Factors Associated With Severe COVID-19 Among Vaccinated Adults Treated in US Veterans Affairs Hospitals.

Importance: With a large proportion of the US adult population vaccinated against SARS-CoV-2, it is important to identify who remains at risk of severe infection despite vaccination. Objective: To characterize risk factors for severe COVID-19 disease in a vaccinated population. Design, Setting, and Participants: This nationwide, retrospective cohort study included US veterans who received a SARS-CoV-2 vaccination series and later developed laboratory-confirmed SARS-CoV-2 infection and were treated at US Department of Veterans Affairs (VA) hospitals. Data were collected from December 15, 2020, through February 28, 2022. Exposures: Demographic characteristics, comorbidities, immunocompromised status, and vaccination-related variables. Main Outcomes and Measures: Development of severe vs nonsevere SARS-CoV-2 infection. Severe disease was defined as hospitalization within 14 days of a positive SARS-CoV-2 diagnostic test and either blood oxygen level of less than 94%, receipt of supplemental oxygen or dexamethasone, mechanical ventilation, or death within 28 days. Association between severe disease and exposures was estimated using logistic regression models. Results: Among 110 760 patients with infections following vaccination (97 614 [88.1%] men, mean [SD] age at vaccination, 60.8 [15.3] years; 26 953 [24.3%] Black, 11 259 [10.2%] Hispanic, and 71 665 [64.7%] White), 10 612 (9.6%) had severe COVID-19. The strongest association with risk of severe disease after vaccination was age, which increased among patients aged 50 years or older with an adjusted odds ratio (aOR) of 1.42 (CI, 1.40-1.44) per 5-year increase in age, such that patients aged 80 years or older had an aOR of 16.58 (CI, 13.49-20.37) relative to patients aged 45 to 50 years. Immunocompromising conditions, including receipt of different classes of immunosuppressive medications (eg, leukocyte inhibitor: aOR, 2.80; 95% CI, 2.39-3.28) or cytotoxic chemotherapy (aOR, 2.71; CI, 2.27-3.24) prior to breakthrough infection, or leukemias or lymphomas (aOR, 1.87; CI, 1.61-2.17) and chronic conditions associated with end-organ disease, such as heart failure (aOR, 1.74; CI, 1.61-1.88), dementia (aOR, 2.01; CI, 1.83-2.20), and chronic kidney disease (aOR, 1.59; CI, 1.49-1.69), were also associated with increased risk. Receipt of an additional (ie, booster) dose of vaccine was associated with reduced odds of severe disease (aOR, 0.50; CI, 0.44-0.57). Conclusions and Relevance: In this nationwide, retrospective cohort of predominantly male US Veterans, we identified risk factors associated with severe disease despite vaccination. Findings could be used to inform outreach efforts for booster vaccinations and to inform clinical decision-making about patients most likely to benefit from preexposure prophylaxis and antiviral therapy.

Veterans Health Administration Scheduling System: The Path to High Reliability Realization.

EXECUTIVE SUMMARY: Timely access to services is the gateway to patient safety and quality, and scheduling is foundational to providing access to highly reliable care. An effective and efficient scheduling strategy is dependent on an evidence-based approach that focuses on critical drivers of the scheduling system related to patient safety and quality as well as access. As part of a continuing effort to improve access, the Veterans Health Administration (VHA) completed a direct causation analysis (2015-2020) using an evidence-based framework and comprehensive measurement plan. The analysis, described here, validates access benefits realized specialty by specialty and facility by facility, identifies opportunities for improvement, and acknowledges limitations of the change from the Veterans Information Systems and Technology Architecture scheduling system to the Medical Appointment Scheduling System.This analysis of the assessments illustrates business validation structures, drivers, processes, and outcomes that can support leadership decision-making related to access. We drew our assessments of people, processes, policies, and technology from on-site interviews, over-the-shoulder observations, large-group discussions, and data from the VHA Support Service Center and facility data systems; we also mapped process steps, keystrokes, and workflow. Our assessments provided support for the VHA's decision to implement the stand-alone Cerner scheduling system at one site while continuing to implement the Cerner Millennium electronic health record platform that includes the Cerner scheduling system at other VHA sites. The VHA experience provides lessons learned for healthcare leaders who seek highly reliable efforts to improve access to care.

Effectiveness of COVID-19 mRNA Vaccines Against COVID-19-Associated Hospitalization - Five Veterans Affairs Medical Centers, United States, February 1-August 6, 2021.

