MAKING AN IMPACT ON THE COVID PANDEMIC

STATEMENT OF PROBLEM/QUESTION: When hospitals and skilled nursing facilities (SNF) were impacted during the COVID surge, what healthcare delivery model can be used to increase hospital bed capacity while maintaining quality care for marginalized patients with no access to a SNF? DESCRIPTION OF PROGRAM/INTERVENTION: Background - Santa Clara Valley Medical Center is the second largest public safety net healthcare system in California. During the COVID surge, our hospitals experienced a significant demand for hospital beds. At this time, SNFs were impacted and did not accept patients with barriers in discharge planning. Problem: How to safely discharge non-acute patients with no accepting SNF to increase hospital bed capacity. Intervention: Develop a post-acute care team (PACT) for marginalized, non-acute patients. These patients were initially hospitalized for severe medical conditions but could not be safely discharged once stabilized. During the COVID surge, Santa Clara County operationalized a 36-bed, lowacuity hospital called DePaul Health Center (DPHC) through an emergency state-issued alternative care license. DPHC implemented a novel healthcare model for post-acute transitions of vulnerable, non-acute patients during a resource-constrained time period. Of the 131 admissions to DPHC, 42% had unstable housing, 29% had active substance use, and 100% had no accepting SNFs. The operationalization involved: - Training volunteer outpatient providers to work in an inpatient setting with COVID-positive patients. - Building a referral model to include all hospitals in our county. - Transition of care services including: direct transition to drug treatment programs, linkage to medical respites, COVID vaccinations, specialty care followup, and medication delivery/teaching at bedside. MEASURES OF SUCCESS: - Number of hospital bed days saved. - Number of additional potential hospital admissions. - Implementation of high-quality inpatient services for non-acute patients. FINDINGS TO DATE: Over six months, DPHC admitted 127 patients across three county hospitals. DPHC allowed for a potential 446 additional hospital admissions (based on 2232 potential bed days saved and an average hospital LOS of 5 days per hospital admission). KEY LESSONS FOR DISSEMINATION: - Establishing a post-acute care team addresses structural inequities prevalent in our healthcare system for marginalized patients. - Incorporating a post-acute care team improves access to SNF for marginalized patients.

LANGUAGE-SPECIFIC BARRIERS AND FACILITATORS TO TELEMEDICINE USE FACED BY SAFETY-NET HEALTH CARE SETTINGS DURING THE COVID-19 PANDEMIC

BACKGROUND: The COVID-19 pandemic forced many primary care visits from in-person to remote via telemedicine, including phone and video visits. Health systems face challenges ensuring telemedicine access for patients with limited English proficiency (LEP) who are disproportionately seen in safetynet health settings. METHODS: We examined safety-net health settings delivering primary care via telemedicine during the pandemic and participating in a quality improvement collaborative across California (n=43 sites, n=11 interview sites). All sites reported the number and modality of primary care visits (in-person, phone, video), patient demographics, payer mix, and language needs. For qualitative data, we purposively sampled to capture sites representing geographic diversity, a range of telemedicine maturity, and with large populations of patients best served in non-English languages. We then conducted semistructured interviews focused on barriers and facilitators to use and uptake of telemedicine among patients, providers, and staff. Interviews were audio recorded, transcribed, and analyzed with a focus on language-specific considerations, using a mixed inductive/deductive approach informed by the Consolidated Framework for Implementation Research. RESULTS: The sites cared for racially and ethnically diverse patients with nearly 75% on Medicaid. Over half of patients (52%) across sites were better served in a language other than English (median: 50%, range 39-83%). All sites experienced an immense increase in the number of telemedicine visits conducted in the six months after March 2020 compared with the six months prior (range: 258-8,273,200%). As of February 2021, most sites provided a minority of telemedicine visits over video compared with phone (median: 5% video, range 0-69%). Interview data showed that most sites mapped telephone visits workflows onto pre-existing infrastructure and resources. Telemedicine vendors provided limited language options and sites faced challenges integrating interpretation services into video visits. Interview respondents were concerned that patients with LEP faced intersecting challenges related to technology access and limited digital literacy, exacerbating language-related barriers to telemedicine. Sites relied on language concordant staff and additional technical support to overcome barriers and facilitate access for LEP patients. CONCLUSIONS: While telemedicine has potential to increase access to primary care, care settings must prioritize language concordance among patients, providers, and staff, and telemedicine platform developers must adapt existing tools to improve their accessibility for patients with LEP.

