Home Oxygen and Monitoring for COVID-19 Patients: A Multidisciplinary Team Approach.

Introduction: During the initial COVID-19 pandemic peak, Stamford Hospital implemented a home oxygen program (HOP) to create a comprehensive, multi-disciplinary outpatient initiative without sacrificing a safe discharge. Primary care physicians monitored program participants, whose only indication for remaining admitted was an oxygen requirement. We retrospectively examined participant co-morbidities and outcomes, including death and readmission rates to evaluate HOP safety. Methods: A retrospective analysis of program participants discharged between April 2020-Janurary 2021 was performed. Variables included demographics, oxygen requirement, days enrolled in the HOP, and major comorbidities such as cardiovascular disease (CVD), diabetes (DM), hypertension (HTN), obesity, chronic kidney disease, malignancies and underlying chronic obstructive pulmonary disease (COPD). Results: Among the 138 HOP participants, ages ranged from 23 to 96 (Mean 65.5), with 47.1% female and 52.9% male. The most represented ethnicity included White (48.6%), Hispanic (29.7%), and Black (15.2%). Patients' average time in the HOP was 19 days, requiring an average of 1.7 L/min of home oxygen. Thirteen patients (9.4%) were readmitted to the hospital with 2.9% secondary to worsening COVID-19 hypoxia, but no deaths occurred at home. A significant relationship was found between age and highest home oxygen need. Patients with COPD, HTN, and DM had significantly higher oxygen requirements (P-value <0.05). Conclusion: Increasing age, underlying COPD, HTN, and DM were associated with higher oxygen requirements in participants. Given limited availability of hospital beds, and no occurrences of death at home, Stamford Hospital HOP safely helped provide care for sicker patients and enhanced resource allocation.

Carbon Dioxide Emissions and Environmental Impact of Different Surgical Modalities of Hysterectomies.

Background and Objectives: The objectives of this study were to determine carbon dioxide (CO2) emissions generated from nonreusable waste and compare across different types of hysterectomies for benign and malignant indications. Overall greenhouse gas emissions were not examined. Methods: This is a prospective cohort study that identified women undergoing a robotic assisted, laparoscopic, vaginal, or abdominal hysterectomy for any indication. The amount of waste generated was collected for each case, along with patient demographics, and details of the procedure. Weight of waste was converted to kilograms of CO2 emissions using the following formula: Carbon dioxide emissions = Waste in pounds × 1 Short ton/2000 pounds × Emission factor kg CO2/short ton× Global warming potential (GWP)We extrapolated the amount of CO2 emissions produced to the number of hysterectomies performed annually in the United States. Results: We found that robotic hysterectomies generated the highest mean CO2 emissions (12.01 kg CO2), while vaginal hysterectomies produced the lowest mean CO2 emissions of 4.48 kg (p < .0001).Our sample size of 100 hysterectomies was equivalent to 1099.4 kg CO2 emissions. When our results were extrapolated, all hysterectomies in the United States produce 5.7 million kg of CO2 emissions. This is equivalent to 234,513 airplane miles, and 95 trips cross-country across the USA from New York, New York to Los Angeles, California. Conclusion: Robotic hysterectomies generated a statistically significant majority of CO2 emissions. Therefore, robotic surgery, as currently practiced, may offer a good initial opportunity for decreasing the carbon footprint of surgery.

Investigating the association between the COVID-19 vaccination and incident gastrointestinal symptomology: A comprehensive dataset.

The coronavirus disease of 2019 (COVID-19) pandemic created a variety of symptoms from mild to acute in the general population. Additional disease burden was experienced in high-risk populations, such as older adults, people with disabilities or overweight, those from racial and ethnic minority groups, and patients with cancer, chronic kidney, lung or liver disease, or diabetes. Although it is well-known that SARS-CoV-2 mostly affects the respiratory tract, studies have revealed the presence of gastrointestinal (GI) symptoms in those patients diagnosed with COVID-19. The best protection against infection is through receipt of the COVID-19 vaccine, which is associated with a low incidence of adverse events. However, there is limited research on the lesser-known side effects experienced following receipt of the COVID-19 vaccination, amongst healthy and special needs populations. This study investigated the association between the COVID-19 vaccination and, when it occurred, infection, and resulting gastrointestinal (GI) symptomology, focusing on both the general population and on those previously diagnosed with GI disorders, Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD). Through a short, anonymous survey, 215 participants were assessed for acute onset of GI issues and/or worsening of pre-existing GI issues following the receipt of one or more COVID-19 vaccine doses and following contraction of COVID-19 itself, when applicable. All analyses were performed using SAS version 9.4, and prior to study initiation, the study protocol was reviewed and approved as exempt by the Stamford Hospital's Institutional Review Board of record. Data analysis included reporting of demographic variables as well as descriptive statistics regarding side effects experienced after receipt of the COVID-19 vaccine, as well as after contracting COVID-19, if it occurred. To assess for statistically significant differences between the groups, ANOVA was conducted for each survey item. Reporting of results consisted of the mean and standard deviation within each of the groups, and an omnibus p-value less than 0.05 (p <0.05) was considered statistically significant. For the purposes of this report, a greater than 0.50 response difference between highest and lowest mean value will be presented. In the event of a statistically significant omnibus p-value, the Scheffe test was used as the post-hoc procedure. The database created through this research demonstrates the prevalence of post-COVID-19 vaccination side effects and can serve as preliminary data for gaining a better understanding of how both general and populations with a higher disease burden are being affected by the COVID-19 vaccine, booster doses, and incident COVID-19 infection in vaccinated individuals.

