Ecmo as a Bridge to Lung Transplantation for Covid-19 Respiratory Failure: Outcomes and Risk Factors for Early Mortality

Severe COVID-19 infection can cause advanced respiratory failure requiring ECMO. In some cases, lung transplantation (LT) is a last viable treatment option. This study aims to evaluate outcomes among COVID patients bridged to LT with ECMO and identify risk factors for early mortality post-LT. Using the UNOS database, we identified 442 patients who underwent LT for COVID-19 respiratory failure between August 2020 and September 2022. Outcomes of patients requiring preoperative ECMO (n=253) were compared to those who did not require ECMO pre-LT (n=189). Survival analyses were conducted using the Kaplan-Meier survival function and Cox proportional hazards models. Risk factors for post-LT mortality were analyzed using a multivariate logistic regression model. Out of 442 patients, 253 required preoperative ECMO support for a median of 73 days (IQR 40, 119). The most common ECMO platform was veno-venous (p=0.0008). Patients requiring ECMO were younger, more frequently in an ICU, had higher LAS scores, more likely to require bilateral LT, had higher rates of tracheostomy and pre-LT dialysis, and were more likely to have ARDS etiologies of respiratory failure (all p<0.0001). At 1 and 6 months post-LT, there was no difference in survival between ECMO and non-ECMO patients (95.5% vs 97.5% at 1 month, 92.7% vs 93.4% at 6 months) (Fig 1a). However, ECMO patients had higher rates of prolonged ventilation, post-operative ECMO, new dialysis, and increased length of stay (all p<0.0001) post-LT. Risk factors for mortality included BMI (p=0.007), pan-resistant bacterial infection (p=0.01), preoperative VA ECMO (p=0.0008), prior cardiac surgery (p=0.05), and single LT procedure (p<0.0001) (Fig 1b). Our findings suggest that ECMO can safely be used as a bridge to LT in well-selected patients with COVID-19 respiratory failure despite prolonged support. Here we identify possible risk factors associated with early mortality that may require further evaluation. [ FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

AN AUDIT OF DNACPR DECISIONS AND DISCUSSIONS DURING THE COVID-19 PANDEMIC

Background Do not attempt cardiopulmonary resuscitation (DNACPR) discussions and decisions are an important part of person-centred care. Compassionate discussion with patients is a legal requirement when clinicians are introducing DNACPR forms. A recent Care Quality Commission report emphasised that all decisions should be individualised and part of broader advance care planning (Care Quality Commission, 2021). Aim The aims of this audit were to evaluate the timing of DNACPR discussions, to explore whether conversations regarding DNACPR were documented and whether DNACPR discussions were part of wider advance care planning. The standards for the audit were based on national Resuscitation Council guidance (2021), 'Deciding Right' regional document (Northern Cancer Alliance, 2015) alongside the Trust policy on resuscitation. Methods All patients with DNACPR forms initiated during an inpatient stay in November 2020 were identified from the Trust's database. A data collection tool was created to retrospectively collate information from the patient's electronic records. Results We identified 62 patients who had a DNACPR initiated in November 2020. The results were overall very positive;a discussion with the patient, or where necessary with a relative, took place in all patients where electronic notes were accessible. Six (10%) DNACPR forms were initiated at the time of deterioration and 39 (63%) were as part of a conversation incorporating elements of advance care planning, with more thorough advance care planning conversations occurring in six patients (10%). Almost 30% of patients audited were positive for COVID-19 infection. Where CPR was felt to be of no clinical benefit, COVID-19 infection was rarely (2% of patients) the named medical condition documented in the DNACPR. Conclusions Documentation regarding the timing of DNACPR decisions and DNACPR discussions was of a high standard, despite increased pressures during the COVID-19 pandemic. Advance care planning discussions occurred, however, further analysis would be necessary to fully evaluate the quality of these discussions.

