Abstract Background Older adults are at high risk for poor outcomes from infectious diseases, yet rates of recommended vaccinations remain low among this age group. This quality improvement initiative aimed to increase vaccination engagement among older adults through patient-provider collaborative learning sessions (CLS) and use of a customized shared decision-making (SDM) tool. Methods From 8/23 – 1/24, the CLS and SDM tools were implemented in 6 primary care/geriatric clinics with surveys administered before and after. Healthcare professionals (HCPs) participated in audit-feedback (A/F) sessions to create action plans to improve their clinic’s vaccination rates. Follow-up patient and HCP surveys were administered 4-6 weeks and 90 days later, respectively. Results The top reported barriers to vaccination amongst the 133 patients who participated in the CLS were knowing which vaccinations were needed (57%) and paying for vaccines (54%). Following the CLS, patients’ knowledge about hospitalization due to RSV significantly increased from 40% (53/133) to 65% (80/123) (P < 0.001). Additionally, 59% (73/123) of patients stated they now planned to get recommended vaccines. Most patients (67%) listed a strong recommendation from a HCP as the best motivator to getting vaccinated, however, only 33% (8/24) of HCPs perceived that would be important (Figure 1). Of the 72 patients who used the SDM tool and completed both surveys, only 40% reported being up-to-date on all recommended vaccines and 76% had not received a single dose of the shingles vaccine; 65% had not regularly discussed barriers to vaccination with their HCP. However, after using the SDM tool, 81% of patients reported they discussed their vaccination concerns more or much more than previous visits. Patients were more willing to get vaccinated following use of the SDM tool (72% to 89%, P = 0.01). Of the 14 HCPs who completed follow-up surveys, 57% reported increased vaccination rates following CLS and SDM implementation, with use of SDM (50%) and incorporating presumptive language into vaccine discussions (43%) as the top strategies employed. Conclusion Use of multi-faceted strategies to engage older adult patients in vaccine decision-making increased clinic-reported vaccine rates and patient-reported willingness to get vaccinated. Disclosures Laurie Archbald-Pannone, MD, MPH, prime, inc: Advisor/Consultant Kelly E. Pillinger, PharmD, AHFS: Contractor

Background: Telehealth can provide innovative models of care for people living in congregate care communities (CCC), but lack of consistent workflow is a barrier for administrators and staff. We propose a framework for CCC to implement workflows for age-inclusive telehealth. Methods: As part of an infection control initiative with a focus on telehealth optimization, Virginia Infection Mitigation, Prevention and Control Through Technology developed relationships with administrators and staff of CCC across the Commonwealth of Virginia. Partners in this community of practice completed a statewide survey that we conducted on anticipated and experienced barriers to telehealth implementation. Through survey responses, virtual meetings with organizational leadership, and on-site facility visits, our team assessed the strengths, needs, and goals for telehealth capability. Working with administrative and clinical teams, we developed a consultation report to define short- and long-term implementation steps. Results: We collaborated with a nonprofit organization supporting a community of people with neurodevelopmental disabilities and a rural Program of All-Inclusive Care for the Elderly. We developed a framework for telehealth optimization with four tiers: Initiate, Integrate, Incentivize, and Inspire. Each stage included an overall goal with corresponding interventions to guide program implementation. Discussion: The "Four I" Framework can be used to outline telehealth readiness and implement workflows for CCC. We aim to further develop an iterative process and to collaborate with additional organizations to optimize telehealth programs.

During the COVID pandemic, telehealth demonstrated the potential to help provide care to residents of long term care facilities (LTCF). Among patients in LTCF in the US, research has demonstrated that urinary tract infections (UTIs) are among the most common infections diagnosed, approximately 20-30% of all reported infections. Moving forward, telemedicine could be utilized to improve diagnosis of UTIs, but there has been limited research examining the current evidence to support the efficacy of telemedicine in diagnosing UTIs. This project consisted of a literature search, focused on research regarding validated criteria for UTI diagnosis and best practices for assessing history and physical examination via telemedicine.

