Latinx immigrants have been profoundly impacted by COVID-19. As the Johns Hopkins Health System faced a surge in admissions of limited English proficiency patients with COVID-19, it became evident that an institutional strategy to address the needs of this patient population was needed. The Johns Hopkins Medicine (JHM) Latinx Anchor Strategy was established in April 2020 with diverse stakeholder engagement to identify the most urgent community needs and develop timely solutions. The JHM Latinx Anchor Strategy provided a platform for information sharing to promote equitable access to resources for Latinxs with limited English proficiency who were impacted by COVID-19. Leveraging institutional, community, and government resources and expertise, the JHM Latinx Anchor Strategy helped establish interventions to improve access to COVID-19 testing and care for low-income immigrants without a primary care doctor and helped mitigate economic vulnerability through the distribution of food for 2,677 individuals and cash to 446 families and 95 individuals (May to August 2020). Expanded linguistic and culturally competent communication through webinars and livestream events reached more than 10,000 community members and partners. Over 7,500 limited English proficiency patients received linguistically congruent direct patient services through the Esperanza Center bilingual hotline, community testing resulting efforts, and inpatient consultations. The first stage of the JHM Latinx Anchor Strategy relied heavily on volunteer efforts. Funding for a sustainable response will be required to address ongoing COVID-19 needs, including expansion of the bilingual/bicultural healthcare workforce, expanded access to primary care, and investments in population health strategies addressing social determinants of health.

Racially and ethnically diverse and socioeconomically disadvantaged communities have historically been disproportionately affected by disasters and public health emergencies in the United States. The U.S. Department of Health and Human Services' Office of Minority Health established the National Consensus Panel on Emergency Preparedness and Cultural Diversity to provide guidance to agencies and organizations on developing effective strategies to advance emergency preparedness and eliminate disparities among racially and ethnically diverse communities during these crises. Adopting the National Consensus Panel recommendations, the Johns Hopkins Medicine Office of Diversity, Inclusion, and Health Equity; Language Services; and academic-community partnerships used existing health equity resources and expertise to develop an operational framework to support the organization's COVID-19 response and to provide a framework of health equity initiatives for other academic medical centers. This operational framework addressed policies to support health equity patient care and clinical operations, accessible COVID-19 communication, and staff and community support and engagement, which also supported the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. Johns Hopkins Medicine identified expanded recommendations for addressing institutional policy making and capacity building, including unconscious bias training for resource allocation teams and staff training in accurate race, ethnicity, and language data collection, that should be considered in future updates to the National Consensus Panel's recommendations.

Coronavirus disease 2019 (COVID-19) exacerbated pre-existing health disparities and disproportionately affected the Latino community. Clinicians identified communication barriers as a major challenge in care for COVID-19 Latino patients with limited English proficiency (LEP). To address these challenges, Juntos (Together) consult service was established to promote language-congruent care with cultural sensitivity, identify barriers to safe discharge, and facilitate referral to appropriate resources. Spanish speaking volunteer health care providers worked synergistically with medical teams caring for LEP Latino patients. Volunteers were trained on consultant responsibilities and discharge planning resources. The program was evaluated by a satisfaction survey distributed to providers who requested a Juntos consult and Juntos volunteers. Between May 5 and July 30, 2020, 19 individuals volunteered time to the Juntos consult service, 12 (63%) Latinos, 14 (74%) physicians, and 5 (26%) staff. The service supported 127 patients, 76 (60%) males, mean age 42 (±16), 83 (65%) uninsured, and 91 (72%) without primary care. The most common referral sources were medical units (52, 41%) and intensive care units (47, 37%). The most common services offered were family engagement (55, 43%), goals of care (35, 28%), and mental status assessment (26, 20%). The majority of providers who consulted Juntos were very satisfied (48/59, 81%) with the care delivered. The Juntos service offered critical support tailored to the patients' and primary teams' needs. The experience reinforced the need for cultural-based communication to provide optimal care to LEP patients. The Juntos consult service could be a model for providing language-congruent care even beyond COVID-19, but to do so will require institutional investment and rigorous outcomes evaluation.

