Inner-city Hospital Research Articles

Implementation and outcomes of monoclonal antibody infusion for COVID-19 in an inner-city safety net hospital: A South-Bronx experience

BackgroundMonoclonal antibody therapy (MAT) is recommended in mild to moderate Coronavirus disease 2019 (COVID-19) patients who are at risk of progressing to severe disease. Due to limited data on its outcomes and the logistic challenges in administering the drug, MAT has not been widely used in the United States (US) despite of emergency use authorization (EUA) approval by the Food and Drug Administration (FDA). AimWe aim to study the outcomes of MAT in patients predominantly from ethnic minority groups and the challenges we experienced in implementing the infusion therapy protocol in an inner-city safety-net-hospital in the South Bronx. Methods and resultsWe conducted a retrospective observational study of 49 patients who were offered MAT as per EUA protocol of FDA. Patient who met the criteria for MAT and received therapy were included in treatment group (n = 38) and the remaining (n = 11) who declined treatment were included in the control group. A majority of patients (76%) in the study group reported symptomatic improvement, the day after infusion. There was statistically significant reduction in COVID-19 related hospitalizations (7.8 vs 54.5%, P = < 0.001) mortality (0 vs 18.1%, P value = 0.008) in the treatment group. ConclusionMAT reduced both hospitalization and mortality in this predominantly Hispanic patient population with mild to moderate COVID-19 with high risk factors for disease progression.

Seeing rainbows through the storms of a health condition: Making space for LGBTQ+ young people to have their identity acknowledged.

LGBTQ+ youth accessing healthcare settings manage the 'storms' of health conditions (e.g. pain, fatigue, social isolation, etc.) while navigating emerging identity exploration and understandings in settings which may have historically overlooked or disaffirmed these identities. The launch of National Health Service Rainbow Badges across the paediatric division of an inner-city hospital provided a context for staff to begin thinking about their practice, development needs and dilemmas in working with LGBTQ+ youth. Through a programme of activity that included staff training, surveys, focus groups and youth engagement, we gained insight into current practice in supporting LGBTQ+ youth and families. This paper presents our findings, ideas for responding to challenges, and areas for future development, including implications in light of the coronavirus pandemic.

Sustained decrease in pediatric asthma emergency visits during the first year of the COVID-19 pandemic.

Background: On January 20, 2020, the first documented case of novel severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) was reported in the United States. The U.S. Centers for Disease Control and Prevention continues to report more morbidity and mortality in adults than in children. Early in Pandemic, there was a concern that patients with asthma would be affected disproportionately from COVID-19, but this was not manifested. It is now recognized that angiotensin-converting enzyme 2 receptors that are used by the coronavirus for infection have low expression in children with atopy that may contribute to decreased infectivity in children who are atopic. There are several early reports of decreased emergency department (ED) visits for children with asthma. The authors previously reported a decrease in pediatric ED visits in the spring of 2020, which correlated with school closure. Objective: To determine if this trend of decreased ED visits for pediatric asthma was sustained throughout the first COVID-19 pandemic year. Methods: ED data from one inner city children's hospital were collected by using standard medical claims codes. Conclusion: We reported a sustained year of decreased ED visits for children with asthma in one pediatric ED in an inner-city hospital; this seemed to be secondary to school closure and decreased exposure to upper respiratory infections.

