Equitable and timely access to outpatient COVID-19 treatment: A review of centralized workflow implementation at an integrated health system.

BACKGROUND: During the evolution of the COVID-19 pandemic, health care entities had to adapt to rapidly changing research and best practices in disease prevention and treatment to maintain the delivery of high-quality patient care. Prompt interdisciplinary efforts amongst physician, pharmacist, nursing, and information technology teammates are needed to develop robust centralized strategies to allocate and administer COVID-19 therapies in the ambulatory setting. OBJECTIVE: The objective of this analysis is to demonstrate the impact of a system-wide, centralized workflow on referral times and treatment outcomes for COVID-19 infected patients in the ambulatory setting. METHODS: Upon release of monoclonal antibodies for the treatment of COVID-19, a centralized approach for patient treatment referrals to the University of North Carolina Health Virtual Practice team was developed due to the limited supply. Collaboration with infectious disease colleagues played a pivotal role in the rapid application of therapeutic guidance and creation of treatment prioritization levels. RESULTS: From November 2020 through February 2022, the centralized workflow team facilitated the administration of over 17,000 COVID-19 treatment infusions. The median time from treatment referral to infusion was 2 days from a positive COVID-19 test result. From January through February 2022, 514 oral COVID-19 treatment courses were dispensed from the health system's outpatient pharmacies. The median time from referral to treatment was 1 day from diagnosis. CONCLUSION: Given the ongoing strain and demand of COVID-19 on the health care system, a centralized, multidisciplinary team of experts allowed for efficient delivery of COVID-19 therapies through one provider touchpoint. The collaboration between outpatient pharmacies, infusion sites, and Virtual Practice culminated in a sustainable, centralized treatment approach that supported widespread reach, and equitable dose distribution, to the most vulnerable patient populations.

Functional Dyspepsia: Evaluation and Management.

Functional dyspepsia is defined as at least one month of epigastric discomfort without evidence of organic disease found during an upper endoscopy, and it accounts for 70% of dyspepsia. Symptoms of functional dyspepsia include postprandial fullness, early satiety, and epigastric pain or burning. Functional dyspepsia is a diagnosis of exclusion; therefore, evaluation for a more serious disease such as an upper gastrointestinal malignancy is warranted. Individual alarm symptoms do not correlate with malignancy for patients younger than 60 years, and endoscopy is not necessarily warranted but should be considered for patients with severe or multiple alarm symptoms. For patients younger than 60 years, a test and treat strategy for Helicobacter pylori is recommended before acid suppression therapy. For patients 60 years or older, upper endoscopy should be performed. All patients should be advised to limit foods associated with increased symptoms of dyspepsia; a diet low in FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) is suggested. Eight weeks of acid suppression therapy is recommended for patients who test negative for H. pylori, or who continue to have symptoms after H. pylori eradication. If acid suppression does not alleviate symptoms, patients should be treated with tricyclic antidepressants followed by prokinetics and psychological therapy. The routine use of complementary and alternative medicine therapies has not shown evidence of effectiveness and is not recommended.

House staff-led interdisciplinary morbidity and mortality conference promotes systematic improvement.

BACKGROUND: Improvements in patient safety are critical to improving clinical outcomes. We present a resident-led interdisciplinary morbidity and mortality (M&M) conference utilizing postconference task forces to identify unique system issues, classify key contributors to interdisciplinary complications, and implement systems solutions. The conference also served to facilitate resident involvement in quality improvement projects. MATERIALS AND METHODS: Members of the UNC Housestaff Council designed and implemented a hospital-wide M&M conference. Cases involving two or more service lines and resulting from systematic failures were selected for presentation by an interdisciplinary group of residents involved in the patient's care. Postconference task forces addressed problems and developed initiatives to improve care. RESULTS: Of the 15 cases presented, 60% were attributable to an error in judgment, 26% to an error in diagnosis, and 13% to an error in technique. Communication (67%), coordination/care utilization (47%), poor process/workflow (40%), and inadequate training (33%) were the main associated contributing factors. Poor communication contributed to all complications resulting from an error in judgment. Inadequate training and poor workflow were the most common contributing factors with an error in technique. Poor utilization of care and inadequate processes were most common with an error in diagnosis. Postconference task forces identified system-based improvement projects in 73% (11 of 15) of cases with 82% (9 of 11) of projects successfully implemented or in process. CONCLUSIONS: House staff-led interdisciplinary M&M conference utilizing postconference task forces is an ideal setting to identify unique system issues and implement system-based improvement strategies.

