Impact of a national collaborative project to improve the care of mechanically ventilated patients

This prospective quasi-experimental study from the NASAM (National Approach to Standardize and Improve Mechanical Ventilation) collaborative assessed the impact of evidence-based practices including subglottic suctioning, daily assessment for spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), head of bed elevation, and avoidance of neuromuscular blockers unless otherwise indicated. The study outcomes included VAE (primary) and intensive care unit (ICU) mortality. Changes in daily care process measures and outcomes were evaluated using repeated measures mixed modeling. The results were reported as incident rate ratio (IRR) for each additional month with 95% confidence interval (CI). A comprehensive program that included education on evidence-based practices for optimal care of mechanically ventilated patients with real-time benchmarking of daily care process measures to drive improvement in forty-two ICUs from 26 hospitals in Saudi Arabia (>27,000 days of observation). Compliance with subglottic suctioning, SAT and SBT increased monthly during the project by 3.5%, 2.1% and 1.9%, respectively (IRR 1.035, 95%CI 1.007-1.064, p = 0.0148; 1.021, 95% CI 1.010-1.032, p = 0.0003; and 1.019, 95%CI 1.009-1.029, p = 0.0001, respectively). The use of neuromuscular blockers decreased monthly by 2.5% (IRR 0.975, 95%CI 0.953-0.998, p = 0.0341). The compliance with head of bed elevation was high at baseline and did not change over time. Based on data for 83153 ventilator days, VAE rate was 15.2/1000 ventilator day (95%CI 12.6-18.1) at baseline and did not change during the project (IRR 1.019, 95%CI 0.985-1.053, p = 0.2812). Based on data for 8523 patients; the mortality was 30.4% (95%CI 27.4-33.6) at baseline, and decreased monthly during the project by 1.6% (IRR 0.984, 95%CI 0.973-0.996, p = 0.0067). A national quality improvement collaborative was associated with improvements in daily care processes. These changes were associated with a reduction in mortality but not VAEs. Registration The study is registered in clinicaltrials.gov (NCT03790150).

The Role of the Temporary Contracting and Visiting Doctor Program in Supporting the Health System during and after COVID-19 Pandemic in Saudi Arabia

Background: Adequate supply of health workforce with proper skills is essential to deliver appropriate health services in normal times and during disasters. Objective: To describe the role of the Saudi Temporary Contracting and Visiting Doctors Program in the provision of critical care during COVID-19 pandemic, and in the clearance of the surgical backlog thereafter. Methods: We reviewed reports of General Directorate of Health Services and Saudi Ministry of Health annual statistical books to obtain the following data: number of temporary healthcare professionals contracted from 2019 to 2022; number of intensive care unit beds before and during COVID-19 pandemic; volume of elective surgeries before, during and after COVID-19 pandemic. Results: In 2020, intensive care unit beds increased from 6341 to 9306 in governmental hospitals in response to COVID-19 pandemic. A total of 3539 temporary healthcare professionals were recruited from April to August 2020 to contribute towards staffing the added beds. During the recovery period from COVID-19 pandemic, 4322 and 4917 temporary health care professionals were recruited in 2021and 2022 respectively. Elective surgeries volume increased from 5074 in September 2020 to 17533 in September 2021 to 26242 in September 2022, surpassing the volume of surgeries in pre-COVID-19 period. Conclusions: In response to COVID-19 pandemic, and through the existing temporary contracting program, the Saudi Ministry of Health was able to recruit temporary staff of verified credentials in a timely manner, to supplement the existing staff, for activation of the newly added intensive care unit beds, and for clearing the resulting surgical backlog.

The Temporary Contracting and Visiting Doctors Program in the Saudi Ministry of Health: Development, Reform and Outputs

Background

Temporary Contracting and Visiting Doctors' Program was initiated by the Saudi Ministry of Health to address issues of sustainable supply of healthcare professionals in the whole country and in remote areas in particular.

Objective

This study aimed to describe the experience of the Saudi Temporary Contracting and Visiting Doctors' Program, the undertaken reform steps and the program outputs.

Methods

We conducted a case study and reviewed documents of the Temporary Contracting and Visiting Doctors' Program to obtain data about the program's development and steps of reform. We also extracted data about the number of different types of temporary contracts, the program budget and the healthcare professionals registered on the "VISITORs" platform.

Results

Scope of the Temporary Contracting and Visiting Doctors' Program had widened from contracting physicians from outside Saudi Arabia to include healthcare professionals from inside the country. The program's reform efforts included: formation of a governing central committee, development of guidelines, adoption of decentralized implementation system and modified budget release system, development of electronic staff bank and e-recruitment system and the introduction of virtual healthcare under the scope of the program. During the program evolution the number of temporary contracts has increased steadily, specifically the more efficient part-time contract variety, the contracts with physicians with rare sub-specialties, and contracts with Saudi healthcare professionals.

Conclusion

Reform undertaken in the Saudi Temporary Contracting and Visiting Doctors' Program ensures needs-based recruitment, efficient use of resources, and supply of staff of verified quality.

Association of cytochromes P450 3A4*22 and 3A5*3 genotypes and polymorphism with response to simvastatin in hypercholesterolemia patients

Backgrounds

Inter-individual variability in response to statin was mainly due to genetic differences. This study aimed to investigate the association of CYP3A4*22 (rs35599367), CYP3A5*3 (rs776746) single nucleotide polymorphism (SNP) with response to simvastatin in hypercholesterolemia patients conducted at King Abdulaziz University hospital (KAUH) in Jeddah, Saudi Arabia.

Patients and methods

A total of 274 participants were registered in the current study. Hypercholesterolemic patients taking simvastatin 20 mg (n = 148) and control subjects (n = 126) were tested for rs35599367 and rs776746 genotypes using Custom Taqman ® Assay Probes. Response to simvastatin in these patients was assessed by determination of low density lipoprotein (LDL-C), total cholesterol (TC) and by measuring statin plasma levels using Liquid Chromatography-Mass Spectrometry (LC-MS).

Results

None of the participants carried a homozygous CYP3A4*22 mutant genotype, while 12 (4.4%) individuals had a heterozygous genotype and 262 (95.6%) had a wild homozygous genotype. The CYP3A5*3 allele was detected in the homozygous mutant form in 16 (5.8%) individuals, while 74 (27.0%) individuals carried the heterozygous genotype and 184 (67.2%) carried the wildtype homozygous genotype. Of the patient group, 15 (11%) were classified as intermediate metabolizers (IMs) and 133 (89%) as extensive metabolizers (EMs). Plasma simvastatin concentrations for the combined CYP3A4/5 genotypes were significantly (P<0.05) higher in the IMs group than in the EMs group. TC and plasma LDL-C levels were also significantly (P<0.05) higher in IMs than in EMs.

Conclusion

The present study showed associations between CYP3A4*22 (rs35599367) and CYP3A5*3 (rs776746) SNP combination genotypes with response to statins in hypercholesterolemia. Patients who had either a mutant homozygous allele for CYP3A5*3 or mutant homozygous and heterozygous alleles for CYP3A4*22 showed increased response to lower TC and LDL-C levels.