Establishment of medical service protocols in large public hospitals for the prevention and control of coronavirus disease 2019.

Coronavirus disease 2019(COVID-19) poses a challenge to hospitals for the prevention and control of public health emergencies. As the main battlefield of preventing and controlling COVID-19, large public hospitals should develop service protocols of diagnosis and treatment for outpatient, emergency, hospitalization, surgery, and discharge. The construction of medical protocols should be based on the risk factors of key points and focused on pre-inspection triage and screening, to establish a rapid response mechanism to deal with exogenous and endogenous risk factors. Implementation of all-staff training and assessment, strengthening the information system, and use of medical internet service are important. This study explores the construction of medical protocols in large public hospitals during the pandemic, and provides a reference for the orderly diagnosis and treatment in hospitals during the pandemic.Copyright © 2021, Peking Union Medical College Hospital. All rights reserved.

External and service factors influencing outcomes in a model of stratified mental health services for Young People

Background: Stratified care aims at matching the intensity and setting of mental health interventions to the needs of help-seeking Young People. In Australia, a 5-tiered system of mental health services is in operation. To aid patient triage to the most appropriate tier, a Decision Support Tool (DST) has been developed and is being rolled out nationally Methods: We analysed outcome data pre-and post-enrolment of about 1500 Young People (aged 16-25) referred to a Youth Mental Health Service delivering medium- and high intensity psychological treatment programs (tiers 3 and 4). We compared outcomes in both tiers during three 12-month periods: (a) in the inaugural phase of tier 4, prior to service saturation and stringent triaging, and prior to the COVID-19 pandemic (2019);(b) during the COVID-19 pandemic when all services were delivered remotely over phone- and video facilities, and when DST triaging was introduced (2020);(c) following return of face-to-face consultations, in a situation of service saturation and stringent DST triaging (2021) Findings: About 22% of Young People in the tier 3 program experienced reliable improvement according to their Kessler-10 (K-10) scale ratings, regardless of changing circumstances. In contrast, 40% of people in the tier 4 program reliably improved during the inaugural phase When circumstances and service delivery changed (COVID-19 restrictions service saturation, DST triaging), the rate of reliable improvement halved to about 20% Conclusion(s): Access to higher intensity psychological programs improves treatment outcomes for help-seeking Young People. However high-intensity services are more sensitive to external and service factors than less intense treatment models.

Radiological Features on HRCT Associated with Poor Outcomes among COVID-19 Patients

Background: Ever since the beginning of the COVID-19 pandemic, physicians started investigating the clinical features and lab markers that can assist in predicting the outcome among hospitalized COVID-19 patients. Aim(s): This study aimed to investigate the association between initial chest CT scan findings and adverse outcomes of COVID-19. Material(s) and Method(s): This was a single centre;hospital (inpatient) based prospective cohort study involving 497 COVID-19 patients admitted to the hospital. The adverse outcome included death and mechanical ventilation. We collected data about 14 identifiable parameters available for the HRCT scan. Result(s): Among 14 studied parameters, only 8 features differed significantly among the patients who had favourable and unfavourable outcomes. These features included number of lobes of lungs involved (3 versus 5, p = 0.008), CT Severity score (16 versus 20, p = 0.004), air bronchogram (p=0.003), crazy paving (p=0.029), consolidation (p=0.021), and pleural effusion (p=0.026). We observed that high CT scores coupled with the diffuse distribution of lung lesions were responsible for poor prognosis in most patients. Conclusion(s): Several features of HRCT when combined can accurately predict adverse outcomes among participants and help in triaging the patient for admission in ICU.Copyright © 2023, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

Resolution Consensus Statement Neutralizing monoclonal antibodies for treatment of COVID-19 - a role in the treatment of vulnerable categories of patients.

In December 2022, the Council of Experts was held. It purpose was to determine the place of virus-neutralizing monoclonal antibodies (NMA) in the ethiotropic treatment of COVID-19 in vulnerable categories of patients. The main issues were identified and their solutions were proposed. At the first visit of pregnant women due to COVID-19, proactive identification of risk factors and early prescription of NMA are recommended, preferably - with published safety data in this category of patients (casirivimab + imdevimab). In patients with oncological and other chronic (rheumatology, pulmonology, gastroenterology) diseases, prophylactic use of NMA is recommended. regardless of the severity of the disease. For patients with chronic pathology regardless of the severity of the disease an early prescription of ethiotropic therapy must be provided, combating the long-term circulation of the virus. To solve the problem of late treatment prescription, it is necessary to: use rapid tests, prescribe NMA if indicated, even if the patient presents late, introduce digital technologies to transfer information about COVID-19 cases between healthcare institutions (HI), create call centers for primary triage of patients, daily hospitals to reduce the burden on the HI. The issue of NMA using related to changes in their activity against new variants of SARS-CoV-2 remains relevant. Among the proposed solutions are: priority of indications over information about the activity of NMA, the diversification of the choice of NMA in HI, taking into account clinical experience, indications for use and prognosis of NMA activity, the use of combined forms of NMA (for example, casirivimab + imdevimab) or a combination of NMA with other means of ethiotropic therapy.Copyright © 2023, Dynasty Publishing House. All rights reserved.

