Inner-city Community Hospital Research Articles

Awareness of Sickle Cell Status among Adolescents and Caregivers in an Inner-City Community Hospital

Awareness of Sickle Cell Status among Adolescents and Caregivers in an Inner-City Community Hospital

Management of Acute Bronchiolitis, Guidelines Vs Practice; An Inner-City Community Hospital Experience

Management of Acute Bronchiolitis, Guidelines Vs Practice; An Inner-City Community Hospital Experience

Association Between COVID-19 Outcomes and Patient Characteristics: A Study in an Inner-City Community Hospital.

BackgroundIt has been shown that certain hematological conditions, such as lymphopenia and thrombocytopenia, are associated with increased severity and mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, a majority of the previous data came from large institutional centers with high academic output. We aimed to explore the association between patient’s characteristics, hematological parameters, and outcomes in admitted persons with coronavirus disease 2019 (COVID-19) at our community hospital in an inner city.MethodsThis study is a retrospective chart review designed to evaluate the potential associations between demographic and clinical characteristics of our patient population and their outcomes when testing positive for SARS-CoV-2. The study population included patients hospitalized in the Saint Francis Medical Center from January 2020 to September 2020. This pilot study included 50 out of the 275 hospitalized patients with a confirmed SARS-CoV-2 infection during this timeframe. Data collection from the patient’s chart included age, sex, comorbidities, admission complete blood cell count, and use of Remdesivir, steroids, and plasma. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included the need for mechanical ventilation and ICU admission.ResultsIn this pilot study, there was an overall mortality rate of 32% (16 out of 50 patients). Charlson Comorbidity Index (CCI) of 3 points or above was present in 87.5% of the patients in the mortality group versus 41.1% in patients who survived (p = 0.0021). There was no statistically significant difference in mortality between males and females after adjusting for other variables with an odds ratio (OR) of 0.19 (95% CI 0.02-1.80, p = 0.09). There were no statically significant differences in mortality between Caucasians, non-Hispanic, Black, and Latinx patients (p = 0.466). Admission platelets were lower in the mortality group with a mean of 157.7 ± 43.23 (Thou/ul) versus 250.06 ± 93.95 (Thou/ul) in the survivors (p = 0.0005). Admission white blood cell count in the mortality group was lower than the survivor group with an average of 5.93 ± 2.58 (Thou/ul) versus 9.3 ± 4.14 (Thou/ul) (p = 0.0039), respectively. The plasma D-dimer level of 3 mg/L fibrinogen equivalent unit (FEU) or higher was associated with increased mortality. There was no association of C-reactive protein (CRP) with mortality (p = 0.93 and p = 0.54, respectively); however, the CRP level revealed an association with ICU admission (p = 0.03). The use of steroids, Remdesivir, and plasma did not have a statistically significant effect on mortality, ICU admission, or sepsis in our study.ConclusionIn this study, older age, higher CCI, and plasma D-dimer level of 3 mg/L FEU or higher were associated with higher mortality among COVID-19 patients. White blood cell count and platelet count were significantly lower in the mortality group in comparison to the survivor group. However, there was no statistical difference in lymphocyte count between the mortality group and the survivor group. COVID-19 patients with thrombocytopenia or serum CRP level of 15 mg/dL or higher were more likely to be admitted to ICU.

Psychiatric Decompensation During the COVID-19 Pandemic: A Literature Review and Case Series.

Here, read 5 case reports of patients with preexisting psychotic disorders seen on the inpatient psychiatry unit of an inner-city community hospital who decompensated for various reasons relating to the COVID-19 pandemic.

