Managing ICU surge during the COVID-19 crisis: rapid guidelines

Emergency medicine updates: Management of sepsis and septic shock

INTRODUCTION

Sepsis is a common condition associated with significant morbidity and mortality. Emergency physicians play a key role in the diagnosis and management of this condition.

OBJECTIVE

This paper evaluates key evidence-based updates concerning the management of sepsis and septic shock for the emergency clinician.

DISCUSSION

Sepsis is a life-threatening syndrome, and rapid diagnosis and management are essential. Antimicrobials should be administered as soon as possible, as delays are associated with increased mortality. Resuscitation targets include mean arterial pressure ≥ 65 mmHg, mental status, capillary refill time, lactate, and urine output. Intravenous fluid resuscitation plays an integral role in those who are fluid responsive. Balanced crystalloids and normal saline are both reasonable options for resuscitation. Early vasopressors should be initiated in those who are not fluid-responsive. Norepinephrine is the recommended first-line vasopressor, and if hypotension persists, vasopressin should be considered, followed by epinephrine. Administration of vasopressors through a peripheral 20-gauge or larger intravenous line is safe and effective. Steroids such as hydrocortisone and fludrocortisone should be considered in those with refractory septic shock.

CONCLUSION

An understanding of the recent updates in the literature concerning sepsis and septic shock can assist emergency clinicians and improve the care of these patients.

Reformulating real-time random safety analysis during the SARS-CoV-2 pandemic

INTRODUCTION

From a safety perspective, the pandemic imposed atypical work dynamics that led to noticeable gaps in clinical safety across all levels of health care.

OBJECTIVES

To verify that Real-Time Random Safety Analyses (AASTRE) are feasible and useful in a high-pressure care setting.

DESIGN

Prospective study (January-September 2022).

SETTING

University Hospital with 350 beds. Two mixed ICUs (12 and 14 beds).

INTERVENTIONS

Two safety audits per week were planned to determine the feasibility and usefulness of the 32 safety measures (grouped into 8 blocks).

MAIN VARIABLES OF INTEREST

1) Feasibility: Proportion of completed audits compared to scheduled audits and time spent. 2) Utility: Changes in the care process made as a result of implementing AASTRE.

RESULTS

A total of 390 patient-days were analyzed (179 were Non-COVID patients and 49 were COVID patients). In the COVID patient subgroup, age, ICU stay, SAPS 3, and ICU mortality were significantly higher compared to the Non-COVID patient subgroup. Regarding feasibility, 93.8% of planned rounds were carried out with an average audit time of 25 ± 8 min. Overall, changes in the care process were made in 11.8% of the measures analyzed.

CONCLUSIONS

In a high-complexity care environment, AASTRE proved to be a feasible and useful tool with only two interventions per week lasting less than 30 min. Overall, AASTRE allowed unsafe situations to be turned safe in more than 10% of the evaluations.

Public perspectives on COVID-19 triage protocols for access to critical care in extreme pandemic context

COVID-19 triage protocols are resource allocation processes to deal with the potential lack of resources in Intensive Care Units (ICU). They have given rise to numerous ethical issues and controversies. Among them is the fear that people will be denied access to ICU on the basis of judgments about their quality of life, social value, frailty or age. This online Democratic Deliberation (DD) with members of the public aimed to discover the necessary considerations and conditions that make triage protocols more acceptable to guide future decisions in terms of the values and criteria that must underpin triage protocols. We simultaneously conducted the online DD in Quebec and Ontario on May 28th and June 4th, 2022, among adults who do not work in the healthcare sector, recruited randomly among the members of the public registered on Leger Opinion poll website to favor sociodemographic diversity. Data was analyzed using thematic analysis. Among the participants who took part in the study, 27 participants were from Ontario and 20 from Quebec. Three main themes emerged: 1) Acceptance of the protocol and values, 2) Considerations to be integrated in triage protocols, 3) Conditions which may favor a greater public acceptance of these protocols. Participants supported the idea of prioritizing patients with the best prognosis of survival under extreme conditions. The maximization of benefits was the most predominant approach. Participants considered that triage protocols are necessary to reduce arbitrariness in decision making and to facilitate these tragic decisions by health professionals.

The facilitators and barriers to implementing virtual visits in intensive care units: A mixed-methods systematic review

BACKGROUND

Visitation has a positive effect on patients and families, yet, it can disrupt intensive care unit (ICU) care and increase the risk of patient infections, which previously favoured face-to-face visits. The coronavirus disease 2019 (COVID-19) pandemic has raised the importance of virtual visits and led to their widespread adoption globally, there are still many implementation barriers that need to be improved. Therefore, this review aimed to explore the use of ICU virtual visit technology during the COVID-19 pandemic and the barriers and facilitators of virtual visits to improve virtual visits in ICUs.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, six databases (CINAHL, China National Knowledge Infrastructure [CNKI], PubMed, Cochrane, VIP and Wang Fang databases) were searched for empirical studies published between 1 January 2020 and 22 October 2023. Studies that investigated and reported barriers to and facilitators of implementing virtual visits in ICUs during the COVID-19 pandemic were included. Evidence from the included studies was identified and thematically analysed using Thomas and Harden's three-step approach. Study quality was appraised with the Mixed-Methods Appraisal Tool.

RESULTS

A total of 6770 references were screened, of which 35 studies met the inclusion criteria after a full-text review. Eight main barriers to virtual visits use were identified: technical difficulties; insufficient resources; lack of physical presence and nonverbal information; low technical literacy; differences in families' perceptions of visual cues; privacy and ethics issues; inequitable access and use of virtual visit technology; and lack of advance preparation. Four facilitating factors of virtual visit use were identified: providing multidimensional professional support; strengthening coordination services; understanding the preferences of patients and their families; and enhancing privacy and security protection. In the quality appraisal of 35 studies, 12 studies were rated as low, five as medium and 18 as high methodological quality.

CONCLUSION

This review identified key facilitating factors and barriers to ICU virtual visits, which can foster the development of infrastructure, virtual visiting workflows, guidelines, policies and visiting systems to improve ICU virtual visiting services. Further studies are necessary to identify potential solutions to the identified barriers.

Oxygenation indices and early prediction of outcome in hypoxemic patients with COVID-19 pneumonia requiring noninvasive respiratory support in pulmonary intermediate care unit

BACKGROUND

Early prediction of non-invasive respiratory therapy (NIRT) failure is crucial to avoid needless prolongation of respiratory support and delayed endotracheal intubation. Data comparing the predictive value of oxygenation indices (OI) in COVID-19 receiving NIRT are scant. The aim of this monocentric retrospective study of prospectively collected data was to assess the effectiveness of different OI in predicting NIRT outcome at baseline (t0), 12 h (t12) and 24 h (t24) of treatment in hypoxemic patients with COVID-19-related pneumonia, managed in a Pulmonary Intermediate Care Unit (October 2020-June 2021).

METHODS

We assessed the predictive value of SpO2/FiO2, PaO2/FiO2, standardised PaO2/FiO2 ratio (s-PaO2/FiO2), respiratory index (RI), arterial-alveolar oxygen gradient (a-ADO2), age adjusted arterial-alveolar oxygen ratio (adj-a-ADO2D). Receiver operating characteristics (ROC), AUC and best sensitivity-specificity cut-off values were calculated at t0, t12, t24. NIRT failure risk was adjusted for non-oxygenation predictors.

RESULTS

Among 590 patients with COVID-19 infection, 368 met the eligibility criteria for inclusion in the study [mean (CI95%): PaO2/FiO2 214(206,8-221,9); PaCO2 mean 32,9 mmHg,(32,4-33,4)]. NIRT failure and hospital mortality rate were 23,4% and 19,6%, respectively. Older age, male gender, agitation/confusion, need for sedation, inability to tolerate prone positioning were independent predictors of NIRT failure. SpO2/FiO2, a-ADO2 and adj-aADO2 at t12 and t24, PaO2/FiO2 and RI at t24 were associated with NIRT failure. Prognostic predictivity of OI increased from t0 to t24. Greater ROC-AUC values were obtained with SpO2/FiO2 0,662 (0,60-0,72) (t0), PaO2/FiO2 0,697 (0,63-0,76) (t12) and s-PaO2/FiO2 0,769 (0,71-0,83) (t24). NIRT failure was independently predicted by PaO2/FiO2, s-PaO2/FiO2 and RI at any observation time and by SpO2/FiO2 and O2 gradients respectively at t0 and t24. SaO2/FiO2 ≤ 300 (t0), PaO2/FiO2 ≤ 151,7 (t12) and s-PaO2/FiO2 ≤ 160,4 (t24) turned out to be the best predictors of NIRT outcome.

CONCLUSIONS

OI showed different effectiveness in predicting NIRT failure within 24 h of treatment in COVID-19 related pneumonia. This may be due to the multi-factorial pathophysiology of hypoxemia. Our study empathises furthermore the role of non-oxygenation-related parameters in contributing to the outcome. These findings may be useful to build a predictive model also in no COVID-19 related hypoxemic pneumonia.

Epidemiology, clinical and biological characteristics, and prognosis of critically ill COVID 19 patients: a single-center experience through 4 successive waves

OBJECTIVE

The aim of this study was to describe the characteristics of patients admitted to the intensive care unit with severe pneumonia due to SARS-CoV-2, comparing them according to successive waves, and to identify prognostic factors for morbidity and mortality.

MATERIALS AND METHODS

This single-center retrospective observational descriptive study was conducted from March 10, 2020, to October 17, 2021. All adult patients admitted with SARS-CoV-2 pneumonia presenting acute respiratory failure were included. COVID 19 diagnosis was confirmed by RT-PCR testing of respiratory specimens. The primary endpoint was ICU mortality. Secondary endpoints were the occurrence of ventilator-associated pneumonia (VAP) or bronchopulmonary aspergillosis.