In the context of the COVID-19 pandemic, reassessing intensive care unit (ICU) use by population should be a priority for hospitals planning for critical care resource allocation. In our study, we reviewed the impact of COVID-19 on a community hospital serving an urban region, comparing the sociodemographic distribution of ICU admissions before and during the pandemic. We executed a time-sensitive analysis to see if COVID-19 ICU admissions reflect the regional sociodemographic populations and ICU admission trends before the pandemic. Sociodemographic variables included sex, race, ethnicity, and age of adult patients (ages 18 years and older) admitted to the hospital's medical and cardiac ICUs, which were converted to COVID-19 ICUs. The time period selected was 18 months, which was then dichotomized into pre-COVID-19 admissions (December 1, 2018 to March 13, 2020) and COVID-19 ICU admissions (March 14 to May 31, 2020). Variables were compared using Fisher's exact tests and Wilcoxon tests when appropriate. During the 18-month period, 1,861 patients were admitted to the aforementioned ICUs. The mean age of the patients was 62.75 (SD 15.57), with the majority of these patients being male (52.23%), White (64.43%), and non-Hispanic/Latinx (95.75%). Differences were found in racial and ethnic distribution comparing pre-COVID-19 admissions to COVID-19 admissions. Compared with pre-COVID-19 ICU admissions, we found an increase in African American versus White admissions (P = .01) and an increase in Hispanic/Latinx versus non-Hispanic/Latinx admissions (P < .01), during the COVID-19 pandemic. During the first 3 months of admissions to COVID-19 ICUs, the number of admissions among Hispanic/Latinx and African American patients increased while the number of admissions among non-Hispanic/Latinx and White patient decreased, compared with the pre-COVID-19 period. These findings support development of strategies to enhance allocation of resources to bolster novel, equitable strategies to mitigate the incidence of COVID-19 in urban populations.

INTRODUCTION:Latinxs have been disproportionately impacted by COVID-19. Latinx immigrants, in particular, face significant barriers to SARS-CoV-2 testing, including lack of insurance, language barriers, stigma, work conflicts, and limited transportation.METHODS:In response to a disproportionately high SARS-CoV-2 positivity rate among Latinxs at the Johns Hopkins Health System, investigators implemented free community-based testing by partnering with religious leaders and leveraging the skill of trusted community health workers. Data were extracted from the electronic health record and a Research Electronic Data Capture database. SARS-CoV-2 positivity was evaluated per event stratified by race/ethnicity. Total rates of SARS-CoV-2 positivity and categorical patient characteristics were compared between groups using chi-square tests.RESULTS:Between June 25, 2020 and October 15, 2020, a total of 1,786 patients (57.5% Latinx, 31.2% non-Hispanic White, 5.9% non-Hispanic Black, and 5.3% non-Hispanic other) were tested for SARS-CoV-2 in 18 testing events. Among them, 355 (19.9%) tested positive. The positivity rate was 31.5% for Latinxs, 7.6% for non-Hispanic Blacks, 3.4% for non-Hispanic Whites, and 5.3% for patients of other races/ethnicities. Compared with Latinxs who tested negative, Latinxs who tested positive were more likely to report Spanish as their preferred language (91.6% vs 81.7%, p<0.001), be younger (30.4 vs 33.4 years, p<0.008), and have a larger household size (4.8 vs 4.3 members, p<0.002).CONCLUSIONS:Community-based testing identified high levels of ongoing SARS-CoV-2 transmission among primarily Latinxs with limited English proficiency. During this period, the overall positivity rate at this community testing site was almost 10 times higher among Latinxs than among non-Hispanic Whites.

Background: Several months into the COVID-19 pandemic, reassessing intensive care unit (ICU) utilization, specifically with regional impact on diverse populations, should be a priority for hospitals planning for critical care resource allocation. In our study, we reviewed the impact of COVID-19 on a community hospital serving an urban region, comparing the sociodemographic distribution of ICU admissions before and during the pandemic. Methods: We executed a time sensitive analysis to see if COVID-19 ICU admissions reflect regional sociodemographic populations as well as ICU admission trends prior to the current pandemic. Collected sociodemographic variables included sex, race, ethnicity, and age of adult patients (age 18 and older) admitted to the hospital’s medical and cardiac ICUs, which were converted to COVID-19 ICUs. The time period selected was 18-months, which was then dichotomized into pre-COVID-19 admissions (December 1, 2018 to March 13, 2020) and COVID-19 ICU admissions (March 14, 2020 to May 31, 2020). Variables were compared using Fisher’s exact tests and Wilcoxon tests when appropriate. Results: During the 18-month period, 1861 patients were admitted to the aforementioned ICUs. The mean age of the 1861 patients was 62.75 + 15.57 years old, with the majority of these patients being male (52.23%), White (64.43%), and non-Hispanic/Latinx (95.75%). There were differences in racial and ethnic distribution comparing pre-COVID-19 admissions to the COVID-19 admissions. Compared to pre-COVID-19 ICU admissions, there was an increase in African American versus White admissions (p=0.01) and an increase in Hispanic/Latinx versus non-Hispanic/Latinx admissions (p<0.01), during the COVID-19 pandemic. Discussion: During the first three months of admissions to COVID-19 ICUs, there was a rise in admissions among Hispanic/Latinx and African-American patients, while non-Hispanic/Latinx and White patient admissions declined compared to the previous pre-COVID year. These findings support development of strategies to enhance allocation of resources to bolster novel, equitable strategies to mitigate the incidence of COVID-19 in minority populations.