Obesity and the increasing odds of cesarean delivery

Background Knowledge of the associations between obesity and cesarean delivery (CD) is limited by previous research that does not separate the highest BMI classes. Methods We identified 25,604 pregnancies in retrospective electronic medical records at an inner-city academic hospital between 2000 and 2015. We examined the association between BMI at pre-pregnancy and delivery, as well as gestational weight gain (GWG), and rates of CD, gestational diabetes mellitus (GD), and pregnancy-induced hypertension (PIH) using logistic regression and chi-square. Results CD increased with each increase in delivery BMI class [X 2 (7, N = 25,604) =151.40, p < .0001]. GD and PIH also significantly increased across each BMI class. Each increasing BMI class predicted 1.21 times greater odds of CD even after adjusting for maternal age, year of birth, GD, and PIH [OR = 1.21 (95% CI, 1.07–1.37)]. As compared with the IOM recommended GWG, less weight gain offered mitigation of CD and GD, though less than the recommended GWG for women who were obese pre-pregnancy also increased odds of preterm birth, low birth weight, and stillbirth. Conclusions Increasing BMI is associated with increasing rates of adverse obstetric outcomes. There exists a “dose-dependent” effect of BMI on CD and limiting GWG may be associated with mitigated risk for this outcome, but increased risk for offspring adverse birth outcomes.

Assessment of 2-Year Mortality With Use of Drug-Coated Devices in Femoropopliteal Disease: A Real World Experience from The Bronx, New York

We sought to compare the 2-year mortality outcome in patients with femoropopliteal arterial disease treated with drug-coated devices (DCDs) vs those treated with non-drug-coated devices (nDCDs) in an inner-city public hospital that mainly serves patients of lower socioeconomic status.

Improving access to perinatal mental health services: the value of on-site resources

Perinatal mood disorders have both short- and long-term negative consequences for mothers and their babies. National organizations recommend universal screening for postpartum depression. Little is known, however, about screening and referral among women living in underserved areas with limited access to care. The objective of this report was to evaluate the utilization of mental health services in an urban, inner-city hospital following the implementation of colocated counseling services across 10 county-sponsored clinics that serve a medically underserved population. We further explored antecedents of a positive postpartum depression screen, factors associated with successful referral, and the rate of perinatal mood disorder diagnoses following universal screening. We hypothesized that integrated mental health services would improve referral rates following positive postpartum depression screening compared with historically separated services. This was a retrospective cohort study of women undergoing universal postpartum depression screening with deliveries from January 2017 to December 2019 who were compared with a historic cohort from the same population from June 2008 to March 2010. The Edinburgh Postnatal Depression Scale was used to evaluate women at their postpartum visit, and a mental health service referral was offered to women with a score of ≥13. The primary outcome was a comparison of completed referrals between cohorts with and without colocated mental health services following a positive postpartum depression screen. Statistical analysis included chi-square tests with a P value of <.05 being considered significant and adjusted multivariate analyses for perinatal outcomes associated with a positive postpartum screen. Between January 2017 to December 2019, 25,425 women completed a postpartum depression screen with 978 (4%) of those recording a positive screen. After implementation of colocated mental health counselors, completed perinatal mental health referrals significantly increased when compared with the historic cohort without colocated services (57%; 560 of 978 vs 22%; 238 of 1106; P<.001). Adverse neonatal outcomes, such as stillbirth (adjusted risk ratio, 9.5; 95% confidence interval, 6.35-14.26) and neonatal demise (adjusted risk ratio, 14.3; 95% confidence interval, 6.67-30.46), were most strongly associated with a positive depression screen. There were 122 (21%) women with a positive screen who were diagnosed with a depressive disorder in the peripartum period. There were no specific features associated with those who did or did not complete referral. One-fifth of women were referred for psychiatric evaluation following an initial evaluation, and the referral rate was associated with higher scores on the depression screen (P<.001). Utilization of mental health services following a positive depression screen more than doubled following the implementation of colocated services.

