Operative team checklist for aerosol generating procedures to minimise exposure of healthcare workers to SARS-CoV-2

Video double-lumen tube for one lung ventilation: implementation and experience in 343 cases of routine clinical use during the first 20 months of the SARS-CoV-2 pandemic

BACKGROUND

Double-lumen tubes (DLTs) are the preferred device for lung isolation. Conventional DLTs (cDLT) need a bronchoscopic position control. Visualisation of correct DLT positioning could be facilitated by the use of a video double-lumen tube (vDLT). During the SARS-CoV-2-pandemic, avoiding aerosol-generation was suggesting using this device. In a large retrospective series, we report both general and pandemic related experiences with the device.

METHODS

All anesthesia records from patients aged 18 years or older undergoing surgery from April 1st, 2020 to December 31st, 2021 in the department of thoracic surgery requiring intraoperative lung isolation were analyzed retrospectively.

RESULTS

During the investigation period 343 left-sided vDLTs (77.4%) and 100 left-sided cDLTs (22.6%) were used for one lung ventilation. In the vDLT group bronchoscopy could be reduced by 85.4% related to the cDLT group. Additional bronchoscopy to reach or maintain correct position was needed in 11% of the cases. Other bronchoscopy indications occured in 3.6% of the cases. With cDLT, in 1% bronchoscopy for other indications than conforming position was observed.

CONCLUSIONS

The Ambu® VivaSight™ vDLT is an efficient, easy-to-use and safe airway device for the generation of one lung ventilation in patients undergoing thoracic surgery. The vDLT implementation was achieved easily with full interchangeability to the left-sided cDLT. Using the vDLT can reduce the need for aerosol-generating bronchoscopic interventions by 85.4%. Continuous video view to the carina enabling position monitoring of the DLT without need for bronchoscopy might be beneficial for both employee's and patient's safety.

Impact of the COVID-19 pandemic on paediatric otolaryngology: a nationwide study

Objective

The COVID-19 pandemic profoundly modified the work routine in healthcare; however, its impact on the field of paediatric otorhinolaryngology (ORL) has been rarely investigated. The aim of this study was to assess the impact of COVID-19 on paediatric ORL.

Methods

A questionnaire was developed by the Young Otolaryngologists of the Italian Society of ORL-Head and Neck Surgery (GOS). The questionnaire consisted of 26 questions related to workplace and personal paediatric ORL activities. The link was advertised on the official social media platforms and sent by e-mail to 469 Italian otolaryngologists.

Results

The questionnaire was completed by 118 responders. During the pandemic, the main reduction was observed for surgical activity (78.8%), followed by outpatient service (16.9%). The conditions that were mostly impacted by a delayed diagnosis were respiratory infections in 45.8% of cases and sensorineural hearing loss in 37.3% of cases.

Conclusions

Paediatric ORL was highly impacted by the COVID-19 pandemic, with a significant reduction of surgical and outpatient activities and a delay in time-sensitive diagnosis. Therefore, the implementation of new strategies, such as telemedicine, is recommended.

Strategies for maintaining and strengthening the health care workers during epidemics: a scoping review

INTRODUCTION

During epidemics such as COVID-19, healthcare workers (HCWs) face several challenges, leading to a shortage and weakening of human resources. To address this issue, employing effective strategies is essential in maintaining and strengthening human resources during outbreaks. This study aimed to gather and classify strategies that could retain and strengthen human health resources during epidemics.

METHODS

In this scoping review, all studies published about strategies for maintaining and strengthening HCWs in epidemics were collected from 4 international databases, including PubMed, Embase, Scopus, and Web of Science. The English language articles published after 2000 up until June 2022 recommended specific strategies regarding the research question. Then, they were analyzed and classified according to thematic analysis based on Braun and Clarke 6 phases protocols.

RESULTS

In total, 9405 records were screened, of which 59 articles were included, and their full texts were reviewed. Fifty factors were identified and classified into five themes: Instruction, Protection, Supporting, Caring, and Communication. Most of the suggestions were conducted in high-income countries and related to the Supporting theme.

