ABSTRACT
Introduction The decision to admit an older patient to the intensive care unit (ICU) should reflect shared goals of care. Resource limitations during the Covid-19 pandemic highlighted challenges in selecting candidates for escalation. Patients and next of kin (NoK) who have experienced ICU are well-placed to reflect on whether the admission was right for them. Objective To explore older patients' (>65 years) and their loved ones' views on escalation decision making. Methods Qualitative study involving semi-structured interviews with patients, NoK of survivors and NoK of deceased who experienced UK ICU admission with Covid-19 respiratory failure between March 2020 and February 2021. A preliminary questionnaire was used to maximise sample diversity of age, sex, ethnicity, survival, decision regret and impact of event scores. Interview data were collected via video conferencing or telephone. Transcripts were analysed using framework analysis. Results 30 participants were interviewed. Results Five themes were identified: 'Inevitability' - a sense that the illness and its management are out of the control of the patient or their loved one;'Disconnect' - differences between hospital and lay person narratives;challenges to bridging that gap included effective communication aided by technology;'Acceptance' - of the consequences, good or bad, of an intensive care admission as unalterable;'Beyond comprehension' - participants had not contemplated ill health or ICU prior to admission and even with the benefit of hindsight struggled to describe which potential outcomes would be acceptable or unacceptable if they needed to be involved in similar decision-making around escalation in the future;'Covid-19' - unique impact of a pandemic. Conclusion This study, which includes bereaved NoK as well as patients and NoK of survivors, adds perspective to inform decision making regarding treatment escalation of older people.
ABSTRACT
Introduction: Familiarity with information technology is increasingly widespread. COVID-19 has increased the use of video conferencing social media within the UK population, including by older people1 This evolving scene has the potential to change how research is conducted.2 Social media has been employed for recruitment to qualitative research,3,4 but mostly in a young cohort. Recruitment through interfaces such as Twitter has the potential to access a larger number of participants, but may not reach all groups, such as older people. Video conferencing (VC) is increasingly used for qualitative interviewing.5 It simulates in-person communication while avoiding the need to travel but requires access to costly equipment and confidence in engaging with the technology. Objective: To explore the experience of using technology in a critical care-based qualitative research study. Methods: The ESCAlation of the eLderly (Age-65years) to criTical carE with COVID-19 (ESCALATE) study uses semi-structured interviews with patients and loved ones to explore views on escalation of older people to critical care during the COVID-19 pandemic. Recruitment took place using two routes: UK-wide social media advertising;and postal invitations via local databases with telephone follow up. For the former, the study was advertised directly via the social media platform Twitter using a specifically created study account (@covidescalate), showing a brief advert and link to a questionnaire and contact form. Relevant charities were invited to disseminate the advertisement. In-person interviews were avoided to maximise participant and interviewer safety in the context of the COVID-19 pandemic. Participant preference for mode of interview (VC or telephone) was established. If participants stated in advance that they were not familiar with video technology or found during the interview that they were unable to manage a VC, interviews were conducted by telephone. Results: There was partial uptake by charities and limited 'retweeting' overall. Only one responder meeting eligibility criteria responded via social media advertising, compared with 44 from local postal/telephone recruitment. Ten interviews were conducted via VC and 12 via telephone, where participants were not familiar with VC. There was no difference in interview duration with VC lasting around 45 minutes and telephone calls lasting around 42 minutes. The researchers found that it was more difficult to pick up on social and non-verbal cues without visual contact but all questions in the topic guide were covered using both media. There was no difference between choice of VC vs. telephone according to participant ethnicity (BAME vs Caucasian) or sex. In one case, several participants from one family joined the VC from different locations. Conclusion: In the ESCALATE study, video conferencing and telephone interviews were both valuable interviewing methods. Social media recruitment was of limited use but this may reflect the participant demographic and research team experience and could still be useful for recruiting certain groups in other studies. Information technology has the potential to increase engagement with research but our experience demonstrates that it must be used flexibly and with consideration.