Girft in Action: Advanced Practice Physiotherapist and Advanced Practice Nurse Expertise Provides Valuable Triage and Assessment Clinics for Non-Urgent Rheumatology Referrals

Background/Aims Rheumatology referrals classified as non-urgent/routine are commonly non-inflammatory conditions or medically non-urgent and can have significant waiting times for appointments. These waits were further escalated by the COVID-19 pandemic. Early intervention for noninflammatory conditions can be crucial to good outcomes and long wait-times can have significant adverse impacts while appropriate care pathways are determined. Recent UK GIRFT recommendations include using non-medical health professional expertise in assessment and management pathways to support right place, right time, right care. This study evaluated effectiveness, impacts and patient experiences of Advanced Practice Physiotherapist (APP) and Advanced Practice Nurse (APN) Triage and Assessment Clinics for routine new referrals. Methods The non-urgent/routine referral waiting list was e-triaged by a Rheumatology APP and APN supported by clinical record searches. Patients were contacted by telephone to update on clinical status and appointment requirements determined. Triage criteria were applied to determine new referrals suitable for APP and APN Rheumatology clinics, which included low likelihood of inflammatory disease or new referrals for known diagnosis/stable conditions. Clinics were undertaken with collocated Consultant clinical supervision. Assessment findings were discussed and management agreed, or seen if needed. With waiting list attrition, clinics were expanded to include Consultantdetermined stable condition reviews and follow-up reviews for nonsuspected inflammatory disease. Results At 01 July 2021, 214 new routine referrals were waiting a Consultant appointment (n=103 over 2yrs). Since service initiation, clinic outcomes to date include: 69% (n=243/358) new routine referrals discharged to GP or directed to right pathway with information, advice and self-management resources;8% (n=29) escalated to urgent;3% (11/358) with medical complexity remained on Consultant waitlist. Most common presentations seen included: Osteoarthritis (general or hand);Back and other spinal pain;Fibromyalgia;Persistent Fatigue and Widespread Pain;JHS/hEDS;Positive ANA without clinical features;Musculoskeletal conditions- other. To date, no patients have been re-referred and 329 new patient and 89 follow-up Consultant direct consultations have been spared. There is currently no wait-time for non-urgent/routine appointments. Patient experience feedback on the service has offered a 100% recommendation to continue and expressed highly positive experiences with the MDT approach. Patients value the breadth of expertise and care support, and the timely, thorough and professional service provided. Conclusion Rheumatology non-urgent/routine new referrals with low probability of underlying autoimmune conditions may be effectively and efficiently managed in a collaborative model using an advanced practice physiotherapist and nurse. This innovation has expanded a traditionally medical pathway to an MDT model utilising value-adding nonmedical expertise in service delivery. It has enhanced interdisciplinary learning and is a valued, collaborative approach to patient care. The initiative provides support to GIRFT recommendations of using an MDT skill-set to support improved patient access, service efficiencies and earlier intervention.

Using Novel Remote Electronic Monitoring to Measure and Manage the Rheumatology Clinic Backlog Generated by Covid-19