DISCUSSION

The majority of strategies discussed in the literature addressed only one or two aspects of human resources. This study provides a holistic perspective on these issues by providing a thematic map of different strategies for strengthening and maintaining HCWs during epidemics. Considering the multidimensionality of human nature, it is suggested that policymakers and managers of health systems provide facilities that simultaneously address a wide range of needs.

Evaluation of the relative potential for contact and doffing transmission of SARS-CoV-2 by a range of personal protective equipment materials

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-the causative agent of coronavirus disease 2019 (COVID-19)-has caused a global public health emergency. Personal protective equipment (PPE) is the primary defence against viral exposure in healthcare and community settings. However, the surfaces of PPE materials may trap virus for contact transmission or through laden aerosols generated during removal of PPE, through cleaning or during movement. In this study, the relative efficacy of current PPE materials in terms of virion adsorption to materials and their antiviral potency, has been evaluated on a wide range of PPE for the first time, including four polymer glove types, two types of scrubs, apron material, a mask, visor and a selection of other commercial polymers and products. Although differences in virion adsorption to the test materials were observed, none of the existing polymer-based PPE resulted in more than tenfold reduction in the SARS-CoV-2 titre within either 10 min or 30 min contact period. The wettability and surface chemistry of the test materials were analysed to investigate any correlations with their surface physicochemical properties. While no correlation was found between wettability and viral retention under air flow challenge, one secondary ion of m/z 101.03 (+) and three secondary ions of m/z 31.98 (-), 196.93 (-) and 394.33 (+) in ToF-SIMS data of the test materials showed positive and negative correlations with the viral retention, respectively, which was identified by PLS regression model, suggesting that the surface chemistry plays a role in determining the extent of virion adsorption. Our findings outline the material aspects that influence the efficacy of current PPE against SARS-CoV-2 transmission and give suggestions on the development of novel simple polymer-based PPE for better infection protection.

Impact of Breathing Pattern and Nebulization on Expelled Viral Content During Mechanical Ventilation Using an Ex Vivo Porcine Lung System

BACKGROUND

Little is known about the fate of expelled viral particulates during the aerosolization of inhaled medications during mechanical ventilation. We hypothesized that breathing patterns that generate a greater degree of shear stress and turbulent air flow will produce a greater concentration of exhaled viral RNA with the presence of a nebulizer during mechanical ventilation.

METHODS

Eight ex vivo pig lungs were utilized as the physiological model. Each lung was dedicated to a specific breathing pattern that consisted of tidal breathing, respiratory distress, cough, and sneeze. Breath simulations were carried out through a commercial mechanical ventilator. Ninety mL of a bacteriophage stock at a concentration of 10⁸ PFU/mL were introduced into the lungs during a 10-min sample collection session. The number of viral particles collected in exhalate was measured using quantitative polymerase chain reaction. The impact of breathing pattern on measured viruses was analyzed through two-way analysis of variance.

RESULTS

The interaction effect between nebulization and breath pattern on exhaled viral quantity was not statistically significant P = .80, partial η² = 0.167. The analysis of the main effects indicated that the effects of the breathing pattern and nebulization phase were not statistically significant P = .26, partial η² = 0.519; P = .98, partial η² = 0, respectively. There were no statistically significant differences among the breathing patterns related to measurable viral RNA. Coughing produced the most measurable increase in measured viral quantity during the nebulization phase and non-nebulization phase with a mean exhaled viral quantity (3.5 × 10⁵ ng/μL [95% CI 1.6 × 10⁵-5.5 × 10⁵] and 2.7 × 10⁵ ng/μL [95% CI 7.1 × 10³-5.5 × 10⁵], respectively). Tidal breathing with the presence of a nebulizer and respiratory distress without a nebulizer produced the lowest measured viral quantities (M = 1.1 × 10⁵ ng/μL [95% CI -1.7 × 10⁵ to 3.9 × 10⁵]; M = 1.2 × 10⁵ ng/μL [95% CI -1.6 × 10⁵ to 4.0 × 10⁵]).

CONCLUSIONS

In this ex vivo porcine model, the introduction of a nebulizer did not increase the mean viral RNA captured throughout all of the breathing patterns.

