An Agent-Based Simulation Model of Epidemic Spread in a Residential School for Children with Disabilities

People with disabilities, especially those living in institutions, are at higher risk during pandemics, while schools also play important roles in disease spread. Yet, less attention is paid to the intersection of risk factors at residential schools for children with disabilities. Better understanding of spatial and behavioral factors that contribute to epidemics in such schools is needed for effective public health plans and responses, especially for pandemics where vaccines may be initially unavailable. An agent-based model of a school for deaf children was developed from Norwegian archival sources and 1918 influenza pandemic data to test impacts of non-pharmaceutical interventions. Results show differences in the timing and pattern of spread based on whether the first case is a student or staff member, while epidemics are smaller with more student bedrooms or a hospital ward. Implications for COVID-19 and future pandemics, including the need to combine different infection control measures, are discussed. Copyright © 2023 The Author(s).

COMMUNICATION CONUNDRUMS OF COVID-19- BARRIERS TO COMMUNICATING WITH DEAF AND HARD OF HEARING PATIENTS DURING A PANDEMIC

CASE: A 53-year-old female with a past medical history of neonatal meningitis complicated by congenital deafness was admitted for evaluation of disorientation. Collateral history provided by family revealed progressive fatigue and labial itching for 1 month. Physical examination revealed excoriated, irregular nodules of the labia with partial obstruction of the vaginal canal. CT of abdomen and pelvis revealed a large mass involving the posterior wall and floor of the bladder with extension to the vagina and vulva, inguinal lymphadenopathy, and multiple liver masses. The admitting team attempted communicating with the patient using a virtual American Sign Language (ASL) interpreter via an iPad and written communication, but both were limited by the patient's vision impairment. The patient was able to lip-read, but this approach was complicated by the need for mask-wearing during the COVID-19 pandemic. The care team was reluctant to remove their masks to avoid putting the patient's health at risk, as her vision impairment would have required them to stand close. The team attempted to arrange for family to assist with communication, but this was limited by hospital policy restricting visitors due to COVID-19. Eventually, an interdisciplinary goals-of-care meeting was held with the patient and her family to discuss diagnosis with the assistance of in-person ASL interpreters. The patient had a better understanding of her diagnosis with in-person interpretation but expressed feeling excluded from her care plan and lack of empathy in communication from her providers. IMPACT/DISCUSSION: This care team was faced with multiple barriers to conveying a life-changing diagnosis and holding a meaningful goals-of-care discussion with the patient. The goal was to convey a diagnosis and create a plan through shared decision-making as promptly and empathetically as would be done for a patient without these barriers to communication. Despite exhausting the available resources for communicating with the deaf population, the ability to communicate at the same standard as patients without their medical condition remained limited. It is important to identify the limitations to communication in this case to improve communication with deaf patients. Unavailability of in-person ASL interpreters during the night, lack of staff education regarding resources available to facilitate communication between providers and patients who are deaf, prevention of communicating emotion with ASL due to mask-wearing, and prevention of family member visitation, who often develop their own effective ways of communicating, due to hospital policy were all barriers to effective communication in this case. CONCLUSION: This case illustrates the challenges imposed by COVID-19 safety precautions on communicating with patients who experience deafness as well as the need for new resources and staff education on current resources available, both inside and outside of their institutions, to assist with communicating with deaf patients.

COMPLICATED COMMUNICATIONS DURING THE PANDEMIC

CASE: The Pandemic has been one of the greatest challenges in health care. Communication is the most vital part of the patient visit. The pandemic hindered the doctor-patient communiciation in unimaginable ways. Besides using Televisits with its new set of challenges, I present these clinic visits with complicated communication. Case 1-Deaf mute patient 45 year male deaf mute with chronic kidney disease stage 3a with hypertension and med "non compliance." The interpreter used Americal sign language along with lip reading. Lip reading is hindered by the standard mask. This interpreter used a special type of lip tranparent mask. We discovered that the patient was confused regarding the BP medications attributing to his non compliance. Repeat BP check at 1 and 3 months was at goal after he understood the instructions. Other patients also found the lip transparent mask to be useful when they had hearing deficit or English accent problem and relied on lip reading for communication. Case 2-Grieving 42 year old Spanish only speaking lady just lost her husband to COVID. She herself was recovering from COVID and was grieving. Computer based interpreter was used along with social distancing and shield and mask. This made comforting the patient challenging. Case 3-Computer based interpreters A 28 year female patient speaking only Amharric had breast pain. I used computer based interpreter with audio only option and kept the video off, especially during the physical examination. 89 year Vietnamese only speaking male had multi organ failure. I had to use the computer based interpreter to explain the situation to him and family and offer them hospice. Hospice concept was totally new to them. They were committed to caring for him at home and felt that hospice was an intrusion that God did not want and was not culturally acceptable. Today they are happy with home hospice care. Case 4-Intellectually challenged patients-Cerebral palsy 40 year aphasic male with cerebral palsy came with his host caregiver. Patient had open sores on his neck that he had been scratching. He was cooperative but was pulling at his mask and was unable to understand my simple instructions through my mask and shield. IMPACT/DISCUSSION: Clear communication is a key to a good clinic visit and patient and provider satisfaction. Low English proficiency (LEP) is a road block that we try to overcome by using interpreters. This vignette is an excellent demonstration of challenges to communication that we encountered during the pandemic. Publication here will give an opportunity to identify with our struggles, exchange ideas and help our trainees. CONCLUSION: Wearing mask and social distancing saved countless lives during the COVID pandemic.It presented unprecendented challenges to doctor-patient communication. It is important to anticipate, understand and educate our learners about these challenges and continue to provide culturally competant care.