TELEMEDICINE DURING COVID-19 PANDEMIC IS AN ACCEPTABLE MODALITY FOR LIVER CARE DELIVERY IN VULNERABLE POPULATIONS WITH FATTY LIVER DISEASE

Background and Aim: The COVID-19 pandemic has modified liver disease-related care delivery with implementation of telemedicine, previously unavailable in safety net settings. We aimed to assess patient satisfaction with telemedicine for hepatology care (telehepatology) in vulnerable populations with fatty liver disease (FLD). Methods: From 06/01/2020-11/ 30/2021, 218 consecutive participants with non-alcoholic or alcohol-related FLD with or without advanced fibrosis/cirrhosis receiving care in hepatology clinics within the San Francisco safety net health care system were surveyed by phone or in person. Sociodemographic and clinical parameters were captured by self-report and through the electronic medical record. Satisfaction with telehepatology was measured using a Likert scale from 1-5 with 1 representing “very dissatisfied” and 5 representing “very satisfied”. Median time of survey assessment since onset of the pandemic (03/01/2020) was 60.3 (range 8.7-90.3) weeks. Alcohol use in the prior 12 months was categorized as none, moderate (#1 drink/day for women and #2 drinks/day for men), and heavy (>moderate). Severity of liver disease was assessed by liver biopsy (n=97), MR elastography (n=88), or presence of liver nodularity on abdominal imaging (n=33). Descriptive analyses were performed and multivariable models were used to assess factors associated with satisfaction with telehepatology, adjusting for age, sex, and time since pandemic onset. Results: Median participant age was 52 years, 62% were female;60% Hispanic, 20% Asian, 11% White, 3% Black, 6% other race/ethnicity;and 75% were non-English speakers. 37% used alcohol (23% had heavy alcohol use), 40% had diabetes, and 35% had advanced (stage 3-4) fibrosis/cirrhosis. 166 participants (76%) had received telemedicine care and 126 (58%) had telehepatology. Overall, 72% reported satisfaction (55% very satisfied) with telehepatology. A similar proportion of those with and without advanced fibrosis/cirrhosis were satisfied with telehepatology (70% vs 71%, p=1.0). Alcohol consumption (vs none) especially moderate use appeared to be associated with less satisfaction (Coef -1.1, p=0.004 for moderate use and Coef -0.5, p=0.2 for heavy use) but no other sociodemographic or clinical factors were associated with telehepatology satisfaction on multivariable analysis. Conclusions: In this diverse and vulnerable population, in which a significant proportion had advanced fibrosis/cirrhosis FLD, over 70% were satisfied with telehepatology. Importantly, alcohol use negatively impacted perceived satisfaction with telehepatology, suggesting that patients who use alcohol may benefit from adaptations to telemedicine care delivery. As vulnerable populations have known barriers to healthcare access, telehepatology represents an important modality for liver care, and has the potential for reducing health disparities.

