key: cord-0906017-kbyz43og
authors: Theodoro, D.; Coneybeare, D.; Lema, P.; Gerhart, C.; Binkley, M.; Chamarti, S.; Hafez, Z.; Ablordeppey, E.; Wallace, L.; Stickles, S.; Adhikari, S.
title: 29EMF Interpreter Variability Of Lung Point-of-Care Ultrasound Rubric in a Population of Non-Critically Ill COVID Patients
date: 2021-08-31
journal: Annals of Emergency Medicine
DOI: 10.1016/j.annemergmed.2021.07.030
sha: 89a837b475a9f55d9914dc5c1fc89d9ced54d4af
doc_id: 906017
cord_uid: kbyz43og

Study Objectives: Lung point-of-care ultrasound (L-POCUS), a novel and radiation-free diagnostic tool, could aid in COVID-19 prognosis. Early studies have yielded scoring rubrics focused heavily on hospitalized populations including the critically ill. Operator characteristics of this novel technology in non-critically ill, ambulatory COVID patients has not been described and is an important consideration for dissemination. The purpose of our study was to determine to the inter-rater reliability of an L-POCUS scoring rubric in a population of non-oxygen dependent patients. Methods: This was a cross sectional study design of patients at three academic institutions in the Northeast, Midwest, and West. We included subjects with respiratory complaints who tested positive for COVID-19 and maintained oxygen saturation ≥92% for two hours after presentation to the emergency department as part of a larger project focused on describing L-POCUS prognostic characteristics in a non-critically ill COVID pneumonia population. L-POCUS was performed on seven lung windows on each side of the chest: two anterior, two lateral, and three posterior. All clips were obtained with a curvilinear probe or a linear probe using machine settings to enhance lung findings ("nerve" or "lung"). The scoring rubric ranged from 0 to 6 for each lung field with 0 being normal lung and 6 indicating severe lung pathology from COVID. We divided lung findings into pleural and parenchymal with the score per lung field representing the sum of the two parts. Pleural findings included normal (0 points), blurring, indenting, or thickening (1 point), and discontinuity (2 points). Parenchymal findings included normal (0 points), B lines (1-3 B lines equaled 1 point, >3 B lines equaled 2 points, coalescing or “waterfall” B lines equaled 3 points), and subpleural consolidation (4 points). As discontinuous pleura necessarily accompanies subpleural consolidations per definition, lung fields with subpleural consolidations automatically scored 6 points. Clips, collected and scored at bedside by an expert sonologist, were randomly selected for scoring by other operators of differing experiences: a resident, a faculty member without ultrasound fellowship training, an ultrasound fellow, and a second expert. Scores were then analyzed using the intraclass correlation coefficient (ICC) using the R package “ICC” to determine inter-rater reliability between the initial expert rater and all other raters. Results: A total of 50 clips lasting 6 seconds each were chosen for scoring, 49 with the culvilinear probe and 1 with the linear probe. The calculated Intraclass Correlation Coefficient (ICC) for expert raters was 0.71 (0.55, 0.83, p<0.0001) 0.83). Moderate agreement between all raters was found with an ICC of 0.72 (0.62, 0.81). The faculty member without ultrasound fellowship training and the fellow disagreed the most from the group and resulted in the highest variability. A Loess graph demonstrates less variability at low scores than high scores. Conclusion: The L-POCUS rubric for scoring lungs infected with COVID in an ambulatory population revealed moderate to good agreement among a diverse group of operators. Greater variation at higher scores reveals ambiguity in definitions of lung pathology in COVID. This warrants future studies refining criteria for lung findings and correlating to clinical implications. [Formula presented]

Study Objective: The COVID-19 pandemic led to profound challenges for health systems and disruptions in care for society's most vulnerable patients, in particular people with opiate use disorders (OUD). The closure of outpatient addiction clinics, cessation of harm-reduction services, and lack of access to support groups have all been attributed to worsening outcomes for patients with OUD during the COVID-19 pandemic. Most concerningly, emerging evidence points to accelerated rates of overdose deaths. In Los Angeles, a city disproportionately affected by high rates of COVID-19, chronic housing insecurity, and substance use disorder, the Department of Public Health reported a 48% increase in accidental drug overdose deaths during the first five months of the pandemic. In March of 2020, a state of emergency was declared for COVID-19 and stay-at-home orders were issued. These events were associated with a sharp reduction in total ED visits. However, with the profound disruption in usual sources of care and support for people with substance use disorders, emergency departments (EDs) remained a critical access point for these patients.

