In bed hybrid tracheostomy procedure in COVID-19 patients. Technique and results

Background: COVID-19 pandemic, results in a great number of critically ill patients requiring long-lasting periods of invasive mechanical ventilatory support;tracheostomy is considered during their hospital stay, to free patients from ventilatory support and optimize the resources, we developed a safe in bed hybrid tracheostomy procedure to avoid the operating room and minimize SARS-CoV2 transmission due to aerosols exposure. Method(s): We developed this protocol using PDCA (Plan, Do, Check, Act) in order to perform a safe in bed hybrid tracheostomy: percutaneous tracheostomy + flexible bronchoscopy. We used the Ciaglia Blue Rhino technique and flexible bronchoscopy. We analyzed: Gender, age, body mass index, intubation days, ventilatory parameters, procedure time, apnea time, oxygen saturation, complications and patient clinical evolution. Statistical evaluation: Fisher test, U Mann-Whitney, T test, logistic regression and Kaplan-Meier curves. Result(s): From march 2020 to February 2021, 292 patients underwent hybrid tracheostomy;Tracheostomy was successfully completed in all patients: 211 men (72.2%);81 women (27.8%), age 58.5 years old, intubation days before tracheostomy 23 days (19 to 28 days), 133 patients (45.5%) deaths due to COVID19 complications. Procedure time 6 to 14 minutes (mean 9 minutes), apnea time 147 to 360 seconds (mean 240 seconds), O2 saturation 66%-96% (mean 87%), PaO2/fiO2 106-194 (mean 142), SOFA 4-6 (mean 5). No complications due to the trachesotomy. Conclusion(s): In bed hybrid tracheostomy procedure implementation with the PDCA cycles is safe, with good results, zero procedure complications and a good and rapid learning curve.

The Cost-Effectiveness of Home-Based Cardiac Rehabilitation Interventions: A Systematic Review

Objectives: Cardiac rehabilitation (CR) is recognised as a cost-effective intervention which can be offered to people following a cardiac event. Home-based alternatives are being increasingly used (versus centre-based options), particularly since the COVID-19 pandemic. This study aimed to assess whether home-based interventions in the CR pathway have been demonstrated to be cost-effective, compared to conventional centre-based delivery, in a population undergoing CR. Method(s): Electronic searches of the PsycINFO, MEDLINE and Embase databases (via Ovid) were conducted to identify relevant published full economic evaluations. Studies were included if they reported a full economic evaluation of home-based CR programmes or an intervention that may be classed as an individual aspect of a comprehensive home-based CR programme, compared to centre-based CR options. The review was restricted to English language studies published within the last 15 years. The protocol was registered on the PROSPERO database (CRD42018108226). Result(s): Database searches identified 2,572 initial records (1,865 after the removal of duplicates). Following screening of titles/s, 53 full-text articles were assessed. Nine studies were included in the review. Interventions were heterogeneous in terms of delivery, components of care (e.g. exercise and behaviour change) and duration. All studies were economic evaluations alongside clinical trials, with sample sizes ranging from 53 to 778. All studies reported quality-adjusted life-years (QALYs), with the EQ-5D as the most common measure of health status (6/9 studies). Most studies (7/9 studies) concluded that home-based CR was cost-effective compared to centre-based options. Conclusion(s): Evidence suggests that home-based CR is cost-effective, which is particularly pertinent given the need for non-centre-based options following the COVID-19 pandemic. There were some limitations to the evidence base, including sample size and limited time horizons. Given heterogeneity in intervention design and delivery, future research is needed to investigate patient preferences for CR intervention and the cost-effectiveness of different modes of delivery. Copyright © 2022

COVID-19 Q&A with Peter C. Doherty

In this bonus chapter, we have the pleasure of talking with Professor Peter C. Doherty. Professor Doherty shared the Noble Prize for Medicine in 1996 and became Australian of the year in 1997. He is Laureate Professor and Patron of the Doherty Institute at the University of Melbourne and Michael F Tamer Chair of Biomedical Research, St Jude Children's Research Hospital Memphis, TN, USA. His expertise lies in viral pathogenesis and immunity, particularly the killer T cell response. Since April 2020, he has been writing weekly lay explainers of the science underlying COVID-19 and our efforts to control it. These can be read athttps://www.doherty.edu.au/;the first 42 of these will be printed, along with related material, in “An Insider's Plague Year” (Melbourne University Publishing) which should come out in July 2021. © 2022 selection and editorial matter, Patricia Fronek and Karen Smith Rotabi-Casares;individual chapters, the contributors.