Factors Affecting Family Caregivers' Satisfaction During Virtual Care Visits.

There are 18 million caregivers in the US who are essential in the care process for patients to facilitate scheduling appointments, administer medication, and assist with care coordination. The objective of this study was to examine the facilitators and barriers to a positive virtual care experience for caregivers. examined the satisfaction levels among caregivers using a virtual care service at a Southeastern Medical Center in the U.S. We analyzed 231 virtual care visits completed by caregivers. We found that insurance status and medication prescription played a significant role in caregivers' ratings of their virtual care experience. Caregivers reported that virtual care can improve their quality of life, while mixed opinions were reported with regard to the use of virtual care, and the quality of care provided.

Factors Associated with Incomplete Telemedicine Visits at an Virtual Urgent Care Center.

Virtual care utilization has exponentially grown since the onset of the pandemic. However, unknown are the factors associated with incomplete virtual care visits. The purpose of this study is to investigate the factors associated with telemedicine call drops. We utilized an on-demand virtual urgent care service to examine the differences between completed and uncompleted visits. We conducted a cross-sectional study of 22,721 telemedicine encounters. We found that older adults were associated with higher rates of completing telemedicine visits, with higher odds with telephone visits. This study adds new knowledge about the factors that may lead to unsuccessful virtual care visits, which is of interest to policy makers.

Utilization and Satisfaction of an On-Demand Telemedicine Service in Urban and Rural Communities.

Health disparities between urban and rural America have been studied extensively, and findings consistently show many inequities. The objective of this study was to evaluate patient experiences and utilization among patients in North Carolina who use telemedicine. A retrospective cohort study was performed to examine the utilization and satisfaction of patients using a virtual care service at a Southeastern Medical Center in the U.S. Of 1974 telemedicine patients, 1366 (79.3%) were female, 1046(60.7%) were between 35-64 years, 913(53%) had insurance coverage. Statistically significant differences between rural and urban patients in how patients rated both their provider (p<0.01) and overall telemedicine experience (p<0.01). Our findings showed high satisfaction scores among both rural and urban communities in using the telemedicine platform with slightly higher scores among rural patients, which shows the need for on-demand telemedicine to increase health access and patient outcomes among rural communities.

Reduction and persistence of co-circulating respiratory viruses during the SARS-CoV-2 pandemic.

To evaluate the co-circulation of respiratory viruses during the SARS-CoV-2 Alpha surge, we performed a molecular respiratory panel on 1,783 nasopharyngeal swabs collected between January 15 and April 15, 2021, from symptomatic outpatients that tested negative for SARS-CoV-2 in North Carolina. Of these, 373 (20.9%) were positive for at least 1 virus tested on the panel. Among positive tests, over 90% were positive for rhinovirus and/or enterovirus, either as a single infection or coinfection, illustrating persistent co-circulation of some respiratory viruses despite active infection control measures.

Evaluation of a COVID-19 convalescent plasma program at a U.S. academic medical center.

Amidst the therapeutic void at the onset of the COVID-19 pandemic, a critical mass of scientific and clinical interest coalesced around COVID-19 convalescent plasma (CCP). To date, the CCP literature has focused largely on safety and efficacy outcomes, but little on implementation outcomes or experience. Expert opinion suggests that if CCP has a role in COVID-19 treatment, it is early in the disease course, and it must deliver a sufficiently high titer of neutralizing antibodies (nAb). Missing in the literature are comprehensive evaluations of how local CCP programs were implemented as part of pandemic preparedness and response, including considerations of the core components and personnel required to meet demand with adequately qualified CCP in a timely and sustained manner. To address this gap, we conducted an evaluation of a local CCP program at a large U.S. academic medical center, the University of North Carolina Medical Center (UNCMC), and patterned our evaluation around the dimensions of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to systematically describe key implementation-relevant metrics. We aligned our evaluation with program goals of reaching the target population with severe or critical COVID-19, integrating into the structure of the hospital-wide pandemic response, adapting to shifting landscapes, and sustaining the program over time during a compassionate use expanded access program (EAP) era and a randomized controlled trial (RCT) era. During the EAP era, the UNCMC CCP program was associated with faster CCP infusion after admission compared with contemporaneous affiliate hospitals without a local program: median 29.6 hours (interquartile range, IQR: 21.2-48.1) for the UNCMC CCP program versus 47.6 hours (IQR 32.6-71.6) for affiliate hospitals; (P<0.0001). Sixty-eight of 87 CCP recipients in the EAP (78.2%) received CCP containing the FDA recommended minimum nAb titer of ≥1:160. CCP delivery to hospitalized patients operated with equal efficiency regardless of receiving treatment via a RCT or a compassionate-use mechanism. It was found that in a highly resourced academic medical center, rapid implementation of a local CCP collection, treatment, and clinical trial program could be achieved through re-deployment of highly trained laboratory and clinical personnel. These data provide important pragmatic considerations critical for health systems considering the use of CCP as part of an integrated pandemic response.

