Battling COVID-19: critical care and peri-operative healthcare resource management strategies in a tertiary academic medical centre in Singapore

Innovative public strategies in response to COVID-19: A review of practices from China

The COVID-19 pandemic presented unparalleled challenges to prompt and adaptive responses from nations worldwide. This review examines China's multifaceted approach to the crisis, focusing on five key areas of response: infrastructure and system design, medical care and treatment, disease prevention and control, economic and social resilience, and China's engagement in global health. This review demonstrates the effectiveness of a top-down command system at the national level, intersectoral coordination, a legal framework, and public social governance. This study also examines medical care and treatment strategies, highlighting the importance of rapid emergency response, evidence-based treatment, and well-planned vaccination rollout. Further discussion on disease prevention and control measures emphasizes the importance of adaptive measures, timely infection control, transmission interruption, population herd immunity, and technology applications. Socioeconomic impact was also assessed, detailing strategies for disease prevention, material supply, livelihood preservation, and social economy revival. Lastly, we examine China's contributions to the global health community, with a focus on knowledge-sharing, information exchange, and multilateral assistance. While it is true that each nation's response must be tailored to its own context, there are universal lessons to be drawn from China's approach. These insights are pivotal for enhancing global health security, especially as the world navigates evolving health crises.

Effects of interventions to promote resilience in nurses: A systematic review

BACKGROUND

Various trials are investigating the effect of digital and face-to-face interventions on nurse resilience; however, it remains unclear whether these interventions have immediate, short-term or long-term effects.

OBJECTIVE

The objective of the systematic review is to identify the types of interventions and assess the immediate (<3 months), short-term (3-6 months), and long-term (>6 months) effects of these interventions on nurse resilience.

DESIGN

This systematic review was registered in the International Prospective Register of Systematic Reviews (Registered Number: CRD 42023434924), and results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol.

METHODS

Data were collated from the databases of CINAHL, Cochrane Library, Embase (OVID), Medline, and Scopus between March and May 2023. The research protocol was determined following the framework of population, exposure, outcomes, and type of study. The articles with full text published between 2000 and 2023 were included. Studies were included if they (1) involved the nurses who provided patient care directly, (2) utilised digital or face-to-face interventions, (3) reported resilience outcomes, and (4) were randomised controlled trials or clinical trials. The JBI critical appraisal tool was utilised to assess the risk of bias for the studies collected.

RESULTS

A total of 18 studies met the criteria and were analysed. Pooled results demonstrated that digital interventions had a statistically significant positive effect on nurse resilience at 4-5-month follow-ups (standardised mean difference [SMD] = 0.71; 95 % CI = 0.13, 1.29; P = 0.02) compared to no interventions. Additionally, pooled data showed no effect on nurse resilience at all the follow-ups, compared to no interventions. No significant results were observed in comparisons of digital or face-to-face interventions between the intervention and control groups.

CONCLUSIONS

The review assessed digital and face-to-face resilience interventions in nurses across 18 trials. Digital methods showed a short-term impact within 4-5 months, whilst face-to-face interventions had no effect during follow-ups. Realistic expectations, ongoing support, and tailored interventions are crucial for nurse resilience enhancement.

TWEETABLE ABSTRACT

It was identified digital interventions had a short-term impact on nurse resilience, whilst face-to-face interventions had no effect during follow-ups @fionayyu.

Theatre practitioners and organisational adaptive capacity in disaster response

Disasters are increasing globally, requiring flexible strategic approaches from healthcare organisations to manage the resultant influx of patients requiring care while also maintaining normal operational services. Theatre practitioners play a key role in disaster response and recovery; however, a lack of appropriate skill utilisation may be reducing overall organisational adaptive capacity and leading to poorer outcomes for organisations, staff and patients. Understanding what skills individual practitioners have, and how they can be deployed to the greatest effect, is a concern for managers to ensure optimal use of resources and to reduce negative impacts of disaster response upon healthcare personnel. This is especially pertinent in the post-COVID healthcare climate where a paucity of operating theatre practitioners and poor workforce planning has led to a lack of surgical capacity at a time when it is most needed.

COVID-19 Pandemic Did not Influence Number of Oncologic and Emergency Surgeries: A Retrospective Cohort Study from a Tertiary Hospital in Austria

BACKGROUND

Many articles described a massive decline in surgical procedures during the COVID-19 pandemic waves. Especially the reduction in oncologic and emergency procedures led to the concern that delays and cancelling surgical activity might lead to a substantial increase in preventable deaths.

METHODS

Overall numbers and types of surgery were analysed in a tertiary hospital in Austria during the winter period (October-April) from 2015/16 to 2021/22. The half-years 2019/20, 2020/21 and 2021/22 were defined as pandemic half-years and were compared with the mean results of the previous, four, pre-pandemic half-years.

RESULTS

A reduction was found for overall numbers and elective surgeries during 2019/20 (4.62%; p < 0.0001 and 12.14; p < 0.0001 respectively) and 2021/22 (14.94%; p < 0.0001 and 34.27; p < 0.0001 respectively). Oncologic surgery increased during 2021/22 (- 12.59%; p < 0.0001) and remained unchanged during the other periods. Emergency surgeries increased during 2019/20 (- 6.97%; p < 0.0001) and during 2021/22 (- 9.44%; p < 0.0001) and remained unchanged during 2020/21.

CONCLUSIONS

The concern that the pandemic led to a decrease in oncologic and emergency surgeries cannot be supported with the data from our hospital. A flexible, day-by-day, resource allocation programme with central coordination adhering to hospital resilience recommendations may have helped to adapt to the impact of the COVID-19 pandemic during the first three pandemic half-years.

Rapid cycle training for non-critical care physicians to meet intensive care unit staff shortage at an academic training center in a developing country during the COVID-19 pandemic

BACKGROUND

The sudden unexpected increase in critically ill COVID-19 patients admitted to Intensive Care Units (ICUs), resulted in an urgent need for expanding the physician workforce. A COVID-19 critical care crash (5C) course was implemented to introduce physicians without formal critical care training to care for critically ill COVID-19 patients. Upon successful completion of the course, physicians were recruited to work in a COVID-19 ICU under the supervision of a board-certified critical care physician. The aim of this study is to describe the methods of a novel course designed specifically to teach the management critically ill COVID-19 patients, while assessing change in knowledge, skill competency, and self-reported confidence.

METHODS

The blended focused 5C course is composed of both virtual and practical components. Candidates may register for the practical component only after successful completion of the virtual component. We assessed knowledge acquisition using a multiple-choice question test (pre- and post-test assessment), skill competency, and self-reported confidence levels during simulated patient settings. Paired T-test was used to compare before and after course results.

RESULTS

Sixty-five physicians/trainees from different specialties were included in the analysis. Knowledge significantly increased from 14.92± 3.20 (out of 20 multiple-choice questions) to 18.81± 1.40 (p< 0.01), skill competence during practical stations had a mean minimum of 2 (out of 3), and self-reported confidence during a simulated patient setting increased significantly from 4.98± 1.15 (out of 10) to 8.76± 1.10 (out of 10) (p< 0.01).

CONCLUSION

We describe our initiative in increasing the ICU physician workforce in the midst of the COVID-19 pandemic. The blended 5C course is a valuable educational program designed by experts from different backgrounds. Future research should be directed at examining outcomes of patients associated with graduates of such program.

Development and Psychometric Properties of the Caring Behaviors of Operating Room Nurses Questionnaire during the COVID-19 Pandemic: A Mixed-Method Study

Background

Considering the threats in the operating room during the COVID-19 pandemic, the optimal care and safety of the operating room nurses should be maintained when performing surgery on an acute respiratory patient. It seems necessary to design a tool to measure the caring behaviors of operating room nurses. Therefore, the present study was conducted with the aim to design a valid and reliable tool for measuring the caring behavior of operating room nurses during the COVID-19 pandemic.

Materials and Methods

In this sequential, exploratory, mixed-method study, the designing and psychometric evaluation of the caring behaviors of operating room nurses questionnaire during the COVID-19 pandemic were performed in qualitative and quantitative phases from August 2021 to July 2022 in Aja University of Medical Sciences, Iran. In the qualitative phase, the concept of caring behaviors of operating room nurses was explored through interviews and a literature review based on online searches. In the quantitative phase, validity (face, content, and construct), and reliability of the questionnaire were evaluated.

Results

The findings supported 21 items in the 5 factors of caring behaviors related to attitude toward patients, knowledge of surgical care, virus prevention principles, self-care knowledge, and self-care performance, which explained 35.92 of the total variance. Scale-Content Validity Index/Average and Cronbach's alpha were calculated to be 0.93 and 0.89, respectively.

Conclusions

Given its desirable reliability and validity, simple scoring, and ease of use by operating room nurses, the Caring Behaviors of Operating Room Nurses Questionnaire is applicable and its use is recommended.