The burden of illness from COVID-19 is strikingly disproportionate among racial and ethnic minorities in the USA. This disparity is well illustrated in Latinx populations, who bear 2·8 times the number of cases and 4·6 times the age-adjusted hospitalisation rate from COVID-19 compared with non-Hispanic whites. As health-care professionals caring for Latinx patients affected by COVID-19, we share here what we have learned and highlight critical considerations for the health-care system and community during the ongoing pandemic. The first line of defense for COVID-19 care is infection prevention. For Latinx immigrants, a number of factors pose challenges to prevention. The lack of language-concordant care, and in particular the lack of reliable and consistent public health information in Spanish, potentially delays critical messaging at a time when recognition of symptoms and precaution application is vital to reduce transmission. The development and dissemination of public health messages related to COVID-19 in Spanish is critical to COVID-19 prevention among Latinx with limited English proficiency. A well established model of care is to leverage the expertise of promotoras, or bilingual and bicultural community health workers trusted by the community. This model includes active linguistic and culturally tailored community outreach by medical professionals and via partnerships with community leaders. Use of bilingual contact tracers might also help build trust within Latinx communities and reduce viral spread when cases are identified. Even with optimal dissemination of information, social, economic, and political factors, specifically housing and employment, make it difficult to follow infection control recommendations. Congregate housing is common, and 25% of the Latinx population live in multigenerational housing, compared with 15% of non-Hispanic whites, making self-isolation more difficult. Financial pressures and the absence of paid sick leave or disability benefits might directly conflict with the need to quarantine or isolate. Additionally, Latinx might serve in frontline jobs that cannot be done via telework and require in-person attendance of all staff, worsening COVID-19 occupational hazards (eg, COVID-19 outbreaks in meat or poultry processing facilities). Provision of alternate housing solutions in the setting of infection might reduce community and household spread but requires proactive reassurance of altruism without repercussion to the individual (eg, revealed immigration status). Resources to maintain finances and employment status during illness are essential but not uniformly available. Many immigrants work in informal economies where paid sick leave is not provided, and undocumented immigrants (vulnerable to work exploitation) are not eligible for unemployment benefits or stimulus checks. State and federal provisions must be strengthened to ensure occupational health protections and adequate personal protective equipment provision is enforced, with resources for employers to institute safe practices for all workers in all work environments. The proportion of people uninsured is higher among Latinx than among any other racial or ethnic group in the USA. Undocumented immigrants are excluded from the Affordable Care Act, often leaving them without primary care providers. The Public Charge Rule, which went into effect in February, 2020, has created additional disincentives to care by including use of Medicaid coverage as a programme, which would negatively impact immigrants applying for a green card or citizenship. This led to marked distrust and avoidance in Medicaid enrollment, creating an additional barrier to affordable care. Patients reported to us their reluctance to come to the emergency department due to their insurance or immigration status, despite escalating symptoms consistent with COVID-19. Delayed presentation contributes to more advanced respiratory failure or hypoxaemia on arrival to hospital in many of our Latinx patients, a now described risk factor for mortality in COVID-19. Continued COVID-19 relief funding should occur throughout the pandemic to provide health-care coverage for Latinx patients. The financial relief that this funding provides to uninsured patients, along with confidentiality of immigration status, must be communicated proactively, and might help decrease hesitancy to present to the hospital. During this pandemic it has become even more obvious that treatment without regard to immigration status is a public health necessity. In the emergency department and while inpatient, necessary isolation precautions create challenges. For example, third party translation, which is necessary to facilitate improved communication with Latinx patients, is challenging due to communication barriers present when using personal protective equipment and limited availability of in-person interpreters on site. Direct communication with qualified bilingual providers is ideal to help build rapport and streamline communication, however, these roles are only available in limited capacity. In addition to isolation precautions, the volume of Latinx patients admitted and time of admission (after business hours) contributes to this communication challenge. Earlier in the pandemic, family visitation was restricted or prohibited, and strict limitations remain. Family visits can provide considerable support for hospitalised patients as well as cultural insight, particularly for patients already in a vulnerable position. A consideration to mitigate such barriers would be to ramp up the bilingual work force and support systems in anticipation of needing to serve this vulnerable population. For many of our Latinx patients, illness in the setting of COVID-19 represented their first presentation to the health-care system. Pre-existing health issues were frequently identified by health-care staff during Latinx in-patient admissions for COVID-19, requiring medical management beyond hospital discharge. Hospitalisation and sequelae, particularly the need for intensive care resources, confers risk for lingering functional, cognitive, and psychiatric impairments (eg, post-intensive care unit syndrome and post-hospital syndrome). Longer-term consequences specific to COVID-19 are incompletely described, but a growing body of literature supports delays in symptom resolution. Engagement in primary care, and connection with resources (eg, insurance, assistance programmes, local free or sliding scale clinics with language proficiency, subspecialty care including mental health care and physical and occupational therapy) to ensure provision of care beyond the initial viral illness is essential. Dedicated post-COVID-19 clinics must account for the additional needs of Latinx patients, link patients with case management, social work, and translator services, and proactively advocate for continued medical access. Patient education materials should be translated, and access to nurses, physicians, and testing via phone or electronic health applications should be provided in language-concordant fashion. Latinx patients might continue to face disproportionate challenges following hospitalisation with COVID-19. Telemedicine, applied nationally for infection control purposes during the pandemic, allows for potential expansion of health-care access by eliminating transportation needs, increasing convenience, and reducing time investment by the patient. Video visits are preferred by providers for visual assessment and diagnosis and rapport-building; however, such visits require a computer or smartphone, in addition to digital access, frequently unavailable in lower-income communities. Telephone visits provide access where social and resource-based limitations to in-person or video visits remain, but have substantially reduced reimbursement and therefore they are disincentivised at the system level. Persistence of telephone visits beyond the COVID-19 pandemic might allow providers to continue to engage Latinx as larger solutions to health-care provision are developed. Federal, state, and local policies and funding, informed by patient experiences and provider input, are needed to ensure durable telemedicine health-care access and resources. Our collective experiences providing care for the Latinx population affected by COVID-19 reflect a magnification of health-care vulnerabilities. Needs are complex and require comprehensive solutions, but it is our undeniable responsibility as health-care professionals, health systems, and world citizens to address these needs. As Latinx populations have been disproportionately affected by the COVID-19 pandemic, it is essential that we listen to our Latinx patients, address the barriers to care they experience, and continue to adjust processes and resources with the goal of eliminating health-care disparities. SEZ reports grants from NHLBI (T32HL007534-36 and F32HL149195-01). All other authors declare no competing interests.