ABSTRACT
Introduction: Almost half the UK population die in hospital and more than two thirds of these are aged 75 years or more.1 Older people make up an increasing proportion of patients admitted to critical care and often have poorer outcomes, especially in the context of COVID-19.2 Loved ones are an essential support network for older patients but their ability to provide support was compromised by visiting restrictions during COVID-19. Little is known about the experiences of older patients in ICU and there is limited literature on the experiences of bereaved relatives.3 Bereaved relatives may be the only way to access the experiences of patients who do not survive, but there are a number of barriers to including bereaved relatives in research. Researchers may feel inhibited from imposing what might be seen as an additional burden on families during the aftermath of a bereavement. The ongoing ESCAlation of the eLderly (age >65years) to criTical carE with COVID-19) (ESCALATE) study includes semi-structured interviews with bereaved loved ones as well as patients and NoK of survivors in the UK. Objectives: To describe successful involvement of bereaved next of kin in critical care-based research Methods: This qualitative research uses semi-structured interviews and thematic analysis. Patient and public involvement from an intensive-care focused charity and local palliative care team advice was sought in order to develop recruitment strategies such as detailed, sympathetically worded participant information packs.4 In keeping with the literature,5 the window for recruitment and interview was approximately one year following bereavement. Following ethical approval, participants were recruited via postal invitations with follow up telephone calls if no response after a minimum of one week. Results: Recruitment was limited by only 40% of bereaved NoK (next of kin) having postal addresses recorded on the hospital systems. 9 /40 bereaved NoK contacted by letter responded and as well as completing a questionnaire, consented to be interview. A further 5/11 contacted by follow-up telephone call agreed to participate (consistent with response rates for patients and NoK of survivors). All of the interviewed bereaved participants completed the interview according to the interview topic guide, with each interview lasting around 45 minutes. More than half were female, and three quarters were Black, Asian or Minority Ethnic. Bereaved relatives were keen to share their experience and some even volunteered additional information with the interviewers, such as resources they had created for their local community and personal diaries. Participants reported that they were happy to be interviewed if it would help others in a similar position. Conclusion: Bereaved relatives of critical care patients are willing to engage in qualitative research. Recruitment is challenging due to practical constraints, but we suggest could be improved through meticulous documentation of contact details and involvement of bereavement services in research. By seeking the views of bereaved loved ones, we can improve care for critically unwell patients at end of life.
ABSTRACT
Introduction: The use of systemic corticosteroids to suppress SARS-CoV-2-induced lung inflammation is advocated in the treatment of COVID-19 ARDS.1,2 Whilst the evidence for low dose early corticosteroids in COVIDARDS is well established, the effect of larger steroid doses (i.e. short-term 'pulse-dose') is yet to be investigated. Objectives: The objective of this study was to examine the effect of pulse dose steroids on ventilatory parameters such as oxygenation in COVID-19 patients with and without established fibrosis or organising pneumonia (OP). Methods: This was a multi-centre, retrospective observational study performed at four teaching hospitals, with the following inclusion criteria: adult patients requiring invasive mechanical ventilation with confirmed PCR SARS-CoV-2 infection;and received high dose steroids for treatment for COVID-ARDS (defined as dose ≥ 20mg dexamethasone or an equivalent dose of methylprednisolone). This study was carried out as a service evaluation within the National Health Service (NHS) and recorded under the auspices of the clinical audit office at Imperial College HealthcareNHS Trust and Institutional Data Protection Office. Study patients were followed for 14 days or until they were discharged from the ICU and physiological or ventilatory variable data was retrospectively collected from patient records. Results: In total, 92 patients were included: 14 patients 20mg/day dexamethasone;5 patients 50mg/day dexamethasone;16 patients 500mg methylprednisolone;and 57 patients 1000mg methylprednisolone. Our data demonstrate a statistically significant improvement in PaO2/FiO2 (P/F) ratio over time, from baseline to day 14, in those patients who received 1000mg Methylprednisolone (baseline PaO2: 14.47 kPa, Day 3: 17.51 kPa, Day 7: 19.51 kPa, Day 14: 22.87 kPa, p<0.001). Whilst not statistically significant, there was a trend to higher P/F ratios by day 14 in patients who received 500mg Methylprednisolone group. There was no increase in P/F ratios in those patients who received 20mg or 50mg dexamethasone. The increase in P/F ratio was most apparent in those patients who had evidence of fibrosis on CT scan, although some benefit was seen in those patients who did not fibrosis on radiological imaging. Cross sectional random effects models were used to determine the effect of 1000mg methylprednisolone on improvement in P/F ratio and demonstrate that there was an increase of P/F ratio of more than 0.38 kPa per day in those patients that received 1000mg methylprednisolone. The was no significant effect on compliance measures. There was also a trend to more ventilator free days but no difference in mortality in those patients receiving large dose methylprednisolone. Reassuringly, rates of fungal infection and pneumothorax/pneumomediastinum for patients who received steroids, including those with high dose, were equivocal. Conclusion: In this study, we present novel data suggesting that large doses of methylprednisolone may be beneficial in patients with severe COVID-19, late in the disease course when ARDS is well established. This benefit was not demonstrated in patients treated with lesser (but still high) doses of steroids (i.e. 20mg or 50mg of dexamethasone) and suggest that larger pulsed-dose steroids may induce reversibility of the disease process, particularly in those who have developed fibrosis.