Clotting of Hemodialysis Access in Patients with COVID-19 in an Inner-City Hospital

<b><i>Background:</i></b> An increased incidence of thrombotic complications in patients with coronavirus disease 2019 (COVID-19) has been reported. Severe acute kidney injury (AKI) is one of the major clinical manifestations of COVID-19 with the need for renal replacement therapy. It was observed that hemodialysis (HD) accesses tended to thrombose more often in the COVID-19 population than in non-COVID-19 patients. We hypothesize that the hypercoagulable state of COVID-19 is associated with higher incidence of access clotting. <b><i>Method:</i></b> In this retrospective single-centered study at Kings County Hospital in New York City, 1,075 patients with COVID-19 were screened, and 174 patients who received HD from January 3, 2021 to May 15, 2020 were enrolled to examine the risk factors of dialysis access clotting in patients with COVID-19. <b><i>Results:</i></b> Of the 174 patients, 109 (63%) were COVID-19 positive. 39 (22.6%) patients had dialysis access clotting at least once during their hospitalization, and they had significantly higher body mass index (BMI) (<i>p</i> = 0.001), higher rates of COVID-19 (<i>p</i> = 0.015), AKI (<i>p</i> &#x3c; 0.001), higher platelet counts (<i>p</i> = 0.029), higher lactate dehydrogenase levels (<i>p</i> = 0.009), and lower albumin levels (<i>p</i> = 0.001) than those without access malfunctions. Low albumin levels (<i>p</i> = 0.008), AKI (<i>p</i> = 0.008), and high BMI (<i>p</i> = 0.018) were risk factors associated with HD access clotting among COVID-19 patients. <b><i>Conclusion:</i></b> Patients with COVID-19 who receive HD for AKI with high BMI are at a higher risk of clotting their HD access.

Improving SCD compliance in trauma patients at Kings County Hospital Center: a quality improvement report

Venous thromboembolism (VTE) is the fourth most commonly reported complication in trauma patients. For these patients, thromboprophylaxis is a standard of care. Patient compliance with sequential compression devices (SCDs), a form of mechanical VTE prophylaxis, has been a focus of efforts to improve patient safety. At our institution, a baseline audit in July 2020 revealed that patients admitted to the trauma floors have poor compliance with the use of SCDs. In this quality improvement project, we developed a patient education intervention to improve SCD compliance. We distributed an informational flyer to patients and led short educational sessions on VTE risk factors and proper SCD use. Our aim was to increase our SCD compliance rate by 30% in 4 weeks. We used three plan-do-study-act (PDSA) cycles to implement and refine our intervention. We measured SCD compliance during morning and afternoon patient observations and generated run charts to understand how our cycles were leading to change. After a 4-week period, we did not achieve our aim, but increased our overall compliance from 45% to 60% and sustained this improvement throughout our PDSA cycles. Morning compliance was lower than afternoon compliance both at baseline (45% vs 48.5%) and at the end the project (45% vs 53%). Our results suggest that patient education should be coupled with interventions that address other barriers to SCD compliance.

Abstract 14229: Hepatobiliary Markers in Minority Heart Failure Patients; Echocardiography and Clinical Outcomes

Introduction: AHA sponsored guidelines and studies have focused on cardiac disease and particular heart failure (HF) profiles among minorities like African, Hispanic, and Asian Americans. Previous studies on liver function tests (LFT) in HF patients, like aspartate and alanine aminotransferase (AST, ALT), alkaline phosphatase (ALP), and bilirubin (Bili), have underrepresented minority groups in study cohorts. We investigated the relationship between LFT levels with echocardiographic (ECHO) findings and readmission outcomes among minority patients at the Heart Health Center (HHC) of NYC Health + Hospitals, Kings County, in Brooklyn, New York. Hypothesis: In minority HF patients, LFT levels are associated with ECHO parameters, and LFT abnormalities are associated with increased risk of admission. Methods: Retrospective review was performed of patients in the HF clinic at the HHC, and during acute HF exacerbation admission from November 2017 - November 2018, with hospitalization monitored through November 2019. Baseline and admission LFT levels were obtained. While abnormal AST, ALP, and Bili levels were classified by the hospital’s laboratory range, abnormal ALT levels were classified based on national gastroenterology guidelines. Regression analysis was used to examine the relationship between LFT levels during acute HF exacerbation and ECHO parameters. Odds ratio (OR) and confidence interval (CI) were used for analysis of readmission outcomes. Results: Among 586 HF patients, there was an increased risk of hospitalization with baseline elevations in AST (OR 2.30, CI 1.24 - 4.25, p = 0.008) and ALP (OR 1.99, CI 1.10 - 3.64, p = 0.023). In those hospitalized with acute HF (n = 147), Bili was positively correlated with mitral valve (MV) EA ratio (r = 0.28, p = 0.002) and tricuspid regurgitation max velocity (r = 0.21, p = 0.004). ALT positively correlated with mean MV e’ velocity (r = 0.23, p = 0.009) and negatively correlated with aortic valve (AV) mean velocity (r = -0.24, p = 0.001). Conclusions: Understanding the association of ECHO findings and risk of hospitalization in minority patients with baseline and acute HF LFT levels has crucial implications for the identification of high risk patients and for the development of patient centered HF care strategies.

A Review of a Psychology Intern's Insights Presented in Brooklyn Zoo: The Education of a Psychotherapist

Brooklyn Zoo: The Education of a Psychotherapist delves into the world of psychiatric care and clinical training within the walls of Kings County Hospital in Brooklyn, New York. The aim of this commentary is to discuss several ethical dilemmas which were repeatedly presented to the author, Darcy Lockman, throughout her year-long internship. Such dilemmas include psychiatrists' overreliance on medicine, the total disregard for patient comfort, the difference in standards of care for white patients and patients of color, as well as the supervisory neglect in the clinical training program.