RESULTS

Over the study period, 437 patients were included of whom 282 (65%) patients were ventilated for 9 [5;20] days. Among the studied population, 38% were treated for one or more episodes of VAP, and 22 (5%) for bronchopulmonary aspergillosis. ICU mortality was 26% in the first wave, then fell and stabilized at around 10% in subsequent waves (p = 0.02). Increased age, Charlson index, SOFA score and lactatemia on admission were predictive of mortality. Survival at 90 days was 85% (95% CI 82-88) and was unaffected by the presence of VAP. However, the occurrence of bronchopulmonary aspergillosis increased mortality to 36%.

CONCLUSION

In this study, we observed mortality in the lower range of those previously reported. Risk factors for mortality mainly included age and previous comorbidities. The prognosis of these critically ill Covid 19 patients improved over the four waves, underlining the likely beneficial effect of vaccination and dexamethasone.

Characteristics and outcomes of ICU-admitted COVID-19 patients in the Omicron and Alpha-dominated periods

BACKGROUND

Comparing the outcomes of intensive care unit (ICU) admitted COVID-19 patients during the Alpha and Omicron-dominated periods.

METHODS

Patients with critical COVID-19 disease, requiring ICU admission from May to September 2021 and February to August 2022, were enrolled from a single medical center in Northern Taiwan. Clinical demographics, comorbidities, disease severity, and management strategies were recorded. The 28-day mortality from the two periods were compared both in the original and propensity score (PS)-matched cohort.

RESULTS

Of 231 patients, 72 (31.2%) were from the Alpha period and 159 (68.8%) from the Omicron period. Patients in the Omicron period were older, had a lower body mass index, more comorbidities, higher disease severities, and increased 28-day mortality (26.4% vs. 13.9%, p = 0.035). In multivariable analysis, the Omicron-dominated period was not identified as an independent factor associated with increased 28-day mortality. COVID-19 patients in Alpha- and Omicron-dominated periods had comparable 28-day mortality in PS-matched cohort (12.1% vs. 18.2%, p = 0.733). Independent factors associated with 28-day mortality were a lower PF ratio (PF ratio <100, adjusted odds ratio [aOR] 2.68, 95% confidence interval, CI 1.21-5.94), septic shock ([aOR] 2.39, 95% CI 1.12-5.09) and absence of remdesivir ([aOR] 0.36, 95% CI 0.16-0.83).

CONCLUSION

While patients in the Omicron period exhibited greater severity, the variant was not independently linked to higher 28-day mortality in ICU-admitted patients.

Clinical research using real-world data: A narrative review

Randomized controlled trials (RCTs) and studies using real-world data (RWD) each have their strengths and weaknesses, and can effectively complement each other. When RCTs are not feasible, RWD studies offer a valuable alternative. In this narrative review, we examine several types of RWD studies, focusing on studies utilizing administrative claims databases. These include the Diagnosis Procedure Combination databases, commercially available health checkups and healthcare claims databases (such as the JDMC and DeSC databases), and the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB). Given that these claims databases cover different populations, patient settings, variables, and levels of accessibility, it is crucial for researchers to select the most appropriate data source to effectively address their research questions. Additionally, it is desirable for readers of studies using these databases to be aware of their characteristics in order to fully understand the context and limitations of the research findings.

Assessment of the development of social skills among undergraduate medical students through participation in a socio-educational project during the coronavirus disease (COVID)-19 pandemic: a Brazilian pilot study

Coronavirus disease (COVID)-19 had an impact on medical graduation, causing weaknesses arising from social isolation and remote emergency teaching, with an emphasis on deficits in the development of non-technical skills (soft skills). In this context, the interaction between a group of medical students and adolescents who develop activities at the Center for Learning and Mobilization for Citizenship in Campinas/SP, Brazil, was evaluated about the development of soft skills during the COVID-19 pandemic. The observational study was carried out using an electronic questionnaire based on a Likert scale on the feelings of undergraduate medical students regarding participation in project activities in the context of the development of social skills. The study demonstrated an important positive impact of student participation in a socio-educational project for the development of soft skills, emphasizing the ability to deal with adverse situations, decision-making, and the ability to deal with the fear of not corresponding. However, the existence of limitations and difficulties in the development of non-technical skills by students was revealed, further reinforced by the challenges brought by the COVID-19 pandemic. In this aspect, the study demonstrated participation in a voluntary social project as an important strategy to improve the teaching of these skills.

Rehabilitation for Patients with COVID-19-Associated Acute Respiratory Distress Syndrome During Quarantine: A Single-Center Experience

Background and Objectives: In this study, we evaluated clinical factors associated with implementing a rehabilitation program for patients with COVID-19-associated acute respiratory distress syndrome (ARDS) requiring mechanical ventilation (MV) during the quarantine period. Materials and Methods: This observational study was conducted in the National Designated Isolated ICU, a dedicated COVID-19 center with 18 beds, from 30 December 2020 to 30 May 2022. One hundred and fifty-four patients (mean age: 67.3 ± 13.4 years; male: 59.7%) were enrolled. The ICU rehabilitation program included early mobilization, chest physiotherapy, and dysphagia treatment. Results: Forty-five patients (29.3%) participated in the rehabilitation program. Multivariate logistic regression identified three significant factors: tracheostomy (odds ratio [OR], 2.796; 95% confidence interval [CI], 1.238-6.316; p = 0.013), body mass index ≥ 25.0 kg/m2 (OR, 2.724; 95% CI, 1.276-5.817; p = 0.010), and extracorporeal membrane oxygenation (OR, 2.931; 95% CI, 1.165-7.377; p = 0.022); patients with all three factors were younger (median 44 vs. 70 years, p < 0.001) and had significantly lower Acute Physiology and Chronic Health Evaluation II scores (median 12 vs. 16, p = 0.002) on the MV day. One-year cumulative mortality rates for patients with 0 to 3 factors were 66.7%, 50.8%, 38.9%, and 15.4%, respectively, with a significant difference among them (log-rank, p < 0.001). Conclusions: Three clinical factors associated with implementing a rehabilitation program during the quarantine period for COVID-19-associated ARDS patients were identified. The program was feasible and beneficial, particularly for younger patients with lower illness severity and fewer comorbidities on the day of MV.

Trends and Patterns of ICU E-Referrals in Saudi Arabia during 2020-2021: Results from the National Saudi Medical Appointments and Referrals Centre

Background/Objectives: Intensive care unit (ICU) e-referrals are an important indicator for exploring potential deficiencies in critical care resources. This study aimed to examine the epidemiology and patterns of ICU e-referrals across all regions of Saudi Arabia during the COVID-19 pandemic using routinely collected data from April 2020 to December 2021. Methods: This descriptive epidemiological study analyzed data from the Saudi Medical Appointments and Referrals Centre (SMARC). This study reveals novel regional ICU e-referral patterns for critical cases using national unique digital health data, adding insights beyond the existing literature. Variables included age, sex, referral timing, reason, specialty, and region of origin. Descriptive statistics and mapping of administrative areas were performed based on e-referral request rates per 10,000 population. Results: During the study period, 36,619 patients had ICU e-referral requests. The mean age was 54.28 years, with males constituting 64.81% of requests. Out-of-scope e-referrals comprised 71.44% of requests. Referrals related to medical specialties, such as cardiology and pulmonology, were the most common (62.48%). Referral patterns showed peaks in July-August 2020 and May 2021. The Northern Border and Albaha areas had the highest request rates per population, potentially reflecting a higher proportion of severe cases requiring ICU-level care compared to other regions. Conclusions: The temporal pattern and geographic distribution of ICU e-referrals mirrored previously reported critical COVID-19 cases in Saudi Arabia. Preventive measures and vaccination programs contributed to a significant decline in ICU e-referral requests, suggesting a positive impact on controlling severe COVID-19 cases. Population-adjusted analysis revealed regional disparities, highlighting the importance of considering population size in healthcare resource management and policy.

Upskill training and preparedness of non-critical-care registered nurses deployed to intensive care units during the COVID-19 pandemic: A scoping review

BACKGROUND

The increase in intensive care unit (ICU) capacity compelled by the COVID-19 pandemic required the rapid deployment of non-critical-care registered nurses to the ICU setting. The upskill training needed to prepare these registered nurses for deployment was rapidly assembled due to the limited timeframe associated with the escalating pandemic. Scoping the literature to identify the content, structure, and effectiveness of the upskill education provided is necessary to identify lessons learnt during the COVID-19 pandemic response so that they may guide workforce preparation for future surge planning.

AIM

The aim of this scoping review was to map the literature to identify the available information regarding upskill training and preparedness of non-critical-care registered nurses deployed to the ICU during the COVID-19 pandemic.

METHODS

This scoping review was conducted in accordance with JBI methodology. A protocol outlined the review questions and used the participants, concept, and context framework to define the inclusion and exclusion criteria. A search of healthcare databases MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), Cochrane, and Scopus was supplemented with a grey literature search via Google.

RESULTS

Screening and review found 32 manuscripts that met the inclusion criterion for examination. Analysis revealed variation in duration of programs, theoretical versus practical content, face-to-face or online mode of delivery, and duration of preparation time at the bedside in the ICU setting. Data on contributors to preparedness for deployment were sparse but included training, support, peer education, buddy time, and clarity around responsibilities and communication.

DISCUSSION

Evaluation of upskill education was mostly limited to post-training surveys. Few studies explored the preparedness of deployed registered nurses as an outcome of their upskill training or described measures of effectiveness of ICU deployment.