COVID-19 mRNA vaccines (Pfizer-BioNTech and Moderna) have been shown to be highly protective against COVID-19-associated hospitalizations (1-3). Data are limited on the level of protection against hospitalization among disproportionately affected populations in the United States, particularly during periods in which the B.1.617.2 (Delta) variant of SARS-CoV-2, the virus that causes COVID-19, predominates (2). U.S. veterans are older, more racially diverse, and have higher prevalences of underlying medical conditions than persons in the general U.S. population (2,4). CDC assessed the effectiveness of mRNA vaccines against COVID-19-associated hospitalization among 1,175 U.S. veterans aged ≥18 years hospitalized at five Veterans Affairs Medical Centers (VAMCs) during February 1-August 6, 2021. Among these hospitalized persons, 1,093 (93.0%) were men, the median age was 68 years, 574 (48.9%) were non-Hispanic Black (Black), 475 were non-Hispanic White (White), and 522 (44.4%) had a Charlson comorbidity index score of ≥3 (5). Overall adjusted vaccine effectiveness against COVID-19-associated hospitalization was 86.8% (95% confidence interval [CI] = 80.4%-91.1%) and was similar before (February 1-June 30) and during (July 1-August 6) SARS-CoV-2 Delta variant predominance (84.1% versus 89.3%, respectively). Vaccine effectiveness was 79.8% (95% CI = 67.7%-87.4%) among adults aged ≥65 years and 95.1% (95% CI = 89.1%-97.8%) among those aged 18-64 years. COVID-19 mRNA vaccines are highly effective in preventing COVID-19-associated hospitalization in this older, racially diverse population of predominately male U.S. veterans. Additional evaluations of vaccine effectiveness among various age groups are warranted. To prevent COVID-19-related hospitalizations, all eligible persons should receive COVID-19 vaccination.

Creating a pronation therapy team: One hospital's journey.

ABSTRACT: Prone positioning is a recommended therapy for patients with COVID-19 who develop acute respiratory distress syndrome. This article describes the creation, operation, and evolution of the pronation therapy team at the author's Veterans Affairs facility.

Temporal Trends in COVID-19 Incidence in Two Healthcare Worker Cohorts.

BACKGROUND: Health care workers (HCWs) experience increased occupational risk of contracting COVID-19, with temporal trends that might inform surveillance. METHODS: We analyzed data from a Veterans Affairs hospital-based COVID-19 worker telephone hotline collected over 40 weeks (2020). We calculated the proportion of COVID-19+ cases among persons-under-investigation (PUIs) for illness compared to rates from a nearby large university-based health care institution. RESULTS: We observed 740 PUIs, 65 (8.8%) COVID-19+. Time trends were similar at the study and comparison hospitals; only for the first of 10 four-week observation periods was the ratio for observed to expected COVID-19+ significant (P < 0.001). DISCUSSION: These data suggest that employee health COVID-19+ to PUI ratios could be utilized as a barometer of community trends. Pooling experience among heath care facilities may yield insights into occupational infectious disease outbreaks.

A Nation-Wide Review of Elective Surgery and COVID-Surge Capacity.

BACKGROUND: The COVID-19 pandemic has resulted in over 225,000 excess deaths in the United States. A moratorium on elective surgery was placed early in the pandemic to reduce risk to patients and staff and preserve critical care resources. This report evaluates the impact of the elective surgical moratorium on case volumes and intensive care unit (ICU) bed utilization. METHODS: This retrospective review used a national convenience sample to correlate trends in the weekly rates of surgical cases at 170 Veterans Affairs Hospitals around the United States from January 1 to September 30, 2020 to national trends in the COVID-19 pandemic. We reviewed data on weekly number of procedures performed and ICU bed usage, stratified by level of urgency (elective, urgent, emergency), and whether an ICU bed was required within 24 hours of surgery. National data on the proportion of COVID-19 positive test results and mortality rates were obtained from the Center for Disease Control website. RESULTS: 198,911 unique surgical procedures performed during the study period. The total number of cases performed from January 1 to March 16 was 86,004 compared with 15,699 from March 17 to May 17. The reduction in volume occurred before an increase in the percentage of COVID-19 positive test results and deaths nationally. There was a 91% reduction from baseline in the number of elective surgeries performed allowing 78% of surgical ICU beds to be available for COVID-19 positive patients. CONCLUSION: The moratorium on elective surgical cases was timely and effective in creating bed capacity for critically ill COVID-19 patients. Further analyses will allow targeted resource allocation for future pandemic planning.

Inpatient antibiotic utilization in the Veterans' Health Administration during the coronavirus disease 2019 (COVID-19) pandemic.

