The saudi critical care society clinical practice guidelines on the management of COVID-19 patients in the intensive care unit

Acceptance, Advocacy, and Perception of Health Care Providers on COVID-19 Vaccine: Comparing Early Stage of COVID-19 Vaccination with Latter Stage in the Eastern Region of Saudi Arabia

Vaccination of healthcare providers has recently gained focused attention of public health officials. As HCPs have direct contact with the population, and HCPs significantly influence the population, this study aimed to compare the acceptance rate, advocacy rate, and beliefs about the COVID-19 vaccine among HCPs in two time periods. In this repeated cross-sectional study, different HCPs were assessed in two periods ten months apart, i.e., November to December 2020 and September to October 2021, which were before and after COVID-19 vaccine approval by authorities. The study was conducted in Qatif Central Hospital, Eastern Region of Saudi Arabia. There were 609 respondents: 236 participants in the first period and 373 participants in the second period. Only 13 participants did not get the COVID-19 vaccine. There was around a 40% difference in the acceptance rate between the two study periods; the latter period was higher at 94.7%. Furthermore, 24.1% was the difference between the willingness to advocate the COVID-19 vaccine for others; the first period had a lower percentage (60.1%). Overall, results of the study showed that vaccine hesitancy, as well as the willingness to advocate for the vaccine, were improved between the pre-vaccine approval period and post-vaccine approval period, showing that the efforts made by the government improved COVID-19 acceptance and advocacy among HCPs. However, vaccine hesitancy is not a new issue, and for a better understanding of HCPs' beliefs, a qualitative study is needed.

Antibiotics Usage and Resistance among Patients with Severe Acute Respiratory Syndrome Coronavirus 2 in the Intensive Care Unit in Makkah, Saudi Arabia

Antibiotic resistance is a global health and development threat, especially during the Severe Acute Respiratory Syndrome Coronavirus 2 (COVID-19) pandemic. Therefore, the current study was conducted to describe antibiotic usage and resistance among patients with COVID-19 in the intensive care unit (ICU) in Makkah, Saudi Arabia. In this cross-sectional study, only patients with positive COVID-19 status (42 patients) admitted to the ICU at the King Faisal Hospital were selected using a census sampling method. The susceptibility test of bacteria was carried out according to the standard protocol. The identified strains were tested in-vitro against several antibiotics drugs. Statistical analysis was performed using SPSS version 24. A total of 42 patients were included, with a mean age of 59.35 ± 18 years. Of them, 38.1% were males, and 61.9% were females. 35.7% have blood group O +. For age and blood groups, statistically significant associations were found between males and females, with p-values = 0.037 and 0.031, respectively. A large percentage (42.7%) of the obtained samples contained Klebsiella Pneumoniae; all bacteria were multidrug-resistance bacteria. Furthermore, 76.2% of bacteria were resistant to Ampicillin, 66.7% were resistant to Ciprofloxacin, 64.3% were resistant to Levofloxacin, 57.1% were resistant to Imipenem, and 57.1% were resistant to Moxifloxacin. On the contrary, among the 40 examined antibiotics, the effective antibiotics were Daptomycin, Linezolid, Mupirocin, Synercid, Teicoplanin, Vancomycin, and Nitrofurantoin. Our study demonstrates that antibiotic resistance is highly prevalent among ICU patients with COVID-19 at the King Faisal Hospital. Additionally, all bacteria were multidrug-resistance bacteria. Therefore, this high prevalence should be seriously discussed and urgently considered.

Early use of tocilizumab in solid organ transplant recipients with COVID-19: A retrospective cohort study in Saudi Arabia

BACKGROUND

Tocilizumab was studied to reduce cytokine syndrome in patients with severe COVID-19 pneumonia in solid organ transplant (SOT) recipients with conflicting results. We aim to study the early use of tocilizumab in SOT with COVID-19 pneumonia on low flow oxygen.

METHODS

This is a retrospective cohort study that was conducted in two transplant centers in Saudi Arabia among 46 SOT with COVID-19 comparing 21 patients who received tocilizumab to 25 patients who received standard of care. Their clinical characteristics and outcomes were described.

RESULTS

Compared to patients who received standard of care, patients in the tocilizumab group were older (60.2 ± 12.8 vs. 48.6 ± 12.3, p = .003), had higher ferritin (862.1 ± 919.1 vs. 414 ± 447.3, p = .025) and C-reactive protein (CRP) (85 ± 83.1 vs. 42.9 ± 57.3, p = .012). More patients in the tocilizumab group required high flow oxygen (38.1% vs. 8.0%, p = .028) compared to patients on standard of care. There were no differences in mortality or mechanical ventilation requirement. Hospital stay was significantly shorter in the tocilizumab group than the standard of care group (9.6 ± 7.4 vs. 20.7 ± 11.7, p < .001).