The COVID-19 public health emergency (PHE) raised important questions of how best to apply telehealth to enable delivery of timely, high-quality health care to medically vulnerable individuals who reside in long-term care facilities. Looking back to the PHE, there have been multiple studies that demonstrate how telehealth can be a tool to improve patient outcomes, for COVID-19 infection, as well as for many other medical conditions. 1 Shaver J. The state of telehealth before and after the COVID-19 Pandemic. PrimaryCare. 2022; 49: 517-530 Google Scholar , 2 Doraiswamy S. Abraham A. Mamtani R. Cheema S. Use of telehealth during the COVID-19 pandemic: scoping review. J Med Internet Res. 2020; 22e24087 Crossref PubMed Scopus (347) Google Scholar , 3 Weiner J.P. Bandeian S. Hatef E. Lans D. Liu A. Lemke K.W. In-person and telehealth ambulatory contacts and costs in a large US insured cohort before and during the COVID-19 pandemic. JAMA Netw Open. 2021; 4e212618 Crossref Scopus (119) Google Scholar , 4 Ulyte A. Mehrotra A. Wilcock A.D. SteelFisher G.K. Grabowski D.C. Barnett M.L. Telemedicine Visits in US skilled nursing facilities. JAMA Netw Open. 2023; 6e2329895 Crossref Scopus (1) Google Scholar , 5 Harris D.A. Archbald-Pannone L. Kaur J. et al. Rapid telehealth-centered Response to COVID-19 Outbreaks in Postacute and long-term care facilities. Telemed J e Health. 2021; 27: 102-106 Crossref PubMed Scopus (34) Google Scholar Telehealth has been shown to decrease unnecessary transfers and decrease overall medical costs. 6 Chess D. Whitman J.J. Croll D. Stefanacci R. Impact of after-hours telemedicine on hospitalizations in a skilled nursing facility. Am J Managed Care. 2018; 24: 385-388 PubMed Google Scholar ,7 Groom L.L. McCarthy M.M. Stimpfel A.W. Brody A.A. Telemedicine and telehealth in nursing homes: an integrative review. J Am Med Dir Assoc. 2021; 22: 1784-1801.e7 Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar However, telehealth implementation and sustainability has remained challenging for many long-term care facilities. 8 Seifert A. Batsis J.A. Smith A.C. Telemedicine in long-term care facilities during and beyond COVID-19: challenges caused by the digital divide. Front Public Health. 2020; 8601595 Crossref PubMed Scopus (50) Google Scholar ,9 Konttila J. Siira H. Kyngäs H. et al. Healthcare professionals' competence in digitalisation: a systematic review. J Clin Nurs. 2019; 28: 745-761 Crossref Scopus (171) Google Scholar Therefore, our research team aimed to assess telehealth usage in the Commonwealth of Virginia before, during, and after the PHE, as well as the view of the anticipated and observed benefits and barriers of telehealth use among staff in congregate care facilities. The survey solicited information on anticipated (for those who did not use telehealth) and experienced (for those who used telehealth) benefits and barriers of telehealth.