Clinical Characteristics and Outcomes Among COVID 19 Hospitalized Patients in a Community Hospital in New York City

Background: COVID-19 has disproportionally affected communities of color in the US. These communities exhibit higher prevalence of chronic preventable disease including type 2 diabetes mellitus (DM2) and obesity. DM2 and obesity have been linked to higher morbidity and mortality in the setting of COVID-19 infection (1). Methods: We query data collected from 521 patients with laboratory-confirmed Covid-19 infection admitted to an inner-city community hospital in Brooklyn, New York between March 20 2020 and May 15 2020. Demographics, pre-infection medical comorbidities, laboratory data at admission and clinical outcomes including in-hospital mortality were analyzed. Results: Patients were 61 years on average (+/-17.2), 42.8% were female, 53.9% were Hispanic and 33% were African-American. Most common comorbidities included: hypertension (62%), chronic kidney disease (20.8%), diabetes (45 %). Mean BMI was 29.9 (+/- 8.2). Among patients with no prior diagnosis of diabetes mean A1c was 5.8% (+/-1.2) and 8.7 (+/-2.5) amongst those with a previous diagnosis of diabetes. Patients hospitalized with moderate to severe COVID-19 infection and a previous diagnosis of DM2 had significantly higher prevalence of CKD and HTN. Amongst those with T2DM, 19.1% presented with DKA. After adjustment for age, gender, race, BMI and creatinine obese patients, compared with normal-weight patients had significantly higher mortality rate (BMI > 30 kg/m2 [OR: 2.29, CI: 95%, P-value: <0.002]) however this association was not observed for DM2 ([OR: 1.25, CI: 95%, P-value: <0.002]). Conclusion: Our cohort represents a particular population affected by the first wave of Covid-19 infection in an urban inner-city community in NYC. The population studied had a larger proportion of African-American, Hispanic and younger patients compared to national averages; these differences are related to the demographics of the communities served by our hospital. Obesity is a negative prognostic factor in the course of Covid-19 infection in comparison to normal-weight patients. Obesity is a proinflammatory condition, associated with high levels of prothrombotic factors including angiotensin-II, also elevated in COVID-19. Understanding that link may yield valuable knowledge on the role obesity plays in numerous disease states beyond COVID-19.

Can the Pediatric Early Warning Score (PEWS) Predict Hospital Length of Stay?

Background: Limited studies have evaluated the utility of scoring systems in the pediatric emergency department (PED) and no studies have evaluated their ability to predict hospital length of stay (LOS) and the usage of Observation units (OUs).Objective: To evaluate the utility of the Pediatric Early Warning Score (PEWS) in predicting LOS in pediatric patients and thus anticipate admission to an OU versus the pediatric ward.Methods: A retrospective study of pediatric inpatients (0 to 18 years) at an inner-city community hospital between January 2014 and December 2014. Patients with psychiatric illness, non-medical reasons for hospital stay, and those not discharged to ‘home’ were excluded. Demographic data, PEWS in the ED, and LOS for each patient were recorded and analyzed.Results: A total of 719 patients were analyzed. PEWS range was 0 to 8. The mean LOS was 56.8 hours for patients with PEWS 0-1 compared to 62.7 hours for patients with PEWS ≥2 (p=0.02). There was a significant difference in PEWS for LOS ≤24 and ≤36 hours in comparison to those with LOS >24 hours and >36 hours, respectively (p<0.001). Overall, the PEWS correlated with LOS (r=0.11, p=0.002). Age correlated inversely with LOS (r=-0.16, p<0.001), without correlation to PEWS (r=-0.002, p= 0.96).Conclusions: PEWS correlated weakly with LOS. A statistically significant lower PEWS was observed for patients who had short stays (both ≤24 and ≤36 hours) in comparison to those requiring longer inpatient care. Therefore, the PEWS is a useful tool to predict LOS and aid ED physicians to determine disposition, although further prospective studies in centers with OUs would better characterize its ability to suggest admission to an OU compared to the wards.

