Retour d'expérience d'un hôpital pédiatrique pendant la crise Covid-19 en Île-de-France

La crise sanitaire de la Covid-19 du printemps 2020 a peu touché les enfants avec peu d'hospitalisations dans les hôpitaux pédiatriques. Le défi a été d'apporter une aide aux hôpitaux adultes avec un personnel principalement formé à la pédiatrie tout en maintenant la permanence des soins urgents pour les enfants atteints ou non de la Covid-19. À l'hôpital universitaire Armand-Trousseau, nous avons créé des unités dédiées pour les enfants atteints de la Covid-19, identifié les spécificités des enfants atteints de la Covid-19 et notamment les formes de Kawasaki like ou PIMS (paediatric multisystem inflammatory syndrome), créé une unité de réanimation adulte au pic de l'épidémie pour augmenter les capacités en lits de réanimation dans notre région, mutualisé notre centre de dépistage pour le personnel d'hôpitaux adultes. Enfin, nous avons envoyé plus de 140 personnels médicaux et paramédicaux dans les hôpitaux adultes de notre groupe hospitalier. Cette aide a pu être organisée grâce aux liens étroits établis par des cellules de crises communes avec les hôpitaux adultes de notre groupe hospitalier. Nous rapportons ainsi un retour d'expérience d'un hôpital pédiatrique au cours de la crise de la Covid-19 en Île-de-France.Alternate : Children were relatively spared by the COVID-19 health crisis during spring 2020, with few hospitalizations in pediatric hospitals. For that reason, one of themain challenges for pediatric hospitals was to provide staff support to adult hospitals with health workers mainly trained in pediatrics. In our hospital, we created dedicated units for children with COVID-19, identified the specificities of children with COVID-19 and more specifically of children with "Kawasaki like” or PIMS-TS (Pediatric Multisystem Inflammatory Syndrome temporally associated with COVID-19), created an adult intensive care unit at the peak of the outbreak to increase adult resuscitation capacity in our region and pooled our staff screening center with the other adult hospitals. Finally, we have sent more than 140 health workers to other adult hospitals. This support was provided thanks to the close links established between our pediatric hospital crisis unit and those from the other adult hospitals included in our Hospital Group. We report here a feedback from a pediatric hospital during the COVID-19 crisis in the region of Ile-de-France.

Ensuring continuity of care during the COVID-19 pandemic in Guinea: Process evaluation of a health indigent fund.

Background: The emergence of the COVID-19 has disrupted the health and socioeconomic sectors, particularly in resource-poor settings such as Guinea. Like many sub-Saharan countries, Guinea is facing shortcomings related to its fragile health system and is further affected by the passage of the Ebola virus disease. The pandemic has worsened the socio-economic situation of the poorest people, leading to their exclusion from health care. To promote access to care for the most vulnerable populations, a system was set up to provide care for these people who are victims of health marginalization to promote their access to care. This study aimed to analyze access to health services by vulnerable populations during the COVID-19 pandemic in Guinea through the establishment of a health indigent fund (HIF). Methods: This was a qualitative study to assess the project implementation process. A total of 73 in-depth individual interviews were conducted with beneficiaries, health workers, community health workers and members of the HIF management committee, and a few informal observations and conversions were also conducted in the project intervention areas. The data collected were transcribed and coded using the deductive and inductive approaches with the Nvivo software before applying the thematic analysis. Results: A total of 1,987 indigents were identified, of which 1,005 were cared for and 64 referred to all 38 intervention health facilities within the framework of the HIF. All participants appreciated the project's social action to promote access to equitable and quality health care for this population excluded from health care services. In addition, the project has generated waves of compassion and solidarity toward these "destitute" people whose main barrier to accessing health care remains extreme poverty. A state of poverty that leads some to sell their assets (food or animal reserves) or to go into debt to ensure access to care for their children, considered the most at risk. Conclusion: The HIF can be seen as an honest attempt to provide better access to health care for the most vulnerable groups. Some challenges need to be addressed including the current system of acquiring funds before the attempt can be considered scalable.