EARLY ONSET COLORECTAL CANCER: RACIAL DISPARITIES & PRESENTATION TO HEALTH SYSTEM

Purpose/Background: Early onset CRC (EO CRC), patients <50yo, is increasing in incidence. Diagnosis is driven by symptoms as the patients are ineligible for screening. Where patients access the health system is unclear. Hypothesis/Aim: We hypothesize that non-white patients with EO CRC present at disproportionate rates to the Emergency Department (ED). Methods/Interventions: Our institutional tumor board registry was reviewed for patients who were presented from August 2020-August 2021. Clinical chart review for race, sex, age, hospital presentation, site of malignancy, and access to health system: primary care, emergency department, outside referral, were extracted. Access to the health system was determined by who ordered the diagnostic colonoscopy or imaging study. Results/Outcome(s): One-hundred ninety-seven patients with colon and rectal adenocarcinoma were discussed at tumor board between August 2020-August 2021 (Table 1). Fifty-seven were EO and 140/197 were age >50. The sex distribution was approximately equal across ages. Of those <50 the median age was 45, and non-white patients were disproportionally represented with 47% Hispanic, 17.5% Black, 10.5% Asian patients. Non-white EO patients were more likely to present through the ED (16/34) relative to white EO patients (1/13). Of all EO patients 17 presented through the Emergency Department, 24 through primary care providers, 11 were referred in from an outside facility, and 2 diagnosed internationally (Figure). Limitations: This is an exploratory, retrospective single institution review of patients discussed at multidisciplinary tumor board over a single year. The population includes a safety-net institution and may not reflect presentation patterns at other hospitals. The cohort size is underpowered for meaningful statistical comparison. The cohort was generated during the COVID-19 pandemic. Conclusions/Discussion: Patients with early onset colorectal cancer are referred for colonoscopic or imaging diagnostics through their primary care doctors, followed by the Emergency Department. Non-white patients, compared to other groups, access the healthcare system through the ED. However, whether this observation is due to the absence of a PCP access, due to restricted screening/diagnostic guidelines, or due to colonoscopic provider availability is unclear. Hispanic patients are disproportionately represented in our early onset cohort relative to the demographics of the hospital referral base. While the study is underpowered, it is provocative for requiring further investigation. Resources to heighten the suspicion for malignancy in patients presenting to our emergency departments and primary care offices, especially in young, non-white populations, may expedite access to diagnosis and definitive therapy for these patients. (Figure Presented).

PREVALENCE, COMPONENTS, AND CONSEQUENCES OF MORAL INJURY AND BURNOUT IN SAFETY NET HOSPITAL ICUS

B Methods: b Critical Care Providers and Nurses at a Midwestern safety net hospital were surveyed in June 2021. Moral distress is associated with burnout and turnover in critical care providers and nurses. Nurses more often experienced lack of resources (68% vs 20% of providers, p < 0.001), lack of administrative support (64% vs 30%, p = 0.011) and abuse by patients/family (48% vs 10%, p = 0.001). [Extracted from the article] Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

MELD-NA SCORE VERSUS SOFA SCORE AND APACHE II SCORE AS EARLY PREDICTORS OF MORTALITY IN COVID-19 PATIENTS WITH LIVER INVOLVEMENT

INTRODUCTION: Acute Physiologic and Chronic Health Evaluation II (APACHE II) Score and the Sequential Organ Failure Assessment (SOFA score) have been validated to determine severity of disease and mortality. The Model for End-Stage Liver Disease modified for Sodium concentration (MELD-Na) Score has been implied as a prognostic tool in acute liver failure. However, these scoring systems have not been studied in COVID 19 patients. We aim to study and compare the utility of MELD-Na Score, SOFA score and APACHE II score in critically ill COVID-19 patients with liver involvement. METHODS: A retrospective study was conducted in 291 patients with confirmed COVID-19 infection and liver involvement that were admitted to ICU level of care at our safety-net institution in suburban New York area. MELD-Na and APACHE II scores were adjusted for confounding variables. Primary outcome was mortality and secondary outcome was length of stay. The outcome variables of mortality and length of stay were analyzed with multivariate logistic regression and multivariate linear regression respectively. All p-values were two-tailed. RESULTS: Mean age was more than 61 years, less than one-third were female, and more than two-thirds of the sample were those from either African American or Hispanic race. Mortality was 58.4% and mean length of stay was 15.6 days. Increased age (OR 1.08-CI 1.04, 1.13), female sex (OR 2.66-CI 1.09, 6.45), high oxygen requirement during hospitalization (OR 13.36-CI 4.59, 38.84) and increased number of organs involved (OR 2.56 - CI 1.77, 3.71) were each significantly associated with increased odds for mortality. APACHE II Score and MELD-Na score were not statistically significant for mortality or length of stay. Alcohol abuse, increased SOFA score, treatment with convalescent plasma, and anticoagulation therapy during admis-sion were each significantly associated with decreased odds for mortality. Alcohol abuse, antibiotic use, steroid treatment and convalescent plasma therapy were each significantly associated with increased length of stay. Increased age was significantly associated with decreased length of stay. CONCLUSION: SOFA, APACHE II and MELD-Na scores did not prove to be statistically significant in patients with COVID-19 and liver involvement. How-ever, increased number of organs involved was associated with increased odds for mortality, which strongly suggests that this may be a stronger prognostic tool than standardized scoring.(Table Presented)(Table Presented)