ABSTRACT
To explore laryngeal function of tracheostomised patients with COVID-19 in the acute phase, to identify ways teams may facilitate and expedite tracheostomy weaning and rehabilitation of upper airway function. Consecutive tracheostomised patients underwent laryngeal examination during mechanical ventilation weaning. Primary outcomes included prevalence of upper aerodigestive oedema and airway protection during swallow, tracheostomy duration, ICU frailty scores, and oral intake type. Analyses included bivariate associations and exploratory multivariable regressions. 48 consecutive patients who underwent tracheostomy insertion as part of their respiratory wean following invasive ventilation in a single UK tertiary hospital were included. 21 (43.8%) had impaired airway protection on swallow (PAS ≥ 3) with 32 (66.7%) having marked airway oedema in at least one laryngeal area. Impaired airway protection was associated with longer total artificial airway duration (p = 0.008), longer tracheostomy tube duration (p = 0.007), multiple intubations (p = 0.006) and was associated with persistent ICU acquired weakness at ICU discharge (p = 0.03). Impaired airway protection was also an independent predictor for longer tracheostomy tube duration (p = 0.02, Beta 0.38, 95% CI 2.36 to 27.16). The majority of our study patients presented with complex laryngeal findings which were associated with impaired airway protection. We suggest a proactive standardized scoring and review protocol to manage this complex group of patients in order to maximize health outcomes and ICU resources. Early laryngeal assessment may facilitate weaning from invasive mechanical ventilation and liberation from tracheostomy, as well as practical and objective risk stratification for patients regarding decannulation and feeding.
ABSTRACT
Background: Recent RECOVERY trial showed use of dexamethasone lead to reduction in 28 days mortality in patients with COVID pneumonia requiring oxygen. NICE recommends offering dexamethasone for 10 days in patients with COVID positive pneumonia. However, outcomes from real world data are lacking. Aim: The aim of this study was to analyse the impact of different duration of dexamethasone on mortality rate in patients with COVID positive pneumonia requiring oxygen. Method: The study was performed retrospectively from single centre using electronic PICS (prescribing information and communication system). We included patients admitted in hospital between the periods of 29/12/2020 to 7/1/2021 with diagnosis of COVID pneumonia, requiring dexamethasone. Data extracted included patient demographics, diabetes status and number of days on dexamethasone. We evaluated outcomes in three groups based on duration of dexamethasone as Group A (10 days), Group B (4-9 days) and Group C (≤3 days). Primary outcomes were mortality rate and length of stay. Results: We identified 179 patients. Mean (SD) age was 65 (17) years, 45.8% were female. Mean BMI was 31(14) kg/m2, 56.9% were Caucasian, 18.9% South Asian,4.4% were Afro-Caribbean,46.9% had diabetes. 128 patients were nursed on general medical ward (GIM) and 51 patients needed ITU setting. The mortality rate was 25 %, 20% and 43.7% in group A, B and C respectively. Mean length of stay (LOS) was 9 (11) days,10 (7) days and 9 (6) days in group A, B and C respectively. Further analysis of patients nursed on GIM ward showed mortality rate of 11.9%, 25% and 66.6% in group A, B and C suggesting an association between longer duration of dexamethasone and reduction in mortality. No difference in LOS was noted. No similar analysis was conducted in patients nursed on ITU setting because of small sample size. Discussion: Longer duration of dexamethasone was associated with better mortality rate in patients nursed on GIM ward and hence we should offer full course of 10 days dexamethasone in patients admitted with Covid pneumonia requiring oxygen. However, our study had small sample size, from single centre and result was not adjusted for co-variables like age, gender, BMI, and amount of oxygen requirement. We need future study with large sample size, multicentre and addressing these limitations.
ABSTRACT
COVID-19 related restrictions made it necessary for mental health outpatient care to abruptly transition to virtual care. For some youth and families, multiple stresses related to isolation, loss of friend and family supports, school cancellation are exacerbated by financial stress, limited parenting skills and challenges with emotion regulation. Such situations put young people at risk for deteriorating mental health and conflictual family situations, which could lead to Emergency (ED) presentations, admission, and child protective service or police involvement. At-risk young people include current outpatients, those who have been referred but not seen, and patients presenting to ED. Methods: A system was developed for categorizing all patients as high, medium or low risk and an algorithm de-veloped as to level of intervention required for each. All patients on the waitlist were triaged for risk level. A pathway was developed to have high risk patients referred from ED seen virtually within 3 days and other high risk patients monitored closely. Patient flow was adjusted to allow flexible matching of capacity to demand. Return visits to ED and evaluation of patient satisfaction with virtual care were used as outcome measures. Results: Patients referred to the rapid response pathway were seen in a shorter time than had previously been the case. Fewer patients returned to the ED on multiple occasions. Conclusions: Development of systems for categorizing patient risk levels, development of a virtual rapid response pathway, and flexing capacity to meet demand has enabled flexible rapid response to high needs patients.