CONCLUSION

There is limited evidence describing preparedness of non-critical-care registered nurses on deployment to the ICU. Further research is needed to identify what elements of upskill education led to preparedness and effective deployment to the ICU setting.

Patient safety culture in times of the COVID-19 pandemic: a cross-sectional study in a hospital

OBJECTIVES

to assess patient safety culture during the COVID-19 pandemic and identify the dimensions that need to be improved in hospital settings and which sector, open or closed, direct or indirect care, exhibits a higher level of safety culture.

METHODS

a descriptive and cross-sectional study. The validated version for Brazil of the Hospital Survey on Patient Safety Culture instrument was applied to assess patient safety culture. Those dimensions with 75% positive responses were considered strengthened.

RESULTS

all dimensions presented results lower than 75% of positive responses. Closed sectors showed a stronger safety culture compared to open ones. Indirect care sectors had a low general perception of patient safety when compared to direct care sectors.

CONCLUSIONS

with the pandemic, points of weakness became even more evident, requiring attention and incisive interventions from the institution's leaders.

Joint modeling of monocyte HLA-DR expression trajectories predicts 28-day mortality in severe SARS-CoV-2 patients

The recent SarsCov2 pandemic has disrupted healthcare system notably impacting intensive care units (ICU). In severe cases, the immune system is dysregulated, associating signs of hyperinflammation and immunosuppression. In the present work, we investigated, using a joint modeling approach, whether the trajectories of cellular immunological parameters were associated with survival of COVID-19 ICU patients. This study is based on the REA-IMMUNO-COVID cohort including 538 COVID-19 patients admitted to ICU between March 2020 and May 2022. Measurements of monocyte HLA-DR expression (mHLA-DR), counts of neutrophils, of total lymphocytes, and of CD4+ and CD8+ subsets were performed five times during the first month after ICU admission. Univariate joint models combining survival at day 28 (D28), hospital discharge and longitudinal analysis of those biomarkers' kinetics with mixed-effects models were performed prior to the building of a multivariate joint model. We showed that a higher mHLA-DR value was associated with a lower risk of death. Predicted mHLA-DR nadir cutoff value that maximized the Youden index was 5414 Ab/C and led to an AUC = 0.70 confidence interval (95%CI) = [0.65; 0.75] regarding association with D28 mortality while dynamic predictions using mHLA-DR kinetics until D7, D12 and D20 showed AUCs of 0.82 [0.77; 0.87], 0.81 [0.75; 0.87] and 0.84 [0.75; 0.93]. Therefore, the final joint model provided adequate discrimination performances at D28 after collection of biomarker samples until D7, which improved as more samples were collected. After severe COVID-19, decreased mHLA-DR expression is associated with a greater risk of death at D28 independently of usual clinical confounders.

Early Deep Sedation Practices Worsened During the Pandemic Among Adult Patients Without COVID-19: A Retrospective Cohort Study

BACKGROUND

There is substantial evidence that patients with COVID-19 were treated with sustained deep sedation during the pandemic. However, it is unknown whether such guideline-discordant care had spillover effects to patients without COVID-19.

RESEARCH QUESTION

Did patterns of early deep sedation change during the pandemic for patients on mechanical ventilation without COVID-19?

STUDY DESIGN AND METHODS

We used electronic health record data from 4,237 patients who were intubated without COVID-19. We compared sedation practices in the first 48 h after intubation across prepandemic (February 1, 2018, to January 31, 2020), pandemic (April 1, 2020, to March 31, 2021), and late pandemic (April 1, 2021, to March 31, 2022) periods.

RESULTS

In the prepandemic period, patients spent an average of 13.0 h deeply sedated in the first 48 h after intubation. This increased 1.9 h (95% CI, 1.0-2.8) during the pandemic period and 2.9 h (95% CI, 2.0-3.8) in the late pandemic period. The proportion of patients that spent over one-half of the first 48 h deeply sedated was 18.9% in the prepandemic period, 22.3% during the pandemic period, and 25.9% during the late pandemic period. Ventilator-free days decreased during the pandemic, with a subdistribution hazard ratio of being alive without mechanical ventilation at 28 days of 0.87 (95% CI, 0.79-0.95) compared with the prepandemic period. Tracheostomy placement increased during the pandemic period compared with the prepandemic period (OR, 1.41; 95% CI, 1.08-1.82). In the medical ICU, early deep sedation increased 2.5 h (95% CI, 0.6-4.4) during the pandemic period and 4.9 h (95% CI, 3.0-6.9) during the late pandemic period, compared with the prepandemic period.

INTERPRETATION

We found that among patients on mechanical ventilation without COVID-19, sedation use increased during the pandemic. In the subsequent year, these practices did not return to prepandemic standards.

Caring for children and families during the COVID-19 pandemic: innovations and changes experienced by nurses

OBJECTIVE

To understand the experience of nurses working in pediatric units in the face of innovations and changes in the process of caring for children and families during the COVID-19 pandemic. Also, the objective is to understand the typical experience of nurses in this care.

METHOD

Qualitative research, which involved the participation of 16 nurses from pediatric units of a public teaching hospital. The data were analyzed according to the theoretical-methodological framework of Alfred Schütz's social phenomenology.

RESULTS

The participants' reports generated the categories: the challenge of experiencing changes amid fear, the team's adaptation to innovations and changes caused by the COVID-19 pandemic and the expectation for care and the work process.

CONCLUSION

The understanding of the nurses' experience highlighted changes, team adaptations and expectations for the care of children and families, which, although permeated by learning, were experienced by ethical dilemmas and moral suffering for these professionals.

Research areas and trends in family-centered care in the 21st century: a bibliometric review

Introduction

Family-centered care (FCC) is a model of care provision that sees a patient's loved ones as essential partners to the health care team and positively influences the psychological safety of patients and loved ones.

Objectives

This review aims to present an overview of impactful publications, authors, institutions, journals, countries, fields of application and trends of FCC in the 21st century as well as suggestions on further research.

Methods

The Web of Science Database was searched for publications on FCC between January 2000 and Dezember 2023. After screening for duplicates, VOS Viewer and CiteSpace were used to analyze and visualize the data.

Results

Scientific interest in FCC has grown and resulted in the scientific output of 4,836 publications originating from 103 different countries. Based on the frequent author keywords, FCC was of greatest interest in neonatology and pediatrics, nursing, critical and intensive care, end-of-life and palliative care, and patient-related outcomes. The recent research hotspots are "patient engagement," "qualitative study," and "health literacy."

Conclusion

FCC has gained recognition and spread from the pediatric to the adult palliative, intensive, end-of-life and geriatric care settings. This is a very reassuring development since adults, especially when older, want and need the assistance of their social support systems. Recent research directions include the involvement of patients in the development of FCC strategies, health literacy interventions and the uptake of telemedicine solutions.

Telemedicine for emergency patient rescue

PURPOSE OF REVIEW

This article summarizes recent developments in the application of telemedicine, specifically tele-critical care (TCC), toward enhancing patient care during various types of emergencies and patient rescue scenarios when there are limited resources in terms of staff expertise (i.e., knowledge, skills, and abilities), staffing numbers, space, and supplies due to patient location (e.g., a non-ICU bed, the emergency department, a rural hospital) or patient volume as in pandemic surges.

RECENT FINDINGS

The COVID-19 pandemic demonstrated the need for rapidly scalable and agile healthcare delivery systems. During the pandemic, clinicians and hospital systems adopted telemedicine for various applications. Taking advantage of technological improvements in cellular networks and personal mobile devices, and despite the limited outcomes literature to support its use, telemedicine was rapidly adopted to address the fundamental challenge of exposure in outpatient settings, emergency departments, patient follow-up, and home-based monitoring. A critical recognition was that the modality of care (e.g., remote vs. in-person) was less important than access to care, regardless of the patient outcomes. This fundamental shift, facilitated by policies that followed emergency declarations, provided an opportunity to maintain and, in many cases, expand and improve clinical practices and hospital systems by bringing expertise to the patient rather than the patient to the expertise. In addition to using telemedicine to maintain patient access to healthcare, TCC was harnessed to provide local clinicians, forced to manage critically ill patients beyond their normal scope of practice or experience, access to remote expertise (physician, nursing, respiratory therapist, pharmacist). These practices supported decades of literature from the telemedicine community describing the effectiveness of telemedicine in improving patient care and the many challenges defining its value.

SUMMARY

In this review, we summarize numerous examples of innovative care delivery systems that have utilized telemedicine, focusing on 'mobile' TCC technology solutions to effectively deliver the best care to the patient regardless of patient location. We emphasize how a 'paradigm of better' can enhance the entirety of the healthcare system.

A faculty-led resident strike team as a force expander during disaster

The emergence of the coronavirus disease 2019 (COVID-19) pandemic produced an unprecedented strain on the United States medical system. Prior to the pandemic, there was an estimated 20,000 physician shortage. This has been further stressed by physicians falling ill and the increased acuity of the COVID-19 patients. Federal medical team availability was stretched to its capabilities with the large numbers of deployments. With such severe staffing shortages, creative ways of force expansion were undertaken. New Orleans, Louisiana, was one of the hardest hit areas early in the pandemic. As the case counts built, a call was put out for help. The Louisiana State University (LSU) system responded with a faculty-led resident strike team out of the LSU Health Shreveport Academic Medical Center. Residents and faculty alike volunteered, forming a multispecialty, attending-led medical strike team of approximately 10 physicians. Administrative aspects such as institution-specific credentialing, malpractice coverage, resident distribution, attending physician oversight, among other aspects were addressed, managed, and agreed upon between the LSU Health Shreveport and the New Orleans hospital institutions and leadership prior to deployment in April 2020. In New Orleans, the residents managed patients within the departments of emergency medicine, medical floor, and intensive care unit (ICU). The residents assigned to the medical floor became a new hospitalist service team. The diversity of specialties allowed the team to address patient care in a multidisciplinary manner, leading to comprehensive patient care plans and unhindered team dynamic and workflow. During the first week alone, the team admitted and cared for over 100 patients combined from the medical floor and ICU. In a disaster situation compounded by staff shortages, a resident strike team is a beneficial solution for force expansion. This article qualitatively reviews the first published incidence of a faculty-led multispecialty resident strike team being used as a force expander in a disaster.