A Qualitative Study of Hospital Interior Environments during the COVID-19 Pandemic

Human beings have encountered different infectious diseases. However, there is not much validated data available on the physical environments of hospitals when responding to highly contagious viruses, such as COVID-19. This study was conducted to assess the physical environments of hospitals during the COVID-19 pandemic. There exists a need to analyze whether the physical environments of hospitals were conducive or obstructive to medical practice during the pandemic. A total of forty-six staff working in intensive care units, progressive care units, and emergency rooms were invited to participate in a semi-structured interview. Out of this group, fifteen staff members participated in the interview. They were asked to list the changes made to the hospital's physical environment during the pandemic, which included equipping the hospital environment for medical practice and protecting staff from becoming infected. They were also asked about desirable improvements that they believe could increase their productivity and ensure safety. The results indicated the difficulty in isolating COVID-19 patients and converting a single occupancy room into a double occupancy room. Isolating COVID-19 patients made it easier for staff to care for the patients, but it made them feel isolated and at the same time increased the walking distance. Signs indicating a COVID area helped them to prepare for medical practices ahead of time. Glass doors provided greater visibility and enabled them to monitor the patients. However, the dividers installed at nursing stations were obstructive. This study suggests that further research should be conducted once the pandemic is over.

Caring in a crisis: Understanding the stressors and uplifts for National Health Service frontline staff through the lens of clinical psychologists

The unprecedented public health crisis of the Covid-19 pandemic resulted in a significant challenge to the delivery of healthcare that has rarely been experienced before. The stress already faced by healthcare staff working in the National Health Service (NHS) has been further exacerbated during Covid-19, putting them at risk of adverse mental health outcomes. Through the lens of clinical psychologists who had provided support to frontline healthcare staff during the Covid-19 pandemic, this study aimed to better understand the stressors and uplifts healthcare staff experienced during Covid-19, the impact of these on the wellbeing of staff and patient care, and to examine the support needed to deal with the impact of a crisis. A qualitative study design using a combination of diaries followed by semi-structured interviews was utilised. Data was analysed using thematic analysis. The following five themes represented the stressors and uplifts experienced by NHS frontline healthcare staff during Covid-19, the impact on staff wellbeing and patient care: facing change; risks of working in the NHS environment; transcending the negatives; challenging professional values and haunted by patient deaths. The findings also highlight the importance of providing psychological support and suggest the need to continue to provide this support service to help NHS staff manage through subsequent waves of the pandemic. These findings can contribute towards both the management of the current Covid-19 pandemic and other similar crises in the future.

Mental health and well-being of anaesthetists during the COVID-19 pandemic: a scoping review

The COVID-19 pandemic has imposed substantial burdens on clinicians and there is a need to better understand the impact on mental health and well-being. This scoping review investigates the prevalence of mental health concerns in anaesthetists, risk and protective factors for mental well-being, and anaesthetists' pandemic-related concerns and support. We searched online databases for articles published between January 2020 and May 2022, using search terms related to: anaesthesia; burnout, well-being, mental health or stress; and COVID-19. We identified 20 articles comprising 19 different populations of anaesthetists (n = 8680) from 14 countries. Studies identified the prevalence of the following condition in anaesthetists: burnout (14-59%); stress (50-71%); anxiety (11-74%); depression (12-67%); post-traumatic stress (17-25%); psychological distress (52%); and insomnia (17-61%). Significant risk factors for poorer mental health included: direct COVID-19-related issues (fear of self and family exposure to infection; requirement for quarantine); practitioner health factors (insomnia; comorbidities); psychosocial factors (loneliness; isolation; perceived lack of support at home and work); demographic factors (female gender; non-white ethnicity; LGBTQIA+); and workplace factors (redeployment outside area of clinical practice; increased work effort; personal protective equipment shortages). Protective factors identified included: job satisfaction; perceived organisational justice; older age; and male sex. Anaesthetists' self-reported concerns related to: personal protective equipment; resource allocation; fear of infection; fear of financial loss; increased workload; and effective communication of protocols for patient treatment. Support from family, colleagues and hospital management was identified as an important coping mechanism. Findings from this review may support the design of interventions to enhance anaesthetists' psychological health during pandemic conditions and beyond. Future research should include consistent psychological outcome measures and rigorous experimental design beyond cross-sectional studies.

The impact of the COVID-19 pandemic on the perioperative transition to specialty practice program

AIM

To understand how the COVID-19 pandemic impacted nurse educators' and novice nurses' experience with the perioperative transition to specialty practice program.

DESIGN

A qualitative descriptive study.

METHODS

Semi-structured interviews were conducted with five perioperative nurse educators and five perioperative transition to specialty practice program participants from a major metropolitan health service in Melbourne. Data were collected between April and July 2021. Interviews were audio-recorded and transcribed verbatim, and data were analysed using reflexive thematic analysis.

RESULTS

Five themes were identified. The value of the perioperative transition to specialty practice program in supporting novice nurses was recognized in the theme 'Nurturing our novices'. Widespread changes to clinical practice were demonstrated in the theme 'Every day is different', including changes to elective surgery, redeployment of staff and the transmission risk of COVID-19. 'The perils and joys of online learning' revealed both challenges and benefits of transitioning theoretical education from face-to-face to online delivery. 'Roller coaster of emotions' represented the heightened emotions participants experienced due to the COVID-19 pandemic. 'Looking back to move forward' encompassed participants' reflections on the year, considering the challenges, adaptive strategies and the future of perioperative nursing education.

CONCLUSION

The perioperative transition to specialty practice program was significantly impacted by the COVID-19 pandemic. Participants needed to adapt to rapid and frequent changes, which contributed to feelings of emotional distress, affected consolidation of clinical learning and reduced engagement with theoretical education.

IMPACT

Perioperative nurses should acknowledge that opportunities for learning were decreased for transition to specialty practice program participants during the pandemic. Ongoing support and education should be provided, to nurture the future generation of perioperative nurses.

Pediatric emergency care admissions for somatic symptom disorders during the COVID-19 pandemic

During the COVID-19 pandemic, children and adolescents with psychiatric disorders experienced an exacerbation of their symptoms with more access to the emergency department (ED). However, little is known about the experience of somatic symptom disorders (SSDs) during the COVID-19 pandemic in children. Therefore, we aimed to compare the rates of pediatric ED admissions for SSDs before and during the COVID-19 pandemic and to understand whether the relative risk of ED admissions for SSDs changed between the two periods. We retrospectively enrolled all children between 4 and 14 years admitted for SSDs in the pediatric ED of Santobono-Pausilipon Hospital, Naples, Italy, from March 11th, 2020, to March 11th, 2021 (pandemic period), and in the same time period of the previous year (pre-pandemic period). We identified 205/95,743 (0,21%) children with SSDs presenting in ED in the pre-pandemic year and 160/40,165 (0,39%) in the pandemic year (p < 0.05). Considering the accesses for age, we observed a relative decrease of the accesses for SSDs over 12 years old (IRR 0,59; CI 0,39-0,88), while we found no differences under 12 years old (IRR 0,87; CI 0,68-1,10).   Conclusion: In this study, we found that despite the massive decrease in pediatric admissions due to the COVID-19 pandemic, somatic symptom disorders' admissions to the pediatric ED increased, suggesting an impact of the pandemic also on pediatric psychiatric disorders. What is Known: • During the COVID -19 pandemic, children and adolescents with a psychiatric disorder experienced exacerbation of their symptoms with more accesses in Emergency Department. What is New: • We found that despite the massive decrease of the pediatric admissions due to the COVID-19 pandemic, somatic symptom disorders admissions in healthy children to the pediatric Emergency Department increased ,suggesting an impact of the pandemic also on the pediatric psychiatric disorders.

Burnout, stress and resilience of an Australian regional hospital during COVID-19: a longitudinal study

Coronavirus disease 2019 (COVID-19) has placed huge strain on hospital staff around the world. The aim of the current longitudinal study was to investigate the resilience, stress and burnout of hospital staff located at a large, regional hospital in Victoria, Australia during the COVID-19 pandemic over time via cross-sectional surveys. The surveys were disseminated six times from August 2020 to March 2021, with the first three data collection points distributed during a state-wide lockdown. A total of 558 responses from various professional roles within the hospital over the survey period were included in the sample. Analysis of variance indicated significant main effects for the psychological variables across time, age, and workload. Hospital staff reported an increase in burnout levels throughout the eight-months. Significant negative relationships were observed between resilience and burnout, and between resilience and stress. A backward regression highlighted the contribution of resilience, stress, age, and nursing roles on burnout. Hierarchical regression analysis indicated that resilience contributed to the stress-burnout relationship. This study strengthens the evidence between resilience and burnout among healthcare workers and hospital staff and highlights the need for psychological wellbeing programs to be implemented for hospital staff impacted by a prolonged worldwide pandemic.

Early COVID-19 respiratory risk stratification using machine learning

Background

COVID-19 has strained healthcare systems globally. In this and future pandemics, providers with limited critical care experience must distinguish between moderately ill patients and those who will require aggressive care, particularly endotracheal intubation. We sought to develop a machine learning-informed Early COVID-19 Respiratory Risk Stratification (ECoRRS) score to assist in triage, by providing a prediction of intubation within the next 48 hours based on objective clinical parameters.

