ABSTRACT
Introduction: Awake prone positioning (APP) may reduce ventilation-perfusion mismatch in the context of acute respiratory distress syndrome. The Intensive Care Society recommends its use in COVID-19 to improve oxygenation and reduce risk of progression to invasive mechanical ventilation. This audit project measured the use of APP on an Acute Respiratory Care Unit (ARCU). Method(s): Observations and patient outcomes were recorded for non-intubated patients where a clinical decision had been made to prone. The activPALTM accelerometer was used as an objective measure of APP (prone or lateral-lie positioning). Analysis was performed using STATA v16. Result(s): Between September 2020 and February 2021, 19 individuals with a median age of 68 years were included. 74% were male. In the first 48 hours, 747 person-hours of data were recorded, with 358 person-hours spent in APP. Eight individuals spent at least 50% of their first 48 hours in APP. Lateral lie was better tolerated than full prone positioning, with a median (interquartile range, IQR) of 11.6 (8.0, 20.2) hours spent in lateral lie and median (IQR) of 1.6 (0.5, 8.3) hours spent fully proned in the first 48 hours. Median (interquartile range, IQR) improvement from baseline in respiratory rate/oxygenation (ROX) index at 48 hours was +1.65 (0.90, 1.89). Median (IQR) ROX index at 12 hours for individuals not in APP was 4.80 (3.04, 8.51) and 10.41 (9.09, 11.42) for individuals who were fully proned. Nine individuals were admitted to intensive care, 13 survived to discharge. Conclusion(s): Accelerometry is an objective method to measure time spent in APP and showed that lateral lie was preferred to full prone position in this cohort. Trends suggest possible improvement in ROX, although numbers were small.
ABSTRACT
Background: The use of dexamethasone has resulted in lower mortality for patients receiving oxygen or invasive mechanical ventilation. It is a first-line treatment for coronavirus disease 209 (COVID-19). However, COVID-19 and dexamethasone both increase the risk of hyperglycaemia (shown to increase COVID-19 morbidity and mortality) and increase the risk of hyperglycaemic emergencies. Aim: To improve management of hyperglycaemia secondary to COVID-19 and dexamethasone use in patients with and without pre-existing diabetes by implementing the Concise Advice on Inpatient Diabetes guidelines at a tertiary centre. Methods: 111 patients from respiratory wards were included in a quality improvement project (QIP) over a period of 0 weeks. Outcome measures included frequency of blood glucose monitoring, appropriate ketone assessment and guideline-concordant management of hyperglycaemia. Plan-Do-Study-Act methodology was used, and interventions included posters, education of nursing staff and junior doctors, and discussion at the departmental meeting. Results: By the end of the QIP there was a 33% increase from baseline in individuals having 6-hourly capillary blood glucose monitoring in the first 48 hours. Management of hyperglycaemia also improved with a 40% increase from baseline in individuals receiving acute correction with insulin and a 2 % increase from baseline in individuals having regular insulin started or adjusted. Conclusion: Both COVID-19 and its treatment increase the risk of hyperglycaemia with consequent morbidity and mortality implications. This QIP improved hyperglycaemia management through guideline implementation. This shows that guideline compliance can enable better patient care. Further system-wide work is required for sustainability.