The Association Between Prepandemic ICU Performance and Mortality Variation in COVID-19: A Multicenter Cohort Study of 35,619 Critically Ill Patients

BACKGROUND

During the COVID-19 pandemic, ICUs remained under stress and observed elevated mortality rates and high variations of outcomes. A knowledge gap exists regarding whether an ICU performing best during nonpandemic times would still perform better when under high pressure compared with the least performing ICUs.

RESEARCH QUESTION

Does prepandemic ICU performance explain the risk-adjusted mortality variability for critically ill patients with COVID-19?

STUDY DESIGN AND METHODS

This study examined a cohort of adults with real-time polymerase chain reaction-confirmed COVID-19 admitted to 156 ICUs in 35 hospitals from February 16, 2020, through December 31, 2021, in Brazil. We evaluated crude and adjusted in-hospital mortality variability of patients with COVID-19 in the ICU during the pandemic. Association of baseline (prepandemic) ICU performance and in-hospital mortality was examined using a variable life-adjusted display (VLAD) during the pandemic and a multivariable mixed regression model adjusted by clinical characteristics, interaction of performance with the year of admission, and mechanical ventilation at admission.

RESULTS

Thirty-five thousand six hundred nineteen patients with confirmed COVID-19 were evaluated. The median age was 52 years, median Simplified Acute Physiology Score 3 was 42, and 18% underwent invasive mechanical ventilation. In-hospital mortality was 13% and 54% for those receiving invasive mechanical ventilation. Adjusted in-hospital mortality ranged from 3.6% to 63.2%. VLAD in the most efficient ICUs was higher than the overall median in 18% of weeks, whereas VLAD was 62% and 84% in the underachieving and least efficient groups, respectively. The least efficient baseline ICU performance group was associated independently with increased mortality (OR, 2.30; 95% CI, 1.45-3.62) after adjusting for patient characteristics, disease severity, and pandemic surge.

INTERPRETATION

ICUs caring for patients with COVID-19 presented substantial variation in risk-adjusted mortality. ICUs with better baseline (prepandemic) performance showed reduced mortality and less variability. Our findings suggest that achieving ICU efficiency by targeting improvement in organizational aspects of ICUs may impact outcomes, and therefore should be a part of the preparedness for future pandemics.

Pulmonary superinfection diagnosed with bronchoalveolar lavage at intubation in COVID patients: A Swedish single-centre study

BACKGROUND

Patients with severe coronavirus disease 2019 (COVID) pneumonia and acute respiratory distress syndrome (C-ARDS) on invasive mechanical ventilation (IMV) have been found to be prone to having other microbial findings than severe acute respiratory syndrome coronavirus 2 (SARS-2)-CoV-19 in the bronchoalveolar lavage (BAL) fluid at intubation causing a superinfection. These BAL results could guide empirical antibiotic treatment in complex clinical situations. However, there are limited data on the relationship between microbial findings in the initial BAL at intubation and later ventilator-associated pneumonia (VAP) diagnoses.

OBJECTIVE

To analyse the incidence of, and microorganisms responsible for, superinfections in C-ARDS patients at the time of first intubation through microbial findings in BAL fluid. To correlate these findings to markers of inflammation in plasma and later VAP development.

DESIGN

Retrospective single-centre study.

SETTING

One COVID-19 intensive care unit (ICU) at a County Hospital in Sweden during the first year of the pandemic.

PATIENTS

All patients with C-ARDS who were intubated in the ICU.

RESULTS

We analysed BAL fluid specimens from 112 patients at intubation, of whom 31 (28%) had superinfections. Blood levels of the C-reactive protein, procalcitonin, neutrophil granulocytes, and lymphocytes were indistinguishable between patients with and without a pulmonary superinfection. Ninety-eight (88%) of the patients were treated with IMV for more than 48 h and of these patients, 37% were diagnosed with VAP. The microorganisms identified in BAL at the time of intubation are normally found at the oral, pharyngeal, and airway sites. Only one patient had an indistinguishable bacterial strain responsible for both superinfection at intubation and in VAP.

CONCLUSIONS

One fourth of the patients with C-ARDS had a pulmonary superinfection in the lungs that was caused by another microorganism identified at intubation. Routine serum inflammatory markers could not be used to identify this complication. Microorganisms located in BAL at intubation were rarely associated with later VAP development.

Fragmentation of the QRS Complex Is Associated with Right Ventricular Dilatation and Mortality in Critically Unwell Coronavirus Disease 2019 Patients

BACKGROUND

QRS fragmentation (fQRS) is a depolarization disorder that can be detected on routine electrocardiography (ECG). Current evidence suggests that fQRS is a prognosticator of adverse cardiovascular events. This study aimed to assess the relationship between fQRS and all-cause mortality in critically unwell coronavirus disease 2019 (COVID-19) patients and to investigate the significance of associated abnormalities on echocardiography.

METHODS

A retrospective cohort study of COVID-19 patients in a critical care setting was performed. Electrocardiography was performed on presentation to hospital, admission to the critical care unit, and at subsequent points according to clinical need. Transthoracic echocardiography was performed at clinical discretion to assess for structural and functional cardiac abnormalities. Primary outcome was in-hospital mortality and secondary outcome was the need for mechanical invasive ventilation.

RESULTS

Totally, 212 consecutive patients were included of which 120 (57%) exhibited fQRS and inferior leads were involved in 88% of the patients. Overall, fQRS was a significant predictor of mortality [65% vs. 44% P =.003; multivariate odds ratio = 2.96, 95% confidence interval (CI): 1.42-6.40, P =.005] and inferior fQRS itself was a significant predictor of mortality (P =.03). There was no significant association between fQRS and the need for invasive mechanical ventilation. A total of 112 patients underwent echocardiography. There was a greater incidence of right ventricular (RV) dilatation in the fQRS group (16% vs. 2% respectively, P =.02) and pulmonary hypertension (33% vs. 14% respectively, P =.03) based on echocardiographic criteria.

CONCLUSION

Our study demonstrates that fQRS is significantly associated with RV dilation, pulmonary hypertension, and mortality in critically unwell COVID-19 patients.

Critical care bed capacity in Asian countries and regions before and during the COVID-19 pandemic: an observational study

Background

The coronavirus disease 2019 (COVID-19) pandemic highlighted the importance of critical care. The aim of the current study was to compare the number of adult critical care beds in relation to population size in Asian countries and regions before (2017) and during (2022) the pandemic.

Methods

This observational study collected data closest to 2022 on critical care beds (intensive care units and intermediate care units) in 12 middle-income and 7 high-income economies (using the 2022-2023 World Bank classification), through a mix of methods including government sources, national critical care societies, personal contacts, and data extrapolation. Data were compared with a prior study from 2017 of the same countries and regions.

Findings

The cumulative number of critical care beds per 100,000 population increased from 3.0 in 2017 to 9.4 in 2022 (p = 0.003). The median figure for middle-income economies increased from 2.6 (interquartile range [IQR] 1.7-7.8) to 6.6 (IQR 2.2-13.3), and that for high-income economies increased from 11.4 (IQR 7.3-22.8) to 13.9 (IQR 10.7-21.7). Only 3 countries did not see a rise in bed capacity. Where data were available in 2022, 10.9% of critical care beds were in single rooms (median 5.0% in middle-income and 20.3% in high-income economies), and 5.3% had negative pressure (median 0.7% in middle-income and 18.5% in high-income economies).

Interpretation

Critical care bed capacity in the studied Asian countries and regions increased close to three-fold from 2017 to 2022. Much of this increase was attributed to middle-income economies, but substantial heterogeneity exists.

Funding

None.

Clinical features that predict the mortality risk in older patients with Omicron pneumonia: the MLWAP score

In December 2022, the Chinese suffered widespread Omicron of SARS-CoV-2 with variable symptom severity and outcome. We wanted to develop a scoring model to predict the mortality risk of older Omicron pneumonia patients by analyzing admission data. We enrolled 227 Omicron pneumonia patients aged 60 years and older, admitted to our hospital from December 15, 2022, to January 16, 2023, and divided them randomly into a 70% training set and a 30% test set. The former were used to identify predictors and develop a model, the latter to verify the model, using the area under the receiver operating characteristic curve (AUC), the Hosmer-Lemeshow goodness-of-fit test, a calibration curve to test its performance and comparing it to the existing scores. The MLWAP score was calculated based on a multivariate logistic regression model to predict mortality with a weighted score that included immunosuppression, lactate ≥ 2.4, white blood cell count ≥ 6.70 × 109/L, age ≥ 77 years, and PaO2/FiO2 ≤ 211. The AUC for the model in the training and test sets was 0.852 (95% CI, 0.792-0.912) and 0.875 (95% CI, 0.789-0.961), respectively. The calibration curves showed a good fit. We grouped the risk scores into low (score 0-7 points), medium (8-10 points), and high (11-13 points). This model had a sensitivity of 0.849, specificity of 0.714, and better predictive ability than the CURB-65 and PSI scores (AUROC = 0.859 vs. 0.788 vs. 0.801, respectively). The MLWAP-mortality score may help clinicians to stratify hospitalized older Omicron pneumonia patients into relevant risk categories, rationally allocate medical resources, and reduce the mortality.