Background/Aims During the COVID-19 pandemic we were unable to provide regular outpatient services for patients with chronic rheumatic diseases. A ''backlog'' of 6812 patients without an allocated follow-up appointment accrued by September 2021. We quantified this cohort and analysed attempts to deliver care remotely (using video, telephone, and electronic remote management forms (RMFs)). Methods We selected a 12-month ''window'' (May 2020-May 2021) and analysed the number of patients awaiting follow-up during this period. This was initially 3259 patients out of the total backlog 6812. We revisited the number of patients remaining in that cohort on four occasions between September 2021 and September 2022: at baseline, then at 1-, 2-, 6- and 12-month intervals. Each audit cycle was conducted using the same methodology. Alongside usual follow up pathways, (face to face, video or telephone), we implemented remote management forms (RMFs) for different disease groups which were designed by the department;they contained a triage questionnaire, including calculation of disease severity scores, and questions about medications. These were sent out by clinicians to some patients in lieu of a telephone, video or face to face appointments. Data from RMFs was stored in a secure database for clinician review. Data analysis performed in Microsoft Excel and R (version 4.2.1). Results The number of patients without allocated follow-up appointments reduced from 3259 to 326 between Sep-21 and Sep-22. This is a 90% reduction in the backlog over a 12-month period, with a 71% reduction achieved by 6 months. There was a significant, progressive reduction in the number of patients over time (p<0.001 - Chi-square test for trend). Of the 1956 RMFs completed between Sep-21 - Mar-22, only 261 patients recorded a previous appointment date. 154/261 (59%) were completed by patients waiting in the ''window'' of May-20 - May- 21. This indicates a preferential use of RMFs targeting backlog patients. Between 2-8% of the total backlog patients were managed using RMFs based on available data. Conclusion We have significantly reduced the size of our backlog of outpatient follow-up due to COVID-19 over a 12-month period. In-addition these results likely underestimate the effect of RMFs due to this dataset being incomplete. Remote management made a sizeable contribution to this reduction, meaning some of this reduction was achieved without face-to-face encounters. The use of 1956 forms over a 6- month period shows robust integration of our RMFs into outpatient services disrupted by COVID-19 and provides evidence for remote management as a useful tool in outpatient management, with relevance to areas such as Patient Initiated Follow Up pathways. Further work is needed to clarify where remote management is best deployed and which patient groups benefit most from this.

Developing Multidisciplinary Models of Care in Rheumatology at University College London Hospital: 18 Months of Learning from Conception to Delivery and Beyond

Background/Aims The COVID-19 pandemic has placed unprecedented pressures on NHS departments, with demand rapidly outstripping capacity. The British Society for Rheumatology 'Rheumatology Workforce: a crisis in numbers (2021)' highlighted the need to provide innovative ways of delivering rheumatology specialist care. At University College London Hospitals (UCLH) we created a rheumatology multidisciplinary team (MDT) clinic to meet rising demands on our service. The aims of the Rheumatology MDT clinic were to: reduce new appointment/follow-up waiting times, increase clinic capacity, incorporate musculoskeletal (MSK) point of care ultrasound, reduce number of hospital visits and add value to each clinic encounter. Methods We ran a 6-month pilot, supported by our outpatient transformation team, incorporating a Rheumatology Advanced Practice Physiotherapist (APP), Clinical Nurse Specialist (CNS) and MSK ultrasound within a Consultant clinic. The success of the pilot helped secure funding for a further 12 months. Over 18 months we have implemented: APP/Consultant enhanced triage - up to 40% of referrals were appropriate for APP assessment, including regional MSK problems and back pain. This increased capacity for consultant-led appointments. Standardisation of time-lapse between CNS and consultant follow-up appointments to ensure appropriate spacing between patient encounters. Facilitated overbooking of urgent cases afforded by additional capacity provided by the APP. MSK ultrasound embedded in the clinic template. 'Zoom' patient education webinars facilitated by MDT members and wider disciplines e.g. dietetics, to empower self-management and reduce the administrative burden of patient emails/phone calls occurring outside the clinic. Patient participation sessions and feedback to help shape the service. Results During the 6-month pilot we reduced our waiting time for follow-up appointments from 9 months to 2. We now have capacity to book 1-2 urgent cases each week. Pre-MDT the average wait from consultant referral to physiotherapist appointment was 55 days. The MDT allows for same day assessment (reducing 2-3 patient journeys a clinic) and where suitable, facilitates discharge or onwards referral to the appropriate service. A dedicated MDT CNS has shortened treatment times, reduced email traffic between CNS and consultant and allows for same day, joint decision-making resulting in fewer appointments. Zoom webinar feedback has been positive. Patients value the broad expertise of allied health professionals which supports self-management. Embedding ultrasound allows for same day diagnostics, decreased referrals to radiology and reduced hospital visits. Conclusion Our MDT model has reduced waiting lists, decreased treatment delays and cut hospital attendances. Point of care ultrasound allows for same day decision making and abolishes the cost and diagnostic delay associated with referrals to radiology or outsourced providers. Shared decision-making adds value to outpatient attendances, which is reflected in patients' positive feedback. The MDT model maximises the existing workforce skill set by enhancing the APP and CNS role, allowing patients immediate access to their expertise.

Rheumatology Advice Lines: How to Manage Rising Demand and Limited Capacity?