Measures adopted by indigent mothers in Kilifi County to tackle maternal health challenges during the COVID-19 pandemic: A qualitative study

Many sub-Saharan African countries have experienced various challenges that threaten the quality of health services offered to the population. The COVID-19 pandemic disrupted access to healthcare services in many countries as they grappled with implementing measures to curb its spread. The consequences of COVID-19 have been catastrophic for maternal and newborn health. There is a dearth of information on expectant mothers' negotiation mechanisms to access maternal health services during COVID-19 in Kenya. This rapid qualitative study draws data from purposefully selected 15 mothers who were either pregnant or had newborn babies during the COVID-19 pandemic in Kilifi county in Kenya. Data were analyzed thematically and presented in a textual description. Women used the following alternatives to access maternal health: giving birth at the homes of traditional birth attendants (TBAs), substituting breastfeeding with locally available food supplements, relying on limited resources and neighbours for delivery and local savings and rotating credit associations. This study shows that urgent measures are needed to provide high quality maternal and child health services during and after the COVID-19 pandemic. These include but are not limited to developing special interventions for the pregnant women for any emergency and establishing trust between communities and individuals through the TBAs. © 2022, Women's Health and Action Research Centre. All rights reserved.

Knowledge of COVID-19 and the impact on indigents' access to healthcare in Burkina Faso.

BACKGROUND: COVID-19 constitutes a global health emergency of unprecedented proportions. Preventive measures, however, have run up against certain difficulties in low and middle-income countries. This is the case in socially and geographically marginalized communities, which are excluded from information about preventive measures. This study contains a dual objective, i) to assess knowledge of COVID-19 and the preventive measures associated with it concerning indigents in the villages of Diebougou's district in Burkina Faso. The aim is to understand if determinants of this understanding exist, and ii) to describe how their pathways to healthcare changed from 2019 to 2020 during the COVID-19 pandemic. METHODS: The study was conducted in the Diebougou healthcare district, in the south-west region of Burkina Faso. We relied on a cross-sectional design and used data from the fourth round of a panel survey conducted among a sample of ultra-poor people that had been monitored since 2015. Data were collected in August 2020 and included a total of 259 ultra-poor people. A multivariate logistic regression to determine the factors associated with the respondents' knowledge of COVID-19 was used. RESULTS: Half of indigents in the district said they had heard about COVID-19. Only 29% knew what the symptoms of the disease were. The majority claimed that they protected themselves from the virus by using preventive measures. This level of knowledge of the disease can be observed with no differences between the villages. Half of the indigents who expressed themselves agreed with government measures except for the closure of markets. An increase of over 11% can be seen in indigents without the opportunity for getting healthcare compared with before the pandemic. CONCLUSIONS: This research indicates that COVID-19 is partially known and that prevention measures are not universally understood. The study contributes to reducing the fragmentation of knowledge, in particular on vulnerable and marginalized populations. Results should be useful for future interventions for the control of epidemics that aim to leave no one behind.

ADDRESSING SOCIAL NEEDS TO ENABLE SUCCESSFUL CARE TRANSITIONS FOR PATIENTS HOSPITALIZED WITH COVID-19: THE CRITICAL ROLE OF COMMUNITY HEALTH WORKERS

STATEMENT OF PROBLEM/QUESTION: The COVID-19 pandemic highlights the disproportionate burden of disease on communities made vulnerable by structural inequities. The pandemic has increased economic hardship, including housing instability, food insecurity and ability to pay bills. Hospitalization for COVID-19 is an opportunity to address unmet healthrelated social needs (HRSNs) and connect patients with community resources. DESCRIPTION OF PROGRAM/INTERVENTION: Community health workers (CHWs) play a critical role in response to public health crises. To address the inequitable burden of COVID-19 on Austin's Latinx population, we implemented a pilot program at an academic hospital where a CHW helps patients navigate care transitions and address unmet HRSNs. The care team referred patients with COVID-19 to the CHW, who met with patients to establish rapport, provide language-concordant communication between the care team and patient/family, deliver health promotion education, and assess HRSNs. MEASURES OF SUCCESS: This includes three typical cases describing key components of the CHW pilot program. CHWs connected patients and families to community resources and facilitated discharge planning and connection with primary care providers. The CHWs continued to follow patients for at least 45 days after discharge to assist with care coordination. We provide qualitative data from patients and healthcare professionals. FINDINGS TO DATE: Patient 1 is a 38-year-old day laborer with hypertension hospitalized with COVID-19 pneumonia. His family of four is undocumented and faced economic insecurity due to loss of work from the pandemic. The CHW assisted with utilities, bills, food and rent through coordination with local organizations to provide direct financial assistance to the family. Patient 2 is a 45-year-old woman with diabetes hospitalized with COVID-19 pneumonia. She is a mother of three children, two with disabilities. In addition to financial insecurity, she identified transportation as a primary HRSN. The CHW arranged financial resources to fix their car, which allowed the family to access school and clinic resources. Patient 3 is a 36-year-old man hospitalized with COVID-19 pneumonia. The CHW connected the family, including three children, with their school social worker, enabling access to financial support for utilities, food and clothes. The CHW arranged free food delivery to their home for four months. The CHW also secured county-based indigent care coverage for the patient, enabling hospital follow-up with a primary care provider. The patient's wife noted, because of the CHW, “We never felt alone” and now feel “capable of navigating a health system that we never felt we had access to.” KEY LESSONS FOR DISSEMINATION: CHWs, as patient advocates and skilled care navigators, build trust, establish longitudinal relationships with patients and address unmet HRSNs that can enable successful care transitions. CHWs can alleviate the disproportionate burden of COVID-19 on individuals with unmet HRSNs. Supporting the work of CHWs within hospital care teams can improve care transitions.