Geographic barriers to prenatal care access and their consequences

Although prenatal care has long been viewed as an important strategy toward improving maternal morbidity and mortality, limited data exist that support the premise that access to prenatal care impacts perinatal outcomes. Furthermore, little is known about geographic barriers that impact access to care in an underserved population and how this may influence perinatal outcomes. This study aimed to (1) evaluate perinatal outcomes among women with and without prenatal care and (2) examine barriers to receiving prenatal care according to block-level data of residence. We hypothesized that women without prenatal care would have worse outcomes and more barriers to receiving prenatal care services. This was a retrospective cohort study of pregnant women delivering at ≥24 weeks' gestation in a large inner-city public hospital system. Maternal and neonatal data were abstracted from the electronic health record and a community-wide data initiative data set, which included socioeconomic and local geographic data from diverse sources. Maternal characteristics and perinatal outcomes were examined among women with and without prenatal care. Prenatal care was defined as at least 1 visit before delivery. Outcomes of interest were (1) preterm delivery at <37 weeks' gestation, (2) preeclampsia or eclampsia, and (3) days in the neonatal intensive care unit after delivery. Barriers to care were analyzed, including public transportation access and location of the nearest county-sponsored prenatal clinic according to block-level location of residence. Statistical analysis included chi-square test and analysis of variance with logistic regression performed for adjustment of demographic features. Between January 1, 2019, and October 31, 2019, 9488 women received prenatal care and 326 women did not. Women without prenatal care differed by race and were noted to have higher rates of substance use (P=.004), preterm birth (P<.001), and longer lengths of newborn admission (P<.001). After adjustment for demographic features, higher rates of preterm birth in women without prenatal care persisted (adjusted odds ratio, 2.65; 95% confidence interval, 1.95-3.55). Women without prenatal care resided in areas that relied more on public transportation and required longer transit times (42 minutes vs 30 minutes; P=.005) with more bus stops (29 vs 17; P<.001) to the nearest county-sponsored prenatal clinic. Women without prenatal care were at a significantly increased risk of adverse pregnancy outcomes. In a large inner city, women without prenatal care resided in areas with significantly higher demands for public transportation. Alternative resources, including telemedicine and ridesharing, should be explored to reduce barriers to prenatal care access.

Clostridioides difficile Is Not Difficult to Predict in Hospital Settings

Background:Clostridioides difficile is a gram-positive bacteria that is the most common cause of hospital-associated infectious diarrhea among traditional and nontraditional high-risk populations. Excess healthcare costs associate with C. difficile infection (CDI) prevalence, morbidity, and mortality is shown to economically impact the US healthcare system with at least an additional $1 billion in annual cost. Exposure to antimicrobial agents resulted in increased risk for hospital-onset CDI (HO-CDI) at an inner-city hospital during 2010 and 2011. Methods: A retrospective case-control study of all persons with HO-CDI in the MICU was conducted at an inner-city hospital between January 1, 2010, and December 31, 2011. A patient was considered to have developed HO-CDI if diarrhea developed after 72 hours of admission into the MICU and a confirmed laboratory stool specimen for Clostridioides difficile infection (CDI) was obtained. A non–HO-CDI person was randomly selected using “risk set sampling.” After the application of inclusion and exclusion criteria, 88 cases were eligible for the study. Of these cases, 29 met the definition for HO-CDI, and 59 met the definition for non–HO-CDI. The relationship between antimicrobial use and the development of HO-CDI in patients in the MICU at an inner-city hospital was investigated using a logistic regression model in which the variable of total antibiotics was used as a possible predictor for predicting a positive HO-CDI. Results: Logistic regression was utilized to determine the relationships between selected study variables and presence or absence of HO-CDI. Total antibiotics was significantly related to HO-CDI. The results of this analysis showed that total antibiotics was a significant predictor for HO-CDI. The total value of the coefficient B for this predictor was 0.47, and the exponentiated value (exp[B]) of this coefficient was 1.60 (95% CI, 1.08–2.35). In this sample, patients who had 1 or more antibiotics were at a 60% greater risk of having a positive HO-CDI culture. There was a significant association between the use of metronidazole and HO-CDI (p &lt; .001). Conclusions: Antimicrobial stewardship is an integral part of patient safety. The findings from this study were instrumental in the implementation of a fledging antimicrobial stewardship program and the use of evidence-based practices at this inner-city hospital.Funding: NoDisclosures: None

