follow the same trend as hospitalisation;10% of patients age ≥ 52 vs 20% of patients < 52 had symptoms > 90. 15% on methotrexate had a recovery time > 90 vs 7% on hydroxychloroquine and 14% on steroids. The overall cohort had a 17% rate of patients having symptoms > 90. Mortality rate within the cohort was 5% (2 patients). Conclusion A case-series of 43 patients with rheumatic diseases and COVID-19 was conducted. The risk factors for hospitalisation, mortality and persistence >90 were similar to other studies. Most significantly the findings show a correlation between black ethnicity and increased risk of all mortality, hospitalisation and symptoms > 90. There was no difference in hospitalisation and different DMARDs.

Study of Biochemical Parameters and Chest CT Score for Diagnosis and Prognosis of COVID-19 Pneumonia Patients

Introduction: COVID-19 pneumonia is a recently discovered, rapidly spreading acute respiratory syndrome. Chest CT has a 97% sensitivity for the diagnosis of COVID-19 pneumonia after a mean interval of 5 days. The typical chest CT findings in COVID-19 pneumonia are bilateral, peripheral, and basal predominant GGOs with or without consolidation and Broncho vascular thickening. The chest CT severity score of lung inflammation and clinical parameter analysis can assess COVID-19 disease and its severity. Aims: Authors evaluated correlation of biochemical parameters with Chest CT Score for diagnosis and prognosis of COVID-19 pneumonia patients. Materials and Methods: A total of 350 Patients diagnosed with COVID-19 pneumonia were included in the present study. We collected clinical and laboratory data for analysis, derived from an electronic medical record system, from June 2020 to July 2021 of patients who were diagnosed with COVID-19 infection by RT - PCR as well as chest HRCT scan. All the patients D-Dimer, LDH, Procalcitonin and ferritin levels were also collected. The statistical analysis was performed by using SPSS 21.0. Results: A significantly elevated levels of D-Dimer (1346±124.60), LDH (768±58.74), Procalcitonin (9.89± 0.97) and Ferritin (567±47.19) observed in all the subjects. The D-Dimer, LDH, Procalcitonin and ferritin was found to be positively correlated with CT severity score (p<0.0001). Conclusion: This study concluded that chest CT severity score can aid in predicting COVID-19 disease outcome, when CT Score is correlated with laboratory investigations useful for diagnosis as well as prognosis of COVID-19 pneumonia.

A Patient-Centric Interoperable, Quorum-based Healthcare System for Sharing Clinical Data

In the current Electronic Medical Record (EMR) systems, the healthcare organizations have the ownership of patient's EMR. Patients have only limited information of the EMR in the form of discharge summary and reports. This was viewed a problem in eHealth consultations during a pandemic like COVID-19, when doctors does not have access to patient data. Patient is the owner of the data and patient should have control over his medical data and should be able to share the data according to his requirement. So currently work is being undertaken to develop patient-centric EMR system. One major challenge here is to ensure the privacy and access management of data being accessed and shared. This paper aims to solve these challenges by using a permissioned blockchain network based FHIR solution for secure interoperability. The proposed system was evaluated by developing a prototype on Quorum Blockchain. The throughput and latency characteristics of the system was analyzed with different workloads and results was promising. © 2022 IEEE.

Screening for genetic risk at the time of mammography

Introduction: Approximately, 10-15% of breast cancers may be hereditary. Early identification of elevated genetic risk may decrease morbidly and mortality associated with breast cancer for this population by enabling timely implantation of optimized screening techniques. Reaching out to women with breast cancer risk assessment at the time of mammography may provide an opportunity to connect risk perception with risk reduction action. We hypothesized that women receiving a high-risk assessment at the time of mammography would facilitate entry to genetic counseling. Methods: In September 2019, Jefferson Health New Jersey (JHNJ) started utilizing a tool to screen individuals for an increased risk for hereditary breast cancer syndromes (family history screening 7;FHS-7) to all women presenting for mammography at its three breast imaging centers. The FHS-7 tool was embedded into the electronic medical record system and would generate a score based on 7 questions related to a patient's family history of breast, ovarian and bowel cancer. Women who were identified at elevated risk (FHS-7 scores ≥1) were asked by the mammography technician prior to performing the screening mammogram for their permission to be contacted by a high-risk counselor for a formal high-risk assessment and potential genetic counseling/testing. In March 2020, nearly all cancer screening services shut down with the COVID-19 pandemic. Services re-opened in June 2020. We report on our experience in three-time frames: September 2019-February 2020;March 2020-May 2020, and June 2020-present. Results: From September 2019-February 2020: 3, 169 mammograms and FHS-7 screenings were performed. 44 had scores ≥1 (1.4%). 4 (9%) agreed to be contacted for an appointment with a high-risk counselor. Of these, 2 had previously met with genetics. No additional appointments were scheduled. From March 2020-May 2020, 576 mammograms and FHS-7 screenings were performed. 9 had scores ≥1 (1.6%). None agreed to be contacted for an appointment with a high-risk counselor. Two appointments had previously been completed. From June 2020-June 2021, 9, 131 mammogramsand FHS-7 screenings were performed. 240 had scores ≥1 (2.6%). 22 (9%) agreed to be contacted for an appointment with genetics. 11 appointments had previously been completed. 8 (73%) were completed as a consequence of this direct outreach. Conclusion: Although our work was interrupted by the COVID-19 pandemic, screening for hereditary risk at the time of mammography may be an effective way of facilitating referrals for genetic counseling/testing for high-risk patients. Consent to be contacted for a formal high-risk assessment was consistent at 9% pre-mammography closure and post-mammography re-opening. Consent to be contacted for genetics is likely to be associated with breast cancer risk perception. Future Directions: We are planning an educational intervention regarding the FSH-7 risk assessment tool and a positive score's association with the risk of hereditary breast cancer syndromes, as well as the benefits of optimized screening techniques depending on a patient's life-time risk of developing breast cancer. We anticipate that this will likely result in greater acceptance of a formal high-risk assessment for this at-risk population.