Contribution of nursing research to fighting against COVID-19 pandemic. A systematic review

Introduction: The 2019 coronavirus disease (COVID-19) pandemic, should be an opportunity to ensure greater visibility of nursing in health systems and society worldwide. Objective: Review and synthesize the patterns on COVID-19 and nursing research, identifying the main journals, country of origin, language, topics, designs, and area of applicability of the results. Materials and Methods: Systematic review. Searches in PubMed, CINAHL, LILACS, and EMBASE databases (from the inception of the pandemic to May 15, 2020) were performed. Articles of any language related were related to SARS-CoV-2 infection or COVID-19 disease and nursing in any of its roles (care, management, education, among others) and using any epidemiological design or a scientific report were included. Two reviewers independently selected the studies and extracted the data. The main findings from the included studies were summarized through narrative synthesis and descriptive tables. The characteristics of the studies were presented as absolute values and proportions. Results: Three hundred and sixty-five articles were assessed for eligibility. Thirty-eight were included, published in 28 journals. Of those, 53.57% (n=15) were nursing specific. Most articles were “narrative reviews”, accounting for 23.68% (n=9). Most studies were conducted in China (n=18, 47.37%), followed by the United Kingdom and the United States. Thirty-four (89.47%) articles were published in English, followed by Portuguese and Chinese. We identified five areas of application of the results, and the most frequent was the “clinical” setting with 47.00% (n=18). Discussion: These findings are crucial to give visibility to nursing work during the emergency of the COVID-19 pandemic. Mental health was the main research topic, while the clinical setting concentrates the major number of articles. This pattern was aligned with the challenges of the initial phase of the pandemic. Conclusion: Future research should explore the current state of evidence in the main topics identified in this review and continue to give visibility to work carried out by nursing in the emergency of the COVID-19 pandemic.

Bronchoscopy simulation training in the post-pandemic world

Bronchoscopy is an important procedure to examine the airways. It is traditionally taught by having trainees perform it in humans. This carries risks, albeit rarely, and causes stress to trainees. The objective of this study was to review bronchoscopy simulators, as well as their use in and impact on medical education, presenting perspectives on the use of simulators in the post-pandemic world. This review was based on articles published in English in 2000-2021 and retrieved from any of the following databases: MEDLINE (PubMed), Embase, SciELO, and Google Scholar. Bronchoscopy simulators have improved markedly over time, allowing the teaching/learning process to take place in a risk-free environment. Bronchoscopy simulation training is an interesting option for the evaluation of the airways, especially in the coming years, with the COVID-19 pandemic highlighting the need for continuing medical education.

Effects of Safety Zone Implementation on Perceptions of Safety and Well-being When Caring for COVID-19 Patients

BACKGROUND

In March 2020, the caseload of patients positive for COVID-19 in hospitals began increasing rapidly, creating fear and anxiety among health care workers and concern about supplies of personal protective equipment.

OBJECTIVES

To determine if implementing safety zones improves the perceptions of safety, well-being, workflow, and teamwork among hospital staff caring for patients during a pandemic.

METHODS

A safety zone process was implemented to designate levels of contamination risk and appropriate activities for certain areas. Zones were designated as hot (highest risk), warm (moderate risk), or cold (lowest risk). Caregivers working in the safety zones were invited to complete a survey regarding their perceptions of safety, caregiver well-being, workflow, and teamwork. Each question was asked twice to obtain caregiver opinions for the periods before and after implementation of the zones.

RESULTS

Significant improvements were seen in perceptions of caregiver safety (P < .001) and collaboration within a multidisciplinary staff (P < .001). Significant reductions in perceived staff fatigue (P = .03), perceived cross contamination (P < .001), anxiety (P < .001), and fear of exposure (P < .001) were also seen. Teamwork (P = .23) and workflow (P = .69) were not significantly affected.

CONCLUSIONS

Safety zone implementation improved caregivers' perceptions of their safety, their well-being, and collaboration within the multidisciplinary staff but did not improve their perceptions of teamwork or workflow.

Nursing care recommendation for pediatric COVID-19 patients in the hospital setting: A brief scoping review

BACKGROUND

The hospitalization of children during the COVID-19 pandemic has affected their physical and mental health. Pediatric nurses have faced challenges in providing high-quality nursing care for children and their families. However, the pediatric nursing care recommendations for COVID-19 patients in the hospital setting remain unclear. The current scoping review provides recommendations for nursing interventions for pediatric COVID-19 patients in the hospital setting.