Methods

Electronic health record data from 3447 COVID-19 hospitalizations, 20.7% including intubation, were extracted. 80% of these records were used as the derivation cohort. The validation cohort consisted of 20% of the total 3447 records. Multiple randomizations of the training and testing split were used to calculate confidence intervals. Data were binned into 4-hour blocks and labeled as cases of intubation or no intubation within the specified time frame. A LASSO (least absolute shrinkage and selection operator) regression model was tuned for sensitivity and sparsity.

Results

Six highly predictive parameters were identified, the most significant being fraction of inspired oxygen. The model achieved an area under the receiver operating characteristic curve of 0.789 (95% CI 0.785 to 0.812). At 90% sensitivity, the negative predictive value was 0.997.

Discussion

The ECoRRS score enables non-specialists to identify patients with COVID-19 at risk of intubation within 48 hours with minimal undertriage and enables health systems to forecast new COVID-19 ventilator needs up to 48 hours in advance.

Level of evidence

IV.

Decline of onset-to-diagnosis interval and its impacts on clinical outcome of COVID-19 in China: a nation-wide observational study

Background

To quantitatively assess the impact of the onset-to-diagnosis interval (ODI) on severity and death for coronavirus disease 2019 (COVID-19) patients.

Methods

This retrospective study was conducted based on the data on COVID-19 cases of China over the age of 40 years reported through China’s National Notifiable Infectious Disease Surveillance System from February 5, 2020 to October 8, 2020. The impacts of ODI on severe rate (SR) and case fatality rate (CFR) were evaluated at individual and population levels, which was further disaggregated by sex, age and geographic origin.

Results

As the rapid decline of ODI from around 40 days in early January to < 3 days in early March, both CFR and SR of COVID-19 largely dropped below 5% in China. After adjusting for age, sex, and region, an effect of ODI on SR was observed with the highest OR of 2.95 (95% CI 2.37‒3.66) at Day 10–11 and attributable fraction (AF) of 29.1% (95% CI 22.2‒36.1%) at Day 8–9. However, little effect of ODI on CFR was observed. Moreover, discrepancy of effect magnitude was found, showing a greater effect from ODI on SR among patients of male sex, younger age, and those cases in Wuhan.

Conclusion

The ODI was significantly associated with the severity of COVID-19, highlighting the importance of timely diagnosis, especially for patients who were confirmed to gain increased benefit from early diagnosis to some extent.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07660-4.

A robust multi-objective model for healthcare resource management and location planning during pandemics

In this study, we consider the problem of healthcare resource management and location planning problem during the early stages of a pandemic/epidemic under demand uncertainty. Our main ambition is to improve the preparedness level and response effectiveness of healthcare authorities in fighting pandemics/epidemics by implementing analytical techniques. Building on lessons from the Chinese experience in the COVID-19 outbreak, we first develop a deterministic multi-objective mixed integer linear program (MILP) which determines the location and size of new pandemic hospitals (strategic level planning), periodic regional health resource re-allocations (tactical level planning) and daily patient-hospital assignments (operational level planning). Taking the forecasted number of cases along a planning horizon as an input, the model minimizes the weighted sum of the number of rejected patients, total travel distance, and installation cost of hospitals subject to real-world constraints and organizational rules. Next, accounting for the uncertainty in the spread speed of the disease, we employ an across scenario robust (ASR) model and reformulate the robust counterpart of the deterministic MILP. The ASR attains relatively more realistic solutions by considering multiple scenarios simultaneously while ensuring a predefined threshold of relative regret for the individual scenarios. Finally, we demonstrate the performance of proposed models on the case of Wuhan, China. Taking the 51 days worth of confirmed COVID-19 case data as an input, we solve both deterministic and robust models and discuss the impact of all three level decisions to the quality and performance of healthcare services during the pandemic. Our case study results show that although it is a challenging task to make strategic level decisions based on uncertain forecasted data, an immediate action can considerably improve the response effectiveness of healthcare authorities. Another important observation is that, the installation times of pandemic hospitals have significant impact on the system performance in fighting with the shortage of beds and facilities.

Perspectives of nursing directors on emergency nurse deployment during the pandemic of COVID‐19: A nationwide cross‐sectional survey in mainland China

Aims

The aim of this study is to investigate the situation and perceptions of nursing directors about emergency nursing staff deployment in designated hospitals during the pandemic of COVID‐19 in mainland China.

Background

The pandemic of COVID‐19 has significantly depleted health care resources, leading to increased burden of nursing care and staffing and exacerbating the crisis in health care facilities. Currently, how to effectively plan and schedule nursing staffing in the pandemic still remains unknown.

Methods

From 14 July 2020 to 8 September 2020, 62 nursing directors of designated hospitals in mainland China were invited to participate in a cross‐sectional online survey for their perceptions of nursing human‐resource allocation during the pandemic of COVID‐19.

Results

A total of 55 valid questionnaires were collected, showing that 96.36% of the hospitals had emergency nursing organizations and management systems during the pandemic, 96.36% had well‐established scheduling principles for nursing human resources and 54.55% of hospitals had human‐resource scheduling platforms. All the hospitals had trained emergency nursing staff in infection control (55, 100%), work process (51, 92.73%) and emergency skills (50, 90.91%). Most of the participants were satisfied with the nursing staffing deployments at their institutions (52, 94.55%). However, more than two thirds of them believed that their human‐resource deployment plans need further improvements (39, 70.91%).

Conclusions

Most of the designated hospitals investigated had established emergency nursing organizations, and management systems, and related regulations for the epidemic. However, the contents mentioned above still need to be further standardized.

Implications for nursing management

The surge of patients in the epidemic was considerable challenge for the emergency capacity of hospitals. In the future, we should pay more attention to the following aspects: building emergency nursing staffing platforms, increasing emergency human‐resource reserves, establishing reliable communication channels for emergency response teams, improving the rules and regulations of emergency human‐resource management, offering more training and drills for emergency‐related knowledge and skills and giving more focus on bio‐psycho‐social wellbeing of nurses.

Mortality of Mechanically Ventilated COVID-19 Patients in Traditional versus Expanded ICUs in NY

RATIONALE

During the first wave of the coronavirus disease 2019 (COVID-19) pandemic in New York City, the number of mechanically ventilated COVID-19 patients rapidly surpassed the capacity of traditional Intensive Care Units (ICUs), resulting in health systems utilizing other areas as expanded ICUs to provide critical care.

OBJECTIVES

To evaluate the mortality of patients admitted to expanded ICUs compared with those admitted to traditional ICUs.

METHODS

Multicenter, retrospective, cohort study of mechanically ventilated patients with COVID-19 admitted to the ICUs at 11 Northwell Health hospitals in the greater New York City area between March 1, 2020 and April 30, 2020.

MEASUREMENTS

In-hospital mortality up to 28 days after intubation of COVID-19 patients.

RESULTS

Among 1,966 mechanically ventilated patients with COVID-19, 1,198 (61%) died within 28 days after intubation, 46 (2%) were transferred to other hospitals outside of the Northwell Health system, 722 (37%) survived in the hospital until 28 days or were discharged after recovery. The risk of mortality of mechanically ventilated patients admitted to expanded ICUs was not different from those admitted to traditional ICUs (HR, 1.07; 95% CI, 0.95-1.20; p = 0.28), while hospital occupancy for critically ill patients itself was associated with increased risk of mortality (HR, 1.28; 95% CI, 1.12-1.45; p < 0.001).

CONCLUSIONS

Although increased hospital occupancy for critically ill patients itself was associated with increased mortality, the risk of 28-day in-hospital mortality of mechanically ventilated patients with COVID-19 who were admitted to expanded ICUs was not different from those admitted to traditional ICUs.

"Well, I Signed Up to Be a Soldier; I Have Been Trained and Equipped Well": Exploring Healthcare Workers' Experiences during COVID-19 Organizational Changes in Singapore, from the First Wave to the Path towards Endemicity

(1) Background: As COVID-19 transmission continues despite vaccination programs, healthcare workers (HCWs) face an ongoing pandemic response. We explore the effects of this on (1) Heartware, by which we refer to morale and commitment of HCWs; and identify how to improve (2) Hardware, or ways of enabling operational safety and functioning. (2) Methods: Qualitative e-diary entries were shared by HCWs during the early phases of the outbreak in Singapore from June to August 2020. Data were collected via an online survey of n = 3616 HCWs of all cadres. Nine institutions—restructured hospitals (n = 5), affiliated primary partners (n = 2) and hospices (n = 2)—participated. Applied thematic analysis was undertaken and organized according to Heartware and Hardware. Major themes are in italics (3) Results: n = 663 (18%) HCWs submitted a qualitative entry. Dominant themes undermining (1) Heartware consisted of burnout from being overworked and emotional exhaustion and at times feeling a lack of appreciation or support at work. The most common themes overriding morale breakers were a stoic acceptance to fight, adjust and hold the line, coupled with motivation from engaging leadership and supportive colleagues. The biggest barrier in (2) Hardware analysis related to sub-optimal segregation strategies within wards and designing better protocols for case detection, triage, and admissions criteria. Overall, the most cited enabler was the timely and well-planned provision of Personal Protective Equipment (PPE) for front-liners, though scope for scale-up was called for by those not considered frontline. Analysis maps internal organizational functioning to wider external public and policy-related narratives. (4) Conclusions: COVID-19 surges are becoming endemic rather than exceptional events. System elasticity needs to build on known pillars coupling improving safety and care delivery with improving HCW morale. Accordingly, a model capturing such facets of Adaptive Pandemic Response derived from our data analyses is described. HCW burnout must be urgently addressed, and health systems moved away from reactive “wartime” response configurations.