SYSTEMATIC REVIEW OF TELEHEALTH INTERVENTIONS IN PATIENTS WITH CHRONIC LIVER DISEASES

Background and aim Telehealth (TH) interventions may improve access to care, diseasespecific and general quality outcomes in chronic liver diseases (CLD). Given the current COVID-19 pandemic, TH interest has grown exponentially. We aimed to systematically evaluate outcomes of TH interventions in a variety of CLD. Methods We used key terms and searched PubMed/EMBASE from inception to 12/5/2020 for observational studies or clinical trials. Two authors independently screened s. We included any type of CLD, including post-transplant patients. Disagreements were solved by a third reviewer. We excluded s, case-reports, and reviews. We extracted the outcomes defined by the authors for each CLD (chronic hepatitis C or B, decompensated cirrhosis, hepatocellular carcinoma-HCC-, liver transplant referral and readmission/rejection after transplantation or weight loss in nonalcoholic fatty liver disease-NAFLD). No meta-analysis was planned due to the heterogeneity of the data. Results Of a total of 3567 studies screened, 29 met inclusion criteria (Table 1). Of these, 17 reported on HCV treatment outcomes [14 video telemedicine, 2 remote specialist consultation, and one texting based intervention]. All studies showed no statistically significant differences between sustained virological response (SVR) rates in telehealth intervention groups compared to control groups or historic general population. 4 retrospective studies examined decompensated cirrhosis/liver transplant referral, followup after transplant, and showed a reduction in time to transplant (138.8 days vs 249 day, P<0.01), mortality or readmission following transplant (28% vs 58%, P=0.004), and improved referral timing (0% immediate rejections of transplant referral vs 41%, P<0.001). Other important outcomes measured also demonstrated benefit in favor of telemedicine incorporation including autoimmune hepatitis remission (100% vs 77.3%, P=0.035). One study assessed chronic hepatitis B outcomes and had no difference in development of hepatocellular carcinoma, ALT fluctuation or cirrhosis over 2 years of follow-up. Finally, two studies assessed weight loss in nonalcoholic fatty liver disease: the prospective study showed no change in weight loss while the randomized clinical trial did. Conclusion TH interventions in patients with CLD shows consistent equivalent or improved clinical outcomes compared to traditional encounter. Similar SVR, decreased time to liver transplant referral and mortality outcomes were observed in the TH groups. In CHB, development of HCC, cirrhosis or biochemical remission was similar as well. In the NAFLD clinical trial, the TH group had 5%+ weight loss over 3 months compared to the control group. In the light of the ongoing COVID19 pandemic, TH in CLD should be the bridge to improve clinical outcomes when face-to-face encounters are not possible. (Table Presented) Abbreviations: DOC: Department of Corrections, TH: Telehealth, SVR: sustained virological response, SVR12: sustained virological response for 12 weeks, SVR24: sustained virological response for 24 weeks, GP: general practitioner, RCT: randomized controlled trial *Sterling et al, 2018 compared patients with private insurance in clinic vs indigent patients in clinic vs patients in the department of corrections using telemedicine. †Lepage et al, 2020 compared patients in outpatient clinic vs mixed delivery including clinic and telemedicine vs telemedicine only. ††These studies reported rates of SVR in their cohort and compared to historical rates of SVR in similar cohorts.

Living Barriers and the Emotional Labor of Accessing Care from the Margins

Farfan-Santos asserts that in my research with undocumented women, I found that mothers take on the role of health mediators and navigators, bridging the gaps in healthcare access for their families as they regularly confront a prohibiting healthcare system despite marginalization and the fear of deportation. Houston is home to the Texas Medical Center, the largest medical center in the country;however, undocumented immigrants who are also uninsured experience limited access to such resources;their access is restricted by their immigration status, but also by their zip code, income, and eligibility for public health programs, among other factors. The cumulative effects of the COVID-19 pandemic are still unclear, but the early months of 2021 quickly revealed the deeply entrenched inequalities and barriers in the U.S. healthcare system. The COVID-19 pandemic has heightened the need to pay closer attention to longstanding socio-structural barriers in healthcare. We must also, however, continue to highlight the nuanced ways in which these barriers manifest in everyday interactions, even before a person reaches a doctor.