CONCLUSIONS

Early use of tocilizumab in SOT was associated with a shorter hospital stay. There was no difference in mortality rate and the requirement for mechanical ventilation in both groups.

COVID-19 Patients’ Satisfaction Levels with Nursing Care: A Cross-Sectional Study

Introduction

COVID-19 is the most recent coronavirus diseases that was first identified in December 2019 and began its exponential spread globally. The critical role of nurses can be severely impacted during pandemics such as COVID-19 when the world is less prepared.

Objective

To investigate and measure COVID-19 patients’ satisfaction levels with the quality of nursing care provided in the Riyadh Province of Saudi Arabia.

Methods

The study used a cross-sectional questionnaire to collect data from COVID-19 patients who were hospitalized or quarantined for at least 48 h or more. The study utilized the Arabic version of the Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ-Ar) to assess patients’ satisfaction levels with nursing care. Descriptive statistics, Mann-Whitney U, and Kruskal-Wallis tests were performed to examine the objectives of the study.

Results

Ninety-six patients reported relatively high satisfaction levels with the overall nursing care. Patients also reported high satisfaction levels with the provided care, and the information that was provided. There were statistically significant differences in the mean score of patients satisfaction in relation to age, educational level, where patients are originally from, and patients recommendation of the hospitals.

Conclusions

Individual characteristics and attributes played a role in the process of evaluating nursing care services. Measuring nursing care quality clarified the significant role of nurses during the COVID-19 pandemic. This study provides valuable information that could help in identifying weaknesses and reinforcing strengths about nursing care to be fully prepared against pandemics and other health-related crises and emergencies in the future.

International alliance and AGREE-ment of 71 clinical practice guidelines on the management of critical care patients with COVID-19: a living systematic review

OBJECTIVE

We aimed to systematically identify and critically assess the clinical practice guidelines (CPGs) for the management of critically ill patients with COVID-19 with the AGREE II instrument.

STUDY DESIGN AND SETTING

We searched Medline, CINAHL, EMBASE, CNKI, CBM, WanFang, and grey literature from November 2019 - November 2020. We did not apply language restrictions. One reviewer independently screened the retrieved titles and abstracts, and a second reviewer confirmed the decisions. Full texts were assessed independently and in duplicate. Disagreements were resolved by consensus. We included any guideline that provided recommendations on the management of critically ill patients with COVID-19. Data extraction was performed independently and in duplicate by two reviewers. We descriptively summarized CPGs characteristics. We assessed the quality with the AGREE II instrument and we summarized relevant therapeutic interventions.

RESULTS

We retrieved 3,907 records and 71 CPGs were included. Means (Standard Deviations) of the scores for the 6 domains of the AGREE II instrument were 65%(SD19.56%), 39%(SD19.64%), 27%(SD19.48%), 70%(SD15.74%), 26%(SD18.49%), 42%(SD34.91) for the scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, editorial independence domains, respectively. Most of the CPGs showed a low overall quality (less than 40%).

CONCLUSION

Future CPGs for COVID-19 need to rely, for their development, on standard evidence-based methods and tools.

The Saudi Critical Care Society practice guidelines on the management of COVID-19 in the ICU: Therapy section

BACKGROUND

The rapid increase in coronavirus disease 2019 (COVID-19) cases during the subsequent waves in Saudi Arabia and other countries prompted the Saudi Critical Care Society (SCCS) to put together a panel of experts to issue evidence-based recommendations for the management of COVID-19 in the intensive care unit (ICU).

METHODS

The SCCS COVID-19 panel included 51 experts with expertise in critical care, respirology, infectious disease, epidemiology, emergency medicine, clinical pharmacy, nursing, respiratory therapy, methodology, and health policy. All members completed an electronic conflict of interest disclosure form. The panel addressed 9 questions that are related to the therapy of COVID-19 in the ICU. We identified relevant systematic reviews and clinical trials, then used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach as well as the evidence-to-decision framework (EtD) to assess the quality of evidence and generate recommendations.

RESULTS

The SCCS COVID-19 panel issued 12 recommendations on pharmacotherapeutic interventions (immunomodulators, antiviral agents, and anticoagulants) for severe and critical COVID-19, of which 3 were strong recommendations and 9 were weak recommendations.

CONCLUSION

The SCCS COVID-19 panel used the GRADE approach to formulate recommendations on therapy for COVID-19 in the ICU. The EtD framework allows adaptation of these recommendations in different contexts. The SCCS guideline committee will update recommendations as new evidence becomes available.

