Service line care delivery model for COVID-19 patient-centric care.

OBJECTIVES: The COVID-19 pandemic has caused hospitals around the world to quickly develop not only strategies to treat patients but also methods to protect health care and frontline workers. STUDY DESIGN: Descriptive study. METHODS: We outlined the steps and processes that we took to respond to the challenges presented by the COVID-19 pandemic while continuing to provide our routine acute care services to our community. RESULTS: These steps and processes included establishing teams focused on maintaining an adequate supply of personal protection equipment, cross-training staff, developing disaster-based triage for the emergency department, creating quality improvement teams geared toward updating care based on the most current literature, developing COVID-19-based units, creating COVID-19-specific teams of providers, maximizing use of our electronic health record system to allocate beds, and providing adequate practitioner coverage by creating a computer-based dashboard that indicated the need for health care practitioners. These processes led to seamless and integrated care for all patients with COVID-19 across our health system and resulted in a reduction in mortality from a high of 20% during the first peak (March and April 2020) to 6% during the plateau period (June-October 2020) to 12% during the second peak (November and December 2020). CONCLUSIONS: The detailed processes put in place will help hospital systems meet the continuing challenges not only of COVID-19 but also beyond COVID-19 when other unique public health crises may present themselves.

Rapid implementation of a cohort for the study of post-acute sequelae of SARS-CoV-2 infection/COVID-19.

BACKGROUND: As the coronavirus disease 2019 (COVID-19) pandemic continues and millions remain vulnerable to infection with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), attention has turned to characterizing post-acute sequelae of SARS-CoV-2 infection (PASC). METHODS: From April 21 to December 31, 2020, we assembled a cohort of consecutive volunteers who a) had documented history of SARS-CoV-2 RNA-positivity; b) were ≥ 2 weeks past onset of COVID-19 symptoms or, if asymptomatic, first test for SARS-CoV-2; and c) were able to travel to our site in San Francisco. Participants learned about the study by being identified on medical center-based registries and being notified or by responding to advertisements. At 4-month intervals, we asked participants about physical symptoms that were new or worse compared to the period prior to COVID-19, mental health symptoms and quality of life. We described 4 time periods: 1) acute illness (0-3 weeks), 2) early recovery (3-10 weeks), 3) late recovery 1 (12-20 weeks), and 4) late recovery 2 (28-36 weeks). Blood and oral specimens were collected at each visit. RESULTS: We have, to date, enrolled 179 adults. During acute SARS-CoV-2 infection, 10 had been asymptomatic, 125 symptomatic but not hospitalized, and 44 symptomatic and hospitalized. In the acute phase, the most common symptoms were fatigue, fever, myalgia, cough and anosmia/dysgeusia. During the post-acute phase, fatigue, shortness of breath, concentration problems, headaches, trouble sleeping and anosmia/dysgeusia were the most commonly reported symptoms, but a variety of others were endorsed by at least some participants. Some experienced symptoms of depression, anxiety, and post-traumatic stress, as well as difficulties with ambulation and performance of usual activities. The median visual analogue scale value rating of general health was lower at 4 and 8 months (80, interquartile range [IQR]: 70-90; and 80, IQR 75-90) compared to prior to COVID-19 (85; IQR 75-90). Biospecimens were collected at nearly 600 participant-visits. CONCLUSION: Among a cohort of participants enrolled in the post-acute phase of SARS-CoV-2 infection, we found many with persistent physical symptoms through 8 months following onset of COVID-19 with an impact on self-rated overall health. The presence of participants with and without symptoms and ample biological specimens will facilitate study of PASC pathogenesis. Similar evaluations in a population-representative sample will be needed to estimate the population-level prevalence of PASC.

Financial Justification for Interventional Pulmonology Programs: Terminology and Programmatic Models.

Interventional pulmonology programs provide clinical benefit to patients and are financially sustainable. To appreciate and illustrate the economic value of interventional pulmonology programs to hospital systems, physicians must have an understanding of basic health-care finance. Total revenue, adjusted gross revenue, contribution margin, variable direct costs, and indirect costs are terms that are essential for understanding the finances of bronchoscopy. Command of such vocabulary and its application is crucial for interventional pulmonologists to successfully establish financially sustainable bronchoscopy programs. Two significant features of an economically sustainable bronchoscopy program are high procedural volume and low direct cost per case. Interventional pulmonology programs are valuable to the patients being served and hospitals as a whole. Consideration of the various factors needed to maintain financial sustainability is essential to improve the quality of care for patients because the cost of care remains a critical driver in defining value.

Benchmarking blood sugar control in the small rural intensive care unit.