IMPROVING COLORECTAL CANCER SCREENING AND POLYP SURVEILLANCE DURING THE COVID-19 PANDEMIC

Introduction: Colorectal cancer screening and surveillance colonoscopy declined drastically during the initial surge of coronavirus infectious disease (COVID-19) cases in the United States. In August 2020, the state of Georgia (GA) had the highest per-capita circulating infection rate in the nation, with an average of more than 25 cases per 100,000 people and was the "most likely" state where someone may be exposed to COVID-19. Our ambulatory endoscopy unit at Emory Healthcare, which is a large, tertiary referral care center in GA had a precipitous drop in show rate for screening and surveillance colonoscopy even after elective procedures resumed. Patients cited fear of acquiring COVID-19 as the primary reason for previously cancelling their procedure. Therefore, we implemented a quality improvement project aimed at improving show rates for screening and surveillance colonoscopy by providing patients structured education via a telephone call regarding the safety of inperson colonoscopy and addressing concerns regarding COVID-19. Methods: We contacted patients between the ages of 40-75 who were due for screening or polyp surveillance colonoscopy in August via a telephone call. Patients were provided a comprehensive overview of public health guidelines regarding COVID-19, and safety precautions at Emory Healthcare to minimize risk of transmission of COVID-19 including pre-procedural testing for COVID-19, social distancing, enforcing a universal masking policy, limited visitor/escort policy, and vigorous surface disinfection. Patients who completed their procedures were asked to complete a survey to provide feedback about the impact of the study phone call using a dichotomous response of agree/disagree. Results: 161 patients were contacted, of which 49% were Caucasian, 48.4% were African-American and 1.9% were Asian. 95% of the patients who were contacted completed their colonoscopies. 91.8% agreed that they received information about COVID-19 that they were previously unaware of;81.4% agreed that they are now more likely to follow public health guidelines of social distancing, hand washing, and wearing a mask. 91.1% felt safer about procedures after the study phone call, and 90.9% agreed that they felt less anxious about the risk of acquiring COVID-19 while in our facility. 70.3% agreed that they may not have come in for their procedures if they did not receive the study phone call. 94.4% agreed that they were satisfied with the procedural protocol at our facility and would come back for another procedure if needed. Conclusions: Our study suggests that specific communication of pandemic related issues are key to reducing peri-procedural concerns about COVID-19. Failure of timely colorectal cancer screening and colonoscopy will lead to a large burden of missed polyps and colorectal cancers leading to increased morbidity and mortality from CRC.

Food Insecurity Prevalence, Severity and Determinants in Australian Households during the COVID-19 Pandemic from the Perspective of Women.

This study aimed to describe the prevalence, severity and socio-demographic predictors of food insecurity in Australian households during the COVID-19 pandemic in 2020, from the perspective of women. A cross-sectional online survey of Australian (18-50 years) women was conducted. The survey collected demographic information and utilised the 18-item US Department of Agriculture Household Food Security Survey Module and the Kessler Psychological Distress Scale (K10). A multivariable regression was used to identify predictors of food security status. In this cohort (n = 1005), 19.6% were living in households experiencing food insecurity; with 11.8% experiencing low food-security and 7.8% very low food-security. A further 13.7% of households reported marginal food-security. Poor mental health status (K10 score ≥ 20) predicted household food insecurity at all levels. The presence of more than three children in the household was associated with low food-security (OR 6.24, 95% CI: 2.59-15.03). Those who were renting were 2.10 (95% CI: 1.09-4.05) times likely to experience very low food-security than those owning their own home. The COVID-19 pandemic may have contributed to an increased prevalence of household food insecurity. This study supports the need for a range of responses that address mental health, financial, employment and housing support to food security in Australia.

Pivot and Persist: A Technical Report on Adapting an Existing Multi-Institutional Bootcamp to a Hybrid Platform.

The coronavirus disease 2019 (COVID-19) pandemic has disrupted most in-person simulation training, including established simulation-based medical bootcamps. These sessions are important for the preparation of new trainees to think critically about common clinical scenarios, practice technical skills, and optimize leadership, teamwork, and communication. Having the opportunity to hone these skills in a safe environment is instrumental for the development of trainees' confidence and professional identity formation, and may contribute to patient safety. When the annual New England/Mid-Atlantic regional first-year neonatology fellows' bootcamp was jeopardized by COVID restrictions, we implemented a novel approach to adapt the existing in-person format and curriculum for large-scale hybrid delivery. The resultant two-day session was well-received by both participants and facilitators. Important lessons from this experience, including adaptions to the curriculum, schedule, simulation interface and hybrid platform, are relevant to educators seeking to conduct large-scale virtual simulation-based educational sessions.