CASE SERIES OF PATIENTS WITH E-CIGARETTE OR VAPING PRODUCT-ASSOCIATED LUNG INJURY: INSIGHTS FROM A SAFETY NET HOSPITAL

SESSION TITLE: Tobacco Cessation and Prevention Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: E-cigarette or vaping product associated lung injury (EVALI) is a rapidly growing epidemic that has sparked great interest in the past year. As a relatively new clinical phenomenon, EVALI is particularly challenging as it causes a spectrum of pulmonary pathology in an otherwise healthy population. The epidemic is fueled by the rising popularity of e-cigarettes, variability in vaping products, lack of centralized control and thereby ease of access. We report a case series of five adult EVALI patients from an inner city safety-net hospital. METHODS: Cases include patients admitted to our facility between August 2019 to November 2019 either to medicine floors or medical intensive care units and who met CDC criteria for EVALI. Criteria includes e-cigarette or vaping product use within the past three months of symptom onset, positive image findings, and evaluation to rule out infectious etiology. Demographic and clinical Information was obtained via retrospective chart review. RESULTS: Of the five cases, four were male with a median age 29 and no previous cardiac or respiratory pathology. Primary symptoms were altered mental status and agitation in setting of drug overdose with one patient presenting with GI and respiratory symptoms. All patients had self-reported or family-reported confirmation of THC-containing vaping use within 90 days of hospital visit, and all reported vaping within 10 days of admission. All patients had a positive urine toxicology for cannabinoids and half were positive for cocaine. Four out of five patients had elevated WBC, four of five had normal ESR, CRP. Three out of five had classic radiological findings of EVALI, with half positive for lipid-laden macrophages in BAL via Oil-Red-O stain. Four patients required ICU admission with intubation for respiratory failure, and two progressed into ARDS, one requiring pronation and the other requiring ECMO. There was no mortality. The average ICU length-of-stay (LOS) was 6.2 days, average hospital LOS at 7.8 days and no readmission to the same facility in 2 months since discharge. CONCLUSIONS: The increasing use of e-cigarette and vaping products has resulted in deadly outcomes. There are very few case series documenting the manifestations of EVALI since the establishment of the diagnosis in September 2019. We present a case series representing the clinical findings and features of EVALI patients and their management in an inner-city community hospital. All of our patients were found to have a positive toxicology screen to one or more illicit drugs, indicating a relationship between vaping and concomitant use of other illicit substances. CLINICAL IMPLICATIONS: EVALI is a rising trend with devastating effects on otherwise healthy population. This case series hopes to shed light on some demographic and clinical characteristics of these patients. DISCLOSURES: No relevant relationships by Jagadish Akella, source=Web Response No relevant relationships by Fatima Anjum, source=Web Response No relevant relationships by Shiva Arjun, source=Web Response No relevant relationships by Alejandro Gutierrez, source=Web Response No relevant relationships by Javed Iqbal, source=Web Response No relevant relationships by Hyfaa Mashaal, source=Web Response No relevant relationships by Daniel Meshoyrer, source=Web Response No relevant relationships by Raghavendra Sanivarapu, source=Web Response

Transoral endoscopic thyroidectomy-vestibular approach: starting a program in an inner-city hospital

: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is quickly gaining popularity as the only truly scarless approach to central neck surgery. The literature reports more than 1,000 cases completed around the world. Starting a program incorporating this approach has obvious challenges in regards to surgeon training, building a team and recruitment of patients. We describe the methods of training and recruitment strategies used in the establishment of a transoral endoscopic thyroid program in an inner-city community hospital. In addition, we describe the demographics, nodule characteristics and operative times for our initial experience with 4 cases. These cases were performed successfully without any complications and great patient satisfaction. On review of the case load of the senior author we estimate that approximately 56% of our head and neck endocrine cases will be eligible for this approach in the future.

Moral Distress in Health Care Professionals (GP784)

• Describe the various elements of moral distress using the validated tool "Moral Distress Scale - Revised” and it's utility in measuring moral distress in health care professionals from an inner city community hospital.• Describes the results of the administration of moral distress scale to health care professionals in a community hospital. Providing uncompromised compassionate care to patients and their families at their most vulnerable time can be a truly rewarding experience for many healthcare workers. A changing landscape in healthcare fueled by contentious debate can place providers in a unique situation, where their ability to carry out clinical duty is questioned due to the perception of ethically inappropriate action. These situations may occur often and are frequent sources of moral distress among providers. To use a validated scale to measure moral distress in health care professionals. The “Moral Distress Scale-Revised”, a 21-item questionnaire, was distributed to third and fourth-year medical students, residents, fellows, and attending physicians of an inner-city community hospital. Additional characteristics regarding the background of the respondents were collected. Examples of a situation provided on the questionnaire include “Follow family wishes to continue life support even though I believe it is not in the best interest of the patient.” Respondents were asked to rate the frequency in which they encounter each situation in clinical practice on a scale of 0 to 4 (0=never, 4=very frequently), and also rate the level of disturbance that they would feel if encountering each situation on a scale of 0 to 4 (0=no disturbance, 4=great extent of disturbance). Respondents were medical students (50%), residents/fellows (30%), and attending physicians (20%). They were from an ethnically diverse background (Caucasian 21%, South Asian 21%, other Asian 17%, Other 41%) and represented several religions (Christian 39%, Muslim 15%, Hindu 10%, Jewish 8%, other 28%). More than half of respondents have encountered the majority of clinical situations presented in the questionnaire. For approximately 80% of the clinical situations given, most respondents felt at least moderate moral disturbance when faced with the provided circumstances. Most medical professionals encounter clinical situations that cause them at least moderate amounts of moral distress, including a significant amount endured during their early years of clinical training.