Background/Aims Advice lines services (ALS) are a key aspect of providing coordinated patient care in rheumatology. Demand for rapid access to specialist advice increased during the pandemic due to the disruption of routine outpatient services but it is not clear whether this demand is sustained. We aimed to investigate the changes in demand for ALS, how this varied pre/during COVID-19 and audit the effect upon response times. We also aimed to assess the impact of introducing an email advice service on demand. Methods We audited the number of advice line contacts of a single rheumatology department, serving a population of 500,000 people. The telephone adviceline is provided as an answer machine with an email advice service set up in April 2020. The outcome of each contact is recorded as a) advice only b) action required (e.g., prescription, blood test, GP letter) or c) required appointment (monitor/nurse/ medical). We audited response times using the RCN guidelines of a two-day response1 as the gold standard. Results Demand for advice had been increasing pre-COVID with an average of 368 calls/month (1/1/19-1/7/19) to 420/month (1/7/19-31/12/19). Sixty percent were advice only calls but 27% required additional action. Response times met the audit standard in 97% of cases pre-COVID. During the first two months of COVID demand for advice services doubled, however demand continued to rise although outcomes were similar (Table 1). As the number of contacts increased the proportion of telephone contacts responded to within the audit standard fell. Numbers of email contacts were variable, but response times exceeded the audit standard. Conclusion This audit demonstrates the demand of adviceline services has continued to increase throughout the pandemic and beyond, impacting the ability of services to respond within a timely manner. Ongoing QI work is assessing mechanisms to manage increased demand (using healthcare support workers to triage calls) and investigating reasons for accessing ALS to ensure appropriate advice is available. (Table Presented).

Improving New Patient Appointment Utilisation in Rheumatology Advanced Practice Physiotherapy

Background/Aims Long Rheumatology waiting lists in the UK were further affected by the COVID-19 pandemic;resulting in negative impacts upon the timeliness and efficiency of patient care. The use of Advanced Practitioners within Rheumatology care pathways has been shown to be safe and effective;they can support the Rheumatology workforce and expedite care where patients are appropriately triaged to them. As part of a service provision change in a NHS Trust, an Advanced Practice Physiotherapist (APP) post was funded with the intent to harness these benefits. Initial utilisation of the APP appointments within the Rheumatology provision was found to be low and could be improved. A Quality Improvement (QI) Project was initiated, with the aim to increase APP appointment utilisation to at least 85% over a period of four months, and for at least 75% of these appointments to contain patients who had been appropriately triaged. Methods The 'Model for Improvement' was chosen as the QI approach. The project was led by an APP. Firstly, a stakeholder analysis was performed to identify staff with influence and interest in the project. A root cause analysis found lack of awareness of triaging clinicians and challenges with booking processes as potential reasons for lowerthan- expected appointment utilisation. Change interventions were devised and tested over three Plan, Do, Study, Act (PDSA) cycles. PDSA one developed communication with booking and triage staff to clarify these processes with them. PDSA two educated clinical staff about the APP role, triage criteria and the booking procedures confirmed in PDSA one. PDSA three focused upon sustaining change by reinforcement of the topics established in PDSA two among staff. Outcome measures used were the percentage of available APP appointments utilised per week, and the percentage of these which contained patients who were appropriately triaged. Results APP appointment utilisation increased from a mean of 22% pre-project to 61% during the change intervention period. Sixty-three patients were seen over the 17-week change intervention period;of which 86% had been appropriately triaged. Data showed that 70% of the patients directed to the APP were managed by them (24% discharged and 46% reviewed). Of the remaining patients, 13% were followed up by a Rheumatologist, 12% did not attend and 5% had an alternative outcome such as awaiting advice. Conclusion This QI project led to an improvement in Rheumatology care provision locally. Engagement with support staff, education of clinical staff and implementation of clear standard operating procedures improved the utilisation of the Rheumatology APP resource. Results suggest that the APP role was effective locally in managing appropriately triaged patients, without a negative effect on patient care or other services. Continuing to improve utilisation will support management of the Rheumatology waiting list and improve patient care.

Analysis of Prolonged Caesarean Section Response Time in True Emergency Obstetric Care during Covid-19 Pandemic Era: Study at Kariadi Tertiary Hospital Indonesia

Intro: COVID-19 pandemic era makes quality of obstetric triage care including caesarean section in obstetric true emergency cases delayed. Maternal fetal triage index (MFTI) score is an instrument used to define true emergency in obstetric cases. Decision to delivery interval (DDI) is time interval from caesarean section decision to delivery within <30 minutes standard in emergency cases.This study was designed to evaluate the decision to delivery time interval and its effect on perinatal outcomes and the associated factors during category-1 emergency caesarean section deliveries. Method(s): A prospective observational descriptive study was conducted from 2020-2022 at Kariadi tertiary Hospital. A total of 40 clients who were undergone category-1 emergency caesarean section were included in this study. This is a indepht analysis pregnant women confirmed with COVID-19 infection and had true emergency cases based on MFTI score (stat-priority 1). Finding(s): Among 346 pregnant women with COVID-19, total 160 C-section cases with 40 eligible data were included in this study. Gestational age mostly in their second and third trimester. Maternal comorbidities were diabetes in pregnancy, HIV, pre eclampsia, SLE and thyroid disease. This study showed that DDI <30 minutes were found in 34 cases (85%), DDI 30-60 minutes as many as 6 (15%), and no (0%) DDI >60 minutes. Emergency cases with the shortest DDI were umbilical cord prolapse 3 (100%), fetal distress 14 (93%), placental abruption 5 (83%), impending uterine rupture 5 (83%), and antepartum hemorrhage 7 (70%). Perinatal outcome were Apgar score lower than 7 at 1 minutes (25%) and stillbirth (5%). Conclusion(s): Most of DDI in this study met the recommendation of <30 minutes, but some cases did not meet the standard. This can be caused by multifactorial factors such as advice from the doctor in charge, patient transfer distance, operating room preparation, and anesthetic preparation due to COVID-19.Copyright © 2023