Description of Intensive Care and Intermediate Care resources managed by Anaesthesiology Departments in Spain and their adaptation capacity during the COVID-19 pandemic

INTRODUCTION

It is essential to understand the strategic importance of intensive care resources in the sustainable organisation of healthcare systems. Our objective has been to identify the intensive and intermediate care beds managed by Anaesthesiology and Resuscitation Services (A-ICU and A-IMCU) in Spain, their human and technical resources, and the changes made to these resources during the COVID-19 pandemic.

MATERIAL AND METHODS

Prospective observational study performed between December 2020 and July 2021 to register the number and characteristics of A-ICU and A-IMCU beds in hospitals listed in the catalogue published by the Spanish Ministry of Health.

RESULTS

Data were obtained from 313 hospitals (98% of all hospitals with more than 500 beds, 70% of all hospitals with more than 100 beds). One hundred and forty seven of these hospitals had an A-ICU with a total of 1702 beds. This capacity increased to 2107 (124%) during the COVID-19 pandemic. Three hundred and eight hospitals had an A-IMCU with a total of 3470 beds, 52.9% (2089) of which provided long-term care. The hospitals had 1900 ventilators, at a ratio of 1.07 respirators per A-ICU; 1559 anaesthesiologists dedicated more than 40% of their working time to intensive care. The nurse-to-bed ratio in A-ICUs was 2.8.

DISCUSSION

A large proportion of fully-equipped ICU and IMCU beds in Spanish hospitals are managed by the anaesthesiology service. A-ICU and A-IMCUs have shown an extraordinary capacity to adapt their resources to meet the increased demand for intensive care during the COVID-19 pandemic.

A Model of Burnout Among Healthcare Professionals

BACKGROUND

Burnout is common and can lead to worse outcomes for both healthcare workers and patients. Our study purpose was to assess the structural relationship among factors that protect against or worsen burnout.

DATA SOURCES AND STUDY SETTING

We surveyed healthcare professionals in 15 different Japanese intensive care units during the 3rd wave of the COVID-19 pandemic (March 2021). Surveys assessed burnout (Mini Z 2.0), resilience (Brief Resilience Scale), depressive (PHQ-9) and anxiety (GAD-7) symptoms, job and work environment characteristics, and personal experience with COVID. We explored survey domains with principal component factor analysis and modeled our results using structural equation modeling.

PRINCIPAL FINDINGS

Among 936 ICU professionals, 24.3% met criteria for burnout. Our model suggested that resilience (β =  - 0.26, 95% CI - 0.32 to - 0.20), teamwork (β =  - 0.23, 95% CI - 0.30 to - 0.16), and feeling safe (β =  - 0.11, 95% CI - 0.18 to - 0.04) reduced burnout. Depression (β =  - 0.32, 95% CI - 0.41 to - 0.23) and anxiety (β =  - 0.20, 95% CI - 0.29 to - 0.10) both decreased resilience as did COVID fear (β = 0.08, 95% CI - 0.14 to - 0.02). In addition to directly reducing resilience, anxiety also indirectly reduced resilience by increasing COVID fear (0.23, 95% CI 0.17 to 0.23), which decreased resilience (β - 0.08, 95% CI - 0.14 to - 0.02).

CONCLUSIONS

Burnout is common among Japanese ICU professionals. Resilience, teamwork, and safety are all correlated with reduced burnout. Those who had depression or anxiety or COVID fear had higher degrees of burnout, an effect that appears to be mediated by reduced resilience. These are potential targets for interventions to reduce burnout.

Management and outcomes of COVID-19 patients admitted in a newly created ICU and an expert ICU, a retrospective observational study

BACKGROUND

The COVID-19 pandemic abruptly increased the inflow of patients requiring intensive care units (ICU). French health institutions responded by a twofold capacity increase with temporary upgraded beds, supplemental beds in pre-existing ICUs, or newly created units (New-ICU). We aimed to compare outcomes according to admission in expert pre-existing ICUs or in New-ICU.

METHODS

This multicenter retrospective observational study was conducted in two 20-bed expert ICUs of a University Hospital (Expert-ICU) and in one 16-bed New-ICU in a private clinic managed respectively by 3 and 2 physicians during daytime and by one physician during the night shift. All consecutive adult patients with COVID-19-related acute hypoxemic respiratory failure admitted after centralized regional management by a dedicated crisis cell were included. The primary outcome was 180-day mortality. Propensity score matching and restricted cubic spline for predicted mortality over time were performed.

RESULTS

During the study period, 165 and 176 patients were enrolled in Expert-ICU and New-ICU respectively, 162 (98%) and 157 (89%) patients were analyzed. The unadjusted 180-day mortality was 30.8% in Expert-ICU and 28.7% in New-ICU, (log-rank test, p =  0.7). After propensity score matching, 123 pairs (76 and 78%) of patients were matched, with no significant difference in mortality (32% vs. 32%, OR 1.00 [0.89; 1.12], p = 1). Adjusted predicted mortality decreased over time (p < 0.01) in both Expert-ICU and New-ICU.

CONCLUSIONS

In COVID-19 patients with acute hypoxemic respiratory failure, hospitalization in a new ICU was not associated with mortality at day 180.

Nucleated red blood cells are a late biomarker in predicting intensive care unit mortality in patients with COVID-19 acute respiratory distress syndrome: an observational cohort study

Background

Nucleated red blood cells (nRBC) are precursor cells of the erythropoiesis that are absent from the peripheral blood under physiological conditions. Their presence is associated with adverse outcomes in critically ill patients. This study aimed to evaluate the predictive value of nRBC on mortality in intensive care unit (ICU) patients with COVID-19 acute respiratory distress syndrome (ARDS).

Material and methods

This retrospective, observational cohort study analyzed data on 206 ICU patients diagnosed with COVID-19 ARDS between March 2020 and March 2022. The primary endpoint was ICU mortality, and secondary endpoints included ICU and hospital stay lengths, ventilation hours, and the time courses of disease severity scores and clinical and laboratory parameters.

Results

Among the included patients, 68.9% tested positive for nRBC at least once during their ICU stay. A maximum nRBC of 105 µl-1 had the highest accuracy in predicting ICU mortality (area under the curve of the receiver operating characteristic [AUCROC] 0.780, p < 0.001, sensitivity 69.0%, specificity 75.5%). Mortality was significantly higher among patients with nRBC >105 µl-1 than ≤105 µl-1 (86.5% vs. 51.3%, p = 0.008). Compared to patients negative for nRBC in their peripheral blood, those positive for nRBC required longer mechanical ventilation (127 [44 - 289] h vs. 517 [255 - 950] h, p < 0.001), ICU stays (12 [8 - 19] vs. 27 [13 - 51] d, p < 0.001), and hospital stays (19 [12 - 29] d vs. 31 [16 - 58] d, p < 0.001). Peak Sepsis-related Organ Failure Assessment (SOFA), Simplified Acute Physiology Score, PaO2/FiO2, interleukin-6, and procalcitonin values were reached before the peak nRBC level. However, the predictive performance of the SOFA (AUCROC 0.842, p < 0.001) was considerably improved when a maximum SOFA score >8 and nRBC >105 µl-1 were combined.

Discussion

nRBC predict ICU mortality and indicate disease severity among patients with COVID-19 ARDS, and they should be considered a clinical alarm signal for a worse outcome. nRBC are a late predictor of ICU mortality compared to other established clinical scoring systems and laboratory parameters but improve the prediction accuracy when combined with the SOFA score.

Development and evaluation of regression tree models for predicting in-hospital mortality of a national registry of COVID-19 patients over six pandemic surges

BACKGROUND

Objective prognostic information is essential for good clinical decision making. In case of unknown diseases, scarcity of evidence and limited tacit knowledge prevent obtaining this information. Prediction models can be useful, but need to be not only evaluated on how well they predict, but also how stable these models are under fast changing circumstances with respect to development of the disease and the corresponding clinical response. This study aims to provide interpretable and actionable insights, particularly for clinicians. We developed and evaluated two regression tree predictive models for in-hospital mortality of COVID-19 patient at admission and 24 hours (24 h) after admission, using a national registry. We performed a retrospective analysis of observational routinely collected data.

METHODS

Two regression tree models were developed for admission and 24 h after admission. The complexity of the trees was managed via cross validation to prevent overfitting. The predictive ability of the model was assessed via bootstrapping using the Area under the Receiver-Operating-Characteristic curve, Brier score and calibration curves. The tree models were assessed on the stability of their probabilities and predictive ability, on the selected variables, and compared to a full-fledged logistic regression model that uses variable selection and variable transformations using splines. Participants included COVID-19 patients from all ICUs participating in the Dutch National Intensive Care Evaluation (NICE) registry, who were admitted at the ICU between February 27, 2020, and November 23, 2021. From the NICE registry, we included concerned demographic data, minimum and maximum values of physiological data in the first 24 h of ICU admission and diagnoses (reason for admission as well as comorbidities) for model development. The main outcome measure was in-hospital mortality. We additionally analysed the Length-of-Stay (LoS) per patient subgroup per survival status.

RESULTS

A total of 13,369 confirmed COVID-19 patients from 70 ICUs were included (with mortality rate of 28%). The optimism-corrected AUROC of the admission tree (with seven paths) was 0.72 (95% CI: 0.71-0.74) and of the 24 h tree (with 11 paths) was 0.74 (0.74-0.77). Both regression trees yielded good calibration and variable selection for both trees was stable. Patient subgroups comprising the tree paths had comparable survival probabilities as the full-fledged logistic regression model, survival probabilities were stable over six COVID-19 surges, and subgroups were shown to have added predictive value over the individual patient variables.