METHODS AND FINDINGS

The selected articles containing management and nursing recommendations for COVID-19 that have occurred in pediatric patients ages 0-19 years old. A search strategy was developed and implemented in seven databases. We included peer-reviewed articles that reported observational or interventional studies, as well as policy papers, guides or guidelines, letters and editorials, and web articles. A total of 134 articles and other documents relevant to this review were included. We categorized the results based on The Nursing Intervention Classification (NIC) taxonomy which consists of six domains (e.g., Physiological: Basic); eleven classes (e.g., Nutrition Support); and eighteen intervention themes (e.g., Positioning, Family Presence Facilitation, Family Support, and Discharge Planning).

CONCLUSION

Apart from the intervention of physical problems, there is a need to promote patient- and family-centered care, play therapy, and discharge planning to help children and families cope with their new situation.

Simultaneous monitoring of SARS-CoV-2, bacteria, and fungi in indoor air of hospital: a study on Hajar Hospital in Shahrekord, Iran

The novel SARS-CoV-2 outbreak was declared as pandemic by the World Health Organization (WHO) on March 11, 2020. Understanding the airborne route of SARS-CoV-2 transmission is essential for infection prevention and control. In this study, a total of 107 indoor air samples (45 SARS-CoV-2, 62 bacteria, and fungi) were collected from different wards of the Hajar Hospital in Shahrekord, Iran. Simultaneously, bacterial and fungal samples were also collected from the ambient air of hospital yard. Overall, 6 positive air samples were detected in the infectious 1 and infectious 2 wards, intensive care unit (ICU), computed tomography (CT) scan, respiratory patients' clinic, and personal protective equipment (PPE) room. Also, airborne bacteria and fungi were simultaneously detected in the various wards of the hospital with concentrations ranging from 14 to 106 CFU m-3 and 18 to 141 CFU m-3, respectively. The highest mean concentrations of bacteria and fungi were observed in respiratory patients' clinics and ICU wards, respectively. Significant correlation (p < 0.05) was found between airborne bacterial concentration and the presence of SARS-CoV-2, while no significant correlation was found between fungi concentration and the virus presence. This study provided an additional evidence about the presence of SARS-CoV-2 in the indoor air of a hospital that admitted COVID-19 patients. Moreover, it was revealed that the monitoring of microbial quality of indoor air in such hospitals is very important, especially during the COVID-19 pandemic, for controlling the nosocomial infections.

Quantifying Viral Particle Aerosolization Risk During Tracheostomy Surgery and Tracheostomy Care

Importance

During respiratory disease outbreaks such as the COVID-19 pandemic, aerosol-generating procedures, including tracheostomy, are associated with the risk of viral transmission to health care workers.

Objective

To quantify particle aerosolization during tracheostomy surgery and tracheostomy care and to evaluate interventions that minimize the risk of viral particle exposure.

Design, Setting, and Participants

This comparative effectiveness study was conducted from August 2020 to January 2021 at a tertiary care academic institution. Aerosol generation was measured in real time with an optical particle counter during simulated (manikin) tracheostomy surgical and clinical conditions, including cough, airway nebulization, open suctioning, and electrocautery. Aerosol sampling was also performed during in vivo swine tracheostomy procedures (n = 4), with or without electrocautery. Fluorescent dye was used to visualize cough spread onto the surgical field during swine tracheostomy. Finally, 6 tracheostomy coverings were compared with no tracheostomy covering to quantify reduction in particle aerosolization.

Main Outcomes and Measures

Respirable aerosolized particle concentration.

