Responsive, adaptive, and future-centred leadership in response to crisis: findings from Australia, Fiji, and New Zealand

The COVID-19 pandemic has caused major disruption to education and highlighted the importance of effective leadership during times of crisis. This paper considers the impact of the pandemic on school leaders in Australia, Fiji, and New Zealand. A secondary analysis of data from five interpretivist, qualitative studies was conducted. The aim of the study was to investigate the similarities and differences between the leaders' experiences across school settings, states/provinces, and countries. Our findings place renewed importance on understanding the role of schools within the community and the vital role school leaders play in helping schools respond to volatile and dynamic circumstances. The findings show how leaders' roles and responsibilities adapted to respond quickly and effectively to the urgency of the crisis, regardless of the context. Furthermore, common practices such as attending to wellbeing and providing clear and timely communication were revealed. The analysis also revealed some interesting nuances in the leaders' responses because of the duration of the crisis, the particular needs of the community, and government requirements. Papers like this provide insights into what leaders do and how schools and systems might prepare and support leaders to lead during times of crisis. © 2023 Informa UK Limited, trading as Taylor & Francis Group.

Pentobarbital for Sedation of Adults Receiving Extracorporeal Membrane Oxygenation for Covid-19

INTRODUCTION: Sedation for ventilated patients with COVID-19 is challenging given the severity and duration of the disease. Complicating this is the introduction of extracorporeal membrane oxygenation (ECMO) for patients with refractory respiratory failure. An ECMO circuit can meaningfully alter drug pharmacokinetics by sequestering drug, increasing the volume of distribution, and altering clearance. Many common sedatives are known to be significantly impacted, thus altering standard dosing. In circumstances warranting deep sedation, such as ARDS, clinicians need a wide array of sedatives and analgesics available when managing patients receiving ECMO support. To our knowledge, no studies have assessed the use of pentobarbital as a sedative in adult patients receiving ECMO support for severe ARDS. We aimed to characterize the use of pentobarbital infusions as part of a multi-modal sedation regimen in adult patients with COVID-19 who were receiving ECMO. METHOD(S): Adults with COVID-19 who were receiving both pentobarbital and VV-ECMO support between March 2020 and December 2021 were included. The primary outcome was change in the dose of concomitant sedatives at 24- and 48-hours post-initiation of pentobarbital. Secondary outcomes included depth of sedation, ventilator synchrony, mean arterial pressure (MAP), and vasopressor doses in norepinephrine equivalents. Additionally, we assessed for adverse drug reactions (ADRs) which included hypotension and transaminitis. RESULT(S): Five patients were included. All patients were initiated on a pentobarbital infusion for the indication of ventilator dyssynchrony. Patients received pentobarbital at an initial rate of 1 mg/kg/hr and infusion rates ranged between 0.5 - 2 mg/kg/hr. Following pentobarbital initiation, all patients became synchronous with the ventilator and doses of continuous sedative infusions decreased. Additionally, the total number and daily dose of rescue sedative medications decreased following pentobarbital initiation. ADRs were common and included hypotension (60%) and transaminitis (20%). CONCLUSION(S): A pentobarbital infusion can be used as part of a multimodal sedation regimen for patients requiring high doses of sedatives to achieve ventilator synchrony.

DEVELOPMENT AND DELIVERY OF A MULTI-DISCIPLINARY HYBRID EDUCATION PROGRAM IN SYNCOPE AND RELATED DISORDERS DURING THE COVID-19 PANDEMIC

Background: Syncope and related disorders is an important area for training of all health professionals. During the COVID-19 pandemic, we adapted the delivery of our annual face-to-face certified program to a 9-month hybrid program. Here, we describe the development, delivery, and evaluation of such new program. Methods: A pre-existing curriculum was modified to incorporate online content, online lecture delivery and interactive group learning, in addition to individual practical placements in a syncope management unit, in line with government and hospital infection control guidance at the time. Monthly content included video consultant case presentations, ECG analysis and interpretation, and instructional videos of diagnostic testing and relevant technologies. A comprehensive online week-long lecture program was developed. Results: The lecture week included 30 clinical lectures, 10 clinical case presentations and 10 ‘how to’ practical videos for testing/monitoring procedures. Further learning over zoom incorporated learner case presentations in a small group format. At the completion of the course the leaners attended a final online half day of lectures and completed the multi choice question examination. Conclusion: “Thank you so much for putting together such a fantastic week of training.” “The quality and expertise of the speakers was outstanding.” “I have taken a huge amount away to incorporate into my practice and local unit.”The above learner feedback is consistent with our aim to deliver a high-quality specialist program for those interested in advancing the management of syncope and related disorders. Over time, this specialist training will aid the development of regional syncope management units across Ireland. The benefits of a hybrid learning model include multiple options to cater for all categories of learners, thus suggesting it is the cornerstone of future learning modalities.