Cancer and COVID-19 Susceptibility and Severity: A Two-Sample Mendelian Randomization and Bioinformatic Analysis

The clinical management of patients with COVID-19 and cancer is a Gordian knot that has been discussed widely but has not reached a consensus. We introduced two-sample Mendelian randomization to investigate the causal association between a genetic predisposition to cancers and COVID-19 susceptibility and severity. Moreover, we also explored the mutation landscape, expression pattern, and prognostic implications of genes involved with COVID-19 in distinct cancers. Among all of the cancer types we analyzed, only the genetic predisposition to lung adenocarcinoma was causally associated with increased COVID-19 severity (OR = 2.93, β = 1.074, se = 0.411, p = 0.009) with no obvious heterogeneity (Q = 17.29, p = 0.24) or symmetry of the funnel plot. In addition, the results of the pleiotropy test demonstrated that instrument SNPs were less likely to affect COVID-19 severity via approaches other than lung adenocarcinoma cancer susceptibility (p = 0.96). Leave-one-out analysis showed no outliers in instrument SNPs, whose elimination rendered alterations in statistical significance, which further supported the reliability of the MR results. Broad mutation and differential expression of these genes were also found in cancers, which may provide valuable information for developing new treatment modalities for patients with both cancer and COVID-19. For example, ERAP2, a risk factor for COVID-19-associated death, is upregulated in lung squamous cancer and negatively associated with patient prognosis. Hence, ERAP2-targeted treatment may simultaneously reduce COVID-19 disease severity and restrain cancer progression. Our results highlighted the importance of strengthening medical surveillance for COVID-19 deterioration in patients with lung adenocarcinoma by showing their causal genetic association. For these patients, a delay in anticancer treatment, such as chemotherapy and surgery, should be considered.

What matters: non-pharmaceutical interventions for COVID-19 in Europe

OBJECTIVES

The purpose of this study is to describe the situation of COVID-19 in European countries and to identify important factors related to prevention and control.

METHODS

We obtained data from World Health Statistics 2020 and the Institute for Health Metrics and Evaluation (IHME). We calculated the Rt values of 51 countries in Europe under different prevention and control measures. We used lasso regression to screen factors associated with morbidity and mortality. For the selected variables, we used quantile regression to analyse the relevant influencing factors in countries with different levels of morbidity or mortality.

RESULTS

The government has a great influence on the change in Rt value through prevention and control measures. The most important factors for personal and group prevention and control are the mobility index, testing, the closure of educational facilities, restrictions on large-scale gatherings, and commercial restrictions. The number of ICU beds and doctors in medical resources are also key factors. Basic sanitation facilities, such as the proportion of safe drinking water, also have an impact on the COVID-19 epidemic.

CONCLUSIONS

We described the current status of COVID-19 in European countries. Our findings demonstrated key factors in individual and group prevention measures.

Impact of COVID-19 on elective, emergency and oncological surgery during the first and the second wave in a tertiary university hospital : Have we learned the lessons?

BACKGROUND

The COVID-19 pandemic caused an important reduction in surgical activities during the first wave. Aim of this retrospective time-trend analysis was to examine whether also during the second wave in fall and winter 2020/2021 surgical interventions decreased.

METHODS

Absolut numbers and types of surgeries in a tertiary university hospital during the second COVID-19 wave in fall/winter 2020/2021 were collected from the surgical planning software and compared with the same time frame over the last 5 years. In a second step, the reduction of surgical interventions during the second wave was compared with the reduction of surgical procedures during the first wave in spring 2020 at the same hospital.

RESULTS

Despite a higher 7‑day incidence of COVID-19 infection and a higher number of patients needing ICU treatment during the second wave, the reduction of surgical interventions was 3.22% compared to 65.29% during the first wave (p < 0.0001). Elective surgical interventions decreased by 88.63% during the first wave compared to 1.79% during the second wave (p < 0.0001). Emergency and oncological interventions decreased by 35.17% during the first wave compared to 5.15% during the second wave (p : 0.0007) and 47.59% compared to 3.89% (p < 0.0001), respectively. Surgical activity reduction in our institution was less pronounced despite higher occupancy of ICU beds during the second COVID-19 wave in fall/winter 2020/2021.

CONCLUSION

Better understanding of the disease, adequate supply of disposables and improved interdisciplinary day by day management of surgical and ICU resources may have contributed to this improvement.

Integrating Risk Assessment and Decision-Making Methods in Analyzing the Dynamics of COVID-19 Epidemics in Davao City, Mindanao Island, Philippines

The COVID-19 pandemic has become a public health crisis in the Philippines and the attention of national and local health authorities is focused on managing the fluctuating COVID-19 cases. This study presents a method that integrates risk management tools into health care decision-making processes to enhance the understanding and utilization of risk-based thinking in public health decision making. The risk assessment consists of the identification of the key risk factors of the COVID-19 contagion via bow-tie diagrams. Second, the safety controls for each risk factor relevant to the Davao City context are taken into account and are identified as barriers in the bow-tie. After which, the prioritization of the identified COVID-19 risks, as well as the effectiveness of the proposed interventions, is performed using the analytic hierarchy process. Consequently, the dynamics of COVID-19 management initiatives were explored using these priorities and a system of ordinary differential equations. Our results show that reducing the number of COVID-19 fatalities should be the top priority of the health authorities. In turn, we predict that the COVID-19 contagion can be controlled and eliminated in Davao city in three-month time after prioritizing the fatalities. In order to reduce the COVID-19 fatalities, health authorities should ensure an adequate number of COVID-ready ICU facilities. The general public, on the other hand, should follow medical and science-based advice and suspected and confirmed COVID-19 patients should strictly follow isolation protocols. Overall, an informed decision-making is necessary to avoid the unwanted consequences of an uncontrolled contagion.

Nursing Home's Measures during the COVID-19 Pandemic: A Critical Reflection

This study examined the pandemic measures taken by nursing leaders to cope with COVID-19 at a nursing home in Singapore. The pandemic has affected over 215 countries, sparking a series of containment and pandemic measures by governments and healthcare organizations worldwide. Long-term care facilities are especially vulnerable to the pandemic, but little has been reported about the nursing homes' measures in handling the pandemic. The present study used Morley's (2014) three-stage critical reflection method to review meeting minutes, organizational emails, and government advisories on the COVID-19 pandemic measures undertaken by nursing leaders at a nursing home in Singapore between January and June 2020. The pandemic measures were broadly classified into four groups: (1) infection surveillance and containment measures; (2) ensuring continuity in clinical care and operational support; (3) resource and administrative coordination; and (4) staff training and development. Nurses have played a vital role in the fight against COVID-19 by ensuring continuity in patient care and demonstrating clinical leadership in pandemic efforts. This study proposes a useful nursing pandemic structure that outlines a set of functions and measures required for handling a pandemic and that can be applied to various medical emergencies and contingencies.

Understanding the Impact of Digital Health Strategies During the COVID-19 Outbreak in Saudi Arabia

BACKGROUND

The impact of COVID-19 has been analyzed from various aspects on the health care services management, accessibility and delivery of health care services. However, the COVID-19 pandemic has led to disruptions in health care services, which led to the increase in adoption of digital health technologies, mostly arising out of need and necessity.

OBJECTIVE

Focusing on the prevailing situations (increasing reliance on digital health services), this study investigates the impact of digital health technologies from the perspectives of policymakers and citizens.

METHODS

A mixed-methods approach was adopted. Twenty-seven semi-structured online interviews were conducted with experts and policymakers for assessing the impact from policymakers' perspectives. An online survey questionnaire instrument was used to collect the responses from 1698 Saudi Arabian citizens in relation to the various aspects of digital health applications.

RESULTS

Health care expenditures increased during the COVID-19 outbreak, resulting in launch of various digital health applications. While policymakers defended their stand in improving health care services and accessibility; citizens reflected inability to book medicines/personal medical equipment online (Mean=2.4) and suffered a lack of personalized care (Mean=2.9) through digital health applications. Moreover, disparities exist between the population groups with respect to the accessibility, utilization, and perceptions of digital health technologies.

CONCLUSION

Policymakers have to consider and address these differences in formulating digital health policies and implementing them.