Antibiotic prescribing practices across the Veterans' Health Administration (VA) experienced significant shifts during the coronavirus disease 2019 (COVID-19) pandemic. From 2015 to 2019, antibiotic use between January and May decreased from 638 to 602 days of therapy (DOT) per 1,000 days present (DP), while the corresponding months in 2020 saw antibiotic utilization rise to 628 DOT per 1,000 DP.

Short-term Effects of Canceled Elective Procedures Due to COVID-19: Evidence From the Veterans Affairs Healthcare System.

OBJECTIVE: To determine whether delayed or canceled elective procedures due to COVID-19 resulted in higher rates of ED utilization and/or increased mortality. SUMMARY OF BACKGROUND DATA: On March 15, 2020, the VA issued a nationwide order to temporarily pause elective cases due to COVID-19. The effects of this disruption on patient outcomes are not yet known. METHODS: This retrospective cohort study used data from the VA Corporate Data Warehouse. Surgical procedures canceled due to COVID-19 in 2020 (n = 3326) were matched to similar completed procedures in 2018 (n = 151,863) and 2019 (n = 146,582). Outcome measures included 30- and 90-day VA ED use and mortality in the period following the completed or canceled procedure. We used exact matching on surgical procedure category and nearest neighbor matching on patient characteristics, procedure year, and facility. RESULTS: Patients with elective surgical procedures canceled due to COVID-19 were no more likely to have an ED visit in the 30- [Difference: -4.3% pts; 95% confidence interval (CI): -0.078, -0.007] and 90 days (-0.9% pts; 95% CI: -0.068, 0.05) following the expected case date. Patients with cancellations had no difference in 30- (Difference: 0.1% pts; 95% CI: -0.008, 0.01) and 90-day (Difference: -0.4% pts; 95% CI: -0.016, 0.009) mortality rates when compared to similar patients with similar procedures that were completed in previous years. CONCLUSIONS: The pause in elective surgical cases was not associated with short-term adverse outcomes in VA hospitals, suggesting appropriate surgical case triage and management. Further study will be essential to determine if the delayed cases were associated with longer-term effects.

Complexities of Corona Virus Disease-19: The Role of Palliative Care at a Veterans Affairs Hospital.

The Corona Virus Disease-19 (COVID-19) pandemic accentuated the need for delivery of quality palliative care. We share the experience of our acute care hospital palliative care team in caring for veteran patients who died from COVID-19 and provide recommendations for palliative care teams caring for older adult populations. We conducted a retrospective chart review on 33 patients to gather characteristics data and delineate palliative care team involvement in their clinical courses. Our palliative care team participated in the care of 87.9% of patients who died from COVID-19. They were medically and psychosocially complex with 75.8% carrying at least four medical comorbidities, 87.8% presenting from an institutional facility, and 39.4% diagnosed with at least one psychiatric condition. Our results emphasize the impact of this pandemic on vulnerable populations and highlight the benefits of palliative care for support of patients, their loved ones, and the clinical teams caring for them.

Characterization of hospital airborne SARS-CoV-2.

BACKGROUND: The mechanism for spread of SARS-CoV-2 has been attributed to large particles produced by coughing and sneezing. There is controversy whether smaller airborne particles may transport SARS-CoV-2. Smaller particles, particularly fine particulate matter (≤ 2.5 µm in diameter), can remain airborne for longer periods than larger particles and after inhalation will penetrate deeply into the lungs. Little is known about the size distribution and location of airborne SARS-CoV-2 RNA. METHODS: As a measure of hospital-related exposure, air samples of three particle sizes (> 10.0 µm, 10.0-2.5 µm, and ≤ 2.5 µm) were collected in a Boston, Massachusetts (USA) hospital from April to May 2020 (N = 90 size-fractionated samples). Locations included outside negative-pressure COVID-19 wards, a hospital ward not directly involved in COVID-19 patient care, and the emergency department. RESULTS: SARS-CoV-2 RNA was present in 9% of samples and in all size fractions at concentrations of 5 to 51 copies m-3. Locations outside COVID-19 wards had the fewest positive samples. A non-COVID-19 ward had the highest number of positive samples, likely reflecting staff congregation. The probability of a positive sample was positively associated (r = 0.95, p < 0.01) with the number of COVID-19 patients in the hospital. The number of COVID-19 patients in the hospital was positively associated (r = 0.99, p < 0.01) with the number of new daily cases in Massachusetts. CONCLUSIONS: More frequent detection of positive samples in non-COVID-19 than COVID-19 hospital areas indicates effectiveness of COVID-ward hospital controls in controlling air concentrations and suggests the potential for disease spread in areas without the strictest precautions. The positive associations regarding the probability of a positive sample, COVID-19 cases in the hospital, and cases in Massachusetts suggests that hospital air sample positivity was related to community burden. SARS-CoV-2 RNA with fine particulate matter supports the possibility of airborne transmission over distances greater than six feet. The findings support guidelines that limit exposure to airborne particles including fine particles capable of longer distance transport and greater lung penetration.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid contamination of surfaces on a coronavirus disease 2019 (COVID-19) ward and intensive care unit.

