Infection control in the intensive care unit: expert consensus statements for SARS-CoV-2 using a Delphi method

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study

PURPOSE

Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA).

METHODS

An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements.

RESULTS

The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care.

CONCLUSION

Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

Recommendations for the implementation and conduct of multidisciplinary team meetings for those providing endometriosis and adenomyosis care - a Delphi consensus of the European Endometriosis League (EEL)

Background

The treatment of endometriosis and adenomyosis requires a complex, multidisciplinary approach. Some centres have established multidisciplinary teams (MDT) and regular meetings. There are currently no international data or recommendations.

Objectives

To examine existing MDT meetings and define consensus recommendations to support implementation and conduct.

Materials and Methods

Online questionnaires were sent through the European Endometriosis League (EEL) based on a Delphi protocol. After a literature review and assessment of existing MDT meetings, essential aspects for consensus statements were identified. The consensus statements were evaluated using a 5-point Likert scale with the possibility to modify them. Results were analysed between rounds and reported to the respondents. Consensus, defined as ≥70% agreement, concluded the Delphi process when achieved in the majority of statements.

Main outcome measures

Prevalence and type of existing MDT meetings and recommendations.

Results

In round 1, 69 respondents participated, with 49.3% (34) having an MDT meeting at their institutions, of which 97% are multidisciplinary. 50 % meet once a month and 64.7% indicated that less than 25% of their patients are discussed. Throughout the three rounds, 47 respondents from 21 countries participated. During the process, 82 statements were defined, with an agreement of 92.7% on the statements.

Conclusions

This study assessed existing MDT meetings for endometriosis and adenomyosis and developed recommendations for their implementation and conduct. The consensus group supports the strengths of MDT meetings, highlighting their role in offering guideline-based, multidisciplinary, and personalised care.

What is new?

This study presents the first international data and recommendations on MDT meetings for endometriosis and adenomyosis.

The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings

Sepsis poses a significant global health challenge in low- and middle-income countries (LMICs). Several aspects of sepsis management recommended in international guidelines are often difficult or impossible to implement in resource-limited settings (RLS) due to issues related to cost, infrastructure, or lack of trained healthcare workers. The Indian Society of Critical Care Medicine (ISCCM) drafted a position statement for the management of sepsis in RLS focusing on India, facilitated by a task force of 18 intensivists using a Delphi process, to achieve consensus on various aspects of sepsis management which are challenging to implement in RLS. The process involved a comprehensive literature review, controlled feedback, and four iterative surveys conducted between 21 August 2023 and 21 September 2023. The domains addressed in the Delphi process included the need for a position statement, challenges in sepsis management, considerations for diagnosis, patient management while awaiting an intensive care unit (ICU) bed, and treatment of sepsis and septic shock in RLS. Consensus was achieved when 70% or more of the task force members voted either for or against statements using a Likert scale or a multiple-choice question (MCQ). The Delphi process with 100% participation of Task Force members in all rounds, generated consensus in 32 statements (91%) from which 20 clinical practice statements were drafted for the management of sepsis in RLS. The clinical practice statements will complement the existing international guidelines for the management of sepsis and provide valuable insights into tailoring sepsis interventions in the context of RLS, contributing to the global discourse on sepsis management. Future international guidelines should address the management of sepsis in RLS.

How to cite this article

Juneja D, Nasa P, Chanchalani G, Cherian A, Jagiasi BG, Javeri Y, et al. The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings. Indian J Crit Care Med 2024;28(S2):S4-S19.

Deisolation in the Healthcare Setting Following Recent COVID-19 Infection

BACKGROUND

Deisolation of persons infected with SARS-CoV-2, the virus that causes COVID-19, presented a substantial challenge for healthcare workers and policy makers, particularly during the early phases of the pandemic. Data to guide deisolation of SARS-CoV-2-infected patients remain limited, and the risk of transmitting and acquiring infection has changed with the evolution of SARS-CoV-2 variants and population immunity from previous vaccination or infection, or both.

AIMS

This review examines the evidence to guide the deisolation of SARS-CoV-2-infected inpatients within the hospital setting when clinically improving and also of healthcare workers with COVID-19 prior to returning to work.

METHODS

A review was performed using relevant search terms in Medline, EMBASE, Google Scholar, and PubMed.

RESULTS AND DISCUSSION

The evidence is reviewed with regards to the nature of SARS-CoV-2 transmission, the role of testing to guide deisolation, and the impact of SARS-CoV-2-specific immunity. A paradigm and recommendations are proposed to guide deisolation for inpatients and return to work for healthcare workers.