Lack of Association of Intraventricular Hemorrhage with Retinopathy of Prematurity

Objective Retinopathy of prematurity (ROP) is the primary cause of visual impairment in premature infants. Our objective was to study the relationship between ROP and intraventricular hemorrhage (IVH) in the premature infant. Methods This study was a retrospective chart review of very low birthweight infants of 1,500 g or less admitted to Kings County Hospital Center's neonatal intensive care unit who were screened for ROP over a 6-year period. Results Of 335 infants screened for ROP, 85 infants were identified to have ROP. Of these, 50 (56%) infants had stage 1 ROP, 25 (29%) had stage 2 ROP, 7 (8%) had stage 3 ROP, and 3 (4%) had stage 4 ROP. The incidence of IVH in our population was 14%. Multiple logistic regression demonstrated a significant association between ROP and gestational age (p = 0.001). There was no significant association between ROP stage and IVH grade. There was also no significant association between birthweight, ethnicity, or 5-minute Apgar score. Conclusions Our data demonstrated no association between IVH and severity of ROP. There was a statistically significant association between ROP and gestational age. We speculate that these data may be a reflection of improvement in neonatal care, with a declining incidence of IVH as well as increased ROP screening efforts.

Impact of bone marrow fibrosis (BMF) at diagnosis in patients with multiple myeloma (MM).

e19522 Background: BMF is known to occur in a minority of myeloma patients, but its incidence in American patients of African origin is not known. The impact of BMT on presenting clinical and laboratory findings, and its relationship to genetic variants has not been defined. Methods: Kings County Hospital is located in the East Flatbush section of Brooklyn, New York, where the population is mainly of African-Caribbean origin. Records and bone marrow specimens of myeloma patients who presented from 2000 through 2010 were reviewed. Degree of fibrosis was graded according to World Health Organization criteria: mild, moderate and severe. Results: Records of 113 patients were reviewed, 110 (97%) 97 of whom were African American or Caribbean; 62 (55%) were female and 51 (45%) male. Their ages ranged from 38 to 89 (median 65). Of the 27 patients with BMF (24%), 17 (63%) were female. Mild, moderate and severe BMF were present in 14 (52%), 7 (26%) and 6 (22%) patients respectively. Presentation calcium and creatinine levels were normal in all patients. Hemoglobin levels were similar (median 9.6 G/dl) in patients without BMF and in those with mild and moderate grades, the median level was 7.5 G/dl in those with severe BMF. Immunoglobulin G, A and D levels (67, 20 and 1) were similar in patients with and without BMF, but lambda light chain expression was greater in the BMF patients: 41 vs 24%. Cytogenetic data (CGD) was available in 46 patients; and abnormal in 10 (22%). All patients with abnormalities of chromosomal number were hyperdiploid. Of the 27 BMF patients CG data was available in 17, and was abnormal in 2 (12%). FISH results were normal in 23 of 25 patients, and in all of those with BMF. The fraction of the BMF and non BMF patients surviving after median follow up periods of 828 and 885 days were similar. Conclusions: BMF in this population was 24%, and severe in 5%. Female preponderance is a characteristic of MM patients of African origin, and was more marked in those with BMF. The BMF patients were characterized by more severe anemia and greater lambda light chain expression.

Addressing the Gaps in Preparation for Quarantine

IntroductionIn the event of an outbreak of a communicable respiratory illness, quarantine may become necessary. The New York Institute for All Hazard Preparedness (NYIAHP) of the State University of New York (SUNY) Downstate Medical Center, in cooperation with the New York City Department of Health and Mental Hygiene's Healthcare Emergency Preparedness Program, (NYC DOHMH-HEPP) quarantine working group, has developed a series of clinical protocols to help health care facilities respond to such an event.ProblemTwo full-scale exercises (FSEs) were designed and conducted a year apart in the quarantine unit at Kings County Hospital Center (KCHC) to test the efficacy and feasibility of these quarantine protocols. The goal of these exercises was to identify the gaps in preparedness for quarantine and increase hospital readiness for such an event.MethodsEvaluators monitored for efficient management of critical physical plants, personnel and material resources. Players were expected to integrate and practice emergency response plans and protocols specific to quarantine. In developing the exercise objectives, five activities were selected for evaluation: Activation of the Unit, Staffing, Charting/Admission, Symptom Monitoring and Infection Control, and Client Management.ResultsThe results of the initial FSE found that there were incomplete critical tasks within all five protocols: These deficiencies were detailed in an After Action Report and an Improvement Plan was presented to the KCHC Disaster Preparedness Committee a month after the initial FSE. In the second FSE a year later, all critical tasks for Activation of the unit, Staffing and Charting/Admission were achieved. Completion of critical tasks related to Symptom Monitoring and Infection Control and Client Management was improved in the second FSE, but some tasks were still not performed appropriately.ConclusionIn short, these exercises identified critical needs in disaster preparedness of the KCHC Quarantine Unit. The lessons learned from this logistical exercise enabled the planning group to have a better understanding of leadership needs, communication capabilities, and infection control procedures. Kings County Hospital Center performed well during these exercises. It was clear that performance in the second exercise was improved, and many problems noted in the first exercise were corrected. Staff also felt better prepared the second time. This supports the idea that frequent exercises are vital to maintain disaster readiness.NathawadR, RoblinPM, PruittD, ArquillaB. Addressing the gaps in preparation for quarantine. Prehosp Disaster Med. 2013;28(2):1-7.