Investigation of hospital discharge cases and SARS-CoV-2 introduction into Lothian care homes

Background The first epidemic wave of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Scotland resulted in high case numbers and mortality in care homes. In Lothian, over a third of care homes reported an outbreak while there was limited testing of hospital patients discharged to care homes. Aim Investigate hospital discharges as a source of SARS-CoV-2 introduction into care homes during the first epidemic wave. Methods A clinical review was performed for all discharges from hospitals to care homes starting 1st March 2020 to 31st May 2020. Episodes were ruled out based on coronavirus disease (COVID-19) test history, clinical assessment at discharge, whole genome sequencing (WGS) data and an infectious period of 14 days. Clinical samples were processed for WGS, and consensus genomes generated were used for analysis by cluster investigation and virus epidemiological tool (CIVET). Patient timelines were obtained using electronic hospital records. Findings In total 787 hospital discharges to care homes were identified. Out of these 776 (99%) were ruled out for hospital discharge introduction. However, for 10 episodes the results were inconclusive as there was low genomic diversity in consensus genomes or no sequencing data. Only one discharge episode had a genomic, time and location link to positive cases during hospital admission leading to 10 further positive cases in the care home. Conclusion Majority of hospital discharges were ruled out for introduction into Lothian care homes highlighting the importance of screening all new admissions when faced with a novel emerging virus and no vaccine available.

Investigation of hospital discharge cases and SARS-CoV-2 introduction into Lothian care homes.

BACKGROUND: The first epidemic wave of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Scotland resulted in high case numbers and mortality in care homes. In Lothian, over one-third of care homes reported an outbreak, while there was limited testing of hospital patients discharged to care homes. AIM: To investigate patients discharged from hospitals as a source of SARS-CoV-2 introduction into care homes during the first epidemic wave. METHODS: A clinical review was performed for all patients discharges from hospitals to care homes from 1st March 2020 to 31st May 2020. Episodes were ruled out based on coronavirus disease 2019 (COVID-19) test history, clinical assessment at discharge, whole-genome sequencing (WGS) data and an infectious period of 14 days. Clinical samples were processed for WGS, and consensus genomes generated were used for analysis using Cluster Investigation and Virus Epidemiological Tool software. Patient timelines were obtained using electronic hospital records. FINDINGS: In total, 787 patients discharged from hospitals to care homes were identified. Of these, 776 (99%) were ruled out for subsequent introduction of SARS-CoV-2 into care homes. However, for 10 episodes, the results were inconclusive as there was low genomic diversity in consensus genomes or no sequencing data were available. Only one discharge episode had a genomic, time and location link to positive cases during hospital admission, leading to 10 positive cases in their care home. CONCLUSION: The majority of patients discharged from hospitals were ruled out for introduction of SARS-CoV-2 into care homes, highlighting the importance of screening all new admissions when faced with a novel emerging virus and no available vaccine.

The effect of steroid dosing on risk of secondary infection in COVID-19 critically ill patients

Introduction: The COVID pandemic has led to devastating consequences for those afflicted. The use of dexamethasone has proven benefit, although the risks and benefits are not fully characterized nor is the optimal dose of steroid. The benefits of steroids may include reduced inflammation in patients with acute respiratory distress syndrome (ARDS), but the risk might include increased viral replication and/or risk of secondary infection. Using a retrospective review of our ICU experience (prior to RECOVERY NEJM publication) we sought to characterize the relationship between steroid use and secondary infections in COVID-19 patients in order to test the hypothesis that steroid dose may be associated with worse ICU outcomes in some patients. Methods: We conducted a retrospective review of our ICU experience from a large academic medical center. We defined secondary infection as positive bacterial or fungal culture from blood stream, urine or sputum deemed by the clinical team to require intervention. Among 130 consecutive patients who received critical care for COVID-19, we identified 41 who had received steroids in the ICU. Among these, 13 had received steroids prior to secondary infection (GP1) whereas 13 had secondary infection documented prior to receiving steroid (GP2) and 15 received steroids without secondary infection (GP3). Results: We observed mortality in all patients involved in this study (n=130) of 27.7%. Among patients who received steroids (n=41) of 29.3% vs. patients who never received steroids (n=89) of 27%. Mortality specific to the steroids groups was 15.4% for GP1 (n=13) vs. 53.8% for GP2 (n=13) vs. 20% for GP3 (n=15). Conclusions: We did not observe an impact of steroid dosage on the risk of secondary infection in a critically ill cohort of COVID-19 patients. We did observe a high mortality among patients who received steroids following documented secondary infection, but further work will be required to determine if this finding reflects confounding by indication i.e. whether steroids are a marker of sicker patients. Optimal steroid dosage in COVID remains unclear, but higher doses (as were given in the DExa-ARDS study) should be rigorously studied.