Clinical and paraclinical manifestations at hospital admission (triage) and their association with severity inpatients for SARS-CoV-2 pneumonia

OBJECTIVE: To explored whether initial laboratory data and symptoms predict further clinical outcome. MATERIALS AND METHODS: Retrospective cohort study. Clinical records from March to September 2020 were revised to extract clinical-demographic characteristics, laboratory data and outcomes from patients with SARS-CoV-2 pneumonia, admitted to Centro Medico Nacional 20 de Noviembre, ISSSTE, Mexico City. RESULT(S): One thousand three patients were evaluated at the Emergency-Triage, diagnosed with SARS-CoV-2 and received further in-hospital medical attention. Most of the patients were younger than 65 years-old, male and showed co-morbid conditions, such as obesity, hypertension or diabetes mellitus. After standard therapy, 389 cases (39%) required mechanical ventilation, vasopressor agents or showed fatal outcome. Higher values of C-reactive protein, D-dimer, procalcitonin and low O2 saturation at triage significantly predicted mechanical ventilation (p <0.05) and mortality (p <0.05);while presenting symptoms like fever, myalgia, cough and ageusia showed a particular association with longer hospital stage (p < 0.05). CONCLUSION(S): Laboratory values and presenting symptoms, both evaluated at hospital admission, showed different ability to predict clinical severity, mortality and longer hospitalization time in patients with COVID-19 pneumonia. These results could be useful in possible future pandemic waves of SARS-CoV-2.Copyright © 2022 Comunicaciones Cientificas Mexicanas S.A. de C.V.. All rights reserved.

Evaluating the Use of Patient Reported Outcome Measures to Assess Intra-Pandemic Psoriatic Arthritis Disease Activity and Comparing Them with Pre-Pandemic Clinical Assessments

Background/Aims In our department, patient reported outcome measures (PROMs), including RAPID-3 and PSAID12, were employed during the COVID-19 pandemic in asynchronous consultations for patients with psoriatic arthritis (PsA). We compared pre-pandemic DAS28-CRP with intrapandemic PROMs to assess changes in disease activity since the pandemic. Whilst previous studies have primarily compared PsA PROMs with clinician-assessed scores (e.g. PASDAS), we compare PsA PROMs with clinicians' overall assessment of disease activity;this judgement considers PROMs, serology studies and individual patient feedback. Finally, we assess whether patients with PROMs indicating active disease were followed up appropriately. Methods Clinician-assessed scores were collected between 01/01/2019-01/03/ 2020 (''pre-pandemic''). Between 01/12/2020-31/03/2022 (''intrapandemic''), patient data from electronic surveys were analysed in a secure database for calculation of PROMs. These data, alongside blood results and patient comments, informed clinicians' triage decisions. Clinical outcome data were collected from electronic patient records;>=3 months follow-up appointment allocation was the target for patients with active disease (moderate/high disease activity). Data analysis was performed using r (version 4.2.2). Results In our pre-pandemic cohort (n=393), 79.8% of patients were in remission (per DAS28-CRP). Conversely, the intra-pandemic cohort (n=231) showed remission rates of 14.3% (per PSAID12) and 0% (RAPID-3). Indeed, 33.7% (based on PSAID12) vs 75.8% (RAPID-3) had moderate/ high disease activity. These results were validated in a paired cohort (n=38, score recorded in both windows). Disease activity worsened during the pandemic for 63.2% (PSAID12) and 97.4% (RAPID-3) of patients. PSAID-12 correlated positively with RAPID-3 (r=0.52, p<0.001), especially when RAPID-3 >=6.5 (r=0.75, p<0.001). When comparing PROMs with clinicians' assessment of PsA activity in our paired cohort, PSAID12 and RAPID-3 accurately reflected disease status in 70.6% and 58.8% of patients respectively. 3/9 and 9/27 patients with active disease, based on PSAID12 and RAPID-3 respectively, were seen within three months. Conversely, 7/10 patients who clinicians had deemed to have active disease were seen within three months. Conclusion Despite approximately 80% of patients being in pre-pandemic remission, the majority reported active intra-pandemic PsA. Whilst RAPID-3 skewed patients towards active disease, PSAID12 skewed patients towards remission/low disease activity. PSAID-12 and RAPID- 3 have been previously correlated;however, here we suggest that they could be used interchangeably in patients with high disease activity. PSAID-12 was a better predictor of clinicians' assessment of disease activity, although neither PROM correlated well with >=3 months followup appointment allocation. Although RAPID-3 and PSAID12 helped inform clinicians' decisions, neither alone sufficiently reflects patients' disease states. Remote management is practicable, but future studies should validate these findings across a larger cohort and assess the utility of different PROMs across PsA disease activity categories. Furthermore, multivariate analysis is warranted to ascertain which (combination of) variable(s) (e.g., PROMs, serology results, tender/ swollen joint count) best correlates with clinician judgement.