Potential predictors of outcomes among hospitalized COVID-19 patients treated with convalescent plasma: a single-center study

ABSTRACT Background: The coronavirus disease 2019 pandemic is a major international public health crisis, which has led to over 3 million deaths as of April 2021. Several therapeutics have been tried for this deadly illness including antivirals, immunosuppressive agents and convalescent plasma (CP). In this study, we present our inner-city safety net hospital experience with CP therapy. Methods: This was a retrospective chart review of hospitalized patients with confirmed COVID-19 who were treated with CP. Results: A total of 60 patients received CP during the study period. The mean age for patients in this study was 58.95 years. The most common presenting symptoms were shortness of breath (85%) and cough (73%). Hypertension (65%) and diabetes mellitus (55%) were the most common comorbidities in our patients. In our multivariate regression analysis, male sex, nausea and loss of appetite at presentation were associated with improvement in oxygenation after CP. Total survival time, history of obstructive airway disease, home use of angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers were associated with decreased survival, whereas Hispanic ethnicity showed a trend towards lower survival after CP therapy. Conclusions: Our study highlights several important characteristics of inner-city safety net hospital patient population who might benefit from CP therapy.

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.

Segmentation of specialised and non-specialised work as a model for dealing with rising demand for paediatric surgical services

Introduction Shifts in the landscape of surgical care provision have resulted in a rise in demand for specialist paediatric surgery services. Here we describe a model of a single paediatric surgery service delivering elective surgery across two sites, a specialist children’s hospital and an inner-city district general hospital. This model has allowed for a management of increased demand while maintaining key quality indicators within national standards. Materials and methods In a single specialist paediatric surgical service working at two sites (specialist and non-specialist), service demand was evaluated by number of referrals and waiting list additions and removals over an eight-year period (2011–2018). Daycase rate, 30-day readmission, and 12-month reoperation for three commonly performed general surgery of childhood procedures (umbilical hernia repair, Inguinal herniotomy, orchidopexy) are reported. NHS Getting it Right First Time data are used to allow comparison with national standards. Results Referrals to the service increased 2.5-fold (955 in 2011/12 compared with 2,419 in 2017/18) and waiting list additions increased 1.4-fold (585 compared with 840), net additions to the waiting list indicate that demand was met. Readmission and reoperation rates met or exceeded national standards. Discussion This model allows for a high quality of care to be provided with acceptable daycase rates and low readmission and reoperation rates. We commend this model to other specialist paediatric surgical centres experiencing increasing demand on their services

Abstract P043: Distance And Clinical Outcomes Of Patients Admitted For Covid-19: Lessons Learned From The Neighbors Of An Inner-city Hospital.

Background: In rural areas, the distance factor has been identified as key in the utilization of health services. We aim to determine whether distance to an inner-city hospital in Newark, was associated with mortality in patients admitted for COVID-19 during the peak of the pandemic. Methods: Patients who were admitted for COVID-19 at the Newark Beth Israel Medical Center (NBIMC) were stratified into two groups based on distance between the zip codes of their primary residence and the hospital. Baseline demographics, clinical characteristics and in-hospital outcomes were compared between subjects living within a 2-mile radius of the zip code of the hospital [Neighbors] and those living further than 2 miles [Distant]. The primary outcome was in-hospital mortality. Secondary outcomes were admission to the intensive care unit (ICU), length of hospitalization, and discharge disposition. Results: Between March 09 and May 04, 2020, a total of 769 patients were admitted for COVID-19 at NBIMC. 406 (53%) resided within a 2-mile radius of the hospital location. Of these 44% were obese. History of hypertension, diabetes mellitus and coronary artery disease was documented in 69%, 48% and 23% respectively. Compared with distant patients, neighbors were older (59 vs. 69 yrs. P=0.048), mostly of Black/African American race (64% vs. 82%; p&lt;0.001) and had a higher incidence of diabetes mellitus (40% vs. 48%; p=0.025) or coronary artery disease (17% vs. 23%; p=0.039). Visitors were more likely to report an exposure history to a COVID-19 patient than neighbors (31% vs. 21%, p=0.001). In-hospital death rate were significantly higher in neighbors than visitors (32% vs. 22%, p=0.007). Admission to the ICU was similar between both groups (p=0.438). Among those who survived to discharge, distant patients had longer length of hospitalization (12 vs. 10 days; p=0.006), than neighbors. Discharge disposition was comparable in both groups (p=0.249) Conclusions: In this cross-sectional study of patients admitted to an inner-city hospital for COVID-19, majority of patients living within a 2-mile radius were of Blacks/African Americans who had a higher incidence of DM and CAD. A paradoxical association between distance to the hospital and in-hospital mortality was observed. Based on these findings, targeted interventions aimed at Impacting social determinants of health seem prudent.