Clostridioides difficile (C. difficile) is a Gram-positive anaerobic spore-forming bacillus that causes toxin-mediated infection and inflammation in the colon. C. difficile most commonly causes infection when antibiotics disrupt the physiologic intestinal microbiome. While factually correct, how do these facts translate into clinical medicine and taking care of our geriatric patients? While the microbiologic characteristics may seem a bit esoteric, there are key characteristics that are important to understand in the prevention and treatment of C. difficile infection (CDI), as well as to help guide appropriate infection control policies. The management of CDI is more than treatment. Appropriate management of CDI includes prevention, infection control and antimicrobial stewardship, appropriate diagnostic testing based on clinical presentation, as well as appropriate treatment regimen. Of the five bacteria cited as “Urgent Threats from Antibiotic Resistance, the Centers for Disease Control and Prevention (CDC) listed C. difficile as the third most urgent threat to address. The complexity and urgent need to address CDI is not due to the resistance patterns the bacterium has developed. CDI ‘is not a resistant infection but is related to antibiotic use and antibiotic resistance’ due to the “same factors that drive antibiotic resistance [1]. CDI is unique when compared to other infections that are common in older adults. CDI has tremendous impact on patients, their communities, and the health care system. In 2017, the health care cost attributable to CDI was approximately one billion United States Dollars (USD). The attributable financial cost per single patient with hospital-onset CDI was $12,675 in 2017 [1]. There are over 200,000 cases of CDI in the US each year, with an estimated 12,800 deaths in hospitals [1]. Over half of all patients diagnosed with CDI reside in longterm care facilities [1]. The CDC report highlights that even this staggering financial impact ‘does not include any downstream healthcare costs that may occur after the index hospitalization, nor does it include any economic impacts to the patient from lost work time, diminished productivity, pain and suffering, or any long-term morbidities resulting from the infection’ which can be tremendous [1]. CDI is more common and becomes a more severe infection more often in patients that are 65 years old and older [1]. Older patients are also at increased risk to develop the cycle of recurrent CDI (rCDI). The risk of subsequent recurrence can be as high as 25–50% for each recurrence [2]. Patient responses to the validated ‘Cdiff32’ survey showed decreased quality in physical, social and mental domains for all patients with CDI and impact that is more pronounced for patients with rCDI [2]. There specific microbiologic characteristics that are important to understanding how to prevent, treat, and prevent spread of CDI. Treatment of CDI is complicated, so we must first focus on prevention of CDI through infection control policies and antimicrobial stewardship. Addressing the sporeforming nature of C. difficile is a critical guide for infection control policies. The spore form of C. difficile can be dormant on surfaces for weeks to months, not killed by antiseptics or alcohol-based cleaning agents [3–5]. Because of these spores, proper hand washing with soap and water is required to physically remove spores from our hands. Additionally, cleaning exposed area with bleach-based solutions are needed to create pores in the spores for the cleaning agents to get to bacterial machinery to kill the bacteria. These increased cleaning protocols for infection control are especially important in congregate living situations, such as subacute skilled and long-term care facilities, to prevent spread to other potentially medically vulnerable residents. Antimicrobial stewardship is the cornerstone of decreasing unnecessary and inappropriate use of antibiotics and, in turn, alterations of a patient’s intestinal microbiome. It is ‘essential that health care providers understand appropriate antimicrobial pharmacotherapy in the elderly patient [6].’ When looking specifically at the population of older adults who reside in long-term care facilities, 50–80% of these residents receive at least 1 course of antibiotics annually, and that 50% of antibiotic use of considered inappropriate [7–9]. Antimicrobial stewardship is in practice and in policy is critical in decreasing a patient’s risk of CDI and the risk of CDI spread within vulnerable populations. Utilization of clinical guidelines can help clinicians to assess a patient’s symptoms and develop likelihood of a true infection that requires antibiotic treatment. Every prescribed antibiotic regimen should contain the ‘antibiotic time out’ with the specific dose,

Fecal Microbiota Transplant (FMT) is an emerging therapy that has had remarkable success in treatment and prevention of recurrent Clostridioides difficile infection (rCDI). FMT has recently been associated with adverse outcomes such as inadvertent transfer of antimicrobial resistance, necessitating development of more targeted bacteriotherapies. To address this challenge, we developed a novel systems biology pipeline to identify candidate probiotic strains that would be predicted to interrupt C. difficile pathogenesis. Utilizing metagenomic characterization of human FMT donor samples, we identified those metabolic pathways most associated with successful FMTs and reconstructed the metabolism of encoding species to simulate interactions with C. difficile . This analysis resulted in predictions of high levels of cross-feeding for amino acids in species most associated with FMT success. Guided by these in silico models, we assembled consortia of bacteria with increased amino acid cross-feeding which were then validated in vitro . We subsequently tested the consortia in a murine model of CDI, demonstrating total protection from severe CDI through decreased toxin levels, recovered gut microbiota, and increased intestinal eosinophils. These results support the novel framework that amino acid cross-feeding is likely a critical mechanism in the initial resolution of CDI by FMT. Importantly, we conclude that our predictive platform based on predicted and testable metabolic interactions between the microbiota and C. difficile led to a rationally designed biotherapeutic framework that may be extended to other enteric infections.