THE IMPACT OF THE COVID-19 PANDEMIC ON THE ACTIVITY OF A RAPID-ACCESS GERIATRIC DAY HOSPITAL SERVICE

Background: In the 1970s, Jack Flanagan developed the first Geriatric Day Hospital (GDH) in Ireland. Since, the GDH model of care has evolved to accommodate for the growing demands of our ageing population. Before the COVID-19 pandemic, the operational scope of our GDH was extended to allow for the rapid medical and multidisciplinary assessment and follow-up of older patients. During the pandemic, the GDH did not suspend operations and remained open as a COVID-negative ambulatory pathway. We evaluated the activity of this GDH service. Methods: Retrospective Service Evaluation Approval was granted by our Research & Innovation Office (Reference: 7419). Pseudonymised data corresponding to all GDH attendances between January 2017 and December 2021 were retrieved from the hospital electronic records. Yearly trends in proportions were tested with the Chi-square for trend statistic. Trends in monthly attendances were assessed via Statistical Process Control (SPC) charts with three-sigma limits. Statistical significance was set at p<0.05. Results: There were 27,278 attendances of patients aged 65 and over to the GDH over the 5-year period (6,362, 5,978, 6,115, 4,306, and 4,517, respectively). Mean age was 82 every year. Of the 7,813 new episodes, yearly proportions referred directly by primary care teams were 10.4%, 29.5%, 38.6%, 24.5%, and 16.3% (p<0.001). SPC charts showed that Apr-May 2020 and Jan-Feb 2021 had significantly lower numbers of review attendances (50-59 and 146-142, respectively, average 324 p/m). However, new appointments did not significantly decline (average 130 p/m). Of the 7,813 new episodes, 2,595 (33.2%) were seen by Physiotherapy, and 1,860 (23.8%) by Occupational Therapy. Conclusion: Our GDH saw a sustained number of new attendances and demonstrated increased community availability during the unprecedented COVID-19 crisis, especially during the first wave of the pandemic when hospital access was most affected. A rapid access GDH model can facilitate integrated care at times of crisis to promote ageing in place.

An evaluation of nutritional status and specific nutritional issues during a rehabilitation period post COVID-19 infection

Patients recovering from COVID-19 infection are at a high risk of malnutrition, reduced nutritional intake and decline in muscle mass and strength.1 The aim of this service evaluation is to describe baseline characteristics, quantify risk of malnutrition, provide an overview of nutritional status and nutritional related outcomes for patients recovering post COVID-19 infection on rehabilitation wards. Data collection occurred between the 1st of February and the 1st of July 2021. This cohort included all patients who were recovering from COVID-19, who were referred to dietetic service and transferred to a rehabilitation ward. Demographic data and nutritional parameters were gathered from electronic records, and dietetic assessments. A total of 54 patients were included: 59% male, 41% female. Ages ranged from 46 to 95 years with average age of 79.9 years and average length of hospital stay of 92 days. One fifth of those included had an ICU stay. Where data was available on sarcopenia risk, 50% were identified as at risk of sarcopenia. Of those where serum 25-hydroxyvitamin D was checked, 45% had insufficient vitamin D levels. A nutrition focused physical exam was completed for 18 patients (one third of the cohort). Using this exam, 61% were diagnosed with moderate or severe malnutrition. At least 15% of patients experienced significant weight loss between their admission to the hospital compared to their weight on admission to post COVID-19 rehabilitation ward. Of those where Malnutrition Screening Tool was completed on admission to COVID-19 rehabilitation ward, 33% were identified as at risk of malnutrition. On discharge from the dietetic caseload, the proportion of those identified at risk of malnutrition using this tool decreased to 18%. During the period from admission to COVID-19 rehabilitation ward and discharge from dietetic service, 42% gained weight, 54% maintained their weight, 4% lost weight. Of those with data available regarding nutritional intake on admission to COVID-19 rehabilitation ward, 28% met energy requirements and 44% met protein requirements. On discharge from dietetic service these proportions increased to 66% meeting energy requirements and 74% meeting protein requirements. The average kcal intake on admission to COVID-19 rehabilitation increased from 1531kcal to 1778kcal on discharge and the average protein intake increased from 67g on admission to post COVID-19 rehabilitation to 75g on discharge. These results demonstrate the high prevalence of malnutrition and high risk of sarcopenia in patients admitted for rehabilitation post COVID-19 infection. With dietetic input, improvements were observed in patient’s nutritional intake, and nutritional outcomes such as weight and malnutrition risk. These results illustrate the need for early dietetic input in those recovering post COVID-19 infection to optimise nutritional status and nutritional outcomes. References: 1. Anker M. S., Landmesser U., von Haehling S et al. Weight loss, malnutrition, and cachexia in COVID-19: facts and numbers. Journal of Cachexia, Sarcopenia and Muscle, 12, 9– 13.