Safe Elective Surgical Practice During COVID-19 Pandemic - A Prospective Observational Study of 303 Elective Surgeries in the UK

Aim During the COVID-19 pandemic, there has been worldwide cancellation of elective surgeries to protect patients from nosocomial viral transmission and peri-operative complications. With the unfolding situation, there is a definite need for an exit strategy to reinstate elective services. Therefore, more literature evidence supporting exit plans for elective surgical services is imperative to adopt a safe working principle. This study aims to provide evidence for safe elective surgical practice during the pandemic. Methodology This single centre, prospective, observational study included adult patients who were admitted and underwent elective surgical procedures in the trust's COVID-free environment at the Birmingham Treatment Centre between May 19 and July 14, 2020. Data were collected on demographic parameters, peri-operative variables, surgical specialities, COVID-19 reverse transcription polymerase chain reaction (RT-PCR) testing results, post-operative complications and mortality. The study also highlighted the protocols it followed for the elective services during the pandemic. Results A total of 303 patients were included with mean age of 49.9 years (SD 16.5) comprising of 59% (178) female and 41% (125) male. They were classified according to the American Society of Anaesthesiologist Grade, different surgical specialities and types of anaesthesia used. Ninety-six percent (96%) of patients were discharged on the same day. Hundred percent (100%) compliance with pre-operative COVID-19 RT-PCR testing was maintained. There was no 30-day mortality or major respiratory complications. Conclusion Careful patient selection, simultaneous involvement of the pre-assessment and anaesthetic team, strict adherence to peri-operative protocols and delivering vigilant post-operative care for COVID-19 infection can help provide safe elective surgical services if the community transmission is under reasonable control. However, it is particularly important to maintain COVID-free safe environment for such procedures.

Impact of COVID-19 Related Lockdown on the Frequency of Acute and Oncological Surgeries-Lessons Learned From an Austrian University Hospital

Innsbruck Medical University Hospital, Austria, provides the highest level of care for a region of approximately 1.8 million people. During the early COVID-19 outbreak in spring 2020 surgical activity was drastically reduced with the prime goal of preserving hospital capacities, especially intensive care beds. We conducted a retrospective analysis of surgical activities performed at Innsbruck Medical University Hospital during the lockdown period from March 15 to April 14, 2020 and compared these activities to the same period during the previous 5 years. Total surgical activity was reduced by 65.4% compared to the same period during the previous 5 years (p < 0.001); elective surgeries were reduced by 88.7%, acute surgeries by 35.3% and oncological surgeries by 47.8% compared to the previous 5 years (all p < 0.001). This dramatic decrease in acute and oncological surgeries can most likely be ascribed to the fact that many patients avoided health care facilities because of the strict stay-at-home policy and/or the fear of contracting SARS-CoV-2 in the hospital. In view of future waves, the population should be encouraged to seek medical help for acute symptoms and to attend cancer screening programs.

Characteristics and outcomes of hospitalised adults with COVID-19 in a Global Health Research Network: a cohort study

OBJECTIVE

To examine age, gender, and temporal differences in baseline characteristics and clinical outcomes of adult patients hospitalised with COVID-19.

DESIGN

A cohort study using deidentified electronic medical records from a Global Research Network.

SETTING/PARTICIPANTS

67 456 adult patients hospitalised with COVID-19 from the USA; 7306 from Europe, Latin America and Asia-Pacific between February 2020 and January 2021.

RESULTS

In the US cohort, compared with patients 18-34 years old, patients ≥65 had a greater risk of intensive care unit (ICU) admission (adjusted HR (aHR) 1.73, 95% CI 1.58 to 1.90), acute respiratory distress syndrome(ARDS)/respiratory failure (aHR 1.86, 95% CI 1.76 to 1.96), invasive mechanical ventilation (IMV, aHR 1.93, 95% CI, 1.73 to 2.15), and all-cause mortality (aHR 5.6, 95% CI 4.36 to 7.18). Men appeared to be at a greater risk for ICU admission (aHR 1.34, 95% CI 1.29 to 1.39), ARDS/respiratory failure (aHR 1.24, 95% CI1.21 to 1.27), IMV (aHR 1.38, 95% CI 1.32 to 1.45), and all-cause mortality (aHR 1.16, 95% CI 1.08 to 1.24) compared with women. Moreover, we observed a greater risk of adverse outcomes during the early pandemic (ie, February-April 2020) compared with later periods. In the ex-US cohort, the age and gender trends were similar; for the temporal trend, the highest proportion of patients with all-cause mortality were also in February-April 2020; however, the highest percentages of patients with IMV and ARDS/respiratory failure were in August-October 2020 followed by February-April 2020.

CONCLUSIONS

This study provided valuable information on the temporal trends of characteristics and outcomes of hospitalised adult COVID-19 patients in both USA and ex-USA. It also described the population at a potentially greater risk for worse clinical outcomes by identifying the age and gender differences. Together, the information could inform the prevention and treatment strategies of COVID-19. Furthermore, it can be used to raise public awareness of COVID-19's impact on vulnerable populations.

Balancing scarce hospital resources during the COVID-19 pandemic using discrete-event simulation

COVID-19 has disrupted healthcare operations and resulted in large-scale cancellations of elective surgery. Hospitals throughout the world made life-altering resource allocation decisions and prioritised the care of COVID-19 patients. Without effective models to evaluate resource allocation strategies encompassing COVID-19 and non-COVID-19 care, hospitals face the risk of making sub-optimal local resource allocation decisions. A discrete-event-simulation model is proposed in this paper to describe COVID-19, elective surgery, and emergency surgery patient flows. COVID-19-specific patient flows and a surgical patient flow network were constructed based on data of 475 COVID-19 patients and 28,831 non-COVID-19 patients in Addenbrooke's hospital in the UK. The model enabled the evaluation of three resource allocation strategies, for two COVID-19 wave scenarios: proactive cancellation of elective surgery, reactive cancellation of elective surgery, and ring-fencing operating theatre capacity. The results suggest that a ring-fencing strategy outperforms the other strategies, regardless of the COVID-19 scenario, in terms of total direct deaths and the number of surgeries performed. However, this does come at the cost of 50% more critical care rejections. In terms of aggregate hospital performance, a reactive cancellation strategy prioritising COVID-19 is no longer favourable if more than 7.3% of elective surgeries can be considered life-saving. Additionally, the model demonstrates the impact of timely hospital preparation and staff availability, on the ability to treat patients during a pandemic. The model can aid hospitals worldwide during pandemics and disasters, to evaluate their resource allocation strategies and identify the effect of redefining the prioritisation of patients.

Impact of public health interventions to curb SARS-CoV-2 spread assessed by an evidence-educated Delphi panel and tailored SEIR model

AIM

To use a Delphi-panel-based assessment of the effectiveness of different non-pharmaceutical interventions (NPI) in order to retrospectively approximate and to prospectively predict the SARS-CoV-2 pandemic progression via a SEIR model (susceptible, exposed, infectious, removed).

METHODS

We applied an evidence-educated Delphi-panel approach to elicit the impact of NPIs on the SARS-CoV-2 transmission rate R₀ in Germany. Effectiveness was defined as the product of efficacy and compliance. A discrete, deterministic SEIR model with time step of 1 day, a latency period of 1.8 days, duration of infectiousness of 5 days, and a share of the total population of 15% assumed to be protected by immunity was developed in order to estimate the impact of selected NPI measures on the course of the pandemic. The model was populated with the Delphi-panel results and varied in sensitivity analyses.

RESULTS

Efficacy and compliance estimates for the three most effective NPIs were as follows: test and isolate 49% (efficacy)/78% (compliance), keeping distance 42%/74%, personal protection masks (cloth masks or other face masks) 33%/79%. Applying all NPI effectiveness estimates to the SEIR model resulted in a valid replication of reported occurrence of the German SARS-CoV-2 pandemic. A combination of four NPIs at consented compliance rates might curb the CoViD-19 pandemic.

CONCLUSION

Employing an evidence-educated Delphi-panel approach can support SARS-CoV-2 modelling. Future curbing scenarios require a combination of NPIs. A Delphi-panel-based NPI assessment and modelling might support public health policy decision making by informing sequence and number of needed public health measures.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10389-021-01566-2.

Knowledge, attitudes, and practices towards COVID-19 among Venezuelans during the 2020 epidemic: An online cross-sectional survey

Background

COVID-19 threatens health systems worldwide, but Venezuela’s system is particularly vulnerable. To prevent the spread of COVID-19, individuals must adopt preventive behaviors. However, to encourage behavior change, we must first understand current knowledge, attitudes, and practices (KAPs) that inform response to this health threat.

Methods

We explored KAPs among Venezuelans using a cross-sectional, internet-based questionnaire. The questionnaire explored individuals’ knowledge about COVID-19; their attitudes toward the world’s and the Venezuelan authorities’ abilities to control it; and their self-reported practices. We also collected demographic data. Binomial logistic regression analyses were used to predict the adoption of preventive behaviors based on demographic variables, individual knowledge level, and individual attitudes.

Results

3122 individuals completed the questionnaire. Participants had a high level of knowledge about COVID-19. They expressed high levels of optimism that the world would eventually control COVID-19, but they were very pessimistic about the public authorities in Venezuela. Most participants adopted preventive practices. Binomial regression suggests younger people, less educated people, and manual laborers hold lower levels of knowledge, and these groups, as well as men, were less likely to adopt preventive practices. Knowledge, by itself, had no association with optimism and little association with self-reported practices.

Conclusions

As other KAP studies in Latin America found, knowledge is not sufficient to prompt behavior change. Venezuelans’ pessimism about their own country’s ability should be explored in greater depth. Health promotion in Venezuela may wish to target the most at risk groups: men, younger people, less educated people, and manual laborers.