The COVID-19 pandemic elevated telehealth as a prevalent care delivery modality for older adults. However, guidelines and best practices for the provision of healthcare via telehealth are lacking. Principles and guidelines are needed to ensure that telehealth is safe, effective, and equitable for older adults. The Collaborative for Telehealth and Aging (C4TA) composed of providers, experts in geriatrics, telehealth, and advocacy, developed principles and guidelines for delivering telehealth to older adults. Using a modified Delphi process, C4TA members identified three principles and 18 guidelines. First, care should be person-centered; telehealth programs should be designed to meet the needs and preferences of older adults by considering their goals, family and caregivers, linguistic characteristics, and readiness and ability to use technology. Second, care should be equitable and accessible; telehealth programs should address individual and systemic barriers to care for older adults by considering issues of equity and access. Third, care should be integrated and coordinated across systems and people; telehealth should limit fragmentation, improve data sharing, increase communication across stakeholders, and address both workforce and financial sustainability. C4TA members have diverse perspectives and expertise but a shared commitment to improving older adults' lives. C4TA's recommendations highlight older adults' needs and create a roadmap for providers and health systems to take actionable steps to reach them. The next steps include developing implementation strategies, documenting current telehealth practices with older adults, and creating a community to support the dissemination, implementation, and evaluation of the recommendations.

Background Advanced age and underlying comorbidities are associated with greater rates of recurrence in patients with Clostridioides difficile infection (CDI). Reducing the likelihood of recurrence through treatment with an antimicrobial followed by a microbiota replacement therapy can decrease the burden of this infection and improve patient outcomes. We report the efficacy and safety of RBX2660, a microbiota-based live biotherapeutic, in older adults with recurrent CDI, grouped by comorbidities. Methods In this post hoc subgroup analysis of the PUNCH CD3 trial, we assessed outcomes in older adults (age >= 65 years) grouped by Charlson Comorbidity Index severity scores at screening (moderate [3-4] and severe [>= 5]) and by the presence of underlying cardiac, renal, or gastrointestinal disorders. Results RBX2660 treatment success rates in older adults with comorbidities were consistent across subgroups and similar to those in the total RBX2660-treated population. A greater percentage of RBX2660-treated older adults remained free of CDI recurrence through 8 weeks following treatment compared with placebo-treated participants in all but 2 subgroups assessed. Across all subgroups, most treatment-emergent adverse events (TEAEs) were mild or moderate in severity and related to a preexisting condition. None of the serious or life-threatening TEAEs that occurred were related to RBX2660 or its administration. Occurrence of TEAEs did not cluster in any subgroup. Conclusions RBX2660 is efficacious and safe in older adults with recurrent CDI and underlying comorbidities. A post hoc subgroup analysis of the PUNCH CD3 phase 3 trial demonstrated the efficacy and safety of RBX2660 in medically complex patients with recurrent CDI, who are often encountered in clinical practice.

INTRODUCTION:Clostridioides difficile is the leading cause of healthcare-associated infections in the USA, with an estimated 1 billion dollars in excess cost to the healthcare system annually. C. difficile infection (CDI) has high recurrence rate, up to 25% after first episode and up to 60% for succeeding episodes. Preliminary in vitro and in vivo studies indicate that alanyl-glutamine (AQ) may be beneficial in treating CDI by its effect on restoring intestinal integrity in the epithelial barrier, ameliorating inflammation and decreasing relapse.METHODS AND ANALYSIS:This study is a randomised, placebo-controlled, double-blind, phase II clinical trial. The trial is designed to determine optimal dose and safety of oral AQ at 4, 24 and 44 g doses administered daily for 10 days concurrent with standard treatment of non-severe or severe uncomplicated CDI in persons age 18 and older. The primary outcome of interest is CDI recurrence during 60 days post-treatment follow-up, with the secondary outcome of mortality during 60 days post-treatment follow-up. Exploratory analysis will be done to determine the impact of AQ supplementation on intestinal and systemic inflammation, as well as intestinal microbial and metabolic profiles.ETHICS AND DISSEMINATION:The study has received University of Virginia Institutional Review Board approval (HSR200046, Protocol v9, April 2023). Findings will be disseminated via conference presentations, lectures and peer-reviewed publications.TRIAL REGISTRATION NUMBER:NCT04305769.