Clinical Characteristics and Predictors of Mortality in African Americans with COVID-19 from an Inner-City Community Hospital in New York

Background: There is limited data on the clinical presentation and predictors of mortality in the African-American (AA) patients hospitalized with COVID-19 despite the disproportionately higher burden and mortality. The aim of this study is to report on the clinical characteristics and the predictors of mortality in hospitalized AA patients with COVID-19 infection. Methods: In this retrospective cohort review, we included all AA patients with confirmed COVID-19 infection admitted to an inner-city teaching community hospital in New York City. Demographics, clinical presentation, baseline co-morbidities, and laboratory data were compared between survivors and non-survivors. The predictors of mortality were assessed using multivariate logistic regression analysis. Results: Of the 408 (median age, 67years) patients included, 276(66.65%, median age 63years) survived while 132(33.35%, median age 71years) died. The most common presenting symptoms were cough, myalgia, fever/chills, shortness of breath, and gastrointestinal symptoms (nausea, vomiting, diarrhea, and abdominal pain), with a prevalence of 62.50%, 43.87%, 53.68%, and 27.21%, respectively. Age (OR 1.06, CI 1.04-1.08, P-<0.001), body mass index (OR 1.07, CI 1.04-1.11, P-<0.001), elevated serum ferritin(OR 1.99, CI 1.08-3.66, P-0.02), C-reactive protein (OR 2.42, CI 1.36-4.33, P-0.01), and D-dimers(OR 3.79, CI 2.21-6.50, P-<0.001) at the time of presentation were identified as the independent predictors of mortality. Conclusions: Cough, shortness of breath, fever/chills, gastrointestinal symptoms, and myalgia were the predominant presentation among African-Americans hospitalized with COVID-19 infection. Advanced age, higher BMI, elevated ferritin, C-reactive protein, and D-dimers are independent predictors of mortality among hospitalized African-Americans with COVID-19 infection. Funding Statement: There was no funding for the study. Declaration of Interests: No conflict of interest for all the authors. Ethics Approval Statement: Ethical clearance was obtained from the hospital's IRB committee. Because our study was limited to chart review with no patient interactions, the requirement for informed consent was waived.

185. Clinical Characterization of Staphylococcus aureus Bacteremia in Children at an Inner-City Community Hospital

Background Staphylococcus aureus bacteremia (SAB) is associated with high morbidity and mortality rates. Data on epidemiology and outcomes of SAB in children is not as well described as in adults. The primary objective of this study was to describe clinical and microbiological cure rates of SAB in hospitalized children. Secondary objectives included time to clinical and microbiological cure, mortality, proportions of methicillin-sensitive and resistant SA (MSSA, MRSA) bacteremia, and antibiotic usage pattern.MethodsThis was an electronic chart abstraction conducted at a community hospital in the South Bronx, NY, of all pediatric cases of SAB (<21 years of age) from January 1, 2010 to March 30, 2017. Demographic, clinical and microbiological data along with risk factors for bacteremia were collected. Clinical cure was defined as resolution of acute symptoms and signs of SAB and microbiological cure was defined as documentation of first negative blood culture after initiation of treatment. Standard definitions were used for hospital-acquired (HA) and community-acquired (CA) isolates of SA.ResultsOf 41 patients, neonates comprised 12%, 1- to 23-month-old infants 56% and 2- to 17-year-olds 31%. Overall, 76% of patients had bacteremia due to MSSA, and 24% MRSA. MRSA was isolated in 37% of HA SAB compared with 14% of CA SAB (P = 0.15). The two highest risk factors identified for SAB were peripherally inserted central catheters lines (PICC, 29%) and skin and soft-tissue infections (22%). SAB in the neonatal period was associated with PICC lines when compared with children outside the neonatal period (80% vs. 22%, P = 0.02). Using available data, clinical and microbiological cure rates were similar at 73%. The median time to clinical cure was 5 days (interquartile range [IQR] 2–10) and to microbiological cure, 2 days (IQR 1–4). A 2-month-old infant died (mortality 2.4%). Initial antibiotic selection was vancomycin (39%), clindamycin (39%), and nafcillin (7%). The proportion of SA resistant to clindamycin was 22%.ConclusionPediatric SAB was uncommon in this community hospital experience over 7 years and is associated with PICC lines in neonates. MSSA was more prevalent than MRSA. Initial antibiotic selection had anti-staphylococcal coverage in 85% of cases, while clindamycin resistance occurred in 22% of SA isolates.Disclosures All authors: No reported disclosures.