Effectiveness of telehealth physical therapy for patients with pelvic floor disorders in a community hospital setting.

PURPOSE: To examine whether there are differences in meeting treatment goals between pelvic floor physical therapy (PFPT) patients who participated in a majority of telehealth visits versus those who participated in mostly traditional office visits at a community hospital. METHODS: Retrospective chart review was performed among patients who received PFPT from April 2019 to February 2021. Cohorts were defined as "Mostly Office Visits" (> 50% office visits) and "Mostly Telehealth" (> / = 50% telehealth visits). Primary outcome measures included demographic data, number/type of visit for each patient, number of no-show/cancelation appointments, and number of patients discharged meeting PFPT goals. Statistical significance was defined as p < 0.05. RESULTS: 234 subjects met criteria for the "Mostly Office Visit" cohort and 48 subjects met criteria for the "Mostly Telehealth" cohort. There were no significant differences observed in age (p = 0.919), BMI (p = 0.817), race/ethnicity (p = 0.170) or insurance type (p = 0.426) between cohorts. There was no significant difference in meeting PFPT goals between the "Mostly Office Visit" cohort (24.4%) and the "Mostly Telehealth" cohort (35.4%) (p = 0.113). There was no difference in the number of canceled visits per patient (mean cancelations "Office visit" 1.98; "Telehealth" 1.63; p = 0.246) and the number of no-show visits per patient (mean no-show's "Office visit" 0.23; "Telehealth" 0.31; p = 0.297) between cohorts. CONCLUSION: There was no difference in meeting discharge goals regardless of whether a patient participated in mostly telehealth visits versus mostly traditional office visits. Therefore, we can conclude that participating in mostly provider-led telehealth visits can be equally efficacious at providing competent PFPT care.

Evaluation of a pain management program for patients with median arcuate ligament syndrome.

Objectives: Median arcuate ligament syndrome is a complex disorder potentially caused by variation in the position of the median arcuate ligament. Symptomology involves chronic abdominal pain, nausea, and malnourishment. Pain management modalities and short-term outcomes for patients undergoing operative surgery for median arcuate ligament syndrome have yet to be fully evaluated. Our hospital implemented a pain management consultation program in 2017 focused on perioperative pain management. The objective of this study is to assess if the introduction of a pain management consultation program concurrent with median arcuate ligament syndrome surgery impacts patient outcomes and post-operative pain management strategies in these patients. Methods: De-identified data was collected retrospectively from our hospital's electronic medical records system, identifying median arcuate ligament syndrome patients and using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes from September 2017 to August 2021. Patients were grouped into the "consultation" cohort if they had scheduled and attended a pre-operative pain consultation. Pre-operative and discharge medications, pain scores, and demographics were collected to evaluate if the initiative impacted outcomes. Results: Median arcuate ligament syndrome patients who had a pre-operative pain management consultation had higher rates of pre-operative opioid (35.5%; p = 0.01) and non-opioid use (60.7%; p < 0.001). Patients without a pre-operative consultation that did not use opioids pre-operatively were more likely to be discharged on one or more opioids. Differences were also found for psychiatric medication at discharge (p < 0.001) with patients receiving pain consultation indicating higher percentages of use. Conclusion: Special consideration on prescribing pain medication should be part of discharge planning for median arcuate ligament syndrome patients. Addition of a pain management consultation can aid in these decisions.

Opportunistic salpingectomy during robotic sacrocolpopexy: Data to support a widely accepted practice.