CONCLUSIONS

We developed and evaluated regression trees, which operate at par with a carefully crafted logistic regression model. The trees consist of homogenous subgroups of patients that are described by simple interpretable constraints on patient characteristics thereby facilitating shared decision-making.

Safety of Same-Day Hospital Discharge Post Patent Foramen Ovale Closure: Findings from a Multicenter Study

Transcatheter patent foramen ovale (PFO) closure is indicated for patients with cryptogenic stroke. Although procedural safety is well established, there are limited data on the safety of same-day (SD) discharge. We aimed to review the outcomes of PFO closure with SD. Patients who underwent transcatheter PFO closure between January 2011 and May 2022 at 4 large US hospitals were retrospectively analyzed, comparing outcomes of SD versus delayed discharge (DD). The primary end point was a composite of access-site complication, stroke, device embolization, atrial arrhythmia, and bleeding. Secondary analysis comparing imaging modality and outcomes was performed. 554 patients (49.2% female) were analyzed (382 discharged SD). Average age was 54.3 ± 15. Baseline characteristics in both groups were broadly similar. Previous stroke (78.0% SD vs 76.2% DD, p = 0.32) was the commonest indication for PFO closure. In the SD group, there was less general anesthesia use (5.5% vs 16.9%, p <0.001). Intraprocedural intracardiac echocardiography was used more frequently in SD cases (95.0% vs 81.4%, p <0.001). In the DD group, median stay was 1 night, and 34.9% stayed beyond 1 night. At 30 days, there was no difference in the primary composite end point (14.9% vs 11.6%, p = 0.15). There was no inter-group difference in individual adverse events (all p >0.05). When comparing imaging modality and outcomes, there was no difference in composite end points between transesophageal and intracardiac echocardiography (6.5% vs 14.7%, p = 0.063). In conclusion, SD discharge after transcatheter PFO closure appears safe. This efficient approach may be advantageous in optimizing workflow and minimizing hospital occupancy.

COVID-19 in the intensive care unit: Unmasking the critical factors impacting patient survival

In the midst of the coronavirus disease 2019 (COVID-19) pandemic, intensive care units (ICUs) around the world have been pushed to their limits as they grapple with the effects of the severe acute respiratory syndrome coronavirus 2 virus. Identifying prognostic factors that influence mortality in COVID-19 patients admitted to the ICU could offer valuable insights for clinicians seeking to prevent disease progression. A retrospective analysis was conducted on COVID-19 patients admitted to the ICU between January and September 2020. The analysis considered patient demographics, comorbidities, neurological and non-neurological symptoms, as well as laboratory markers. The multivariate logistic regression analysis aims to uncover associations between these factors and patient outcomes. Of the 387 patients included in this study, nearly half (48.5%) of the ICU patients succumbed to COVID-19. Factors that contributed to increased mortality included being 60 years of age or older, impaired consciousness, lung disease, elevated international normalized ratio (INR), and elevated blood urea nitrogen (BUN) levels. Surprisingly, symptoms such as dizziness/lightheadedness, myalgia, and headache were associated with a higher likelihood of survival. In addition, elevated D-dimer and aspartate aminotransferase (AST) levels, as well as lymphopenia, were more commonly observed in deceased patients. The study concluded that those who died in the ICU tended to be older, white, and burdened with more comorbidities and impaired consciousness. With the intriguing link between specific symptoms and survival, further research is essential to uncover the underlying pathophysiological mechanisms that influence ICU patient outcomes in the context of COVID-19.

Critical care and pandemic preparedness and response

Critical care was established partially in response to a polio epidemic in the 1950s. In the intervening 70 yr, several epidemics and pandemics have placed critical care and allied services under extreme pressure. Pandemics cause wholesale changes to accepted standards of practice, require reallocation and retargeting of resources and goals of care. In addition to clinical acumen, mounting an effective critical care response to a pandemic requires local, national, and international coordination in a diverse array of fields from research collaboration and governance to organisation of critical care networks and applied biomedical ethics in the eventuality of triage situations. This review provides an introduction to an array of topics that pertain to different states of pandemic acuity: interpandemic preparedness, alert, surge activity, recovery and relapse through the literature and experience of recent pandemics including COVID-19, H1N1, Ebola, and SARS.

Mortality in older patients admitted to an ICU for COVID-19: A systematic review

PURPOSE

The objective was to conduct a systematic review of mortality and factors independently associated with mortality of older patients admitted to an intensive care unit (ICU) for COVID-19.

MATERIALS AND METHODS

Data sources were MEDLINE, EMBASE, the Cochrane Library, and references of included studies. Two reviewers independently selected studies evaluating mortality of older patients (≥ 70 years) admitted to an ICU for COVID-19. They extracted general characteristics, mortality rate, and factors independently associated with mortality. The methodological quality of each study was evaluated by using the Critical Appraisal Skills Programme checklist.

RESULTS

We selected 36 studies (11,989 patients). Many of the studies were conducted in Europe (42%) and many were retrospective (61%) and multicenter (61%). ICU mortality ranged from 8% to 90%, 1-month mortality from 33% to 90% and 3-month mortality, reported in five studies, from 46% to 60%. Frailty, assessed by the Clinical Frailty Score (CFS), was significantly associated with 1-month and 3-month mortality respectively in two studies (hazard ratio [HR]: 3.2 [2.56-4.13] and HR: 2.83 [95% CI: 1.96-4.08]).

CONCLUSION

In this systematic review of older patients admitted to an ICU with COVID-19, we documented high heterogeneity of mortality rates.

Physician and administrator experience of preparing to implement Ontario's intensive care unit Triage Emergency Standard of Care during the COVID-19 pandemic: a qualitative study

BACKGROUND

As the COVID-19 pandemic created a surge in demand for critical care resources, the province of Ontario, Canada, released the Adult Critical Care Clinical Emergency Standard of Care for Major Surge (Emergency Standard of Care [ESoC]), a triage framework to guide the allocation of critical care resources in the expectation that intensive care units would be overwhelmed. Our aim was to understand physicians' and administrators' experiences and perceptions of planning to implement the ESoC, and to identify ways to improve critical care triage processes for future pandemics.

METHODS

We conducted semistructured qualitative interviews with critical care, emergency and internal medicine physicians, and hospital administrators from various Ontario health regions who were involved in their hospital's or region's ESoC implementation planning. Interviews were conducted virtually between April and October 2021. We analyzed the data using thematic analysis.

RESULTS

We conducted interviews with 11 physicians and 10 hospital administrators representing 9 health regions. We identified 4 themes regarding participants' preparation to implement the ESoC: infrastructure to enable effective triage implementation; social, medical and political supports to enable effective triage implementation; moral dimensions of triage implementation; and communication of triage results. Participants outlined administrative and implementation-related improvements that could be provided at the provincial level, such as billing codes for ESoC. They also suggested improving ethical supports for the usability and quality of the ESoC (e.g., designating an ethicist in each region), and ways to improve the efficiency and usability of the tools for assessing short-term mortality risk (e.g., create information technology solutions such as a dashboard).

INTERPRETATION

The implementation of a jurisdiction-level triage framework poses moral challenges for a health care system, but it also requires dedicated infrastructure, as well as institutional supports. Lessons learned from Ontario's process to prepare for ESoC implementation, as well as participants' suggestions, can be used for planning for current and future pandemics.

A Tale of 8 Cities: Pediatric Critical Care Redeployment to Adult Care During Wave 1 of COVID-19

BACKGROUND

Pediatric hospital resources including critical care faculty (intensivists) redeployed to provide care to adults in adult ICUs or repurposed PICUs during wave 1 of the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVES

To determine the magnitude of pediatric hospital resource redeployment and the experience of pediatric intensivists who redeployed to provide critical care to adults with COVID-19.

METHODS

A mixed methods study was conducted at 9 hospitals in 8 United States cities where pediatric resources were redeployed to provide care to critically ill adults with COVID-19. A survey of redeployed pediatric hospital resources and semistructured interviews of 40 redeployed pediatric intensivists were simultaneously conducted. Quantitative data were summarized as median (interquartile range) values.

RESULTS

At study hospitals, there was expansion in adult ICU beds from a baseline median of 100 (86-107) to 205 (108-250). The median proportion (%) of redeployed faculty (88; 66-100), nurses (46; 10-100), respiratory therapists (48; 18-100), invasive ventilators (72; 0-100), and PICU beds (71; 0-100) was substantial. Though driven by a desire to help, faculty were challenged by unfamiliar ICU settings and culture, lack of knowledge of COVID-19 and fear of contracting it, limited supplies, exhaustion, and restricted family visitation. They recommended deliberate preparedness with interprofessional collaboration and cross-training, and establishment of a robust supply chain infrastructure for future public health emergencies and will redeploy again if asked.

CONCLUSIONS

Pediatric resource redeployment was substantial and pediatric intensivists faced formidable challenges yet would readily redeploy again.

Impact of adapting paediatric intensive care units for adult care during the COVID-19 pandemic: a scoping review

OBJECTIVES

The objectives were to categorise the evidence, map out the existing studies and explore what was known about the organisation of paediatric intensive care units (PICUs) during the first 18 months of the COVID-19 pandemic. Additionally, this review set out to identify any knowledge gaps in the literature and recommend areas for future research.

DESIGN

Scoping review.

METHODS

This study used Arksey and O'Malley's six-stage scoping review framework. A comprehensive search was conducted using the following databases, CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE and grey literature search engines. A search strategy with predefined inclusion criteria was used to uncover relevant research in this area. Screening and data collection were done in duplicate.