Objective: We sought to determine a benchmark for our blood glucose monitoring and compare our data to published data.Methods: Natividad Medical Center is a 172-bed rural hospital located in Salinas, California.Point of care blood glucose (POC-BG) data was extracted from our EMR for all ICU patients greater than 18 years of age between January 2014 and May 2018. Patient day-weighted mean POC-BGs were calculated for each patient by calculating the average POC-BG per day for each patient. Proportion measurements for each of our measurements groups were recorded (>180 mg/dL, <70 mg/dL, >250 mg/dL and <50 mg/dL). Monthly averages were plotted for visual comparison. Benchmarks were calculated by using 2x Standard Deviation for each measurement group.Results: A total of 3164 patients were found with 21,006 POC-BG measurements. The average POC-BG was 136 mg/dL and median 119 mg/dL. Proportion measurements of monthly day-weighted mean POC-BGs ranged from 0-1.2%, 5.3-44.8%, 0-0.3% and 0.6-16.5%, respectively for less than 70 mg/dL, greater than 180 mg/dL, less than 50 mg/dL and greater than 250 mg/dL. A 2x Standard Deviation was used to calculate our benchmark cut offs which provides a 95% confidence interval and includes 97.5% when neglecting the lower range. Our calculated benchmark values are 1.2, 38.2, 0.19, and 13.1% respectively for measurement groups less than 70 mg/dL, greater than 180 mg/dL, less than 50 mg/dL and greater than 250 mg/dL.Conclusion: Here we present data from a small rural hospital in the Western United States. We calculated benchmarks that could be used to track our ongoing hyper/hypoglycemia improvement projects. We found that when compared to published data, our hyper/hypoglycemia data was comparable to national data.

Longitudinal changes in directly measured physical activity in patients with chronic obstructive pulmonary disease: the trajectory of change.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is a systemic disease with various outcomes of importance, for example, exercise capacity and dyspnea. These variables may follow different trajectories over time. It is established that physical activity decreases in COPD, although its process over time has not been evaluated. Accordingly, we compared longitudinal changes in physical activity with changes in standard outcome assessments: forced expiratory volume in 1 second (FEV(1)), 6-minute walk distance, and dyspnea. METHODS: Physical activity was measured with tri-axial accelerometers worn on a lateral position at the waist for 7 consecutive days. Nonuse was eliminated using a computer algorithm for this device. Activity was assessed in 2 ways: (1) as vector magnitude units (VMU), the sum of movements per minute in 3 planes, and (2) VM250, the percent of time worn when VMU was 250 or more counts per minute. Eighteen patients with COPD (FEV(1) 61 ± 17% predicted) from a larger population were restudied. The interval between the baseline and followup assessments was 609 ± 58 days. RESULTS: Mean VMU at followup was less than at baseline: 146 ± 70 vs 198 ± 85 counts per minute, respectively (P = .002). VM250 was also reduced: 19 ± 9% vs 25 ± 11%, respectively (P = .003). There was no significant longitudinal change in FEV(1). The 6-minute walk distance decreased by 39 m (P = .04). The Medical Research Council dyspnea increased by 0.5 units (P = .04). CONCLUSION: Directly measured physical activity decreases over time in COPD, similar to other outcomes of importance.

Physiologic responses during the six minute walk test in obese and non-obese COPD patients.

Although obesity is a common co-morbid condition in COPD, relatively little is known how it may affect functional exercise capacity. Accordingly, we compared physiologic responses during a 6 min walk test in 10 obese and 10 non-obese COPD patients matched by gender, age, and spirometric severity category. Patients first exercised on a treadmill to determine maximal exercise responses, then following a rest period they completed a 6 min walk test. Breath by-breath analyses of expired air via a facemask was obtained using a portable, battery operated device. Oxygen consumption (VO(2)), carbon dioxide production (VCO(2)), tidal volume (VT), respiratory rate (RR), minute ventilation (VE), and inspiratory capacity (IC) were compared. The mean FEV1 in the obese and non-obese groups was 52 ± 13 and 58 ± 18 percent of predicted, respectively, and the BMI of the obese patients was 37 ± 02 kg/m(2). Obese patients had shorter 6 min walk distances than non-obese patients (247 ± 73 vs 348 ± 51 m, respectively, p = 0.003), but walk-work, defined as 6 min walk distance × weight (in kg), was not different. There were no significant between-group differences in any exercise variable measured during the 6 min walk test. In both groups, VO(2) and VE increased linearly over the first 2-3 min, then plateaued at approximately 80% of maximum. Although 6 min walk distance is shorter in obese COPD patients, their physiologic responses are similar to those of non-obese patients.

Polar body formation in Spisula oocytes: function of the peripheral aster.

Activated Spisula oocytes proceed through meiotic stages rapidly and in near synchrony, providing an excellent system for analyzing polar body formation. Our previous studies suggested that cortical spreading of the metaphase peripheral aster determines spatial features of the cortical F-actin ring that is generated prior to extrusion of the polar body. We tested this hypothesis by experimentally altering the number and cortical contact patterns of peripheral asters. Such alteration was achieved by (a) lovastatin-induced arrest at metaphase I, with and without hexylene glycol modification, followed by washout; and (b) cytochalasin-D inhibition of extrusion of the first polar body, with washout before extrusion of the second polar body. Both methods induced simultaneous formation of two or more cortically spreading asters, correlated with subsequent formation of double, or even triple, overlapping F-actin rings during anaphase. Regardless of pattern, ring F-actin was deposited near regions of greatest astral microtubule density, indicating that microtubules provided a positive stimulus to which the cortex responded indiscriminately. These results strongly support the proposed causal relationship between peripheral aster spreading and biogenesis of the F-actin ring involved in polar body formation.