Clinical Practice and Barriers of Ventilatory Support Management in COVID-19 Patients in Saudi Arabia: A Survey of Respiratory Therapists

Objective:

This study was conducted to determine the clinical practice and barriers of ventilatory support management in COVID-19 patients in Saudi Arabia among respiratory therapists.

Methods:

A validated questionnaire comprising three parts was distributed to all critical care respiratory therapists registered with the Saudi Society for Respiratory Care through the official social networks.

Results:

A total of 74 respiratory therapists completed the survey. The mean (±standard deviation) of intensive care unit beds was 67 ± 79. Clinical presentation (54%) and arterial blood gas (38%) were the two main diagnostic tools used to initiate ventilatory support. While protocols for the initiation of invasive mechanical ventilation (IMV; 81%) were widely available, participants had limited availability of protocols for the use of non-invasive ventilation (NIV; 34%) and high-flow nasal cannula (HFNC; 34%). In mild cases of COVID-19, most respondents used HFNC (57%), while IMV was mostly used in moderate (43%) and severe (93%) cases. Regular ventilator check was mostly done every 4 h (57%). BiPAP (47.3%) and full-face masks (45.9%) were the most used mode and interface, respectively, while pressure-regulated volume control (55.4%) and pressure control (27%) were the most used mechanical ventilation modes for COVID-19 patients. In terms of use of proning, 62% used it on IMV, while 26% reported using awake proning. Staff shortage (51.4%), personal protective equipment (PPE) shortage (51.4%), increased workload (45.9%), inadequate training (43.2%) and lack of available protocols and policies (37.8%) were the main barriers.

Conclusion:

Ventilatory support management of COVID-19 in Saudi Arabia was inconsistent with the global practice, lacked uniformity, and there was limited use of standard protocols/treatment guidelines. Shortage of staff and PPE, increased workload and insufficient training were the most prevalent barriers.

Managing critical care during COVID-19 pandemic: The experience of an ICU of a tertiary care hospital

Background

The COVID-19 pandemic has strained ICUs worldwide. To learn from our experience, we described the critical care response to the outbreak.

Methods

This is a case study of the response of the Intensive Care Department (75-bed capacity) at a tertiary-care hospital to COVID-19 pandemic, which resulted in a high number of critically ill patients.

Results

Between March 1 and July 31, 2020, 822 patients were admitted to the adult non-cardiac ICUs with suspected (72%)/confirmed (38%) COVID-19. At the peak of the surge, 125 critically ill patients with COVID-19 were managed on single day. To accommodate these numbers, the bed capacity of 4 ICUs was increased internally from 58 to 71 beds (+40%) by cohorting 2 patients/room in selected rooms; forty additional ICUs beds were created in 2 general wards; one cardiac ICU was converted to managed non-COVID-19 general ICU patients and one ward was used as a stepdown for COVID-19 patients. To manage respiratory failure, 53 new ICU ventilators, 90 helmets for non-invasive ventilation and 47 high-flow nasal cannula machines were added to the existing capacity. Dedicated medical teams cared for the COVID-19 patients to prevent cross-contamination. The nurse-to-patient and RT-to-patient ratio remained mostly 1:1 and 1:6, respectively. One-hundred-ten ward nurses were up-skilled to care for COVID-19 and other ICU patients using tiered staffing model. Daily executive rounds were conducted to identify patients for transfer and at least 10 beds were made available for new COVID-19 admissions/day. The consumption of PPE increased multiple fold compared with the period preceding the pandemic. Regular family visits were not allowed and families were updated daily by videoconferencing and phone calls.

Conclusions

Our ICU response to the COVID-19 pandemic required almost doubling ICU bed capacity and changing multiple aspects of ICU workflow to be able to care for high numbers of affected patients.

Helmet Non-Invasive Ventilation for COVID-19 Patients (Helmet-COVID): study protocol for a multicentre randomised controlled trial

INTRODUCTION

Non-invasive ventilation (NIV) delivered by helmet has been used for respiratory support of patients with acute hypoxaemic respiratory failure due to COVID-19 pneumonia. The aim of this study was to compare helmet NIV with usual care versus usual care alone to reduce mortality.

METHODS AND ANALYSIS

This is a multicentre, pragmatic, parallel randomised controlled trial that compares helmet NIV with usual care to usual care alone in a 1:1 ratio. A total of 320 patients will be enrolled in this study. The primary outcome is 28-day all-cause mortality. The primary outcome will be compared between the two study groups in the intention-to-treat and per-protocol cohorts. An interim analysis will be conducted for both safety and effectiveness.

ETHICS AND DISSEMINATION

Approvals are obtained from the institutional review boards of each participating institution. Our findings will be published in peer-reviewed journals and presented at relevant conferences and meetings.

TRIAL REGISTRATION NUMBER

NCT04477668.