On coronavirus disease 2019 (COVID-19) wards, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid was frequently detected on high-touch surfaces, floors, and socks inside patient rooms. Contamination of floors and shoes was common outside patient rooms on the COVID-19 wards but decreased after improvements in floor cleaning and disinfection were implemented.

Correlates of death among SARS-CoV-2 positive veterans: The contribution of lifetime tobacco use.

Despite a growing body of research examining correlates and consequences of COVID-19, few findings have been published among military veterans. This limitation is particularly concerning as preliminary data indicate that veterans may experience a higher rate of mortality compared to their civilian counterparts. One factor that may contribute to increased rates of death among veterans with COVID-19 is tobacco use. Indeed, findings from a recent meta-analysis highlight the association between lifetime smoking status and COVID-19 progression to more severe or critical conditions including death. Notably, prevalence rates of tobacco use are higher among veterans than civilians. Thus, the purpose of the current study was to examine demographic and medical variables that may contribute to likelihood of death among veterans testing positive for SARS-CoV-2. Additionally, we examined the unique influence of lifetime tobacco use on veteran mortality when added to the complete model. Retrospective chart reviews were conducted on 440 veterans (80.5% African American/Black) who tested positive for SARS-CoV-2 (7.3% deceased) at a large, southeastern Veterans Affairs (VA) hospital between March 11, 2020 and April 23, 2020, with data analysis occurring from May 26, 2020 to June 5, 2020. Older age, male gender, immunodeficiency, endocrine, and pulmonary diseases were positively related to the relative risk of death among SARS-CoV-2 positive veterans, with lifetime tobacco use predicting veteran mortality above and beyond these variables. Findings highlight the importance of assessing for lifetime tobacco use among SARS-CoV-2 positive patients and the relative importance of lifetime tobacco use as a risk factor for increased mortality.

Impact of the COVID-19 pandemic on the use of advance care planning services within the veterans administration system in Taiwan.

BACKGROUND: The aim of this study is to investigate the effect of COVID-19 on the outpatient advance care planning (ACP) services provided by veterans hospitals in Taiwan. METHODS: This study adopted a retrospective data analysis. We investigated ACP services provided by 15 veterans hospitals in Taiwan from 2019 to June 2020. We also conducted a statistical analysis on the ACP services provided by the Taipei Veterans General Hospital. RESULTS: From 2019 to June 2020, 15 veterans hospitals in Taiwan provided ACP services to 2493 individuals. The outpatient ACP services declined significantly after January 2020, decreasing from a national average of 206.2 ± 29.2 declarants per month to 106.2 ± 30.8 declarants per month in the 6 months immediately following the COVID-19 pandemic outbreak (p < 0.001). From the official implementation of the ACP in January 2019 to the end of June 2020, a total of 1126 declarants accepted ACP services at the Taipei Veterans General Hospital. When the COVID-19 pandemic was prevalent, the declarants who received ACP services were younger (i.e., 60.1 ± 15.2 vs 65.5 ± 16.3 years; p < 0.001). After the variables had been adjusted, the changes in the characteristics of the declarants receiving ACP services when the COVID-19 pandemic was prevalent were as follows: a significant increase in the percentage of hospital staff receiving ACP services (odds ratio [OR]: 5.460, 95% confidence interval [CI]: 2.378-12.536); An increase in the percentage of declarants who paid for the ACP services received at their own expense (OR: 3.417, 95% CI: 1.591-7.339); and an increase in the percentage of declarants who received the consultations with three or more people (OR: 2.017, 95% CI: 1.278-3.182). CONCLUSION: COVID-19 severely changed outpatient ACP services provided by hospitals. The results obtained by this study offer valuable insight regarding the provision of outpatient ACP services.

Using COVID-19 cycle threshold and other lab values as predictors of hospitalization need.