A Protocol-Driven, Bedside Digital Conversational Agent to Support Nurse Teams and Mitigate Risks of Hospitalization in Older Adults: Case Control Pre-Post Study.

BackgroundHospitalized older adults often experience isolation and disorientation while receiving care, placing them at risk for many inpatient complications, including loneliness, depression, delirium, and falls. Embodied conversational agents (ECAs) are technological entities that can interact with people through spoken conversation. Some ECAs are also relational agents, which build and maintain socioemotional relationships with people across multiple interactions. This study utilized a novel form of relational ECA, provided by Care Coach (care.coach, inc): an animated animal avatar on a tablet device, monitored and controlled by live health advocates. The ECA implemented algorithm-based clinical protocols for hospitalized older adults, such as reorienting patients to mitigate delirium risk, eliciting toileting needs to prevent falls, and engaging patients in social interaction to facilitate social engagement. Previous pilot studies of the Care Coach avatar have demonstrated the ECA’s usability and efficacy in home-dwelling older adults. Further study among hospitalized older adults in a larger experimental trial is needed to demonstrate its effectiveness.ObjectiveThe aim of the study was to examine the effect of a human-in-the-loop, protocol-driven relational ECA on loneliness, depression, delirium, and falls among diverse hospitalized older adults.MethodsThis was a clinical trial of 95 adults over the age of 65 years, hospitalized at an inner-city community hospital. Intervention participants received an avatar for the duration of their hospital stay; participants on a control unit received a daily 15-min visit from a nursing student. Measures of loneliness (3-item University of California, Los Angeles Loneliness Scale), depression (15-item Geriatric Depression Scale), and delirium (confusion assessment method) were administered upon study enrollment and before discharge.ResultsParticipants who received the avatar during hospitalization had lower frequency of delirium at discharge (P<.001), reported fewer symptoms of loneliness (P=.01), and experienced fewer falls than control participants. There were no significant differences in self-reported depressive symptoms.ConclusionsThe study findings validate the use of human-in-the-loop, relational ECAs among diverse hospitalized older adults.

Risk Factors for Stillbirth in an Inner-City Community Hospital [18C

INTRODUCTION: The stillbirth rate at Lincoln Medical and Mental Health Center (LMMHC) in the Bronx is 1/130, which is higher than the national average. Our aim was to compare the reported risk factors for term stillbirth with the identified antenatal risk factors for all cases of fetal demise that occurred after 39 weeks of gestation. METHODS: For this IRB approved quality improvement project, we reviewed data from all of the term fetal demise that occurred at LMMHC from 2013-2017. We categorized women based on the following characteristics which have been reported as risk factors for stillbirth: Hypertension, Diabetes, Obesity (BMI>30), and Advanced Maternal Age (>35). RESULTS: For births at LMMHC from 2013-2015, the relative risk (RR) of having a Stillbirth for a woman with Obesity was 3.2 (CI 95% 1.8-5.3, p<0.0001), RR for Diabetes was 3.5 (CI 95% 1.9-6.2, p<0.0001), RR for Hypertension was 3.1 (CI 95% 1.7-5.5, p<0.0001). For births from 2016-2017, the RR of a woman with Diabetes to have a Stillbirth was 3.8 (CI 95%, 1.8-7.9, p<0.0004), the RR for Hypertension was 3.5 (CI 95% 1.6-7.3, p<0.0010). We did not have the BMI data for this time period. We did not see an increased risk of stillbirth in patients with AMA. CONCLUSION: Considering the known risk factors of stillbirth and the potential benefits of delivery at 39 weeks gestation, induction can be considered to potentially decrease the risk of stillbirth. Physicians should utilize shared decision making with their patients who exhibit these risk factors.