Regional differences in COVID-19 ICU admission rates in the Kingdom of Saudi Arabia: A simulation of the new model of care under vision 2030

Objective

Saudi Arabia has succeeded in having one of the lowest rates of COVID-19 worldwide due to the government’s initiatives in taking swift action to control both the spread and severity of the virus. However, Covid-19 can serve as a test case of the expected response of the new healthcare system under Vision 2030. This study used data from the thirteen present administrative regions of KSA to simulate the variations in ICU admission as a quality indicator in the five business units proposed by a new Model of Care.

Methods

We determined the rates of ICU admission for patients with confirmed SARS-CoV-2 (COVID-19) from March to mid-July 2020. The final sample included 1743 inpatients with moderate to severe COVID-19. Patient characteristics, including demographics, pre-existing chronic conditions, and COVID-19 complications, were collected. Business units (BUs) were compared with respect to the relative odds of ICU admission by using multiple logistic regression.

Results

After keeping patient and clinical characteristics constant, clear BU differences were observed in the relative odds of ICU admission of COVID-19 patients. Inpatient admission to ICU in our total sample was almost 50%. Compared to the Central BU, the Northern and Western BUs showed significantly higher odds of ICU admission while the Eastern & Southern BUs had significantly lower odds.

Conclusion

ICU use for COVID-19 patients differed significantly in KSA healthcare BUs, consistent with variations in care for other non-COVID-19-related conditions. These differences cannot be explained by patient or clinical characteristics, suggesting quality-of-care differences. We believe that privatization and the shift to fewer administrative BUs will help lessen or eliminate altogether the present variations in healthcare service provision.

Clinical, epidemiological, and laboratory characteristics of mild-to-moderate COVID-19 patients in Saudi Arabia: an observational cohort study

Background

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) emerged from China in December 2019 and has presented as a substantial and serious threat to global health. We aimed to describe the clinical, epidemiological, and laboratory findings of patients in Saudi Arabia infected with SARS-CoV-2 to direct us in helping prevent and treat coronavirus disease 2019 (COVID-19) across Saudi Arabia and around the world.

Materials and methods

Clinical, epidemiological, laboratory, and radiological characteristics, treatment, and outcomes of pediatric and adult patients in five hospitals in Riyadh, Saudi Arabia, were surveyed in this study.

Results

401 patients (mean age 38.16 ± 13.43 years) were identified to be SARS-CoV-2 positive and 80% of cases were male. 160 patients had moderate severity and 241 were mild in severity. The most common signs and symptoms at presentation were cough, fever, fatigue, and shortness of breath. Neutrophil and lymphocyte counts, aspartate aminotransferase, C-reactive protein, and ferritin were higher in the COVID-19 moderate severity patient group. Mild severity patients spent a shorter duration hospitalized and had slightly higher percentages of abnormal CT scans and X-ray imaging.

Conclusions

This study provides an understanding of the features of non-ICU COVID-19 patients in Saudi Arabia. Further national collaborative studies are needed to streamline screening and treatment procedures for COVID-19.

Nursing Surge Capacity Strategies for Management of Critically Ill Adults with COVID-19

Background: There is a vital need to develop strategies to improve nursing surge capacity for caring of patients with coronavirus (COVID-19) in critical care settings. COVID-19 has spread rapidly, affecting thousands of patients and hundreds of territories. Hospitals, through anticipation and planning, can serve patients and staff by developing strategies to cope with the complications that a surge of COVID-19 places on the provision of adequate intensive care unit (ICU) nursing staff—both in numbers and in training. Aims: The aim is to provide an evidence-based starting point from which to build expanding staffing models dealing with these additional demands. Design/Method: In order to address and develop nursing surge capacity strategies, a five-member expert panel was formed. Multiple questions directed towards nursing surge capacity strategies were posed by the assembled expert panel. Literature review was conducted through accessing various databases including MEDLINE, CINAHL, Cochrane Central, and EMBASE. All studies were appraised by at least two reviewers independently using the Joanna Briggs Institute JBI Critical Appraisal Tools. Results: The expert panel has issued strategies and recommendation statements. These proposals, supported by evidence-based resources in regard to nursing staff augmentation strategies, have had prior success when implemented during the COVID-19 pandemic. Conclusion: The proposed guidelines are intended to provide a basis for the provision of best practice nursing care during times of diminished intensive care unit (ICU) nursing staff capacity and resources due to a surge in critically ill patients. The recommendations and strategies issued are intended to specifically support critical care nurses incorporating COVID-19 patients. As new knowledge evidence becomes available, updates can be issued and strategies, guidelines and/or policies revised. Relevance to Clinical Practice: Through discussion and condensing research, healthcare professionals can create a starting point from which to synergistically develop strategies to combat crises that a pandemic like COVID-19 produces.