Results

Cough, airway humidification, open suctioning, and electrocautery produced aerosol particles substantially above baseline. Compared with uncovered tracheostomy, decreased aerosolization was found with the use of tracheostomy coverings, including a cotton mask (73.8% [(95% CI, 63.0%-84.5%]; d = 3.8), polyester gaiter 79.5% [95% CI, 68.7%-90.3%]; d = 7.2), humidification mask (82.8% [95% CI, 72.0%-93.7%]; d = 8.6), heat moisture exchanger (HME) (91.0% [95% CI, 80.2%-101.7%]; d = 19.0), and surgical mask (89.9% [95% CI, 79.3%-100.6%]; d = 12.8). Simultaneous use of a surgical mask and HME decreased the particle concentration compared with either the HME (95% CI, 1.6%-12.3%; Cohen d = 1.2) or surgical mask (95% CI, 2.7%-13.2%; d = 1.9) used independently. Procedures performed with electrocautery increased total aerosolized particles by 1500 particles/m3 per 5-second interval (95% CI, 1380-1610 particles/m3 per 5-second interval; d = 1.8).

Conclusions and Relevance

The findings of this laboratory and animal comparative effectiveness study indicate that tracheostomy surgery and tracheostomy care are associated with significant aerosol generation, putting health care workers at risk for viral transmission of airborne diseases. Combined HME and surgical mask coverage of the tracheostomy was associated with decreased aerosolization, thereby reducing the risk of viral transmission to health care workers.

Protective Measures against COVID-19: Dental Practice and Infection Control

The onset of the Coronavirus 2019 (COVID-19) pandemic has challenged the worldwide healthcare sector, including dentistry. The highly infectious nature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and risk of transmission through aerosol generating procedures has profoundly impacted the delivery of dental care services globally. As dental practices with renewed infection control strategies and preventive measures are re-opening in the "new normal" period, it is the responsibility of healthcare professionals to constantly analyze new data and limit the spread of COVID-19 in dental care settings. In the light of new variants of SARS-CoV-2 rapidly emerging in different geographic locations, there is an urgent need to comply more than ever with the rigorous public health measures to mitigate COVID-19 transmission. The aim of this article is to provide dental clinicians with essential information regarding the spread of SARS-CoV-2 virus and protective measures against COVID-19 transmission in dental facilities. We complied and provided guidance and standard protocols recommended by credible national and international organizations. This review will serve as an aid to navigating through this unprecedented time with ease. Here we reviewed the available literature recommended for the best current practices that must be taken for a dental office to function safely and successfully.

International cooperation group of emergency surgery during the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic has changed working conditions for emergency surgical teams around the world. International surgical societies have issued clinical recommendations to optimize surgical management. This international study aimed to assess the degree of emergency surgical teams' adoption of recommendations during the pandemic.

METHODS

Emergency surgical team members from over 30 countries were invited to answer an anonymous, prospective, online survey to assess team organization, PPE-related aspects, OR preparations, anesthesiologic considerations, and surgical management for emergency surgery during the pandemic.

RESULTS

One-hundred-and-thirty-four questionnaires were returned (N = 134) from 26 countries, of which 88% were surgeons, 7% surgical trainees, 4% anesthetists. 81% of the respondents got involved with COVID-19 crisis management. Social media were used by 91% of the respondents to access the recommendations, and 66% used videoconference tools for team communication. 51% had not received PPE training before the pandemic, 73% reported equipment shortage, and 55% informed about re-use of N95/FPP2/3 respirators. Dedicated COVID operating areas were cited by 77% of the respondents, 44% had performed emergency surgical procedures on COVID-19 patients, and over half (52%), favored performing laparoscopic over open surgical procedures.

CONCLUSION

Surgical team members have responded with leadership to the COVID-19 pandemic, with crisis management principles. Social media and videoconference have been used by the vast majority to access guidelines or to communicate during social distancing. The level of adoption of current recommendations is high for organizational aspects and surgical management, but not so for PPE training and availability, and anesthesiologic considerations.

Patient Safety/Quality Improvement Primer, Part III: The Role of Simulation

Simulation training has taken a prominent role in otolaryngology-head and neck surgery (OTO-HNS) as a means to ensure patient safety and quality improvement (PS/QI). While it is often equated to resident training, this tool has value in lifelong learning and extends beyond the individual otolaryngologists to include simulation-based learning for teams and health systems processes. Part III of this PS/QI primer provides an overview of simulation in medicine and specific applications within the field of OTO-HNS. The impact of simulation on PS/QI will be presented in an evidence-based fashion to include the use of run and statistical process control charts to assess the impact of simulation-guided initiatives. Last, steps in developing a simulation program focused on PS/QI will be outlined with future opportunities for OTO-HNS simulation.

Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review

OBJECTIVE

In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy.

DATA SOURCES

PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents.

REVIEW METHODS

Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations.

CONCLUSIONS

Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel.

IMPLICATIONS FOR PRACTICE

Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.

Occupational hazards in anaesthesiology during the COVID-19 pandemic

According to the Occupational Safety and Health Administration of the Department of Labor of the United States, the exposure risk for anaesthesiologists working with COVID-19 patients can be classified as high or very high. This is mostly due to fact that the anaesthesiologists work in close contact with patients' airways, and the aerosol-generating nature of some procedures they perform. Fortunately, despite the occupational hazard, the incidence of COVID-19 among anaesthesiologists and intensivists remains relatively low. Current evidence suggests that the majority of SARS-CoV-2 infections in this group were either contracted outside of the work environment or can be attributed to personal protective equipment (PPE) malfunction. This article focuses on different aspects of anaesthesiologists' safety, risks connected with different clinical scenarios and procedures, issues related to testing and screening, as well as modifiable and non-modifiable risk factors for severe illness or from COVID-19. This analysis is accompanied by a review of guidelines dedicated to mitigating said risks. Educating the personnel, introducing appropriate procedures, and proper utilisation of PPE are essential to the safety of all parties involved in hospital care, particularly those with significant exposure risk.

Otology practice during COVID-19 era: a review of current practice

Background

The novel coronavirus started as an outbreak in Wuhan, China, in December 2019.The outbreak was declared a pandemic by the WHO on 12 March 2020. The virus is called SARS-CoV-2, and the virus-induced disease is called COVID-19. The infection spreads via droplets or direct contact with contaminated surfaces. Airborne transmission occurs during aerosol-generating procedures on patients. Many otologic procedures are considered AGPs and therefore require precautions to protect staff and patients and minimize transmission of the disease.

Main body

Outpatient otology activity has seen changes, including virtual clinics and limitation of face-to-face consultations, to ensure safety. Powered instrumentation should be avoided during surgical procedures unless necessary or replaced with other tools, and if performed, enhanced personal protective equipment (PPE) must be used. Ear, nose, and throat (ENT) examination is recommended for any patient with full PPE in place except for consultations done without examination. Systemic steroid administration for treating conditions such as Bell’s palsy and sudden sensorineural hearing loss should be discussed with both the patient and infectious diseases specialist to weigh risks against benefits. Triaging of patients and prioritization is unavoidable during the pandemic and even after due to the limitations of clinic and theater time. All emergency/urgent cases are considered potentially COVID-19 positive. For the semi-urgent and all elective cases, COVID-19 testing 48 h prior to surgery, strict quarantine awaiting test results, and repeat testing on day of surgery if rapid tests are available are the precautions suggested. Different measures should be in place to minimize staff potential exposure intraoperatively.

Conclusions

Otology practice has been affected by the COVID-19 pandemic. Various measures are in place to ensure the delivery of safe and effective service for patients and health care workers.

Minimising risk to thoracic surgical teams in an era of COVID-19: exploring possible preventative measures

The demands of curtailing the impact of the coronavirus disease 2019 (COVID-19) global pandemic have disrupted the world’s ability to care for patients with thoracic pathologies. Those who undergo thoracic surgical therapeutic procedures are a high-risk category, likely to have impaired lung function but also high risk for exposing clinical teams to aerosolised viral loads. In light of this global pandemic, thorough pre-procedural planning, adequate personal protective equipment (PPE), experienced personnel and judicious anaesthetic and intra-operative measures will serve to be instrumental in ensuring positive patient outcomes whilst still protecting the safety of healthcare workers.

Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review

BACKGROUND

Evidence from disease epidemics shows that healthcare workers are at risk of developing short- and long-term mental health problems. The World Health Organization (WHO) has warned about the potential negative impact of the COVID-19 crisis on the mental well-being of health and social care professionals. Symptoms of mental health problems commonly include depression, anxiety, stress, and additional cognitive and social problems; these can impact on function in the workplace. The mental health and resilience (ability to cope with the negative effects of stress) of frontline health and social care professionals ('frontline workers' in this review) could be supported during disease epidemics by workplace interventions, interventions to support basic daily needs, psychological support interventions, pharmacological interventions, or a combination of any or all of these.