The influence of paralytics on the safety and efficacy of prone positioning in COVID19 ARDS

Rationale: Prone positioning has proven benefit but is generally underutilized in moderate to severe Acute Respiratory Disease Syndrome (ARDS). Common practice includes administering neuromuscular blockade [paralytic medication] when proning this population, despite equivocal data regarding benefits of routine paralysis in ARDS. During the COVID19 pandemic, drug shortages and other factors have driven clinicians to prone patients without therapeutic paralysis. Recent publications also suggest prone positioning may be beneficial for non-intubated (non-paralyzed patients). We hypothesized that intubated patients with COVID19-related ARDS can be safely proned without therapeutic paralysis and would experience similar improvement in gas exchange (as evidenced by improved PF [Pa02/Fi02] and SF [Sp02/Fi02] ratios). Methods: Observational data on ICU patients were collected at a large tertiary university hospital from March to September 2020. Clinical teams directed use of sedatives, paralytics, mechanical ventilation settings, and timing of prone vs. supine positioning and blood draws. Comparison of demographics, gas exchange in supine and prone positions (within the same subjects), as well as oxygen requirements, ventilator settings, adverse events and hemodynamic parameters were analyzed using descriptive statistics. Results: Among our cohort of 156 patients, a total of 15 patients were identified that changed from supine to prone position with and without the use of paralytics while in the ICU. All 15 patients had moderate to severe ARDS per the Berlin Criteria, secondary to COVID19. PF and SF ratios were compared in the same patient before and after proning with and without paralytics (within subject comparisons). All groups had an improvement in both average PF ratio (34.7% with and 24.0% without paralysis, p=0.52) and average SF ratio (5.2% with and 6.1% without paralysis, p=0.92) after proning (Figure 1). There were no serious adverse events associated with prone positioning with or without paralytics. Conclusions: When proning patients with COVID19 ARDS, we found no statistically significant difference to support routine use of paralytics when proning. Safety and efficacy were similar when COVID19 patients were being proned with or without neuromuscular blockade. Use of paralytic medication should be an individualized decision rather than given routinely. Larger randomized controlled trials comparing proning with or without paralysis are needed to identify the optimal approach in this population.

Evaluating 'creating caring communities': A medical student pilot wellness program to aid in the transition to medical school during COVID-19

Objective: The transition to medical school is challenging;even more so with the added stress and isolation from the COVID-19 pandemic. While studies have examined medical student wellness programs, few have been implemented during a pandemic, a time of high uncertainty and change. The purpose of this study was to evaluate a novel wellness program, Creating Caring Communities (CCC), its impact on students, and its helpfulness in their transition to medical school during COVID-19. Methods: All incoming first-year medical students (N=183) were required to participate in the mandatory first two of six, one-hour virtual sessions of CCC;a checkin with 10 students and 2 trained facilitators to create a safe space for connectivity and sharing. An online SurveyMonkey was administered to all participants after the sixth session to assess program impact, social isolation, meaningful experience, and helpfulness of CCC in the transition to medical school. Descriptive and bivariate analyses, including crosstabs, were completed using SPSS.25. Openended questions were thematically analyzed. Results: 126 M1 participants completed the post-CCC evaluation (68.9% response rate). Social isolation scores were consistent with the national average for the U.S. general adult population (M=51.96, SD=6.94). M1s who attended more than two sessions (39%) had significantly greater reports of meaningful experiences and helpfulness in transitioning to medical school (respectively, 58.1%;70.8%) compared to M1s who attended two or fewer sessions (respectively, 41.9%;29.2%;p<.05). When asked about the most valuable aspects of CCC, the most common themes reported were: building connections (49.6%), having a safe place to share experiences (17.0%), and not feeling alone (12.6%). Conclusion: Many students found that CCC was helpful with their transition to medical school. Future program refinement should consider whether sessions should be mandatory, the timing and length of the program, and participant input prior to starting CCC for group placement based on individual needs and interests.