Heart Failure: Right-Sided Heart Failure.

When evaluating patients for left-sided heart failure (HF), physicians should consider right-sided HF as well. There is significant crossover in symptoms, and these conditions frequently are seen together. Common causes of acute right-sided HF include pulmonary embolism and hypoxemia. Pulmonary hypertension is a common cause of chronic right-sided HF. Given the physiology of the right side of the heart, management of underlying conditions is vital to restoring function regardless of whether the right-sided HF is acute or chronic. It is important to consider fluid status, preload and afterload, in management. In situations in which medical management is ineffective, temporary mechanical circulatory support can be considered, as well as evaluation for heart and/or lung transplantation.

COVID-19 symptoms at time of testing and association with positivity among outpatients tested for SARS-CoV-2.

INTRODUCTION: Symptoms associated with SARS-CoV-2 infection remain incompletely understood, especially among ambulatory, non-hospitalized individuals. With host factors, symptoms predictive of SARS-CoV-2 could be used to guide testing and intervention strategies. METHODS: Between March 16 and September 3, 2020, we examined the characteristics and symptoms reported by individuals presenting to a large outpatient testing program in the Southeastern US for nasopharyngeal SARS-CoV-2 RNA RT-PCR testing. Using self-reported symptoms, demographic characteristics, and exposure and travel histories, we identified the variables associated with testing positive using modified Poisson regression. RESULTS: Among 20,177 tested individuals, the proportion positive was 9.4% (95% CI, 9.0-9.8) and was higher for men, younger individuals, and racial/ethnic minorities (all P<0.05); the positivity proportion was higher for Hispanics (26.9%; 95% CI. 24.9-29.0) compared to Blacks (8.6%; 95% CI, 7.6-9.7) or Whites (5.8%; 95% CI, 5.4-6.3). Individuals reporting contact with a COVID-19 case had the highest positivity proportion (22.8%; 95% CI, 21.5-24.1). Among the subset of 8,522 symptomatic adults who presented for testing after May 1, when complete symptom assessments were performed, SARS-CoV-2 RNA PCR was detected in 1,116 (13.1%). Of the reported symptoms, loss of taste or smell was most strongly associated with SARS-CoV-2 RNA detection with an adjusted risk ratio of 3.88 (95% CI, 3.46-4.35). The presence of chills, fever, cough, aches, headache, fatigue and nasal congestion also significantly increased the risk of detecting SARS-CoV-2 RNA, while diarrhea or nausea/vomiting, although not uncommon, were significantly more common in those with a negative test result. Symptom combinations were frequent with 67.9% experiencing ≥4 symptoms, including 19.8% with ≥8 symptoms; report of greater than three symptoms increased the risk of SARS-CoV-2 RNA detection. CONCLUSIONS: In a large outpatient population in the Southeastern US, several symptoms, most notably loss of taste or smell, and greater symptom burden were associated with detection of SARS-CoV-2 RNA. Persons of color and those with who were a contact of a COVID-19 case were also more likely to test positive. These findings suggest that, given limited SARS-CoV-2 testing capacity, symptom presentation and host characteristics can be used to guide testing and intervention prioritization.

Integrating an Urgent Care Clinic Into an Academic Family Medicine Practice.