OBJECTIVES

Objective 1: to assess the effects of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic. Objective 2: to identify barriers and facilitators that may impact on the implementation of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic.

SEARCH METHODS

On 28 May 2020 we searched the Cochrane Database of Systematic Reviews, CENTRAL, MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Global Index Medicus databases and WHO Institutional Repository for Information Sharing. We also searched ongoing trials registers and Google Scholar. We ran all searches from the year 2002 onwards, with no language restrictions.

SELECTION CRITERIA

We included studies in which participants were health and social care professionals working at the front line during infectious disease outbreaks, categorised as epidemics or pandemics by WHO, from 2002 onwards. For objective 1 we included quantitative evidence from randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies, which investigated the effect of any intervention to support mental health or resilience, compared to no intervention, standard care, placebo or attention control intervention, or other active interventions. For objective 2 we included qualitative evidence from studies that described barriers and facilitators to the implementation of interventions. Outcomes critical to this review were general mental health and resilience. Additional outcomes included psychological symptoms of anxiety, depression or stress; burnout; other mental health disorders; workplace staffing; and adverse events arising from interventions.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently applied selection criteria to abstracts and full papers, with disagreements resolved through discussion. One review author systematically extracted data, cross-checked by a second review author. For objective 1, we assessed risk of bias of studies of effectiveness using the Cochrane 'Risk of bias' tool. For objective 2, we assessed methodological limitations using either the CASP (Critical Appraisal Skills Programme) qualitative study tool, for qualitative studies, or WEIRD (Ways of Evaluating Important and Relevant Data) tool, for descriptive studies. We planned meta-analyses of pairwise comparisons for outcomes if direct evidence were available. Two review authors extracted evidence relating to barriers and facilitators to implementation, organised these around the domains of the Consolidated Framework of Implementation Research, and used the GRADE-CERQual approach to assess confidence in each finding. We planned to produce an overarching synthesis, bringing quantitative and qualitative findings together.

MAIN RESULTS

We included 16 studies that reported implementation of an intervention aimed at supporting the resilience or mental health of frontline workers during disease outbreaks (severe acute respiratory syndrome (SARS): 2; Ebola: 9; Middle East respiratory syndrome (MERS): 1; COVID-19: 4). Interventions studied included workplace interventions, such as training, structure and communication (6 studies); psychological support interventions, such as counselling and psychology services (8 studies); and multifaceted interventions (2 studies). Objective 1: a mixed-methods study that incorporated a cluster-randomised trial, investigating the effect of a work-based intervention, provided very low-certainty evidence about the effect of training frontline healthcare workers to deliver psychological first aid on a measure of burnout. Objective 2: we included all 16 studies in our qualitative evidence synthesis; we classified seven as qualitative and nine as descriptive studies. We identified 17 key findings from multiple barriers and facilitators reported in studies. We did not have high confidence in any of the findings; we had moderate confidence in six findings and low to very low confidence in 11 findings. We are moderately confident that the following two factors were barriers to intervention implementation: frontline workers, or the organisations in which they worked, not being fully aware of what they needed to support their mental well-being; and a lack of equipment, staff time or skills needed for an intervention. We are moderately confident that the following three factors were facilitators of intervention implementation: interventions that could be adapted for local needs; having effective communication, both formally and socially; and having positive, safe and supportive learning environments for frontline workers. We are moderately confident that the knowledge or beliefs, or both, that people have about an intervention can act as either barriers or facilitators to implementation of the intervention.

AUTHORS' CONCLUSIONS

There is a lack of both quantitative and qualitative evidence from studies carried out during or after disease epidemics and pandemics that can inform the selection of interventions that are beneficial to the resilience and mental health of frontline workers. Alternative sources of evidence (e.g. from other healthcare crises, and general evidence about interventions that support mental well-being) could therefore be used to inform decision making. When selecting interventions aimed at supporting frontline workers' mental health, organisational, social, personal, and psychological factors may all be important. Research to determine the effectiveness of interventions is a high priority. The COVID-19 pandemic provides unique opportunities for robust evaluation of interventions. Future studies must be developed with appropriately rigorous planning, including development, peer review and transparent reporting of research protocols, following guidance and standards for best practice, and with appropriate length of follow-up. Factors that may act as barriers and facilitators to implementation of interventions should be considered during the planning of future research and when selecting interventions to deliver within local settings.