Impact of QRS Duration in Heart Failure with Preserved Ejection Fraction

Abstract QRS prolongation is a surrogate marker for ventricular dyssynchrony and an independent predictor of mortality in heart failure with reduced ejection fraction (HFrEF). However, the relevance of QRS prolongation in heart failure with preserved ejection fraction (HFPEF) has not been extensively studied. Retrospective chart review of all consecutive patients admitted with a primary diagnosis of acute decompensated heart failure (ADHF) for a period of 1 year at an inner-city community hospital (n=388). Patients were divided into 4 groups on the basis of their ejection fraction and QRS duration. There was high 1-year all-cause mortality (25.7%) in patients presenting with ADHF. There was no significant difference in LOS or 1-year all-cause mortality between patients with HFrEF and HFPEF. In patients with HFPEF, there was higher 1-year all-cause mortality in those with QRS prolongation, though not statistically significant. There is no difference in outcomes of LOS or 1-year all-cause mortality in HFrEF and HFPEF, with QRS prolongation portending a worse prognosis. Further studies are needed to elucidate the etiology of this high mortality in HFPEF.

Predictors of Early Readmission in Heart Failure Patients in an Inner-City Community Hospital

Heart failure (HF) is the most common hospital discharge diagnosis among the elderly. It accounts for nearly 1.4 million hospitalizations and $21 billion in spending per year in the United States. Readmission rates remain high with estimates ranging from 15-day readmission rates of 13%, 30- day readmission rates of 25%, to 6-month readmission rates of 50%. The Center for Medicare and Medicaid Services (CMS) has started penalizing hospitals with higher than expected readmission rates. Objective: To identify factors associated with increased 30-day readmission among heart failure patients in an inner-city community-based teaching hospital. Methods: A retrospective cohort study of patients with principal discharge diagnosis of acute Heart Failure between 2008 and 2010. Demographic, clinical characteristics, length of stay, discharge medications, disposition and all-cause 30-day readmission were abstracted from the hospital’s administrative database and analyzed. Results: Almost 8 out of 10 patients were 65 years or older (mean age 75.4 ± 14.3) and 51% were female. The in-hospital mortality rate was 2.7% (95% confidence interval [CI], 1.6% - 4.3%) with a median length of stay of 5.0 days (Interquartile range of 3 - 7). The all-cause 30-day readmission rate was 17.7% (95% CI 14.9% - 20.8%). By univariate analysis, readmissions were predicted by black race, prior history of HF, length of stay of more than 7 days and discharge to extended care facility (ECF). By logistic regression analysis, black race (OR 2.4, 95% CI 1.4 - 3.8), prior history of HF (OR 1.7, 95% CI 1.5 - 2.6) and discharge to an ECF (OR 2.4, 95% CI 1.5 - 3.7) were the independent predictors of 30-day readmission. HF accounted for 43.7% of the readmissions. Conclusion: Prior diagnosis of HF, black race, and discharge to an ECF were independent predictors of 30-day readmission in this cohort, and over half of the readmissions were for reasons other than HF.

Inappropriate Use of Intravenous PPI for Stress Ulcer Prophylaxis in an Inner-city Community Hospital

Inappropriate Use of Intravenous PPI for Stress Ulcer Prophylaxis in an Inner-city Community Hospital

Clinical Outcomes of Patients With Bacteremic Streptococcal Pneumonia Infection in a Large Inner-city Community Hospital

PURPOSE: Streptococcal pneumoniae is a common infectious disease processes. We wanted to describe a cohort of patients with bacteremic Streptococcal pneumoniae in a large inner city community hospital setting.