Pre-existing chronic liver disease is associated with poor outcome in patients with SARS-CoV2 infection

COVID-19 is characterized by predominant respiratory and gastrointestinal symptoms. Liver enzymes derangement is seen in 15-55% of the patients. Cirrhosis is characterized by immune dysregulation, leading to concerns that these patients may be at increased risk of complications following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Patients with metabolic dysfunction-associated fatty liver (MAFLD) had shown a 4-sixfold increase in severity of COVID-19, and its severity and mortality increased in patients with higher fibrosis scores. Patients with chronic liver disease had shown that cirrhosis is an independent predictor of severity of COVID-19 with increased hospitalization and mortality. An international European registry study included 756 patients with chronic liver disease from 29 countries reports high mortality in patients with cirrhosis (32%). Data of 228 patients collected from 13 Asian countries on patients with CLD, known or newly diagnosed, with confirmed COVID-19 (APCOLIS study) showed that SARSCoV- 2 infection produces acute liver injury in 43% of CLD patients without cirrhosis. Additionally, 20% of compensated cirrhosis patients develop either ACLF or acute decompensation. In decompensated cirrhotics, the liver injury was progressive in 57% of patients, with 43% mortality. Patients with CLD and associated diabetes and obesity had a worse outcome. Liver related complications were seen in nearly half of the decompensated cirrhotics, which were of greater severity and with higher mortality. Increase in Child Turcotte Pugh (CTP) score and model for end-stage liver disease (MELD) score increases the mortality in these patients. In a subsequent study of 532 patients from 17 Asian countries was obtained with 121 cases of cirrhosis. An APCOLIS risk score was developed, which included presence of comorbidity, low platelet count, AKI, HE and respiratory failure predicts poor outcome and an APCOLIS score of 34 gave a sensitivity and specificity of 79.3%, PPV of 54.8% and NPV of 92.4% and predicted higher mortality (54.8% vs 7.6%, OR = 14.3 [95 CI 5.3-41.2], p<0.001) in cirrhosis patients with Covid-19. The APCOLIS score is helpful in triaging and prognostication of cirrhotics with Coivd-19. The impact of COVID-19 on patients with cirrhosis due to non-alcoholic fatty liver disease (NASH-CLD) was separately studied in 177 NASH-CLD patients. Obese patients with diabetes and hypertension had a higher prevalence of symptomatic COVID. Presence of diabetes [HR 2.27], fraility [HR 2.68], leucocyte counts [HR 1.69] and COVID-19 were independent predictors of worsening liver functions in patients with NASH-CLD. Severity of Covid in Cirrhosis could also be assessed by measuring ICAM1 the Intercellular Adhesion Molecule, an indicator of Endothelial Injury Marker. in Cirrhosis with Covid 19 Immunosuppression should be reduced prophylactically in patients with autoimmune liver disease and post-transplantation with no COVID-19. Hydroxychloroquine and remdesivir are found to be safe in limited studies in a patient with cirrhosis and COVID-19. And is safe in cirrhosis patients. However, flare of AIH has been reported in AIH patients. For hepatologists, cirrhosis with COVID-19 is a pertinent issue as the present pandemic cause severe disease in patients with chronic liver disease leading to more hospitalization and decompensation.