Methods: We examined all visits to public safety-net hospital EDs in Los Angeles County. We considered OUD-related ED visits as those which included any of the following: visits with a discharge diagnosis related to OUD, patients who received buprenorphine or naloxone while in the ED, and visits where a prescription for buprenorphine or naloxone was given on discharge. We performed a logistic regression to examine patient characteristics of opiate use disorder-related visits from April 2019-Feb 2020 compared with April 2020-Feb 2021.

Results: Overall, there was a 22% increased odds of an ED visit being related to OUD when we compared pre-and post-COVID shutdown periods in Los Angeles. Visit acuity levels increased across all ESI scores. There was a statistically significant increase in the predicted probability of OUD visits for black and Hispanic patients of 17% and 25% respectively compared to pre-COVID levels. Patients were more likely to present for OUD-related encounters if they were publicly insured, uninsured, or brought in by ambulance. Admitted patients were four times more likely to have an OUD-related ED visit on presentation.

Conclusions: Rates of OUD-related ED visits increased during COVID-related shutdowns. These increases were most pronounced among black and Hispanic patients and those with no insurance or publicly funded insurance plans. Patients admitted to the hospital had higher odds of OUD-related complaints. This reinforces the importance of the emergency department as a safety net resource for the most vulnerable patients suffering from OUD during the pandemic and highlights the opportunity to address these disparities with ED-based interventions. Study Objectives: Lung point-of-care ultrasound (L-POCUS), a novel and radiation-free diagnostic tool, could aid in COVID-19 prognosis. Early studies have yielded scoring rubrics focused heavily on hospitalized populations including the critically ill. Operator characteristics of this novel technology in non-critically ill, ambulatory COVID patients has not been described and is an important consideration for dissemination. The purpose of our study was to determine to the inter-rater reliability of an L-POCUS scoring rubric in a population of non-oxygen dependent patients.

Methods: This was a cross sectional study design of patients at three academic institutions in the Northeast, Midwest, and West. We included subjects with respiratory complaints who tested positive for COVID-19 and maintained oxygen saturation 92% for two hours after presentation to the emergency department as part of a larger project focused on describing L-POCUS prognostic characteristics in a non-critically ill COVID pneumonia population. L-POCUS was performed on seven lung windows on each side of the chest: two anterior, two lateral, and three posterior. All clips were obtained with a curvilinear probe or a linear probe using machine settings to enhance lung findings ("nerve" or "lung"). The scoring rubric ranged from 0 to 6 for each lung field with 0 being normal lung and 6 indicating severe lung pathology from COVID. We divided lung findings into pleural and parenchymal with the score per lung field representing the sum of the two parts. Pleural findings included normal (0 points), blurring, indenting, or thickening (1 point), and discontinuity (2 points). Parenchymal findings included normal (0 points), B lines (1-3 B lines equaled 1 point, >3 B lines equaled 2 points, coalescing or "waterfall" B lines equaled 3 points), and subpleural consolidation (4 points). As discontinuous pleura necessarily accompanies subpleural consolidations per definition, lung fields with subpleural consolidations automatically scored 6 points. Clips, collected and scored at bedside by an expert sonologist, were randomly selected for scoring by other operators of differing experiences: a resident, a faculty member without ultrasound fellowship training, an ultrasound fellow, and a second expert. Scores were then analyzed using the intraclass correlation coefficient (ICC) using the R package "ICC" to determine inter-rater reliability between the initial expert rater and all other raters.

Results: A total of 50 clips lasting 6 seconds each were chosen for scoring, 49 with the culvilinear probe and 1 with the linear probe. The calculated Intraclass Correlation Coefficient (ICC) for expert raters was 0.71 (0.55, 0.83, p<0.0001) 0.83). Moderate agreement between all raters was found with an ICC of 0.72 (0.62, 0.81). The faculty member without ultrasound fellowship training and the fellow disagreed the most from the group and resulted in the highest variability. A Loess graph demonstrates less variability at low scores than high scores.

Conclusion: The L-POCUS rubric for scoring lungs infected with COVID in an ambulatory population revealed moderate to good agreement among a diverse group of operators. Greater variation at higher scores reveals ambiguity in definitions of lung pathology in COVID. This warrants future studies refining criteria for lung findings and correlating to clinical implications. Study Objectives: Social determinants of health (SDOH) influence the health outcomes of COVID-19 patients; yet, little is known about how patients at risk of significant disease burden view this relationship. Our study sought to explore patient perceptions of the influence of SDOH on their COVID-19 infection experience and COVID-19 transmission within their communities.