Hospital staff well-being during the first wave of COVID-19: Staff perspectives

The purpose of this research is to determine the impact of working during the early stage of the COVID-19 pandemic on the well-being of staff at one 600-bed acute hospital in metropolitan Melbourne, Australia. This exploratory study is part of a larger mixed methods survey project, reporting the qualitative data from an on-line survey of clinical staff working at one acute hospital between April 16th and May 13th, 2020 during the COVID-19 pandemic. Responses to five free-text questions were analysed using inductive content analysis. 321 medical, nursing, allied health and non-clinical staff responded to the survey. Respondents reported anxiety, fear and uncertainty related to the pandemic, from the perspectives of work, home, family and community. They reported feeling confused by inconsistent messages received from government, hospital executive, managers and media. Seven themes were identified: (i) worrying about patient care, (ii) changed working conditions, (iii) working in the changed hospital environment, (iv) impact of the pandemic, (v) personal isolation and uncertainty, (vi) leadership and management and (vii) additional support needed for staff. Despite the pandemic being comparatively well-controlled in Australia, all disciplines reported a high degree of anticipatory anxiety. Staff working in healthcare require both managerial and psychological support to minimise anxiety and promote well-being and resilience in order to deal with the health crisis. Regular unambiguous communication directing the way forward is crucial.

Use of powered air-purifying respirator(PAPR) as part of protective equipment against SARS-CoV-2-a narrative review and critical appraisal of evidence

BACKGROUND

The last 2 decades have seen an increasing frequency of zoonotic origin viral diseases leaping from animal to human hosts including Severe Acute Respiratory Syndrome Coronaviruses (SARS-CoV-2). Respiratory component of the infectious disease program against SARS-CoV-2 incorporates use of protective airborne respiratory equipment.

METHODS

In this narrative review, we explore the features of Powered Air Purifying Respirators (PAPR) as well as logistical and evidence-based advantages and disadvantages.

RESULTS

Simulation study findings support increased heat tolerance and wearer comfort with a PAPR, versus decreased communication ability, mobility, and dexterity. Although PAPRs have been recommended for high-risk procedures on suspected or confirmed COVID-19 patients, this recommendation remains controversial due to lack of evidence. Guidelines for appropriate use of PAPR during the current pandemic are sparse. International regulatory bodies do not mandate the use of PAPR for high-risk aerosol generating procedures in patients with SARS-CoV-2. Current reports of the choice of protective respiratory technology during the SARS-CoV-2 pandemic are disparate. Patterns of use appear to be related to geographical locations.

DISCUSSION

Field observational studies do not indicate a difference in healthcare worker infection utilizing PAPR devices versus other compliant respiratory equipment in healthcare workers performing AGPs in patients with SARS-CoV-2. Whether a higher PAPR filtration factor translates to decreased infection rates of HCWs remains to be elucidated. Utilization of PAPR with high filtration efficiency may represent an example of "precautionary principle" wherein action taken to reduce risk is guided by logistical advantages of PAPR system.

Workplace factors associated with mental health of healthcare workers during the COVID-19 pandemic: an international cross-sectional study

BACKGROUND

The association of workplace factors on mental health of healthcare workers (HCWs) during the COVID-19 pandemic needs to be urgently established. This will enable governments and policy-makers to make evidence-based decisions. This international study reports the association between workplace factors and the mental health of HCWs during the pandemic.

METHODS

An international, cross-sectional study was conducted in 41 countries. The primary outcome was depressive symptoms, derived from the validated Patient Health Questionnaire-2 (PHQ-2). Multivariable logistic regression identified factors associated with mental health outcomes. Inter-country differences were also evaluated.

RESULTS

A total of 2527 responses were received, from 41 countries, including China (n = 1213; 48.0%), UK (n = 891; 35.3%), and USA (n = 252; 10.0%). Of all participants, 1343 (57.1%) were aged 26 to 40 years, and 2021 (80.0%) were female; 874 (34.6%) were doctors, and 1367 (54.1%) were nurses. Factors associated with an increased likelihood of depressive symptoms were: working in the UK (OR = 3.63; CI = [2.90-4.54]; p < 0.001) and USA (OR = 4.10; CI = [3.03-5.54]), p < 0.001); being female (OR = 1.74; CI = [1.42-2.13]; p < 0.001); being a nurse (OR = 1.64; CI = [1.34-2.01]; p < 0.001); and caring for a COVID-19 positive patient who subsequently died (OR = 1.20; CI = [1.01-1.43]; p = 0.040). Workplace factors associated with depressive symptoms were: redeployment to Intensive Care Unit (ICU) (OR = 1.67; CI = [1.14-2.46]; p = 0.009); redeployment with perceived unsatisfactory training (OR = 1.67; CI = [1.32-2.11]; p < 0.001); not being issued with appropriate personal protective equipment (PPE) (OR = 2.49; CI = [2.03-3.04]; p < 0.001); perceived poor workplace support within area/specialty (OR = 2.49; CI = [2.03-3.04]; p < 0.001); and perceived poor mental health support (OR = 1.63; CI = [1.38-1.92]; p < 0.001).

CONCLUSION

This is the first international study, demonstrating that workplace factors, including PPE availability, staff training pre-redeployment, and provision of mental health support, are significantly associated with mental health during COVID-19. Governments, policy-makers and other stakeholders need to ensure provision of these to safeguard HCWs' mental health, for future waves and other pandemics.

Comparing outcomes of tunnelled dialysis catheter insertions and exchanges with or without fluoroscopy

BACKGROUND/OBJECTIVE

To study the safety and outcome profiles of tunnelled dialysis catheter (TDC) insertions and exchanges with fluoroscopy versus without fluoroscopy.

METHODS

This was a retrospective cohort study of all TDC insertions or exchanges performed at our centre, between January 2017 and December 2017. Patient demographics, laboratory results and catheter placement information were obtained from electronic records. Immediate technical success, early and late catheter associated complications were collected. Outcomes for TDC inserted with or without fluoroscopy were statistically analysed.

RESULTS

A total of 351 TDC insertions and 253 TDC exchanges were performed. Out of 351 TDC insertions, 261 were done with fluoroscopy while 90 were done without. Out of 253 TDC exchanges, 219 were done with fluoroscopy while 34 were done without. For both TDC insertions and exchanges, there were no significant differences in complication rates when done with or without fluoroscopy. Mean duration of catheter patency was longer for TDC inserted without fluoroscopy, after adjusting for site of insertion and presence of previous TDC.

CONCLUSIONS

The technique of inserting TDC in the right internal jugular vein (IJV) without fluoroscopy is a safe and effective method in selected patients. This supports the practice of performing the procedure without fluoroscopy, especially in institutions where fluoroscopy facilities are not readily available. This potentially translates into reduced healthcare resources and hospitalisation days, which is particularly valuable in times of limited resources such as the current Coronavirus Disease 2019 (COVID-19) pandemic.

Use of capnography to verify emergency ventilator sharing in the COVID-19 era

Exacerbation of COVID-19 pandemic may lead to acute shortage of ventilators, which may require shared use of ventilator as a lifesaving concept. Two model lungs were ventilated with one ventilator to i) test the adequacy of individual tidal volumes via capnography, ii) assess cross-breathing between lungs, and iii) offer a simulation-based algorithm for ensuring equal tidal volumes. Ventilation asymmetry was induced by placing rubber band around one model lung, and the uneven distribution of tidal volumes (VT) was counterbalanced by elevating airflow resistance (HR) contralaterally. VT, end-tidal CO2 concentration (ETCO2), and peak inspiratory pressure (Ppi) were measured. Unilateral LC reduced VT and elevated ETCO2 on the affected side. Under HR, VT and ETCO2 were re-equilibrated. In conclusion, capnography serves as simple, bedside method for controlling the adequacy of split ventilation in each patient. No collateral gas flow was observed between the two lungs with different time constants. Ventilator sharing may play a role in emergency situations.

Preparedness of ICU networks for pandemics

PURPOSE OF REVIEW

The recent COVID-19 outbreak has clearly shown how epidemics/pandemics can challenge developed countries' healthcare systems. Proper management of equipment and human resources is critical to provide adequate medical care to all patients admitted to the hospital and the ICU for both pandemic-related and unrelated reasons.

RECENT FINDINGS

Appropriate separate paths for infected and noninfected patients and prompt isolation of infected critical patients in dedicated ICUs play a pivotal role in limiting the contagions and optimizing resources during pandemics. The key to handle these challenging events is to learn from past experiences and to be prepared for future occurrences. Hospital space should be redesigned to quickly increase medical and critical care capacity, and healthcare workers (critical and noncritical) should be trained in advance.

SUMMARY

A targeted improvement of hospital and ICU protocols will increase medical care quality for patients admitted to the hospital for any clinical reasons during a pandemic.