Pneumonia and urinary tract infections (UTI) are 2 of the most common diagnoses of residents of long-term care facilities (LTCF), accounting for over 40% of antibiotic use. However, studies have repeatedly shown much of the antibiotic prescribing to be unnecessary. The Loeb criteria, a tool for antibiotic stewardship, is an established minimum set of signs and symptoms to be met for initiation of antibiotics in LTCF residents. This criteria has been shown to be effective in decreasing unnecessary antibiotic use, without increasing hospitalizations or mortality. The expansion of telemedicine with the COVID-19 pandemic has shown potential for improving clinical outcomes for LTCF residents. We performed a review of the literature to determine if there is evidence to support use of telemedicine as a tool to apply the Loeb criteria in making the decision to initiate antibiotics for pneumonia and UTI in LTCF residents.

Introduction: Age and certain underlying comorbidities are among the risk factors for recurrent Clostridioides difficile infection (rCDI). Here, we report the efficacy and safety of RBX2660, a microbiota-based live biotherapeutic, in patients with rCDI grouped by age and baseline Charlson Comorbidity Index (CCI) severity scores. This is a subgroup post-hoc analysis of the PUNCH CD3 trial (NCT03244644), a prospective, multicenter, randomized, double-blind, placebo-controlled phase 3 trial. Methods: Participants enrolled in PUNCH CD3 were ≥18 years old with documented rCDI and completed standard-of-care antibiotic therapy prior to treatment with RBX2660 or placebo. Treatment success was defined as remaining free of CDI recurrence 8 weeks after treatment. In this subgroup post hoc analysis, we assessed outcomes of participants grouped by age (< 65 years, 65 to < 75 years, and ≥75 years) and CCI severity scores at screening (0 to 2 [mild], 3 to 4 [moderate], and ≥5 [severe]). The treatment-emergent adverse events (TEAEs) were summarized for the double-blind treatment period within 8 weeks and censored if a patient received open-label RBX2660 after CDI recurrence. Results: Of 262 total participants in the modified intent-to-treat population, 143 (55%) were < 65 years old, 68 (26%) were between 65 and < 75 years old, and 51 (19%) were ≥75 years old. A greater percentage of RBX2660-treated participants remained recurrence free through 8 weeks following treatment compared to placebo-treated participants in the following subgroups: < 65 years old with moderate and severe CCI severity scores; ≥65 years to < 75 years with mild, moderate, and severe CCI severity scores; and ≥75 years old with severe CCI severity scores (Figure 1A). In the total safety population (N=267), the overall incidence of TEAEs was 52% following RBX2660 treatment compared to 44% following placebo treatment, with mild events (mostly gastrointestinal) accounting for most of the difference. Similar percentages of participants categorized by age and CCI severity scores reported TEAEs (Figure 1B). Serious and life-threatening TEAEs did not cluster with any particular age or CCI subgroup and none were related to RBX2660 or its administration. Conclusion: RBX2660 is efficacious and safe in adults with rCDI regardless of age and baseline comorbidities.Figure 1.: (A) Summary of treatment success and (B) adverse events in participants with recurrent Clostridioides difficile infection across age and Charlson Comorbidity Index severity score subgroups