RESULTS

47 631 articles were obtained through searching. However, only 25 articles met the inclusion criteria and were included in the analysis. Three dominant themes emerged from the literature: (1) the reorganisation of space for managing increased capacity; (2) increased staffing and support; and (3) the resulting challenges.

CONCLUSION

COVID-19 has strained institutional resources across the globe. To relieve the burden on intensive care units (ICUs), some PICUs adjusted their units to care for critically ill adults, with other PICUs making significant changes, including the redeployment of staff to adult ICUs to provide extra care for adults. Overall, PICUs were collectively well equipped to care for adult patients, with care enhanced by implementing elements of holistic, family-centred PICU practices. The pandemic fostered a collaborative approach among PICU teams and wider hospital communities. However, specific healthcare guidelines had to be created to safely care for adult patients.

Epidemiological Characteristics and Outcomes Predictors for Intensive Care Unit COVID-19 Patients in Al-Madinah, Saudi Arabia. Retrospective Cohort Study

Introduction

The global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) increased the demand for intensive care unit (ICU) services. Mortality and morbidity rates among ICU COVID-19 patients are affected by several factors, such as severity, comorbidities, and coinfections. In this study, we describe the demographic characteristics of COVID-19 patients admitted to an ICU in Saudi Arabia, and we determined the predictors for mortality and prolonged ICU length of stay. Additionally, we determined the prevalence of bacterial coinfection and its effect on the outcomes for ICU COVID-19 patients.

Methods

We retrospectively studied the medical records of 142 COVID-19 patients admitted to the ICU at a tertiary hospital in Madinah, Saudi Arabia. Data on demographics, medical history, mortality, length of stay, and presence of coinfection were collected for each patient.

Results

Neutrophil-to-Lymphocyte ratio (NLR) and intubation were reliable predictors of mortality and ICU length of stay among these ICU COVID-19 patients. Moreover, bacterial coinfections were detected in 23.2% of the patients and significantly (p < 0.001) prolonged their ICU length of stay, explaining the 10% increase in the length of stay for these patients. Furthermore, mortality reached 70% among the coinfected patients, and 60.8% of the isolated coinfecting pathogens were multidrug-resistant (MDR) strains of Klebsiella pneumoniae, Acinetobacter baumannii, and Staphylococcus aureus.

Conclusion

Increased NLR and intubation are predictors of mortality and prolonged length of stay in COVID-19 patients admitted to the ICU. Coinfection with MDR bacterial strains potentially results in complications and is a high-risk factor for prolonged ICU length of stay.

Oral manifestations in hospital-admitted COVID-19 patients: a case control study

The oral cavity can present early manifestations of several systemic diseases. Since the emergence of the COVID-19 pandemic, there have been many published studies reporting the direct effect of the virus on orofacial structures. In the present study, oral signs and symptoms of 22 hospital-admitted COVID-19 patients were examined and compared to a matching control group. Loss of taste and smell was the most prevalent symptom (65%), followed by oral dryness (45%) and halitosis (30%). The most common oral lesions were candidal infections (68%). Other less common manifestations were oral ulcerations (36%) followed by the appearance of white patches (27.3%). There was a statistically significant association between candidal infection and age in the study group, where the p-value was 0.008. In the present study, 80% of those who had candida infections were aged 60 years or above. There was no significant association with comorbidities such as diabetes mellitus and hypertension.

Assessment of psychological and physical stressors among nurses in different functional areas before and during the COVID-19 pandemic: a cross-sectional study

BACKGROUND

The COVID-19 (coronavirus disease) pandemic placed a great burden on all health-care resources, especially nurses. The prevalence and underlying risk factors of affective symptoms related to the COVID-19 pandemic have been studied primarily among nurses in intensive care units (ICU) and emergency departments. The aim of this study was to identify at-risk nursing areas by examining the psychological and physical stress values of nurses in different functional areas.

METHODS

A questionnaire with standardized items was developed to assess psychological and physical stress values. At least 50 nurses with a minimum work experience of 3 years were recruited from the ward, outpatient clinic (OC), intermediate care (IMC) unit, and operating room (OR) of the University Hospital RWTH Aachen. The participants answered the questionnaire by referring to their perceptions before and during the COVID-19 pandemic. Absolute differences and relative trends in psychological and physical stress values were compared within and across functional areas.

RESULTS

The ward and OR nurses experienced significant increases in workload (p < 0.001 and p = 0.004, respectively) and time stressors (p < 0.001 and p = 0.043, respectively) during the COVID-19 pandemic. Regardless of functional area, the nurses showed strong tendencies toward increases in subclinical affective symptoms. After adjustments for age, sex, working in a shift system, the treatment of patients with COVID-19, and the impact of the COVID-19 pandemic on personal life, the values for working with pleasure decreased significantly among the ward (p = 0.001) and OR nurses (p = 0.009) compared with the OC nurses. In addition, the ward (p < 0.001) and OR nurses (p = 0.024) were significantly more likely to express intent to leave their profession than OC nurses.

CONCLUSIONS

The IMC nurses showed good adaptation to the exacerbated situation caused by the COVID-19 pandemic. The ward nurses, followed by the OR nurses, were the most vulnerable to mental and physical exhaustion, which threatened the nurses' resilience and retention in the wake of the COVID-19 pandemic. Therefore, intervention programs must specifically address the professional and emotional needs of ward and OR nurses to prepare the health-care system for future crises.

Assessment of Family Satisfaction with Remote Communication for Critically Ill COVID-19 Patients: An Observational Cohort Study

Background

During the pandemic, traditional family meetings were replaced by remote telecommunications. We assessed the families' satisfaction with these communications using a survey-based questionnaire.

Methods

The study involved 20-minute telephonic surveys conducted with the family member who was updated during the hospitalization of the patient. A thematic-based questionnaire with responses on a scale of 5 ranging from very dissatisfied to very satisfied was used. The responses were dichotomized into bad and good reports for analysis.

Results

A total of 196 patients were eligible. Only 154 patients' family representatives consented to the study. The frequency and content of the telephonic updates were satisfactory. The bad report was assigned to 5% of families only. Among features assessing empathy of communication providers, the satisfaction rate was much higher with 3% of families alone providing a bad report. The response was significantly biased against the final outcome of the patient with poor review often provided by relatives of patients who had succumbed to the illness. The dissatisfaction rate was much higher, above 12% for the trust of communication and ICU visitation. However, the final outcome of the patient did not affect the trust in the information conveyed by the physician.

Interpretation

This study highlights several drawbacks in the communication strategy during the second surge of coronavirus disease-2019 (COVID-19). The final outcome of the patient was the key decisive factor for the response to most of the questionnaire. Sustained faith in communication by the physician despite the final outcome of the patient, re-emphasizes the need for emotional connection and training for breaking bad news.

How to cite this article

Varghese MP, Selwyn T, Nair S, Samuel S, Chacko B, Pichamuthu K. Assessment of Family Satisfaction with Remote Communication for Critically Ill COVID-19 Patients: An Observational Cohort Study. Indian J Crit Care Med 2023;27(8):537-544.

Necessary Products for the Prevention and Treatment of Pressure Injuries: Lessons Learned That Translate Beyond the COVID-19 Pandemic

OBJECTIVE

To identify the challenges encountered in obtaining the required support surfaces and products to meet pressure injury (PrI) prevention and treatment needs during COVID-19.

METHODS

The authors used SurveyMonkey to gather data on healthcare perceptions and the challenges experienced regarding specific product categories deemed necessary for PrI prevention and treatment in US acute care settings during the pandemic. They created three anonymous surveys for the target populations of supply chain personnel and healthcare workers. The surveys addressed healthcare workers' perceptions, product requests, and the ability to fulfill product requests and meet facility protocols without substitution in the categories of support surfaces and skin and wound care supplies.

RESULTS

Respondents answered one of the three surveys for a total sample of 174 respondents. Despite specific instructions, nurses responded to the surveys designed for supply chain personnel. Their responses and comments were interesting and capture their perspectives and insights. Three themes emerged from the responses and general comments: (1) expectations differed between supply chain staff and nurses for what was required for PrI prevention and treatment; (2) inappropriate substitution with or without proper staff education occurred; and (3) preparedness.

CONCLUSIONS

It is important to identify experiences and challenges in the acquisition and availability of appropriate equipment and products for PrI prevention and treatment. To foster ideal PrI prevention and treatment outcomes, a proactive approach is required to face daily issues or the next crisis.

A queuing model for ventilator capacity management during the COVID-19 pandemic

We applied a queuing model to inform ventilator capacity planning during the first wave of the COVID-19 epidemic in the province of British Columbia (BC), Canada. The core of our framework is a multi-class Erlang loss model that represents ventilator use by both COVID-19 and non-COVID-19 patients. Input for the model includes COVID-19 case projections, and our analysis incorporates projections with different levels of transmission due to public health measures and social distancing. We incorporated data from the BC Intensive Care Unit Database to calibrate and validate the model. Using discrete event simulation, we projected ventilator access, including when capacity would be reached and how many patients would be unable to access a ventilator. Simulation results were compared with three numerical approximation methods, namely pointwise stationary approximation, modified offered load, and fixed point approximation. Using this comparison, we developed a hybrid optimization approach to efficiently identify required ventilator capacity to meet access targets. Model projections demonstrate that public health measures and social distancing potentially averted up to 50 deaths per day in BC, by ensuring that ventilator capacity was not reached during the first wave of COVID-19. Without these measures, an additional 173 ventilators would have been required to ensure that at least 95% of patients can access a ventilator immediately. Our model enables policy makers to estimate critical care utilization based on epidemic projections with different transmission levels, thereby providing a tool to quantify the interplay between public health measures, necessary critical care resources, and patient access indicators.