While surgical outcomes of prophylactic salpingectomy as an ovarian cancer risk reducing measure at the time of hysterectomy for benign indications has already been studied, data has traditionally been extrapolated to surgery for prolapse repair. A retrospective chart review was performed from medical records of patients who had undergone a sacrocolpopexy for pelvic organ prolapse. Variables collected included operation duration, length of hospital stay, readmission within 31 days, estimated blood loss (EBL), number and size of incisions, as well as narcotic use during hospitalization. Additional procedures performed at the time of operation including vaginal or laparoscopic hysterectomy, transobturator sling, anterior or posterior colporrhaphy, cystoscopy, and robotic ventral mesh rectopexy were collected as potential confounding variables. In addition, data to allow examination of pathology results of all fallopian tubes was collected to determine the proportion of pre-malignant and malignant pathology results. Statistical analyses were performed using SAS version 8. Two cohorts were created: (1) Patients who underwent adnexal surgery (bilateral salpingectomy or salpingoopherectomy) at time of the sacrocolpopexy and (2) Patients who underwent a sacrocolpopexy without adnexal surgery. Comparisons were performed with chi-square analysis for discrete variables and group t-tests for continuous level data. Narcotics administered during the immediate post-operative period until discharge was collected for each patient and converted to morphine milligram equivalents (MME) via multiplying the administered dose by the CDC established evidence-based conversion factor. Analysis of covariance (ANCOVA) as well as logistic regression was used to control for confounding variables, including the additional procedures patients had during their operation. An omnibus p-value of 0.05 was used to determine statistical significance for all tests. Due to the exploratory nature of this analysis, there were no corrections applied for multiple comparisons. This data can be used as a basis for researchers to build upon when assessing ovarian cancer primary prevention strategies and associated treatment modalities.

Augmentation of a Hospital Incident Command System to Support Continued Waves of the COVID-19 Pandemic.

Stamford Hospital (SH) is a 305 bed Level II Trauma center located in Fairfield County, the epicenter of the coronavirus disease 2019 (COVID-19) pandemic in Connecticut. The COVID-19 pandemic was a fast paced, rapidly evolving crisis, presenting our leadership team with unique challenges related to resource availability, patient care, and staff safety. The existing Hospital Incident Command System (HICS) was activated in March 2020 to coordinate our operational emergency management planning, response, and recovery capability for this unplanned event. Although HICS lays the groundwork for hospital preparations and protocol implementation, it is not designed to withstand prolonged crisis circumstances. Given the conditions that the COVID-19 pandemic presented, the possibility for future waves became an impending reality, prompting the need for a long-term solution. To establish guidelines that promoted balance between necessary preparations in the case of additional surges of the pandemic and concurrent resumption then maintenance of routine hospital operations, the SH COVID-19 Playbook was created. The Playbook, presented here, is arranged in accordance with the evidence-based 4 S's (Space, Staff, Systems, and Stuff) strategic critical care planning framework, to address surge capacity management within our hospital's four main patient care areas and additional supportive services. Through feedback from frontline caregivers and leaders within SH, the Playbook captures our experience, best practices, and insight acquired during the first wave of the pandemic. Established with the intentions of equipping leadership and staff globally, guidelines are presented to aid in the navigation of future pandemic surges and successfully care for COVID-19 patients, ensure staff safety, allow for normal services to operate, and provide optimal communication and support for the community, patients, and staff.

Effects of the COVID-19 Crisis on Resident Well-Being in a Community Teaching Hospital.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has been an unexpected crisis that continues to challenge the medical community at large. Healthcare environments have been forced to change dramatically, including for medical residents, who are vital members of the innovative emergency response teams. Articles have previously been published on the effects of crises on the well-being of healthcare practitioners; however, there is a paucity of literature targeting medical residents' experiences and general wellness during devastating events. The objective of our study aimed at understanding the emotional impact of the COVID-19 pandemic on residents' stress, academics, and support systems. METHODS: An anonymous, voluntary Likert scale questionnaire was sent via SurveyMonkey to Internal Medicine and Family Medicine residents in July 2020. Questions focused on residents' mood; stress levels; sense of support; and academics before, during, and immediately after the first surge of COVID-19 at our hospital between March 13 and June 15, 2020. RESULTS: Residents felt sad, stressed, and overworked during the first wave, as opposed to feelings of neutrality and happiness before and immediately after. Levels of concern for personal and loved ones' safety were significantly increased during and after our first wave. The impact on educational training was rated as neutral. Residents noted that institutional support could be improved by the provision of wellness activities and sponsored social events. CONCLUSIONS: This study provides insight on resident well-being during the initial months of the pandemic and identifies areas that could be improved. Our results demonstrated that the pandemic affected many aspects of residents' well-being and education, and the lessons learned can help guide healthcare institutions when implementing wellness activities for trainees during subsequent crises.