Prevalence of elevated right ventricular pressure in children with obstructive sleep apnea syndrome undergoing pulmonary hypertension screening.

Our objective was to determine the prevalence of elevated right ventricular pressure (RVP) as a surrogate marker for pulmonary hypertension in children with obstructive sleep apnea syndrome (OSAS) undergoing echocardiography. This was a retrospective chart review of children ages 2-21 years diagnosed with OSAS by an overnight polysomnogram who underwent cardiac echocardiogram to screen for pulmonary hypertension within 6 months of polysomnogram in a tertiary inner-city pediatric hospital. The primary outcome was elevated RVP defined by estimated RVP ≥ 25 mm Hg above right atrial pressure or ventricular septal configuration consistent with elevated RVP. A total of 174 children were included. The median (interquartile range) age was 8.9 (5.5-13.1) years with 59.2% male, 41.4% Hispanic, and 25.9% non-Hispanic Black patients. The prevalence of obesity was 72.0% and severe or very severe OSAS was present in 93.1%. The median (interquartile range) apnea-hypopnea index was 28.3 events/h (18.8-52.7 events/h). Seven children (4.0%) had elevated RVP. There was no association between elevated RVP and age, sex, race, body mass index percentile, apnea-hypopnea index, oxygen nadir, or severe OSAS (apnea-hypopnea index ≥ 10 events/h). Elevated RVP was rare and was not associated with OSAS severity. The prevalence in this cohort is higher than the prevalence of pulmonary hypertension noted in similar studies (0%-1.8%), which may be related to differences in methodology or unassessed cohort characteristics. Further effort to determine the optimal role for pulmonary hypertension screening in pediatric OSAS is needed. Bitners AC, Arens R, Mahgerefteh J, etal. Prevalence of elevated right ventricular pressure in children with obstructive sleep apnea syndrome undergoing pulmonary hypertension screening. J Clin Sleep Med. 2021;17(11):2225-2232.

Use of Chest X-ray in the Evaluation of Acute Cough in the Pediatric Emergency Department of an Inner-City Hospital

Background: Cough has been identified as one of the most common complaints at physician visits and accounts for an estimated 29.5 million annual outpatient visits [1]. Acute cough is defined as cough of less than 2 weeks in duration [2]. Current clinical practice guidelines have recommended against routine use of chest x-rays in evaluation of common causes of cough in the emergency department (ED) except in cases with significant respiratory distress or hypoxemia [3–5]. Despite these guidelines, there is still an increased use of chest x-ray in evaluation of children in the pediatric ED. We aimed to determine the prevalence of children presenting with acute cough in the pediatric ED, the proportion of these patients evaluated with chest x-ray, and to review their chest x-ray findings. Methods: The study was a retrospective cross-sectional study involving patients aged 1 month – 21 years presenting to the pediatric ED of BronxCare Health System with acute cough from January 2019 to December 2019. Data was extracted from the hospital’s Electronic Health Record. Frequency tables were used to describe sociodemographic and clinical characteristics, and chest x-ray findings. Results: Of the 30,014 patients who presented to the pediatric ED during the study period, 3560 (11.9%) had acute cough, of whom 949 (26.7%) had a chest x-ray done. Most of the patients with acute cough (75.6%) had no respiratory distress. Majority of them (68.4%) had fever for 1–14 days, and the most frequent cough duration was 2 days (28.7%). The most common chest x-ray finding was peri-bronchial cuffing (52.6%), while 33% of the chest x-rays were normal (Table 1). Most of the patients (70.4%) were discharged home. Conclusion: A significant proportion of children presenting with acute cough to the pediatric ED routinely have a chest x-ray done as part of their management, findings of which are mostly insignificant and contribute little to their care. We therefore recommend judicious use of chest x-ray and adherence to existing guidelines in cases of acute cough presenting to the pediatric ED.