ABSTRACT
The COVID pandemic has led to unprecedented levels of stress in parents and families (Ipsos Annual Mental Health Index Survey, 2020). Methods: To support parents through COVID, a team of parent leaders from PLEO (Parents' Lifeline of Eastern Ontario) and an interdisciplinary team of mental health (MH) professionals jointly created and co-hosted a two-session webinar series. Using principles of family engagement (Ontario Centre of Excellence for Child and Youth Mental Health, Oct 2019), the first half of each webinar was a powerpoint didactic on practical strategies for adaptive parenting during COVID. The second half was an opportunity for parents to ask the interdisciplinary panel experts (including peer support parents) questions about strengthening child and youth MH. At the conclusion of each session, the webinar recording, PDFs of slides and a transcript of the Questions and Answers were posted online for free, permanent access. Results: Participants (n=380) completed online surveys after the webinars. Feedback was overwhelmingly positive with satisfaction 90-95% for content, topics and panel discussion. Top strengths: 1) session content;2) suggestions and recommendations;3) session panel. Top suggestions for improvement: 1) more time for questions and answers;2) having the powerpoint slides available in advance;3) more in-depth topics. Conclusions: Parents and professionals co-developed and co-facilitated a two-session webinar to support 380 parents across Ontario. Feedback was overwhelmingly positive. The co-development/co-facilitation model is a promising practice. Further steps will explore how to fund and run future sessions, and expand the range of topics.
ABSTRACT
OBJECTIVES: As the pathophysiology of COVID-19 emerges, this paper describes dysphagia as a sequela of the disease, including its diagnosis and management, hypothesised causes, symptomatology in relation to viral progression, and concurrent variables such as intubation, tracheostomy and delirium, at a tertiary UK hospital. RESULTS: During the first wave of the COVID-19 pandemic, 208 out of 736 patients (28.9 per cent) admitted to our institution with SARS-CoV-2 were referred for swallow assessment. Of the 208 patients, 102 were admitted to the intensive treatment unit for mechanical ventilation support, of which 82 were tracheostomised. The majority of patients regained near normal swallow function prior to discharge, regardless of intubation duration or tracheostomy status. CONCLUSION: Dysphagia is prevalent in patients admitted either to the intensive treatment unit or the ward with COVID-19 related respiratory issues. This paper describes the crucial role of intensive swallow rehabilitation to manage dysphagia associated with this disease, including therapeutic respiratory weaning for those with a tracheostomy.
ABSTRACT
Background and aim: Healthcare workers (HCW) are at increased risk of developing coronavirus disease 2019 (COVID-19). Providing cardiopulmonary resuscitation (CPR) to a COVID-19 patient is an aerosol-generating procedure. Guidelines for personal protective equipment (PPE) use and providing CPR to COVID-19 patients have been developed locally for the purpose of improving patient and HCW safety. Medical simulation is used to educate HCWs. We aimed to the determine the utility of COVID-19 CPR simulation in improving HCWs ability, confidence and knowledge in managing medical emergencies. Methods: 108 HCWs participated in a standardised 1-h moderate-fidelity CPR simulation designed and delivered in the medical simulation laboratory at our tertiary metropolitan hospital in Sydney, Australia. Participant-filled surveys were collected pre and post-simulation. Data was categorised into assessment of perceived knowledge, confidence and ability in PPE use and providing CPR using a 5-point Likert scale. Statistical analyses were performed using the Mann–Whitney U test. Results: Of 108 participants, 94 were doctors and 14 nurses. The mean subjective scores of confidence in providing CPR pre and post-simulation were 2.3 and 3.9 respectively (p < 0.001);perceived ability to provide CPR pre and post-simulation were 2.5 and 4.0 respectively (p < 0.001);confidence in PPE use pre and post-simulation were 3.1 and 4.2 respectively (p < 0.001);perceived ability in PPE use pre and post-simulation were 3.3 and 4.2 respectively (p < 0.001) (see Fig. 1). Adequate knowledge of specific elements of newly developed guidelines improved from 14% to 97% of participants pre and post-simulation. Conclusion: Our study shows that during the COVID-19 pandemic, simulation of medical emergency scenarios is a valuable tool in improving knowledge, confidence and perceived ability of HCWs in PPE use and providing CPR in medical emergencies where real-life experience may be limited. Inadequate preparation before encountering real-life scenarios in COVID-19 patients may compromise the safety of both patients and healthcare workers.