Implementing a Neurohospitalist Program Improves Stroke Care Metrics and Patient Satisfaction Scores.

Objective: Compare the differences in health outcomes and patient satisfaction between a neurohospitalist model of care and a community-based neurologists model at a single community-based teaching hospital among in-patients diagnosed with a cerebrovascular accident (CVA). Methods: Data was collected from the Stamford Hospital's electronic medical records system. An assessment of patient health outcomes and satisfaction scores was conducted, comparing both discrete and continuous variables between the two time periods. An omnibus P-value of 0.05 (P < 0.05) was considered statistically significant. Results: The sample consisted of 341 patients between the two periods, pre-period n = 168 (49.3%) post-period n = 173 (50.7%). Door to lab and door to tPA times decreased significantly between pre- and post-periods (P = 0.003 and P = 0.002, respectively) as did the number of MRIs (P < 0.001). In addition, statistically significant increases were found between pre-period and post-period percentages, all increasing over time: stroke education (P < 0.001), discharged on anticoagulant medication (P < 0.001), and discharged on anti-thrombolytic medication (P = 0.019). Patient satisfaction scores demonstrated mean gain across both periods for five of six items. Two items "Doctor's Concern of my Questions/Worries" and "Skill of Doctors" demonstrated statistical significance (P = 0.020 and P = 0.029, respectively). Conclusions: The introduction of a neurohospitalist service at a community-based teaching hospital improved patient health outcomes on time to intervention, stroke education, discharge medications as well as patient satisfaction. Therefore, it may be beneficial for hospitals to implement a neurohospitalist model of care for their patients presenting with CVA.

A comprehensive dataset describing nurse's emotions, perceived stressors and coping mechanisms during the first surge of the COVID-19 pandemic.

A comprehensive and validated questionnaire modified from previous epidemics [1,2] was distributed to frontline HCWs at high risk for COVID-19 at our community-based teaching hospital, the epicenter of the pandemic in our state. Results of the full analysis were previously reported [3] indicating that our nursing staff were more likely to report feelings of stress, emotional exhaustion and fatigue compared to physicians and other health professionals. We highlight the pandemic's specific impact on nurses' emotions, perceived stressors and effective coping mechanisms used during the first surge of COVID-19.

Healthcare worker's emotions, perceived stressors and coping mechanisms during the COVID-19 pandemic.

Increasing cases, insufficient amount of personal protection equipment, extremely demanding workloads, and lack of adequate therapies to save lives can contribute to a psychological burden directly related to working during disease outbreaks. Healthcare workers (HCWs) are at a high risk of contracting COVID-19 due to its ability to spread efficiently through asymptomatic and symptomatic individuals. There are limited studies assessing the pandemic's psychological impact on HCWs, specifically those in close proximity to hospitalized patients with COVID-19. Our study explored the emotions, perceived stressors, and coping strategies of front-line HCWs at high risk of exposure to COVID-19 during the first surge at our community-based teaching hospital, the epicenter of COVID-19 in Connecticut. A validated comprehensive questionnaire derived and modified from previous epidemics was used to inquire about staff feelings, factors that caused stress and factors that mitigated stress. Personal coping strategies and factors that can increase staff's motivation to work during future events of similar nature were also asked. Emotional reactions, coping mechanisms, and stressors varied by healthcare role, while some experiences and reactions were similar among groups. Willingness to participate in a second wave of the pandemic or future outbreaks is strongly driven by adequate personal protective equipment, financial recognition, and recognition from management, similarly reported in previous disease outbreaks. All groups felt a reduction in stress due to a sense of camaraderie and teamwork, as well as when sharing jokes or humor with colleagues. Our HCWs at high risk of exposure experienced significant emotional distress during the first wave of the COVID-19 pandemic. By understanding the needs and experiences of our HCWs at highest risk, we can improve our psychological support using targeted interventions during future waves of this pandemic or similar devastating events.

The association of pregnancy control, emotions, and beliefs with pregnancy desires: A new perspective on pregnancy intentions.