Background:Clinicians identify challenges in using telehealth with older adults, yet they continue to use it at high rates. We conducted a nation-wide survey of US clinicians to assess the views and uses of telehealth for older adults (≥65 years old); as well as the perceived advantages and challenges of telehealth and use of age-friendly telehealth practices.Materials/Methods:We distributed an online survey (Wallin Opinion Research) to assess the use of telehealth and clinicians' views on advantages/challenges of telehealth in care of older adults. Respondents were eligible if they were active US clinicians with self-attestation of patient population ≥10% older adults. The survey was distributed through established professional networks. Eligible respondents received a gift card for participation, fulfilled by a third-party vendor. Survey participation was voluntary. Completion of the survey was considered consent to participate. The study was reviewed and determined exempt by the WCG's IRB Affairs Department. SPSS Version-26 was used for descriptive statistics.Results:Approximately 13,300 surveys were distributed and there were 7,246 (55%) respondents. Over half (56%) respondents were licensed independent practitioners. The majority of respondents practiced geriatric medicine (22%) or primary care (9.7%). The most common use was in hospitals (53%), long-term care facilities (47%), and outpatient (47%) settings. The majority of respondents (55%) selected "telehealth improves healthcare for older adults by enhancing engagement between stakeholders" as a top advantage. Fewer primary care clinicians (47%) reported sufficient support in the use of telehealth, as compared with clinicians in geriatrics (62%) or other specialties (60%). A majority (65%) of respondents reported use one or more age-friendly practice (40% often; 25% always). Only 5% of respondents reported that their telehealth program never utilized age-friendly practices.Discussion and Conclusion:Clinicians use telehealth in care of older adults, across clinical roles, sites, and purposes. Our survey results suggest perceived advantages of telehealth outweigh challenges, in care of older adults. This highlights an opportunity for guidance and resources to optimizing telehealth with older adults.

To the Editor: The COVID-19 pandemic has disrupted the lives of older U.S. adults living in long-term care facilities (LTCFs). For some, the threat of illness has materialized into suffering and death. While minimizing contact with others has been a public health necessity, isolation has contributed to older adults’ worsening mental and physical health. 1 In response, we created a telephone call program that paired University of Virginia (UVA) medical students with residents in regional LTCFs. Twenty-eight students took a training course on COVID-19 epidemiology and communication strategies developed by the UVA Geriatrics Division. We phoned our resident partners biweekly between March and June 2020. As students, our goal was to form social relationships over the phone with residents. We listened to stories and, in turn, spoke about our lives and medical school experiences. At times, we learned valuable lessons about medical practice. One LTCF resident, a retired hospice nurse, spoke about “what happens around death” and the “emotional experiences” involved in hospice care; she recommended that we as physicians take time to process loss. Many resident partners were socially isolated in lockdown, unable to leave their apartments or see family. Our conversations enabled them to teach us about resilience in the face of hardship and about confronting uncertainty—core competencies we will need as clinicians. Likewise, LTCF resident partners reported benefit from feelings of generativity gained from speaking with us, younger adults. 2 Although this student-initiated telephone program was not sustained, it supported the well-being of older adults and medical students alike and contributed in practical, experiential ways to students’ formation as caring persons and compassionate physicians. The UVA School of Medicine took note, and, building upon our voluntary initiative, has integrated virtual encounters and more phone calls into the Patient Student Partnership, a longitudinal program in which all students are paired with chronically ill patients throughout the 4 years of medical school. Acknowledgments: The authors wish to thank the long-term care facility (LTCF) administrators and staff for their efforts to assist with the formed pairs. They also wish to thank their LTCF resident and student participants for their dedication to the program and time spent providing valuable feedback.