SARS-COV-2 (COVID-19) is a novel virus that has caused over 28 million cases worldwide and over 900,000 deaths since early 2020, rightfully being classified as a pandemic. COVID-19 is diagnosed via polymerase chain reaction testing which looks at cycle threshold (CT) values of two genes, N2 and E. This study examined CT values of COVID-positive patients at the VA hospital in Reno as well as other lab values and comorbidities to determine if any could aid clinicians in predicting the need for hospitalization and higher levels of care. Multiple variables, including N2 CT value, absolute lymphocyte count (ALC), D-dimer, erythrocyte sedimentation rate, C-reactive protein, fibrinogen, and ferritin were evaluated for potential associations with N2 CT value as well as required level of care (based on World Health Organization [WHO] ordinal score). The results suggest that patients with a N2 CT value less than 34 are four times more likely to have WHO ordinal scores of 4-8 (p = .0021) while controlling for age and comorbidities (DM, cardiac, kidney, and lung disease). Patients of age 55 or greater were 15.18 times more likely to have WHO ordinal scores of 4-8 (p = .012) controlling for N2 CT value and comorbidities. Furthermore, patients with ALC less than 1 were 5.88 times more likely to have WHO ordinal score of 4-8 (p = .00024). N2 CT values also appear to be associated with many commonly obtained markers such as ALC, white blood cell count, C-reactive protein, and D-dimer. Patients with N2 CT values less than 34 were 3.49 times more likely to have ALC values less than 1, controlling for age and comorbidities (p = .0072) while patients 55 or older were 6.66 times more likely to have ALC less than 1 (p = .027). Finally, this study confirms previous conclusions that patients with advanced age had more severe infections and thus will likely require higher levels of care.

COVID-19-Related Hospitalization Rates and Severe Outcomes Among Veterans From 5 Veterans Affairs Medical Centers: Hospital-Based Surveillance Study.

BACKGROUND: COVID-19 has disproportionately affected older adults and certain racial and ethnic groups in the United States. Data quantifying the disease burden, as well as describing clinical outcomes during hospitalization among these groups, are needed. OBJECTIVE: We aimed to describe interim COVID-19 hospitalization rates and severe clinical outcomes by age group and race and ethnicity among US veterans by using a multisite surveillance network. METHODS: We implemented a multisite COVID-19 surveillance platform in 5 Veterans Affairs Medical Centers located in Atlanta, Bronx, Houston, Palo Alto, and Los Angeles, collectively serving more than 396,000 patients annually. From February 27 to July 17, 2020, we actively identified inpatient cases with COVID-19 by screening admitted patients and reviewing their laboratory test results. We then manually abstracted the patients' medical charts for demographics, underlying medical conditions, and clinical outcomes. Furthermore, we calculated hospitalization incidence and incidence rate ratios, as well as relative risk for invasive mechanical ventilation, intensive care unit admission, and case fatality rate after adjusting for age, race and ethnicity, and underlying medical conditions. RESULTS: We identified 621 laboratory-confirmed, hospitalized COVID-19 cases. The median age of the patients was 70 years, with 65.7% (408/621) aged ≥65 years and 94% (584/621) male. Most COVID-19 diagnoses were among non-Hispanic Black (325/621, 52.3%) veterans, followed by non-Hispanic White (153/621, 24.6%) and Hispanic or Latino (112/621, 18%) veterans. Hospitalization rates were the highest among veterans who were ≥85 years old, Hispanic or Latino, and non-Hispanic Black (430, 317, and 298 per 100,000, respectively). Veterans aged ≥85 years had a 14-fold increased rate of hospitalization compared with those aged 18-29 years (95% CI: 5.7-34.6), whereas Hispanic or Latino and Black veterans had a 4.6- and 4.2-fold increased rate of hospitalization, respectively, compared with non-Hispanic White veterans (95% CI: 3.6-5.9). Overall, 11.6% (72/621) of the patients required invasive mechanical ventilation, 26.6% (165/621) were admitted to the intensive care unit, and 16.9% (105/621) died in the hospital. The adjusted relative risk for invasive mechanical ventilation and admission to the intensive care unit did not differ by age group or race and ethnicity, but veterans aged ≥65 years had a 4.5-fold increased risk of death while hospitalized with COVID-19 compared with those aged <65 years (95% CI: 2.4-8.6). CONCLUSIONS: COVID-19 surveillance at the 5 Veterans Affairs Medical Centers across the United States demonstrated higher hospitalization rates and severe outcomes among older veterans, as well as higher hospitalization rates among Hispanic or Latino and non-Hispanic Black veterans than among non-Hispanic White veterans. These findings highlight the need for targeted prevention and timely treatment for veterans, with special attention to older aged, Hispanic or Latino, and non-Hispanic Black veterans.