Critical Care Guidance for Tracheostomy Care During the COVID-19 Pandemic: A Global, Multidisciplinary Approach

PURPOSE

Critical care nurses caring for patients with a tracheostomy are at high risk because of the predilection of SARS-CoV-2 for respiratory and mucosal surfaces. This review identifies patient-centered practices that ensure safety and reduce risk of infection transmission to health care workers during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Consensus statements, guidelines, institutional recommendations, and scientific literature on COVID-19 and previous outbreaks were reviewed. A global interdisciplinary team analyzed and prioritized findings via electronic communications and video conferences to develop consensus recommendations.

RESULTS

Aerosol-generating procedures are commonly performed by nurses and other health care workers, most notably during suctioning, tracheostomy tube changes, and stoma care. Patient repositioning, readjusting circuits, administering nebulized medications, and patient transport also present risks. Standard personal protective equipment includes an N95/FFP3 mask with or without surgical masks, gloves, goggles, and gown when performing aerosol-generating procedures for patients with known or suspected COVID-19. Viral testing of bronchial aspirate via tracheostomy may inform care providers when determining the protective equipment required. The need for protocols to reduce risk of transmission of infection to nurses and other health care workers is evident.

CONCLUSION

Critical care nurses and multidisciplinary teams often care for patients with a tracheostomy who are known or suspected to have COVID-19. Appropriate care of these patients relies on safeguarding the health care team. The practices described in this review may greatly reduce risk of infectious transmission.

What is the Preferred Screening Tool for COVID-19 in Asymptomatic Patients Undergoing a Surgical or Diagnostic Procedure?

Introduction

Since the outbreak of COVID-19, measures were taken to protect healthcare staff from infection, to prevent infection of patients admitted to the hospital and to distribute PPE according to need. To assure the proper protection without overuse of limited supply of these equipments, screening of patients before surgical or diagnostic procedure was implemented. This study evaluates the results of this screening.

Method

All patients screened for COVID-19 before procedure warranting either general, locoregional anaesthesia or sedation were included. Screening included a symptom questionnaire by phone, PCR and HRCT chest testing. Surgical or procedural details were registered together with actions taken based on screening results.

Results

Three hundred ninety-eight screenings were performed on 386 patients. The symptom questionnaire was completed in 72% of screenings. In 371 screenings, PCR testing was performed and negative. HRCT chest found 18 cases where COVID-19 could not be excluded, with negative PCR testing. Three patients had their surgery postponed due to inconclusive screening, and additional measures were taken in three other patients. There were incidental findings in 14% of HRCT chest scans.

Discussion

Pre-operative screening will differentiate if PPE is needed for procedures and which patients can safely have elective surgery during this COVID-19 pandemic and in the times to come. HRCT chest has no additional value in the pre-operative screening of asymptomatic patients. Screening can be performed with a symptom questionnaire, and additional screening with PCR testing in high-risk patient groups should be considered.

Ocular oncology practice guidelines during COVID-19 pandemic-An expert consensus

The outbreak of rapidly spreading COVID-19 pandemic in December 2019 has witnessed a major transformation in the health care system worldwide. This has led to the re-organization of the specialty services for the effective utilization of available resources and ensuring the safety of patients and healthcare workers. Suspension of oncology services will have major implications on cancer care due to delayed diagnosis and treatment leading to irreversible adverse consequences. Therefore various oncology organizations have called for a continuation of cancer care during this crisis with diligence. The COVID-19 pandemic has forced the clinicians to transform the components of care from screening to outpatient care and primary management. The purpose of this article is to establish guidelines and recommendations for ocular oncology in the management of ocular tumors set by a multidisciplinary team of experts including ocular, medical and radiation oncologists, and pathologists. As the pandemic is evolving fast, it will require constant updates and reformation of health strategies and guidelines for safe and quality health care.