A free-standing children's hospital helps a post-partum woman needing VV-ECMO during COVID-19 Pandemic when ECMO resources were limited

Our case is a 21 y/o pregnant female, 26weeks gestation who presented to OB triage with COVID-19. She was admitted to OB/GYN unit in acute hypoxic respiratory failure and started on steroids and remdesivir. On hospital day 6, she underwent an emergent c-section for fetal distress due to increasing hypoxia and severe ARDS. As her arterial blood gas being ph 7.17/81/40/29.6/-0.4, lactate 6.8nmol/L with escalating vasoactive medication and ventilator settings;ECMO was decided. However, all adult ECMO resources were limited, even within other adult facilities in Central Florida. Through multidisciplinary discussions amongst OB/GYN, adult ICU, and our pediatric ECMO activation team, it was decided to transfer the patient to our free-standing pediatric hospital. The patient was successfully transferred and cannulated for VV-ECMO. Total ECMO run was 413 hours. On ECMO day #12 patient underwent a tracheostomy. On ECMO day # 17, patient developed headaches and seizure activity in which CT revealed a subdural hemorrhage. She was taken off ECMO and underwent an emergent decompressive craniectomy with hematoma evacuation by our pediatric neurosurgical team. Once stable enough, she was discharged post ECMO day #15 (PICU day #32) to rehabilitation center. Two weeks later she had her bone flap replaced, trach removed, and she walked out of our unit home. This case exudes two key points for discussion. The first point of understanding ECMO physiology allows a team to treat many different patient populations. Although this patient was unusual to our pediatric bedside providers being post-partum, our team knew we could help. The second key point is excellent multidisciplinary teamwork and that communication is essential. At Orlando Health Arnold Palmer Hospital, our ECMO activation team consists of surgeons, pediatric intensivists, CT surgeons, perfusionists, nursing, and administration. We meet virtually to discuss how to execute initiation and daily ECMO treatment plans. There were some on the virtual call that were hesitant in accepting care of this adult due to variety of reasons, saying no would have been the easier answer, but not the right thing to do. What we learned from this case may seem so obvious and simple but very difficult to execute;multidisciplinary teamwork, humility, and open communication gave this patient the ability to walk out of the hospital with her baby. Other pediatric ECMO teams can learn from this case is they too can help in extraordinary times such as during a pandemic when adult recourses are limited.

A Template for Video Telehealth Hand and Wrist Consultations during the Covid-19 Pandemic: A Preliminary Analysis of Patient and Provider Reported Outcomes

Purpose of Study: COVID-19 introduced a rapid shift to video telehealth patient visits. At our institution in Loma Linda, California, less than 13% of hand surgery patients were seen in person at the height of the pandemic, with the majority of patients being triaged to video telehealth appointments. This was challenging for the hand surgeon due to the complexity of a hand patient's physical examination. During this time, it was critical to rapidly develop, test, and implement a tool to assist the surgeon in evaluating and triaging patients effectively over video. The purpose of this project was to develop and implement a tool that would improve the effectiveness and efficiency of video telehealth visits for hand and wrist patients. Methods Used: We developed an informational packet that was sent to patients prior to their video telehealth visit containing a letter of explanation, a new patient questionnaire, and a step-by-step guide with photos for a virtual hand examination. The letter explained the guide's purpose and provided additional instructions to ensure visit effectiveness- remove jewelry and watches, find a space with optimal lighting, wear a short sleeve shirt, etc. In the virtual hand examination guide, we explained common physical examination maneuvers and The Ten Test to assist with virtual sensation assessment. A short "how-to" description in lay terms was given for each of the physical examination maneuvers and included corresponding photographs to maximize patient comprehension. Patients were instructed to read the guide prior to their video visit and to have it available during the visit. Summary of Results: We began to implement this tool in our hand practice for new and established patients in March 2020, and we have since found that our virtual hand examination has become more thorough and efficient. Surgeon satisfaction with this tool has been high, and patients have reported satisfaction and comfort. Patients have felt that it increased their understanding of the virtual physical examination process, decreased frustration, and have stated that they would recommend this guide to other patients scheduled to undergo a video telehealth visit. Conclusion(s): The COVID-19 pandemic necessitated a rapid shift from in-person visits to video telehealth consultations. This subsequently changed the way in which hand surgeons could evaluate their patients. The procedural changes that were adopted during the pandemic can be viewed as a sign of things to come, and we anticipate that video telehealth visits will continue to be commonplace in the future. In the wake of this change, we feel confident that this tool equips the hand surgeon well for an effective and efficient virtual examination and ultimately contributes to patient satisfaction.