Abstract Background Disruptions to gut microbiota composition can result in dysbiosis and subsequent intestinal colonization by opportunistic pathogens such as Clostridioides difficile.1,2 The incidence of Clostridioides difficile infection (CDI) in persons ≥ 65 years old is greater than in those < 65 years old,3 with 1 in 11 CDI patients ≥ 65 years old dying within 1 month of diagnosis.4 We report the efficacy and safety of RBX2660, a microbiota-based live biotherapeutic, in patients with recurrent CDI (rCDI) who were ≥ 65 years old with comorbidities. This is a subgroup analysis of the PUNCH CD3 trial (NCT03244644), a prospective, multicenter, randomized, double-blind, placebo-controlled phase 3 trial. Methods Participants enrolled in PUNCH CD3 were ≥ 18 years old with documented rCDI who completed standard-of-care antibiotic therapy prior to treatment with RBX2660 or placebo. Treatment success was defined as remaining recurrence-free 8 weeks after intervention. In this subgroup analysis, we assessed outcomes of participants ≥ 65 years old with underlying cardiac disorders, chronic kidney disease (CKD), and gastrointestinal (GI) disorders. The treatment-emergent adverse events (TEAEs) were summarized for the double-blind treatment period within 8 weeks and censored if a patient received open-label RBX2660 after CDI recurrence. Results In the modified intent-to-treat population, 119 of 262 participants (45%) were ≥ 65 years old. Of these 119 participants, 42% had a cardiac disorder, 19% had CKD, and 61% had a GI disorder; the respective RBX2660 treatment success rates were 69%, 68%, and 67% (Figure 1). In the total safety population, the overall incidence of TEAEs was 52% with RBX2660 treatment compared to 44% with placebo treatment; mild events accounted for most of the difference (40% vs 30%) (Table 1). The overall incidence of TEAEs was 51% in RBX2660-treated participants ≥ 65 years old and 61%, 68%, and 51% in those participants with a cardiac disorder, CKD, or GI disorder, respectively. Most TEAEs were mild or moderate in severity and related to a pre-existing condition. Conclusion RBX2660 is safe and efficacious across a range of medically complex patients and consistently reduced rCDI in adults ≥ 65 years old, regardless of baseline comorbidities. Disclosures Glenn S. Tillotson, PhD, Ferring Pharmaceuticals: Advisor/Consultant|Paratek Pharmaceuticals: Grant/Research Support|Spero Pharmaceuticals: Advisor/Consultant|Taro Pharmaceuticals: Advisor/Consultant Paul Feuerstadt, MD, FACG, AGAF, Ferring/Rebiotix Pharmaceuticals: Advisor/Consultant|Ferring/Rebiotix Pharmaceuticals: Grant/Research Support|Merck and Co: Advisor/Consultant|SERES Therapeutics: Advisor/Consultant|SERES Therapeutics: Grant/Research Support|Takeda Pharmaceuticals: Advisor/Consultant Stuart Johnson, M.D., Ferring Pharmaceuticals: Membership on Ferring Publication Steering Committee|Ferring Pharmaceuticals: Employee|Summit Plc: Advisor/Consultant Adam Harvey, PhD, Ferring Pharmaceuticals: Employment.

Background: Residents of nursing homes are among the most vulnerable to COVID-19. There is no standardized approach for integration with hospitals for outbreak response. Previously, we described collaboration between a hospital and regional facilities. As a component of our COVID-19 Outbreak Response, we describe the impact of virtual daily rounds as an efficient and effective tool for facility outbreak in Central Virginia. Methods: At this facility, 82 (60%) residents were infected. Our team rapidly deployed technology to support staff at the facility. Virtual daily rounds created a systematic approach for patient care. The goals of virtual daily rounds include (1) efficiently facilitating HIPAA-compliant communication between nursing and all licensed independent providers, (2) rapid identification of clinical decline, (3) facilitation of care escalation, (4) facilitating bidirectional transfers, and (5) rapid and efficient identification of patients appropriate for telemedicine pulmonary consultation. Results: The outbreak remained active 6 weeks; 82 of 136 (60%) residents were infected, and 36 (44%) COVID-19 positive residents were seen by telemedicine consultation. Fifty-seven (70%) residents remained in-facility for treatment. Twenty-one residents died (15%); 10 in facility, 11 in hospital. Of those seen in telemedicine consultation, 24 (69%) remained on the treat-in-place protocol with goal-concordant care. These hospitalization and mortality rates are significantly lower than similar outbreaks reported. Discussion and Conclusion: We have since instituted this system at seven other facilities. A model of virtual daily rounding holds promise for decreasing mortality/hospitalization in this vulnerable population through systematically identifying patients most appropriate for telemedicine and cultivating close collaboration between hospitals and nursing homes.