Ethical analysis examining the prioritisation of living donor transplantation in times of healthcare rationing

The transplant community has faced unprecedented challenges balancing risks of performing living donor transplants during the COVID-19 pandemic with harms of temporarily suspending these procedures. Decisions regarding postponement of living donation stem from its designation as an elective procedure, this despite that the Centers for Medicare and Medicaid Services categorise transplant procedures as tier 3b (high medical urgency-do not postpone). In times of severe resource constraints, health systems may be operating under crisis or contingency standards of care. In this manuscript, the United Network for Organ Sharing Ethics Workgroup explores prioritisation of living donation where health systems operate under contingency standards of care and provide a framework with recommendations to the transplant community on how to approach living donation in these circumstances.To guide the transplant community in future decisions, this analysis suggests that: (1) living donor transplants represent an important option for individuals with end-stage liver and kidney disease and should not be suspended uniformly under contingency standards, (2) exposure risk to SARS-CoV-2 should be balanced with other risks, such as exposure risks at dialysis centres. Because many of these risks are not quantifiable, donors and recipients should be included in discussions on what constitutes acceptable risk, (3) transplant hospitals should strive to maintain a critical transplant workforce and avoid diverting expertise, which could negatively impact patient preparedness for transplant, (4) transplant hospitals should consider implementing protocols to ensure early detection of SARS-CoV-2 infections and discuss these measures with donors and recipients in a process of shared decision-making.

Differences in clinical characteristics and outcomes between COVID-19 and influenza in critically ill adult patients: a national database study

OBJECTIVE

Prior to the coronavirus disease 2019 (COVID-19) pandemic, influenza was the most frequent cause of viral respiratory pneumonia requiring intensive care unit (ICU) admission. Few studies have compared the characteristics and outcomes of critically ill patients with COVID-19 and influenza.

METHODS

This was a French nationwide study comparing COVID-19 (March 1, 2020-June 30, 2021) and influenza patients (January 1, 2014-December 31, 2019) admitted to an ICU during pre-vaccination era. Primary outcome was in-hospital death. Secondary outcome was need for mechanical ventilation.

RESULTS

105,979 COVID-19 patients were compared to 18,763 influenza patients. Critically ill patients with COVID-19 were more likely to be men with more comorbidities. Patients with influenza required more invasive mechanical ventilation (47 vs. 34%, p<0·001), vasopressors (40% vs. 27, p<0·001) and renal-replacement therapy (22 vs. 7%, p<0·001). Hospital mortality was 25 and 21% (p<0·001) in patients with COVID-19 and influenza, respectively. In the subgroup of patients receiving invasive mechanical ventilation, ICU length of stay was significantly longer in patients with COVID-19 (18 [10-32] vs. 15 [8-26] days, p<0·001). Adjusting for age, gender, comorbidities, and modified SAPS II score, in-hospital death was higher in COVID-19 patients (adjusted sub-distribution hazard ratio [aSHR]=1.69; 95%CI=1.63-1.75) compared with influenza patients. COVID-19 was also associated with less invasive mechanical ventilation (aSHR=0.87; 95%CI=0.85-0.89) and a higher likelihood of death without invasive mechanical ventilation (aSHR=2.40; 95%CI=2.24-2.57).

CONCLUSION

Despite younger age and lower SAPS II score, critically ill COVID-19 patients had a longer hospital stay and higher mortality than patients with influenza.

Public voices on tie-breaking criteria and underlying values in COVID-19 triage protocols to access critical care: a scoping review

Background

To reduce the arbitrariness in the allocation of rare resources in intensive care units (ICU) in the context of the pandemic, tiebreakers were considered in some COVID-19 triage algorithms. They were also contemplated to facilitate the tragic decisions of healthcare workers when faced with two patients with similar prognosis and only one ICU bed available. Little is known about the public's perspective on tiebreakers.

Objectives

To consolidate the available scientific literature on public consultations, particularly on tiebreakers and their underlying values. Also, to obtain an overview of the key arguments presented by the participating public and to identify potential gaps related to this topic.

Methods

The steps described by Arksey and O'Malley was the preferred method to our approach. Seven electronic databases were searched from January 2020 to April 2022, using keywords for each database: PubMed, Medline, EMBASE, Web of Science, PsycINFO, EBM reviews, CINAHL complete. We also searched in Google and Google Scholar, and in the references of the articles found. Our analysis was mainly qualitative. A thematic analysis was performed to consider the public's perspectives on tiebreakers and their underlying values, according to these studies.

Results

Of 477 publications found, 20 were selected. They carried out public consultations through various methods: surveys (80%), interviews (20%), deliberative processes (15%) and others (5%) in various countries: Australia, Brazil, Canada, China, France, Germany, India, Iran, Italy, Japan, Korea, Netherlands, Portugal, Spain, Switzerland, Thailand, United Kingdom, and United States. Five themes emerged from our analysis. The public favored the life cycle (50%) and absolute age (45%) as a tiebreaker. Other values considered important were reciprocity, solidarity, equality, instrumental value, patient merit, efficiency, and stewardship. Among the new findings were a preference for patient nationality and those affected by COVID-19.

Conclusions

There is a preference for favoring younger patients over older patients when there is a tie between similar patients, with a slight tendency to favor intergenerational equity. Variability was found in the public's perspectives on tiebreakers and their values. This variability was related to socio-cultural and religious factors. More studies are needed to understand the public's perspective on tiebreakers.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44250-023-00027-9.

Technical Innovation in Critical Care in a World of Constraints: Lessons from the COVID-19 Pandemic

The COVID-19 crisis was characterized by a massive need for respiratory support, which has unfortunately not been met globally. This situation mimicked those which gave rise to critical care in the past. Since the polio epidemic in the 50's, the technological evolution of respiratory support has enabled health professionals to save the lives of critically-ill patients worldwide every year. However, much of the current innovation work has turned around developing sophisticated, complex, and high-cost standards and approaches whose resilience is still questionable upon facing constrained environments or contexts, as seen in resuscitation work outside intensive care units, during pandemics, or in low-income countries. Ventilatory support is an essential life-saving tool for patients with respiratory distress. It requires an oxygen source combined to a ventilatory assistance device, an adequate monitoring system, and properly trained caregivers to operate it. Each of these elements can be subject to critical constraints, which we can no longer ignore. The innovation process should incorporate them as a prima materia, whilst focusing on the core need of the field using the concept of frugal innovation. Having a universal access to oxygen and respiratory support, irrespective of the context and constraints, necessitates: i) developing cost-effective, energy-efficient, and maintenance-free oxygen generation devices; ii) improving the design of non-invasive respiratory devices (for example, with oxygen saving properties); iii) conceiving fully frugal ventilators and universal monitoring systems; iv) broadening ventilation expertise by developing end-user training programs in ventilator assistance. The frugal innovation approach may give rise to a more resilient and inclusive critical care system. This paradigm shift is essential for the current and future challenges.

The challenge of estimating the direct and indirect effects of COVID-19 interventions - Toward an integrated economic and epidemiological approach

Decisions on public health measures to contain a pandemic are often based on parameters such as expected disease burden and additional mortality due to the pandemic. Both pandemics and non-pharmaceutical interventions to fight pandemics, however, produce economic, social, and medical costs. The costs are, for example, caused by changes in access to healthcare, social distancing, and restrictions on economic activity. These factors indirectly influence health outcomes in the short- and long-term perspective. In a narrative review based on targeted literature searches, we develop a comprehensive perspective on the concepts available as well as the challenges of estimating the overall disease burden and the direct and indirect effects of COVID-19 interventions from both epidemiological and economic perspectives, particularly during the early part of a pandemic. We review the literature and discuss relevant components that need to be included when estimating the direct and indirect effects of the COVID-19 pandemic. The review presents data sources and different forms of death counts, and discusses empirical findings on direct and indirect effects of the pandemic and interventions on disease burden as well as the distribution of health risks.

The Impact of a 3-Tiered Model of Nursing Redeployment During the COVID-19 Pandemic: A Cross-Sectional Study

Objective

The COVID-19 pandemic resulted in extreme system pressures, requiring redeployment of nurses to intensive care units (ICUs). We aimed to assess the impacts of a 3-tiered pandemic surge model on nurses working in ICUs during the COVID-19 pandemic.

Methodology

In this cross-sectional study, 931 nurses (464 ICU and 467 redeployed nurses) who worked within 4 adult ICUs in Western Canada during pandemic surge(s) were invited via email to participate in a survey. The survey explored the impact of redeployment, rapid ICU orientations, just-in-time training, and the 3-tiered model of nursing during pandemic surge. Burnout was measured utilizing the Copenhagen Burnout Inventory questionnaire.

Results

A total of 191 survey responses were retained (59 ICU nurses and 132 redeployed). Survey results are reported by tier, with outcomes varying based on team leadership, ICU, and redeployment nursing roles. Burnout in personal and workplace domains was present amongst all nursing tiers, while only team leadership roles experienced burnout in the patient domain. Overall, team leadership roles and permanent ICU nurses experienced the highest rates of burnout. Redeployed nurses reported numerous aids to success including support from colleagues, prior experience, and educational supports. Skill-based orientation, ongoing education, optimized scheduling, role clarity, and mitigators of psychological impacts were identified by respondents as potential facilitators of redeployment and surge models.

Conclusion

Nurses working within this tiered model experienced high degrees of burnout, with highest prevalence amongst team leads and ICU nurses. Optimization of support for and interventions aimed at improving well-being are important considerations going forward.