CONTEXT: Standard pregnancy intentions measures do not always align with how people approach pregnancy. Studies that have investigated beyond a binary framework found that those with "ambivalent" feelings towards pregnancy are less likely to use contraception consistently, but the reasons for this are unclear. We sought to gain a nuanced understanding of pregnancy desires, and how perceptions about pregnancy are associated with contraceptive use. METHODS: We used non-probability quota sampling based on sex, age, and geographic region for a web-based survey of heterosexual men and women, aged 21-44 years, who could become pregnant/impregnate and were not currently pregnant (n = 1,477; 51% female). The survey was created using unique items informed by recent literature. Bivariate and multivariable analyses explored relationships between various perceptions about pregnancy with pregnancy desires categorized as: wanting a pregnancy, not wanting a pregnancy, and not trying but would be okay with a pregnancy. We conducted a sub-group analysis of those who were not trying but would be okay with a pregnancy (n = 460), using descriptive statistics to examine how consistent contraceptive use was associated with emotions and beliefs about avoiding pregnancy. RESULTS: After adjustment, those who felt that pregnancy may not always be avoidable, but instead determined by fate/higher power, or a natural process that happens when it is meant to, were significantly more likely (aOR: 1.83, 95% CI: 1.05-3.36; aOR: 2.21, 95% CI: 1.29-3.76, respectively) to report not trying but being okay with pregnancy, whereas those with negative feelings about a pregnancy were less likely to feel okay about a pregnancy (aOR: 0.11, 95% CI: 0.08-0.15), versus not wanting a pregnancy. In the sub-group analysis, those who felt pregnancy was determined by fate/higher power or a natural process were more likely to report not using contraception consistently (70%, 68%, respectively). CONCLUSIONS: Those who state they are not trying but would be okay with pregnancy may not use contraception consistently because of beliefs that pregnancy is predetermined. Our findings support less categorical and more multidimensional approaches to measuring fertility intentions, with important implications for reproductive health service provision.

Implementing a WIC-Based Intervention to Promote Exclusive Breastfeeding: Challenges, Facilitators, and Adaptive Strategies.

OBJECTIVE: Understand factors that contributed to the implementation of a successful multicomponent intervention to promote exclusive breastfeeding (EBF) within Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC) clinics. DESIGN: Qualitative study of staff implementers' experiences using implementation status reports, facilitated group discussion immediately after implementation, and WIC administrative data. SETTING: WIC staff from 12 clinics participated in an EBF Learning Community composed of 8 intervention trainings and ongoing support from trainers and peers. PARTICIPANTS: A total of 47 WIC staff including 11 directors, 20 other administrators, 8 nutritionists, and 6 peer counselors. INTERVENTION: A WIC-integrated EBF promotion initiative, supported through a Learning Community, composed of prenatal screening, tailored trimester-specific counseling, and timely postpartum follow-up. PHENOMENON OF INTEREST: Challenges and facilitators to implementation within clinics. ANALYSIS: Iterative qualitative analysis using directed, emergent, and thematic coding. RESULTS: Implementation experiences were characterized by (1) perceived benefits of implementation, including improved EBF knowledge and counseling confidence among staff; and (2) managing implementation, including responding to challenges posed by clinic settings (resources, routine practices, values, and perceptions of mothers) through strategies such as adapting clinic practices and intervention components. CONCLUSIONS AND IMPLICATIONS: Implementation was shaped by clinic setting and adaptive strategies. Future WIC interventions may benefit from formal consideration of intervention fit with local clinic setting and allowable adaptations.

Food cravings in pregnancy: Preliminary evidence for a role in excess gestational weight gain.

Currently, more than 50% of American women gain an excessive amount of weight during pregnancy as per guidelines established by the Institute of Medicine and American Congress of Obstetrics and Gynecology. This excess gestational weight gain (GWG) is associated with health complications in both mothers and children. This study sought to examine the hypothesized causal role of cravings in excess GWG. Pregnant women were recruited from a local hospital (n = 40) and via posts on pregnancy-related websites (n = 43). Weight (current and pregravid) and height data were collected to calculate body mass index (BMI) and recommended versus excess GWG. Participants completed the Food Craving Inventory (FCI), which quantifies "frequency" of cravings for specific foods and the likelihood of "giving in" to these cravings. Overweight/obesity prior to pregnancy was reported by 40.5%-57.9% of participants. At the time of survey completion, 19.5% of online and 31.6% of hospital respondents had gained more than the recommended amount of weight for their stage of gestation. All women had experienced and given in to at least one craving, with cravings for "sweets" and "fast foods" being most common. Craving "frequency" accounted for a substantial portion of variance in excess GWG (25.0% in the online sample and 32.0% in respondents recruited at the hospital). Frequency of "giving in" to cravings accounted for 35.0% of the variance in excess GWG in the online sample only. Findings suggest that both craving frequency and consumption of craved foods may increase risk of excess GWG, providing support for the development of interventions targeting cravings in pregnancy as potentially modifiable determinants of energy intake.