Early impact of school closure and social distancing for COVID-19 on the number of inpatients with childhood non-COVID-19 acute infections in Japan

Many countries have implemented school closures as part of social distancing measures intended to control the spread of coronavirus disease 2019 (COVID-19). The aim of this study was to assess the early impact of nationwide school closure (March-May 2020) and social distancing for COVID-19 on the number of inpatients with major childhood infectious diseases in Japan. Using data from the Diagnosis Procedure Combination system in Japan, we identified patients aged 15 years or younger with admissions for a diagnosis of upper respiratory tract infection (URTI), lower respiratory tract infection (LRTI), influenza, gastrointestinal infection (GII), appendicitis, urinary tract infection (UTI), or skin and soft tissue infection (SSTI) between July 2018 and June 2020. Changes in the trend of the weekly number of inpatients between the two periods were assessed using interrupted time-series analysis. A total of 75,053 patients in 210 hospitals were included. The overall weekly number of inpatients was decreased by 52.5%, 77.4%, and by 83.4% in the last week of March, April, and May 2020, respectively, when compared on a year-on-year basis. The estimated impact was a reduction of 581 (standard error 42.9) inpatients per week in the post-school-closure period (p < 0.001). The main part of the reduction was for pre-school children. Remarkable decreases in the number of inpatients with URI, LRTI, and GII were observed, while there were relatively mild changes in the other groups.Conclusion: We confirmed a marked reduction in the number of inpatients with childhood non-COVID-19 acute infections in the post-school-closure period. What is Known: • Most countries have implemented social distancing measures to limit the spread of the novel coronavirus disease 2019 (COVID-19). • A large decrease in pediatric emergency visits has been reported from several countries after the social distancing. What is New: • Based on administrative claims data, a marked reduction in the number of inpatients for childhood non-COVID-19 acute infections was found in the post-school-closure period in Japan. • The magnitude of the reduction was different between the disease groups.

Impact of COVID-19 on pediatric emergencies and hospitalizations in Singapore

BACKGROUND

Coronavirus disease 2019 (COVID-19) has impacted the provision of health services in all specialties. We aim to study the impact of COVID-19 on the utilization of pediatric hospital services including emergency department (ED) attendances, hospitalizations, diagnostic categories and resource utilization in Singapore.

METHODS

We performed a retrospective review of ED attendances and hospital admissions among children < 18 years old from January 1st to August 8th 2020 in a major pediatric hospital in Singapore. Data were analyzed in the following time periods: Pre-lockdown (divided by the change in Disease Outbreak Response System Condition (DORSCON) level), during-lockdown and post-lockdown. We presented the data using proportions and percentage change in mean counts per day with the corresponding 95% confidence intervals (CIs).

RESULTS

We attended to 58,367 children with a mean age of 5.1 years (standard deviation, SD 4.6). The mean ED attendance decreased by 331 children/day during lockdown compared to baseline (p < 0.001), attributed largely to a drop in respiratory (% change - 87.9, 95% CI - 89.3 to - 86.3, p < 0.001) and gastrointestinal infections (% change - 72.4, 95%CI - 75.9 to - 68.4, p < 0.001). Trauma-related diagnoses decreased at a slower rate across the same periods (% change - 40.0, 95%CI - 44.3 to - 35.3, p < 0.001). We saw 226 children with child abuse, with a greater proportion of total attendance seen post-lockdown (79, 0.6%) compared to baseline (36, 0.2%) (p < 0.001). In terms of ED resource utilization, there was a decrease in the overall mean number of procedures performed per day during the lockdown compared to baseline, driven largely by a reduction in blood investigations (% change - 73.9, 95%CI - 75.9 to - 71.7, p < 0.001).

CONCLUSIONS

We highlighted a significant decrease in infection-related presentations likely attributed to the lockdown and showed that the relative proportion of trauma-related attendances increased. By describing the impact of COVID-19 on health services, we report important trends that may provide guidance when planning resources for future pandemics.

Knowledge, Attitudes, and Practices Towards COVID-19 Among Ecuadorians During the Outbreak: An Online Cross-Sectional Survey

Preventing the transmission of SARS-CoV-2 (causative agent for COVID-19) requires implementing contact and respiratory precautions. Modifying human behavior is challenging and requires understanding knowledge, attitudes, and practices (KAPs) regarding health threats. This study explored KAPs among people in Ecuador. A cross-sectional, internet-based questionnaire was used to assess knowledge about COVID-19, attitudes toward ability to control COVID-19, self-reported practices related to COVID-19, and demographics. A total of 2399 individuals participated. Participants had moderate to high levels of knowledge. Participants expressed mixed attitudes about the eventual control of COVID-19 in Ecuador. Participants reported high levels of adoption of preventive practices. Binomial regression analysis suggests unemployed individuals, househusbands/housewives, or manual laborers, as well as those with an elementary school education, have lower levels of knowledge. Women, people over 50 years of age, and those with higher levels of schooling were the most optimistic. Men, individuals 18-29, single, and unemployed people took the riskiest behaviors. Generally, knowledge was not associated with optimism or with practices. Our findings indicate knowledge about COVID-19 is insufficient to prompt behavioral change among Ecuadorians. Since current COVID-19 control campaigns seek to educate the public, these efforts' impacts are likely to be limited. Given attitudes determine people's actions, further investigation into the factors underlying the lack of confidence in the ability of the world, and of Ecuador, to overcome COVID-19, is warranted. Edu-communicational campaigns should be accompanied by efforts to provide economically disadvantaged populations resources to facilitate adherence to recommendations to prevent the spread of the virus.

From cholera to COVID-19: How pandemics have shaped the development of anaesthesia and intensive care medicine

The infectious pandemics and epidemics of the past 200 years have caused millions of deaths. However, these devastating events have also led to creative thinking, imaginative experimentation and the evolution of medical care. As a result, the history of critical care medicine is entwined with the story of these global disasters. This article will take case studies from recent pandemics and epidemics and examine their impact on the development of anaesthesia and intensive care medicine.

Home quarantine is a useful strategy to prevent the coronavirus outbreak: Identifying the reasons for non-compliance in some Iranians

INTRODUCTION

The coronavirus outbreak has become a worrying issue and some people refuse to stay at home. Therefore, this study aims to identify the reasons behind some Iranian people's refusal to stay at home to prevent further virus transmission.

METHOD

This cross-sectional study was conducted on postgraduate students in Iran. A questionnaire was designed based on 50 experts' opinions by using the Delphi method and 203 students completed the designed questionnaire in telegram groups.

RESULTS

35% of participants were upper 30 years of age, 70.4% were female, 74.4% had no coronavirus infection among their relatives, and 54.7% of them were Ph.D. candidates. The relations between "unclear accountability of events by some officials" and age as well as "failure to provide dissenting viewpoints and critical comments" and age were statistically significant (p = 0.027، p = 0.014). Moreover the relation between coronavirus infected relative and "persistent beliefs" was statistically significant (p = 0.014). The Chi-square test showed that gender, degree, resident and education province did not affect questions answering. The greatest agreement with questions is as following: lack of real situation understanding; 89.7%, people's livelihoods, and lack of government planning for low-income groups support; 86.7%, lack of people's knowledge concerning the coronavirus; 80.8%, lack of communicative educations for crisis situations; 79.8%, false assurance as well as minimizes the risks; 78.3%.

CONCLUSION

Identifying the non-compliance factors with health recommendations can guide health care providers and managers to implementation of beneficial intervention.

A Systematic Narrative Review of Comprehensive Preparedness Strategies of Healthcare Resources for a Large Resurgence of COVID-19 Nationally, with Local or Regional Epidemics: Present Era and Beyond

Coronavirus disease 2019 (COVID-19) has penetrated our daily lives, leading us to a new normal era. The unexpected impact of COVID-19 has posed a unique challenge for the health care system, bringing innovation around the world. Considering the current pandemic pattern, comprehensive preparedness strategies of healthcare resources need to be implemented to prepare for a large resurgence of COVID-19 within a short time. With the unprecedented spread of the new pandemic and the impending influenza season, scientific evidence-based schemes need to be developed through cooperation, coordination, and solidarity. Based on the early experience with the current pandemic, this narrative interpretive review of qualitative studies suggests a 6-domain plan to establish a better health care system that is prepared to deal with the current and future public health crises. The 6 domains are medical institutions, medical workforce, medical equipment, COVID-19 surveillance, data and information application, and governance structure.

Core Outcomes Set for Trials in People With Coronavirus Disease 2019

OBJECTIVES

The outcomes reported in trials in coronavirus disease 2019 are extremely heterogeneous and of uncertain patient relevance, limiting their applicability for clinical decision-making. The aim of this workshop was to establish a core outcomes set for trials in people with suspected or confirmed coronavirus disease 2019.

DESIGN

Four international online multistakeholder consensus workshops were convened to discuss proposed core outcomes for trials in people with suspected or confirmed coronavirus disease 2019, informed by a survey involving 9,289 respondents from 111 countries. The transcripts were analyzed thematically. The workshop recommendations were used to finalize the core outcomes set.

SETTING

International.

SUBJECTS

Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public and health professionals (including clinicians, policy makers, regulators, funders, researchers).

INTERVENTIONS

None.

MEASUREMENTS

None.