Methods: We conducted a qualitative study of patients in a North Carolina health care system's registry who tested positive for COVID-19 from March 2020 through February 2021. All patients' addresses across six counties served were georeferenced and analyzed by Kernel Density Estimation (KDE) to identify population-dense outbreaks of COVID-19 (hotspots). Spatial autocorrelation analysis was performed to identify census area clusters of white, Black and Hispanic populations, based on the 2019 American Community Survey dataset. Patients were identified by a randomized computer-generated sampling method. Patients participated in semi-structured phone interviews in English or Spanish based on patient preference by trained bilingual researchers. Each interview was evaluated using a combination of deductive and inductive content analysis to determine prevalent themes related to COVID-19 knowledge and diagnosis, disease experience, and the impact of SDOH.

Results: The 10 patients interviewed from our COVID-19 hotspots were of equal distribution by sex, and predominantly Black (70%), ages 22-70 years (IQR 45-62 years), and presented to the ED for evaluation (70%). The respondents were more frequently publicly insured (50% medicaid/medicare; vs 30% uninsured; vs 20% private). The interviews demonstrated themes surrounding the experience and impact of COVID-19. The perceived risk of contracting COVID-19 and knowledge of how to prevent infection varied greatly and could be in part explained by SDOH such as their occupation and living conditions. The experiences of COVID-19 testing, diagnosis, isolation and treatment were most influenced by the timing of infection in relation to the study period. Earlier in the pandemic, the knowledge of isolation requirements and available support systems seemed to have negatively impacted the ability to isolate and follow public health guidance, as well as the support mechanisms provided by employers during this period. Communication of infection status once diagnosed varied greatly, with some voicing feelings of shame, and others advocating for sharing of infection experiences to change community behaviors. Suggestions for how to improve the COVID-19 response included improving communication and enforcing public health guidelines, including raising awareness for vulnerable populations.

Conclusion: Further exploration of important themes and related SDOH that influenced how the participants experienced the COVID-19 pandemic will be necessary to decrease the negative impacts of SDOH in communities that are high-risk for COVID-19 spread. Study Objective: Monoclonal antibody therapy (MOAB) has recently emerged as a treatment for mild to moderate COVID-19, potentially preventing those with underlying conditions from progressing to severe illness and hospitalization. While MOAB administration has commonly been restricted to infusion centers or inpatient settings, the infection prevention needs of patients with acute COVID-19 and the ambulatory nature of the therapy make the emergency department (ED) a useful setting to offer this treatment. Further, as EDs are the primary point of health care access for many at-risk individuals, offering MOAB in the ED may increase availability of treatment options for patients from traditionally underserved communities.

Methods: A retrospective chart review was conducted of patients 12 years and above who received treatment in our urban, academic, community hospital. A multidisciplinary group comprised of stakeholders in emergency medicine, pediatrics, infectious disease, nursing, informatics, and pharmacy developed a comprehensive ED-based MOAB program. Patients 12 years and older were screened for eligibility during ED visits or during follow-up calls providing positive test results. Staff was trained on specific consent, infusion, monitoring, and documentation procedures adherent to MOAB administration under the Emergency Use Authorization. Patients were contacted following MOAB and queried regarding symptom resolution and health care utilization. Data regarding patient demographics, ED course, and 7-day unscheduled visits were collected.

Patients had a mean age of 52.3 years (SD 24.4); 21% were 12-17 years of age and 37% were >65 years old. 52% were male. 33% self-reported as Caucasian, 19% Black, 18% Asian/Pacific Islander, 21% as other, and 9% were unknown. 17% identified as Latinx. 19% of patients were insured by Medicaid, 36% Medicare, 39% commercially insured, and 6% were uninsured. Patients had symptoms a median of 3 days prior to MOAB. After age (46%), the most commonly reported eligibility criteria was obesity (20%), followed by hypertension (11%) and immunocompromised state (11%). 74% of infusions were administered during nights and weekends. No infusion reactions occurred. 8% returned to an ED within 7 days of MOAB, 5% were hospitalized. No patients required ICU admission or died. Conclusion: ED-based MOAB has been safely implemented and may be an effective treatment for patients with mild to moderate COVID-19

Decay of Anti-SARS-CoV-2 Nucleocapsid IgG in Seropositive Health Care Workers Over Time

The CONSERVE-HCW Research Group/Dignity Health Research Institute Arizona/ Dignity Health Arizona General Hospital