INCREASING HERPES ZOSTER VACCINATION RATES IN A HIGH RISK IBD POPULATION

Background and Aim: The American College of Gastroenterology recommendations are that adults over age 50 years old, with Inflammatory Bowel Disease (IBD), including those on immunosuppression, should be vaccinated against Herpes Zoster (HZ). Recently a recombinant HZ vaccine that is safe for people on immunosuppression called Shingrix, was approved and is administered as a 2-dose series with the second dose given 2 to 6 months after the first. The aim of this study is to improve HZ vaccination rates in IBD patients seen in the gastroenterology (GI) clinic at a Houston county hospital serving an indigent population over a 1-year period to over 75%. Methods We performed a retrospective analysis of IBD patients over age 50 years old, that have been seen in the GI clinic over a 2-month period at a 323-bed county hospital in northeast Houston that serves an uninsured/ underinsured lower socioeconomic population. We found that only 4.8% (1/21) of these patients were vaccinated for HZ. We then implemented a series of QI interventions as follows 1) Stakeholders had a 10-minute informal training session about the latest vaccination guidelines, vaccination side effects and safe practices with a stepwise algorithm placed at all clinic computer stations 2) A standardized IBD template was created with hard prompts to record vaccination status and 3) Nurses were educated on performing 2nd dose vaccination series on clinic follow up. Results During the past 4 months, 41 patients have met the vaccination criteria. Out of those 41 patients, 80.5% (33/41) received vaccinations, while 12.2% (5/41) did not receive immunizations and 3 declined immunizations when offered (Figure 1). At this time, 18.2% (6/33) patients have received their second Shingrix dose with no recorded side effects to date. Discussion A query of ICD-10 codes of HZ infections in IBD patients seen in our clinic over the past 5 years, revealed that 15 patients had experienced significant HZ flares;of whom 20 % (3/15) developed a secondary flair during that 5-year period and another 20% (3/15) developed herpes zoster opthalmicus, causing unilateral blindness in 2 out of those 3 patients (Figure 2). Through our QI implementation, we have successfully increased HZ vaccination rates from 4.8% to 80.5%. We hope to increase our 2nd dose vaccination rates in the following year, which has largely been impacted by a decrease in in person clinic visits due to COVID-19. This will help prevent HZ flares and serious complications from HZ in the future (Image Presented) (Image Presented) (Table Presented)

Pandemic adaptation measurement of cook county health pain patients to acupuncture telehealth over a 12-month period

Background: Cook County Health (CCH) was founded in 1834 to provide health aid to the indigent residents of Cook County. Prior to the Covid-19 pandemic, this safety net for healthcare provided care to thousands of people, with over 1 million unique visits per year. In 2011, the Acupuncture Department was added to the Pain Management Center, as an Integrative Medicine approach to pain management, with Frank Yurasek appointed as Director, under the direction of Dr. Maria Torres, MD, PMC Chair. Pain Management Center patients, suffering in order of complaint, from: back, neck, hip, shoulder, knee pain, gun shot, beating and stabbing victims, workplace injuries, and motor vehicle accidents. Pre-pandemic patient levels averaged 20 to 25 treatments daily, Monday through Friday. That number went to zero in March of 2020, due to the pandemic. Telehealth Program: Following shutdown, the acupuncture department met to develop and deliver Telehealth Acupuncture services to its patients, who had come to depend on acupuncture as an opiate sparing intervention. Customized Acupuncture Telehealth visits included tailored acupressure instructions to provide pain relief, as well as exercise, stretching and breathing routines based on simplified Qi Gong practices, diet modifications, and herbal tea recommendations. Follow-up calls were made to monitor progress and modify program components as needed. The weekly flow chart, follow-up scripts, and response summaries will be reviewed in this presentation. Proposal: Acupuncture Pain Management patients have begun to return to the clinic for in person follow-up care. Completion of a proposed anonymous, short questionnaire will be discussed with acupuncture patients. Those interested in participation, will pick up the questionnaire, complete, and leave behind with the front desk Clerk. In the past, the utilization of acupuncture patient questionnaires has provided valuable feedback, and we look forward to providing the patient feedback on our Telehealth Acupuncture visits.