Risk factors for delirium among SARS-CoV-2 positive veterans.

There have been increasing reports of atypical neuropsychological symptoms among patients hospitalized with Coronavirus Disease 2019 (COVID-19). Although numerous pathophysiological mechanisms have been proposed to account for the association between COVID-19 and delirium, few studies have examined factors associated with its development and none have done so in the context of a veteran sample. The current study exploratorily examined demographic and medical variables that might be associated with delirium among a cohort of SARS-CoV-2 positive veterans. Demographic and medical data were extracted from the computerized patient records of 162 veterans who were admitted to a large southeastern Veterans Affairs hospital for COVID-19 complications between March 1, 2020 and April 20, 2020. At the zero-order level, age, a history of cardiovascular illness, length of stay, intensive care unit admission, initiation of new dialysis, and the development of new thromboembolic or cardiac findings were associated with delirium. However, when simultaneously examining the impact of these predictor variables in a logistic regression, only length of stay and new cardiac findings increased the odds of delirium. Findings highlight the importance of continued investigation into factors that may account for neuropsychiatric dysfunction among COVID-19 patients.

Predictors of Functional Dependence After COVID-19: A Retrospective Examination Among Veterans.

OBJECTIVE: The aim of this study was to examine the impact of demographics, preexisting medical conditions, and in-hospital complications of COVID-19 infection on functional status at discharge. DESIGN AND PARTICIPANTS: A retrospective chart review was conducted on 119 patients hospitalized for COVID-19 infection between March 1, 2020, and April 20, 2020. Demographics, preexisting medical conditions, and newly diagnosed COVID-19 complications were collected from electronic medical records and entered in a deidentified database. MAIN OUTCOME: The primary outcome was functional status at discharge, as measured by independence in activities of daily living. RESULTS: Older age, respiratory failure, cardiac conditions, and thromboembolic complications all made a statistically significant contribution to functional dependence at discharge, with thromboembolic complications evincing the strongest association (odds ratio, 25.58). CONCLUSION AND RELEVANCE: New diagnosis of thrombosis during COVID-19 hospitalization, a measure of COVID-19 disease severity, was the factor most associated with dependence in activities of daily living at discharge. Interestingly, preexisting conditions including hypertension, severe obesity, lung disease, and diabetes did not correlate with dependent functional status at discharge.

Addressing Palliative Care Needs of COVID-19 Patients in New Orleans, LA: A Team-Based Reflective Analysis.

Background: New Orleans, Louisiana served as a central location for a surge of novel coronavirus cases during the months of March 2020 to May 2020. To provide guidance to palliative care teams naive to the palliative care demand associated with a surge of coronavirus cases, we document our protocol to best optimize palliative care resources. This report aims to present this information and reflect upon what was most beneficial/least beneficial to serve as a roadmap for palliative teams facing this pandemic. Objective: To pilot a team-based structured protocol to categorize severity of COVID-19 intensive care unit (ICU) admissions and subsequently collaborate with the palliative interdisciplinary team to assess physical, spiritual, and psychosocial needs. Design: New ICU consults were categorized into color-coded clinical severity "pots" during daily ICU interdisciplinary rounds. Clinical decision making and communication with patient/next of kin were based on "pot" classification. Settings/Subjects: Palliative medicine consults were placed on all COVID-19 positive patients admitted to the ICU between March 29, 2020, and May 1, 2020. Measurements: A retrospective chart review was performed to analyze the effect of palliative care consultation on completion of goals-of-care conversations and the life-sustaining treatment (LST) document, an advance directive form specific to the Veterans Affairs hospital system between March 29, 2020 and May 1, 2020. Results: Of the palliative consults evaluated by a palliative provider, 74% resulted in completion of a LST document, 58% resulted in video contact with family members, and 100% incorporated a goals-of-care discussion. Conclusions: We found that standardizing palliative care consultation on all COVID-19 positive ICU admissions subjectively alleviated the burden on ICU providers and staff in the midst of a crisis, resulted in increased documentation of patient goals-of-care preferences/LSTs, facilitated clinical updates to family members, and better distributed clinical burden among palliative team members.

A Case Report of COVID-19 in New Orleans, Louisiana: Highlighting the Complexities of Prognostication in a Critically Ill Patient.

Palliative care teams and intensive care teams have experience providing goals-of-care guidance for critically ill patients and families. Critical coronavirus disease 2019 (COVID-19) infection is defined as infection requiring intensive care unit care, respiratory support, and often multiorgan involvement. This case presents a 53-year-old critically ill COVID-19 patient in multisystem organ failure who appeared hours from death despite best medical efforts. Comfort-focused care and compassionate extubation were offered after all medical teams felt near certain that death was imminent. Overnight, while options were being considered by the family, the patient began to markedly improve hemodynamically and was extubated several days later. Weeks later, the patient survived the hospital stay and was discharged to rehabilitation. After rehabilitation he returned home, able to walk, communicate freely, and independently perform all activities of daily living. Dialysis was no longer necessary and was stopped. The challenges of assisting in goals-of-care conversations for patients with serious COVID-19 infection are discussed.

Hospice emergency kit for veterans: a pilot study.

BACKGROUND: Although the provision of hospice emergency kits (HEKs) by home hospice agencies is thought to be widespread, little is known about their use, safety, and impact. OBJECTIVE: This study evaluated HEK medication utilization, safety, diversion, and perceived impact. DESIGN: Evaluation consisted of a retrospective patient chart abstraction and an anonymous questionnaire for home hospice nurses. SETTING/SUBJECTS: Chart abstraction examined the computerized records of deceased veterans discharged to home hospice in 2009 (N=76). The questionnaire was completed by 78 home hospice nurses from 16 agencies. MEASUREMENTS: Chart abstraction examined HEK medication utilization, symptoms addressed, and safety/diversion concerns. The hospice nurse questionnaire assessed their perceptions of HEK utilization, safety, and impact, including efficacy for preventing emergency department (ED) visits and hospitalizations. RESULTS: Of patients who received an HEK, its use was documented in 50% of cases. The most used items were morphine concentrate and antibiotics. Nurses estimated that the HEK was utilized in 66.3% of cases, with the most frequently used medications being morphine, lorazepam, promethazine, and haloperidol. Fifty-nine percent of nurses felt HEKs were helpful 100% of the time (mean=84.2%; median=100% of the time) and 93% felt that an emergency department (ED) visit or hospitalization was avoided by having the kit in the home. Eighteen percent believed that medications in the kit are used by someone other than the patient. CONCLUSIONS: HEKs have value as a means to alleviate many symptoms that emerge predictably in home hospice patients and may avoid unwanted hospitalizations and ED visits.