IMPROVING INPATIENT INFLUENZA VACCINATION RATES—THE VALUE OF AN ELECTRONIC PATIENT RECORD REMINDER SYSTEM

Background Influenza vaccination, particularly for vulnerable, older adults, will have added importance this winter given the possibility of further waves of COVID-19 pandemic. Previous interventions at the study site noted poor awareness on the need for inpatient Influenza vaccination1. This study examines a vaccination reminder process using an electronic patient record (EPR) to identify high-priority eligible inpatients. Methods The study site is a 900-bed university teaching hospital with all clinical notes accessed via an EPR. We included a convenience sample of 750 adults aged≥50 years (mean age 75.9 +/− 0.4 years, 48% female) and high-priority for influenza vaccination (Age > 65 years and/or length of stay (LOS) >30 days) from October 1st 2020 to January 12th 2021. A live electronic dashboard identified eligible inpatients for vaccination, prompting vaccination reminders to the clinical teams via the antimicrobial pharmacist. Data was collected retrospectively. Logistic regression models reporting odds ratios were used to assess the association of these reminders with vaccine uptake. Results Over one third (35%, 264/750) of high-priority patients received the Influenza vaccine while inpatients, including 40% aged ≥80 years. The reminder was sent on 41% (305/750) of patients and was associated with an almost 50% higher likelihood of vaccination after adjusting for other covariates (Odds Ratio 1.48 (95% CI 1.00–2.20);p = 0.048). Other factors independently associated with vaccination were advancing age (Odds Ratio 2.69 (95% CI 1.12–6.47) for age ≥ 80 years);LOS (4% higher likelihood of vaccination for every additional day in hospital) and admission under geriatric medicine (Odds Ratio 3.71 (95% CI 2.45–5.62) when compared to other specialities). Conclusion Our study shows relatively low uptake of inpatient Influenza vaccination and strategies to improve uptake are required. Reminders sent to clinical teams using the EPR appear to be an effective means of increasing Influenza vaccination and should be considered as part of this year’s inpatient vaccination drive.

Justifying quarantine in preventing the spread of COVID-19 in healthcare.

BACKGROUND: The first COVID-19-positive patient was identified in Ireland on 29 February 2020 (Department of Health, Government of Ireland; https://www.gov.ie/en/pressrelease/2f75fd-statement-from-the-national-public-healthemergency-team-sat-29-feb/). Healthcare worker (HCW) quarantining became a core intervention for those identified as 'close contacts' to reduce onward transmission within the workplace to patients and colleagues. Whether a quarantining strategy could be justified at a time when there was an increased demand for the services of HCWs remained unknown. AIMS: To establish whether quarantining staff away from a healthcare setting during a pandemic is justified. METHODS: This retrospective study examined close contacts of COVID-19-positive index cases (both residents and HCWs) in a community hospital over a 4-week period from 1 to 28 April 2020. Close contacts were identified in accordance with national guidelines. Zones of the hospital were examined to determine the number of COVID-positive index cases and their close contacts. A cumulative result for the hospital was recorded. RESULTS: While outcomes varied over time, per zone and per HCW category, the overall conversion rate from close contact to an index case was 30%. CONCLUSIONS: This study vindicates the policy of quarantining close contact HCWs from their workplaces as they pose a significant threat to both their patients and fellow workers.

Physical and mental health of older people while cocooning during the COVID-19 pandemic.

BACKGROUND: Cocooning or shielding, i.e. staying at home and reducing face-to-face interaction with other people, was an important part of the response to the COVID-19 pandemic for older people. However, concerns exist regarding the long-term adverse effects cocooning may have on their physical and mental health. AIM: To examine health trajectories and healthcare utilization while cocooning in a cohort of community-dwelling people aged ≥70 years. DESIGN: Survey of 150 patients (55% female, mean age 80 years and mean Clinical Frailty Scale Score 4.8) attending ambulatory medical services in a large urban university hospital. METHODS: The survey covered four broad themes: access to healthcare services, mental health, physical health and attitudes to COVID-19 restrictions. Survey data were presented descriptively. RESULTS: Almost 40% (59/150) reported that their mental health was 'worse' or 'much worse' while cocooning, while over 40% (63/150) reported a decline in their physical health. Almost 70% (104/150) reported exercising less frequently or not exercising at all. Over 57% (86/150) of participants reported loneliness with 1 in 8 (19/150) reporting that they were lonely 'very often'. Half of participants (75/150) reported a decline in their quality of life. Over 60% (91/150) agreed with government advice for those ≥70 years but over 40% (61/150) reported that they disliked the term 'cocooning'. CONCLUSIONS: Given the likelihood of further restrictions in coming months, clear policies and advice for older people around strategies to maintain social engagement, manage loneliness and continue physical activity and access timely medical care and rehabilitation services should be a priority.