Application of failure mode and effect analysis in ICU admission of potentially COVID-19 infected patients

BACKGROUND

To analyze the admission and treatment process of potentially COVID-19-infected patients in the intensive care unit under normalization, prevention, and control of the pandemic.

METHODS

A multidisciplinary team was assembled to develop a flowchart of potentially COVID-19-infected patients admitted to the intensive care unit and identify potential failure steps and modes throughout the process using the failure mode and effect analysis method. Through risk priority number (RPN) analysis of each failure mode, those with the highest impact on nosocomial infection were identified, and the priority of implementation was determined. Related corrective measures have been developed to continuously improve clinical practice and management.

RESULTS

Eighty potential failure modes were identified, and 8 potential failure modes were identified with RPNs greater than 100. These high RPNs of the failure modes were associated with careless inquiries of epidemiological histories by nurses, inadequate implementation of management standards by nursing assistants, and exposure of attending physicians to potentially risky environments. Finally, 18 general corrective measures are proposed.

CONCLUSIONS

Application of the failure mode and effect analysis method for quality improvement is a powerful tool for predicting potential failures in the process and can suggest corrective measures that could help avoid nosocomial infection during a pandemic.

Knowledge and awareness of infection control practices among nursing professionals: A cross-sectional survey from South Asia and the Middle East

BACKGROUND

The proficiency of nursing professionals in the infection prevention and control (IPC) practices is a core component of the strategy to mitigate the challenge of healthcare associated infections.

AIM

To test knowledge of nurses working in intensive care units (ICU) in South Asia and Middle East countries on IPC practices.

METHODS

An online self-assessment questionnaire based on various aspects of IPC practices was conducted among nurses over three weeks.

RESULTS

A total of 1333 nurses from 13 countries completed the survey. The average score was 72.8% and 36% of nurses were proficient (mean score > 80%). 43% and 68.3% of respondents were from government and teaching hospitals, respectively. 79.2% of respondents worked in < 25 bedded ICUs and 46.5% in closed ICUs. Statistically, a significant association was found between the knowledge and expertise of nurses, the country’s per-capita income, type of hospitals, accreditation and teaching status of hospitals and type of ICUs. Working in high- and upper-middle-income countries (β = 4.89, 95%CI: 3.55 to 6.22) was positively associated, and the teaching status of the hospital (β = -4.58, 95%CI: -6.81 to -2.36) was negatively associated with the knowledge score among respondents.

CONCLUSION

There is considerable variation in knowledge among nurses working in ICU. Factors like income status of countries, public vs private and teaching status of hospitals and experience are independently associated with nurses’ knowledge of IPC practices.

Demographic and risk characteristics of healthcare workers infected with SARS-CoV-2 from two tertiary care hospitals in the United Arab Emirates

BACKGROUND

Understanding the transmission dynamics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among healthcare workers (HCWs) and their social contacts is crucial to plan appropriate risk-reduction measures.

AIM

To analyze the socio-demographic risk factors and transmission of SARS-CoV-2 infection among HCWs in two tertiary care hospitals in Dubai, United Arab Emirates.

METHODS

The demographic and clinical characteristics were available for all HCWs in both facilities from the human resources department. A cross-sectional survey was conducted from January-April 2022 among HCWs who tested positive through Reverse Transcriptase Polymerase Chain Reaction of the nasopharyngeal swab for SARS-CoV-2 between March 2020 and August 2021 in two tertiary-level hospitals. The survey included questions on demographics, work profile, characteristics of coronavirus disease 2019 (COVID-19), and infection among their household or co-workers. The survey also checked the knowledge and perception of participants on the infection prevention measures related to SARS-CoV-2.

RESULTS

Out of a total of 346 HCWs infected with SARS-CoV-2, 286 (82.7%) HCWs consented to participate in this study. From the sample population, 150 (52.5%) of participants were female, and a majority (230, 80.4%) were frontline HCWs, including 121 nurses (121, 42.4%). Only 48 (16.8%) participants were fully vaccinated at the time of infection. Most infected HCWs (85%) were unaware of any unprotected exposure and were symptomatic at the time of testing (225, 78.7%). Nearly half of the participants (140, 49%) had co-infection among household, and nearly one-third (29.5%) had co-infection among three or more household. Another 108 (37.8%) participants reported cross-infection among co-workers. The frontline HCWs were significantly more infected (25.1% vs 8.6%, P < 0.001) compared to non-frontline HCWs. Another significant risk factor for a high infection rate was male sex (P < 0.001). Among the infected frontline HCWs, a significantly higher proportion were male and shared accommodation with family (P < 0.001). COVID-19 vaccination significantly reduced the infection rate (83.2% vs 16.8, P < 0.001) among HCWs. Most participants (99.3%) were aware about importance of appropriate use of personal protective equipment. However, only 70% agreed with the efficacy of the COVID-19 vaccination in preventing an infection and severe disease.