MAIN RESULTS

Six themes were identified. "Responding to the critical and acute health crisis" reflected the immediate focus on saving lives and preventing life-threatening complications that underpinned the high prioritization of mortality, respiratory failure, and multiple organ failure. "Capturing different settings of care" highlighted the need to minimize the burden on hospitals and to acknowledge outcomes in community settings. "Encompassing the full trajectory and severity of disease" was addressing longer term impacts and the full spectrum of illness (e.g. shortness of breath and recovery). "Distinguishing overlap, correlation and collinearity" meant recognizing that symptoms such as shortness of breath had distinct value and minimizing overlap (e.g. lung function and pneumonia were on the continuum toward respiratory failure). "Recognizing adverse events" refers to the potential harms of new and evolving interventions. "Being cognizant of family and psychosocial wellbeing" reflected the pervasive impacts of coronavirus disease 2019.

CONCLUSIONS

Mortality, respiratory failure, multiple organ failure, shortness of breath, and recovery are critically important outcomes to be consistently reported in coronavirus disease 2019 trials.

Regional extracorporeal membrane oxygenation retrieval service during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic: an interdisciplinary team approach to maintain service provision despite increased demand

OBJECTIVES

Coronavirus disease 2019 is a new contagious disease that has spread rapidly across the world. It is associated with high mortality in those who develop respiratory complications and require admission to intensive care. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy option for selected severely ill patients who deteriorate despite the best supportive care. During the coronavirus disease 2019 pandemic, extra demand led to staff reorganization; hence, cardiac surgery consultants joined the ECMO retrieval team. This article describes how we increased service provisions to adapt to the changes in activity and staffing.

METHODS

The data were collected from 16 March 2020 to 8 May 2020. The patients were referred through a dedicated Web-based referral portal to cope with increasing demand. The retrieval team attended the referring hospital, reviewed the patients and made the final decision to proceed with ECMO.

RESULTS

We reported 41 ECMO retrieval runs during this study period. Apart from staffing changes, other retrieval protocols were maintained. The preferred cannulation method for veno-venous ECMO was drainage via the femoral vein and return to the right internal jugular vein. There were no complications reported during cannulation or transport.

CONCLUSIONS

Staff reorganization in a crisis is of paramount importance. For those with precise transferrable skills, experience can be gained quickly with appropriate supervision. Therefore, the team members were selected based on skill mix rather than on roles that are more traditional. We have demonstrated that an ECMO retrieval service can be reorganized swiftly and successfully to cope with the sudden increase in demand by spending cardiac surgeons services to supplement the anaesthetic-intensivist roles.

Peri-operative COVID-19 infection in urgent elective surgery during a pandemic surge period: a retrospective observational cohort study

Maintaining safe elective surgical activity during the global coronavirus disease 2019 (COVID-19) pandemic is challenging and it is not clear how COVID-19 may impact peri-operative morbidity and mortality in this population. Therefore, adaptations to normal care pathways are required. Here, we establish if implementation of a bespoke peri-operative care bundle for urgent elective surgery during a pandemic surge period can deliver a low COVID-19-associated complication profile. We present a single-centre retrospective cohort study from a tertiary care hospital of patients planned for urgent elective surgery during the initial COVID-19 surge in the UK between 29 March and 12 June 2020. Patients asymptomatic for COVID-19 were screened by oronasal swab and chest imaging (chest X-ray or computed tomography if aged ≥ 18 years), proceeding to surgery if negative. COVID-19 positive patients at screening were delayed. Postoperatively, patients transitioning to COVID-19 positive status by reverse transcriptase polymerase chain reaction testing were identified by an in-house tracking system and monitored for complications and death within 30 days of surgery. Out of 557 patients referred for surgery (230 (41.3%) women; median (IQR [range]) age 61 (48-72 [1-89])), 535 patients (96%) had COVID-19 screening, of which 13 were positive (2.4%, 95%CI 1.4-4.1%). Out of 512 patients subsequently undergoing surgery, 7 (1.4%) developed COVID-19 positive status (1.4%, 95%CI 0.7-2.8%) with one COVID-19-related death (0.2%, 95%CI 0.0-1.1%) within 30 days. Out of these seven patients, four developed pneumonia, of which two required invasive ventilation including one patient with acute respiratory distress syndrome. Low rates of COVID-19 infection and mortality in the elective surgical population can be achieved within a targeted care bundle. This should provide reassurance that elective surgery can continue, where possible, despite high community rates of COVID-19.

Renal impairment and its impact on clinical outcomes in patients who are critically ill with COVID-19: a multicentre observational study

Renal impairment is common in patients who are critically ill with coronavirus disease-19 (COVID-19). We examined the association between acute and chronic kidney disease with clinical outcomes in 372 patients with coronavirus disease-19 admitted to four regional intensive care units between 10 March 2020 and 31 July 2020. A total of 216 (58%) patients presented with COVID-19 and renal impairment. Acute kidney injury and/or chronic kidney disease was associated with greater in-hospital mortality compared with patients with preserved renal function (107/216 patients (50%) (95%CI 44-57) vs. 32/156 (21%) (95%CI 15-28), respectively; p < 0.001, relative risk 2.4 (95%CI 1.7-3.4)). Mortality was greatest in patients with renal transplants (6/7 patients (86%) (95%CI 47-100)). Mortality rates increased in patients with worsening renal injury according to the Kidney Disease: Improving Global Outcomes classification: stage 0 mortality 33/157 patients (21%) (95%CI 15-28) vs. stages 1-3 mortality 91/186 patients (49%) (95%CI 42-56); p < 0.001, relative risk 2.3 (95%CI 1.7-3.3). Survivors were less likely to require renal replacement therapy compared with non-survivors (57/233 patients (24%) vs. 64/139 patients (46%), respectively; p < 0.001, relative risk 1.9 (95%CI 1.4-2.5)). One-fifth of survivors who required renal replacement therapy acutely in intensive care continued to require renal support following discharge. Our data demonstrate that renal impairment in patients admitted to intensive care with COVID-19 is common and is associated with a high mortality and requirement for on-going renal support after discharge from critical care. Our findings have important implications for future pandemic planning in this patient cohort.

Characteristics and Outcomes of COVID-19 Patients with Respiratory Failure Admitted to a “Pandemic Ready” Intensive Care Unit – Lessons from Singapore

Introduction: Singapore was one of the first countries affected by the coronavirus disease 2019 (COVID-19) pandemic but has been able to prevent its healthcare system and intensive care units (ICU) from being overwhelmed. We describe the clinical features, management and outcomes of COVID-19 patients with respiratory failure admitted to our ICU. Materials and Methods: A case series of COVID-19 patients admitted to our ICU for respiratory failure from 7 February, with data censoring at 30 June 2020, was performed from a review of medical records. Results: Twenty-two COVID-19 patients were admitted to our ICU for respiratory failure. The median age was 54.5 years (IQR 30–45.5), 72.7% were male and had at least one comorbidity. The Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 2.5 (IQR 1.25–7) and 10 (8.25–12) respectively. Thirteen patients required invasive mechanical ventilation (IMV) and had a median PaO2/FiO2 ratio of 194 mmHg (IQR 173–213) after intubation. The 28-day survival was 100%, with 2 patients demising subsequently. The overall ICU mortality rate was 9.1% at the time of data censoring. In IMV survivors, length of IMV and ICU stay were 11 days (IQR 9–17.75) and 16 days (IQR 12–32) respectively. Conclusion: Low COVID-19 ICU mortality was observed in our “pandemic-ready” ICU. This was achieved by having adequate surge capacity to facilitate early ICU admission and IMV, lung protective ventilation, and slow weaning. Being able to maintain clinical standards and evidence-based practices without having to resort to rationing contributed to better outcomes. Keywords: Acute respiratory distress syndrome, Coronavirus, Critical care, Pandemic, Pneumonia

Transplantation in Asia during the coronavirus disease-19 (COVID-19) pandemic: briefs from member countries of the Asian Society of Transplantation

The coronavirus disease-19 (COVID-19) pandemic has affected 1,029,968 people in Asia as of May 16, 2020. Although Asia was the first continent to be affected, many countries in the region continue to battle COVID-19, which challenges the way transplant programs provide their services. Given the diversity of healthcare systems in Asia, the countermeasures in response to COVID-19 are as potentially diverse. This review reports the experiences of transplant services in member countries of the Asian Society of Transplantation (AST) as well as provides a platform for sharing of best practices during the COVID-19 pandemic. AST invited member countries to provide a short description of their transplant experiences during the COVID-19 pandemic. Whenever information is available, countries were asked to provide information on COVID-19 related statistics, status of transplant programs, mitigation measures taken to prevent COVID-19, and other areas of transplant programs impacted by COVID-19. Ten countries responded to the invitation of which seven still have active transplant programs at varying levels of activity. All countries have protocols for donor/recipient screening and countermeasures to prevent COVID-19 infections in recipients and healthcare providers. Interestingly, these countries report only 16 transplant recipients with COVID-19 infection but no cases of donor-transmitted COVID-19 infection. Despite the diversity of healthcare systems in Asia, transplant centers in Asia have taken appropriate precautions to avoid COVID-19 infections, though the long-term impact of COVID-19 remains unclear.