Dissemination of validated health literacy videos: A tailored approach.

e18505 Background: Previously, we showed that chemotherapy and precision medicine terminology are remarkably difficult for patients to understand. Therefore, we developed short, animated videos explaining key terminology and demonstrated that they significantly improved understanding. These videos, though effective and published, including freely downloadable, will only be helpful if appropriately disseminated. In the past, even after a video-based educational tool for prostate cancer was proven effective for improving patient comprehension, no dissemination plan was implemented due to copyright issues. Therefore, in order to propel these validated health literacy videos from the academic community into clinic workflow, we aimed to determine the best dissemination method at two different hospitals with disparate populations just six miles apart: an underserved, inner-city hospital and a higher SES hospital. Methods: The dissemination interview was developed in collaboration with an expert Intervention Development, Dissemination, and Implementation team. The draft was cognitively tested with physicians and staff who were not oncologists and finalized. With consent, interviews were conducted with both Winship Cancer Institute and Grady Memorial Hospital providers (GMH). All interviews were audio recorded, transcribed and analyzed using a semantic content analysis method. Results: Eleven providers at GMH and 22 providers at Winship were interviewed, reaching saturation of themes. 72% (n = 8) of the GMH providers felt that the best place for patients to view the videos was in the clinic, compared to 27% (n = 6) of the Winship providers. 68% (n = 15) of the Winship providers stated an app would be the most useful format, compared to 27% (n = 3) at GMH. All agreed that it would be useful for the patient’s family or caregiver to view the videos (GMH = 100%, Winship = 72%), that translation of the videos to Spanish would be beneficial (GMH = 90%, Winship = 63%), and that a nurse would be best to introduce the videos (GMH = 81%, Winship = 68%). Conclusions: Educational materials explaining complicated oncology treatment terminology enhance patient-centered care, yet without proper dissemination these crucial educational tools may never reach the intended patient population. The hospitals examined in this study served significantly different patient populations and the dissemination recommendations were quite different. Providers believed that the underserved patients needed the videos accessible in the clinic whereas providers serving higher SES patients thought that a web-based app, requiring a smart device or internet access, was more appropriate. Our study shows that it is crucial to ensure that educational materials are accessible to all populations, not just those with more means. Without a location-specific dissemination plan, educational tools may only further exacerbate disparities, rather than alleviate them.

Culturally Informed, Codesigned, Supportive Care for Aboriginal and Torres Strait Islander People With Cancer and Their Families