A Novel Emr-Based Care Pathway for Nephrolithiasis: Development and 1 Year Utilization

INTRODUCTION AND OBJECTIVE: Patients with acute renal colic due to stones frequently visit the ED. With limited ED resources due to the COVID-19 pandemic, we developed a best practice management pathway within our electronic medical records (EMR) to provide consistent, expeditious and appropriate care for patients with nephrolithiasis. The objective of this study is to describe the development and 1 year outcomes of our EMR Care Pathway for nephrolithiasis. METHOD(S): Our hospital system is composed of many centers. To standardize best practice care, we convened a clinical consensus group, with key stakeholders in emergency medicine, urology, interventional and diagnostic radiology to develop a pathway for the initial work up and management of acute renal colic. AUA guidelines, current literature, and expert consensus across specialties were used to develop the pathway to guide work up and management. Risk assessment tools, and criteria for specific imaging modalities, lab work, and pain protocols were outlined. Criteria for routine discharge with follow-up, including pre-populated links for referrals, indications for urology consult, hospital admission and urgent decompression (stent versus nephrostomy tube) were provided. Data was gathered through the EMR analytics team and descriptive statistics were performed. RESULT(S): The Care Pathway was utilized 944 times from August 3, 2021-September 17, 2022 at 11 different hospitals or care centers (Table 1). Usage increased overtime (r2=0.77). The majority of usage was in the ED (892, 94.4%). A total of 194 providers utilized the Pathway with the majority being residents (64, 33.0%). The pathway included care of 505 unique patients, with 106 primary diagnosis key words triggering pathway use. 139 Urology referrals were placed through the pathway with 124 new 28 day prescriptions of tamsulosin. CONCLUSION(S): An EMR-integrated care pathway has been readily utilized in our system and may augment triage and best practice management of patients presenting with stone disease. Further studies are needed to understand the full impact on outcomes.

How accurate is the clinical component of triple assessment

Introduction: There are eight SBD Clinics (symptomatic breast clinics) across the Republic of Ireland (plus Letterkenny satellite), where over 40,000 new patients are referred by their General Practitioner (GP) each year. Same day triple assessment clinics (TAC) worked well when the TACs were small, but with the current volumes it is not possible to image all patients same day. The first component of the triple assessment is clinical (E score). The E score dictates what imaging is required (E1 normal, E2 benign, E3 likely benign, E4 suspicious, E5 clinically breast cancer) and triages patients into urgent /non urgent and this became even more important in the COVID crisis. Despite the importance of the E score, there is very little in the literature about its accuracy. The aim of this study was to look at how good the E score is at indicating/not indicating cancer in a large volume SBD clinic in Dublin. Method(s): Single large centre SBD clinic in St James Hospital, Dublin. The study included the E score and cancer/not in all patients attending TAC clinic from 2018 to 2021. Data was collected prospectively and collated by database manager. Result(s): [Formula presented] Conclusion(s): This single centre study suggests that the E score is a reliable triage tool in a busy TAC clinic. As breast surgeons we need to establish a standard level of accuracy for clinical assessment in the TAC similar to that for the R (radiology ) score and B (biopsy) score.Copyright © 2023

Strategies to reduce risk of SARS-CoV-2 in respiratory function laboratories

Introduction: SARS-CoV-2 is a highly infectious disease transmitted by aerosol and droplet particles. Respiratory function tests are aerosol generating procedures. Consequently, this increases the risk of exposure to SARS-Cov-2 to healthcare workers and patients visiting respiratory function laboratories. Proposed recommendations on pulmonary function testing during the SARS-CoV-2 pandemic were published by the ERS and the ANZSRS/TSANZ. Aim(s): To identify strategies implemented in respiratory function laboratories to reduce the risk of SARS-CoV-2 transmission. Method(s): An electronic questionnaire of respiratory laboratories on infection control measures implemented during the SARS-CoV-2 pandemic was sent to active ANZSRS members in an explanatory email. All data obtained was de-identified with only one response per laboratory included in the analysis. Result(s): Responses were received from 32 laboratories. 81% were from a hospital setting, 61% were TSANZ accredited. 94% and 78% of laboratories identified that they had read the ANZSRS/TSANZ statement and the ERS statements, respectively. 25% and 22% of laboratories implemented modifications based on these statements while 13% and 9% indicated barriers prevented changes being made. Infrastructure was the main barrier identified following both statements. The main strategies implemented are summarised in the below table. Strategy implemented Laboratories (%) Triage patients on clinical urgency 91 Screening prior to appointment or on arrival 100 Scientist wearing fit-tested masks during tests 78 Scientist wearing eyewear during tests 75 Wait time post close contacts (routine-14 days) 50 Wait time post positive infection (routine-14 days) 43 Wait time post close contacts (urgent-10 days) 31 Wait time post positive infection (urgent-10 days) 22 Investigated air room changes/hour 66 Allow at least a 15-min washout period between patients 34 Investigated best cleaning methods for their equipment 65 Utilise telehealth 21 Conclusion(s): Laboratories in Australia and New Zealand have put in place a variety of changes in accordance with recommendations made in position statements to reduce risk of SARS-CoV-2 transmission. While some laboratories had already implemented strategies, the ERS and ANZSRS/TSANZ publications have given clear guidelines to reduce aerosolised transmission of SARS-CoV-2.