CONCLUSION

The risk profiling of the HCWs infected with SARS-CoV-2 found that working at frontline and being male increase the rate of infection. COVID-19 vaccination can effectively reduce the rate of transmission of SARS-CoV-2 among HCWs.

Agile Delphi methodology: A case study on how technology impacts burnout syndrome in the post-pandemic era

Introduction

In the post-pandemic era, many habits in different areas of our lives have changed. The exponential growth in the use of technology to perform work activities is one of them. At the same time, there has been a marked increase in burnout syndrome. Is this a coincidence? Could they be two interconnected developments? What if they were? Can we use technology to mitigate this syndrome? This article presents the agile Delphi methodology (MAD), an evolved version of the Delphi method, adapted to the needs of modern-day society.

Methods

To drive Occupational Health and Safety (OHS) experts to reach a consensus on what technological and non-technological factors could be causing the burnout syndrome experienced by workers in the post-pandemic era, MAD has been used in a specific case study. This study formally presents MAD and describes the stages enacted to run Delphi experiments agilely.

Results

MAD is more efficient than the traditional Delphi methodology, reducing the time taken to reach a consensus and increasing the quality of the resulting products.

Discussion

OHS experts identified factors that affect and cause an increase in burnout syndrome as well as mechanisms to mitigate their effects. The next step is to evaluate whether, as the experts predict, burnout syndrome decreases with the mechanisms identified in this case study.

Ventilator-associated pneumonia in critically ill patients with COVID-19 infection, a narrative review

COVID pneumonitis can cause patients to become critically ill. They may require intensive care and mechanical ventilation. Ventilator-associated pneumonia is a concern. This review aims to discuss the topic of ventilator-associated pneumonia in this group. Several reasons have been proposed to explain the elevated rates of VAP in critically ill COVID patients compared to non-COVID patients. Extrinsic factors include understaffing, lack of PPE and use of immunomodulating agents. Intrinsic factors include severe parenchymal damage, immune dysregulation, along with pulmonary vascular endothelial inflammation and thrombosis. The rate of VAP has been reported at 45.4%, with an ICU mortality rate of 42.7%. Multiple challenges to diagnosis exist. Other conditions such as acute respiratory distress syndrome, pulmonary oedema and atelectasis can present with similar features. Frequent growth of gram-negative bacteria has been shown in multiple studies, with particularly high rates of pseudomonas aeruginosa. The rate of invasive pulmonary aspergillosis has been reported at 4–30%. We would recommend the use of invasive techniques when possible. This will enable de-escalation of antibiotics as soon as possible, decreasing overuse. It is also important to keep other possible causes of ventilator-associated pneumonia in mind, such as COVID-19 associated pulmonary aspergillosis, cytomegalovirus, etc. Diagnostic tests such as galactomannan and B-D-glucan should be considered. These patients may face a long treatment course, with risk of re-infection, along with prolonged weaning, which carries its own long-term consequences.

Impact of the Organizational Model Adopted during the COVID-19 Pandemic on the Perceived Safety of Intensive Care Unit Staff

BACKGROUND

The SARS-CoV-2 pandemic had a devastating health, social, and economic effect on the population. Organizational, technical and structural operations aimed at protecting staff, outpatients and inpatients were implemented in an Italian hospital with a COVID-19 dedicated intensive care unit. The impact of the organizational model adopted on the perceived safety among staff was evaluated.

METHODS

Descriptive, structured and voluntary, anonymous, non-funded, self-administered cross-sectional surveys on the impact of the organizational model adopted during COVID-19 on the perceived safety among staff.

RESULTS

Response rate to the survey was 67.4% (153 completed surveys). A total of 91 (59%) of respondents had more than three years of ICU experience, while 16 (10%) were employed for less than one year. Group stratification according to profession: 74 nurses (48%); 12 medical-doctors (7%); 11 physiotherapists (7%); 35 nurses-aides (22%); 5 radiology-technicians (3%); 3 housekeeping (1%); 13 other (8%). The organizational model implemented at ISMETT made them feel safe during their workday. A total of 113 (84%) agreed or strongly agreed with the sense of security resulting from the implemented measures. A vast majority of respondents perceived COVID-19 as a dangerous and deadly disease (94%) not only for themselves but even more as vectors towards their families (79%). A total of 55% of staff took isolation measures and moved away from their home by changing personal habits. The organizational model was perceived overall as appropriate (91%) to guarantee their health.

CONCLUSION

The vast majority of respondents perceived the overall model applied during an unexpected, emergency situation as appropriate.