ABSTRACT Aboriginal and Torres Strait Islander people experience significant disparities in accessing cancer care and in cancer outcomes when compared with non-Indigenous Australians. Social workers and Aboriginal Hospital Liaison Officers from an inner-city hospital partnered with local Aboriginal organisations to develop, implement, and evaluate a culturally informed model of supportive cancer care. The initiative adopted an “appreciative inquiry” approach and engagement with Indigenous stakeholders, drawing on the Aboriginal and Torres Strait Islander Quality Improvement Framework and Toolkit for Hospital Staff (AQIFTHS, 2015). Using a process of codesign, strategies were developed with consumers to address the social and cultural determinants of health across the cancer journey. The new evidence-based model of care incorporated culturally informed identification of needs, culturally appropriate engagement, and maintenance of respectful connections to develop codesigned care plans with tailored information and provide practical support and advocacy. Findings illustrate the complex challenges faced by Aboriginal and Torres Strait Islander people living with cancer as well as their strengths. AQIFTHS processes and model of care provide guidance for social workers and other health professionals seeking to partner with stakeholders to promote health equity and improve supportive cancer care in accordance with optimal care guidelines and national quality standards. IMPLICATIONS Supportive care needs of Aboriginal and Torres Strait Islander people living with cancer are often complex and multifaceted, but links with community and culture are noted strengths. Social workers in Australian health settings have an important role in improving access and promoting a culturally responsive model of care for this population. Appropriate support can only occur when it is codesigned with the individual patient and their family members, Aboriginal Hospital Liaison Officers, and community.

Knowledge, Attitudes and Perceptions of COVID-19 Vaccination among Healthcare Workers of an Inner-City Hospital in New York.

Introduction: New York City is one of the areas most affected by the COVID-19 pandemic in the United States. Healthcare workers are among those at high risk of contracting the virus, and a vital source of information and trust in vaccines to the community. Methods: This study was conducted about attitudes towards COVID-19 vaccination among healthcare workers at a public hospital in New York City during the beginning of COVID-19 vaccination. 428 hospital employees responded. Results: Several factors were significantly associated with vaccine attitudes, including demographics such as gender (p = 0.002), age (p = 0.005), race (p < 0.001) and home location (p < 0.001), role within the hospital (p < 0.001), knowledge about the virus (p < 0.001) and confidence in and expectations about personal protective equipment and behaviors (p < 0.001). Structural equation modeling revealed that the most predictive factors were prior vaccine attitudes and concern with the speed of testing and approval of the vaccines (p < 0.001). Multivariate analysis reinforced these, while also identifying perceived personal risk as significant (p = 0.033). Conclusions: Several modifiable factors that reflect confidence in science, scientific knowledge, personal risk perception, experience and medical authority are correlated with vaccine attitudes, indicating that a holistic educational approach to improve trust in science is likely to be effective in long-term reduction in vaccine hesitancy.

Twenty Years Baby-Friendly: Personal Reflections on Change.

Background: Boston Medical Center (BMC) is an inner-city hospital located in Boston, Massachusetts. In 1995, like many maternity hospitals in the United States, BMC had policies that routinely separated mothers from their babies, limited breastfeeding education for staff, provided no hospital-funded lactation consultants, and did not initiate any limitations on the presence of the formula industry in the hospital. This all changed in 1999 when BMC became the first Baby-Friendly designated hospital in Massachusetts and the 22nd in the nation. Objective: Describe challenges encountered on the hospital's journey to Baby-Friendly and subsequent re-designations and share strategies used to overcome them. Materials and Methods: Policy changes and new programs instituted over the twenty-year period are described as well as personal reflections on change by the author. Results: Over the time period chronicled, improvements in breastfeeding initiation and exclusivity rates were observed. From 1997 to 2019, the breastfeeding initiation rate increased from 53% to 90% and the exclusive breastfeeding rate increased from 6% to 50-60%. Delivery volume at the hospital increased from 1600 to 2850 births per year in the same time period. Following the Ten Steps is an important way to decrease racial disparity gaps. Conclusions: Change is possible in the hospital setting. Achieving and maintaining Baby-Friendly designation is a successful strategy to increase maternity unit breastfeeding rates.

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.

P123. Reduced uptake of breast reconstruction persists amongst South Asian women in a large inner city UK hospital following removal of known barriers to treatment

Uptake of breast reconstruction following mastectomy for breast cancer in South Asian patients is low worldwide compared to other ethnic groups. Our large inner-city teaching hospital has the largest South Asian population in the UK. We examined breast reconstruction rates in our South Asian patients, free from financial or communication barriers, and identify reasons for any variation.