BACKGROUND AND OBJECTIVES: There has been a growth in the demand for convenient, walk-in access in health care across the United States, resulting in primary care practices seeing a shift in services to urgent care centers (UCCs). In order to incorporate the flexibility of a UCC and improve primary care access and preventive care for our regular patients, the University of North Carolina (UNC) Family Medicine Center (FMC) established a UCC within the practice. This report describes that process and the impact of the new UCC on our academic practice. METHODS: With the support of the UNC health care system, our primary objectives were to provide enhanced access for patients with acute problems, decrease emergency department (ED) utilization, and increase enrollment of new patients for ongoing primary care. As part of our intervention, we asked providers to respond to a series of questions at the end of each visit. These questions, along with data regarding number of visits and revenue, were tracked longitudinally. RESULTS: By the end of our first year, we were treating about 900 patients per month, of which approximately one-third would have otherwise visited the ED. We averaged 115 new patients establishing care per quarter. In addition to the success of this new service line, our primary practice maintained provider continuity and grew at a higher rate than prior to opening the UCC. CONCLUSIONS: The opening of urgent care at the UNC FMC provided improved access for our patients, increased the number of patients empaneled in our primary care practice, and provided a new revenue stream.

SARS-CoV-2 Seroprevalence among a Southern U.S. Population Indicates Limited Asymptomatic Spread under Physical Distancing Measures.

Characterizing the asymptomatic spread of SARS-CoV-2 is important for understanding the COVID-19 pandemic. This study was aimed at determining asymptomatic spread of SARS-CoV-2 in a suburban, Southern U.S. population during a period of state restrictions and physical distancing mandates. This is one of the first published seroprevalence studies from North Carolina and included multicenter, primary care, and emergency care facilities serving a low-density, suburban and rural population since description of the North Carolina state index case introducing the SARS-CoV-2 respiratory pathogen to this population. To estimate point seroprevalence of SARS-CoV-2 among asymptomatic individuals over time, two cohort studies were examined. The first cohort study, named ScreenNC, was comprised of outpatient clinics, and the second cohort study, named ScreenNC2, was comprised of inpatients unrelated to COVID-19. Asymptomatic infection by SARS-CoV-2 (with no clinical symptoms) was examined using an Emergency Use Authorization (EUA)-approved antibody test (Abbott) for the presence of SARS-CoV-2 IgG. This assay as performed under CLIA had a reported specificity/sensitivity of 100%/99.6%. ScreenNC identified 24 out of 2,973 (0.8%) positive individuals among asymptomatic participants accessing health care during 28 April to 19 June 2020, which was increasing over time. A separate cohort, ScreenNC2, sampled from 3 March to 4 June 2020, identified 10 out of 1,449 (0.7%) positive participants.IMPORTANCE This study suggests limited but accelerating asymptomatic spread of SARS-CoV-2. Asymptomatic infections, like symptomatic infections, disproportionately affected vulnerable communities in this population, and seroprevalence was higher in African American participants than in White participants. The low, overall prevalence may reflect the success of shelter-in-place mandates at the time this study was performed and of maintaining effective physical distancing practices among suburban populations. Under these public health measures and aggressive case finding, outbreak clusters did not spread into the general population.

Oyster-related tenosynovitis: a rare case of Mycobacterium szulgai in the immunocompromised.

A 66-year-old man with a history of renal transplant on chronic immunosuppression presented to his primary care physician with a swollen right index finger. On examination, mild swelling was present. Conservative management failed and initial plain films were negative. Corticosteroid injection was performed by orthopaedics, but symptoms recurred several months later and an MRI showed flexor digitorum tenosynovitis and abscesses of the superficialis and profundus tendons. A flexor tenolysis was performed with cultures positive for Mycobacterium szulgai, a rare, non-tuberculous mycobacterial infection. Treatment was initiated with moxifloxacin, ethambutol and azithromycin daily for nearly 4 months. Repeat MRI 3 months after completion of antibiotics showed near resolution of the tenosynovitis.

PURLs: Yeast infection in pregnancy? Think twice about fluconazole.

This study's findings regarding the risk of miscarriage may mean it's time to forego fluconazole in favor of topical azoles as first-line treatment.

Sterile or non-sterile gloves for minor skin excisions?

Non-sterile gloves are just as effective as sterile gloves in preventing surgical site infection after minor skin surgeries.