Background: Door to Needle Time (DNT) for IV tPA administration in acute stroke, has become an important quality metric. The rationale for this is based on evidence that earlier administration of IV tPA, improves patient outcomes. Methods: In 2010 we undertook a review of our hospital’s performance and process for administration of IV tPA for acute stroke. At the time, we were already using 7 elements of the AHA’s Target Stroke 10 best practices. We created a pocket card for our Brain Attack team to record the time at which each task in the process was completed. We found that the greatest delay was in the time between the decision to treat and administration of tPA. The factors that contributed were insertion of a Foley catheter (part of our order set at the time), blood pressure control, and mixing tPA. We instituted the 3 remaining Target Stroke best practices: activation of the Brain Attack team upon EMS advance hospital notification, mixing tPA ahead of time (right after CT scan), and prompt data feedback (case by case and aggregate). We also eliminated the Foley catheter insertion requirement from the order set, instituted a streamlined blood pressure control guideline, created an incentive pin awarded for treatment under 60 minutes, started timely case by case review and feedback, and included DNT on our department’s safety dashboard. Results: From 2007 to 2010, there were 5/43 (11.6%) patients with a DNT less than 60 minutes (DNT<60), and the average yearly median DNT was 80 min. After implementation: In 2011, DNT<60 was 5/14 (35.7%) and median DNT was 67 min. In 2012, DNT<60 was 11/28 (39%), DNT<45: 1/28 (3.6%),and median DNT was 67 min. In 2013, DNT<60 was 16/39 (41%), DNT<45: 3/39 (7.7%), and median DNT was 68 min. In 2014, DNT<60 was 19/39 (49%), DNT<45: 7/39 (18%), and median DNT was 61 min. Adjusted (aDNT<60) results based on the Get With The Guidelines accepted medical reasons for exclusion of the metric (released in the Fall of 2012). In 2013, aDNT<60 was 8/13 (61.5%) and median DNT was 55 min. In 2014, aDNT<60 was 9/10 (90%) and median DNT was 56 min. Conclusions: Efforts to reduce DNT are effective and create incremental improvement over time. The organization required to lower door to needle time, results in an increase of the number of patients treated. This may be a result of the greater efficiency needed to achieve fast administration of IV tPA, which in turn, improves recognition of stroke patients and efficiency of decision making. Our experience demonstrates that these gains are sustainable.