Design and evaluation of an interactive quality dashboard for national clinical audit data: a realist evaluation

BACKGROUND: National audits aim to reduce variations in quality by stimulating quality improvement. However, varying provider engagement with audit data means that this is not being realised. AIM: The aim of the study was to develop and evaluate a quality dashboard (i.e. QualDash) to support clinical teams' and managers' use of national audit data. DESIGN: The study was a realist evaluation and biography of artefacts study. SETTING: The study involved five NHS acute trusts. METHODS AND RESULTS: In phase 1, we developed a theory of national audits through interviews. Data use was supported by data access, audit staff skilled to produce data visualisations, data timeliness and quality, and the importance of perceived metrics. Data were mainly used by clinical teams. Organisational-level staff questioned the legitimacy of national audits. In phase 2, QualDash was co-designed and the QualDash theory was developed. QualDash provides interactive customisable visualisations to enable the exploration of relationships between variables. Locating QualDash on site servers gave users control of data upload frequency. In phase 3, we developed an adoption strategy through focus groups. 'Champions', awareness-raising through e-bulletins and demonstrations, and quick reference tools were agreed. In phase 4, we tested the QualDash theory using a mixed-methods evaluation. Constraints on use were metric configurations that did not match users' expectations, affecting champions' willingness to promote QualDash, and limited computing resources. Easy customisability supported use. The greatest use was where data use was previously constrained. In these contexts, report preparation time was reduced and efforts to improve data quality were supported, although the interrupted time series analysis did not show improved data quality. Twenty-three questionnaires were returned, revealing positive perceptions of ease of use and usefulness. In phase 5, the feasibility of conducting a cluster randomised controlled trial of QualDash was assessed. Interviews were undertaken to understand how QualDash could be revised to support a region-wide Gold Command. Requirements included multiple real-time data sources and functionality to help to identify priorities. CONCLUSIONS: Audits seeking to widen engagement may find the following strategies beneficial: involving a range of professional groups in choosing metrics;real-time reporting;presenting 'headline' metrics important to organisational-level staff;using routinely collected clinical data to populate data fields;and dashboards that help staff to explore and report audit data. Those designing dashboards may find it beneficial to include the following: 'at a glance' visualisation of key metrics;visualisations configured in line with existing visualisations that teams use, with clear labelling;functionality that supports the creation of reports and presentations;the ability to explore relationships between variables and drill down to look at subgroups;and low requirements for computing resources. Organisations introducing a dashboard may find the following strategies beneficial: clinical champion to promote use;testing with real data by audit staff;establishing routines for integrating use into work practices;involving audit staff in adoption activities;and allowing customisation. LIMITATIONS: The COVID-19 pandemic stopped phase 4 data collection, limiting our ability to further test and refine the QualDash theory. Questionnaire results should be treated with caution because of the small, possibly biased, sample. Control sites for the interrupted time series analysis were not possible because of research and development delays. One intervention site did not submit data. Limited uptake meant that assessing the impact on more measures was not appropriate. FUTURE WORK: The extent to which national audit dashboards are used and the strategies national audits use to encourage uptake, a realist review of the impact of dashboards, and rigorous evaluations of the impact of dashboards and the effectiveness of adoption strategies should be explored. STUDY REGISTRATION: This study is registered as ISRCTN18289782. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research;Vol. 10, No. 12. See the NIHR Journals Library website for further project information.

Telemedicine during the covid-19 pandemic

Telemedicine worldwide and in Mexico has been very useful during the COVID-19 pandemic. Being able to provide health care services where distance is a critical factor, at a time when health services are saturated, and where face-to-face care implies a risk for both the health care provider and the patients, it has been indispensable during the pandemic. The speed with which telemedicine services have been implemented globally has been very different. There are still great challenges to be solved in order to provide this type of care worldwide. It should be noted that telemedicine complements patient care, rather than replacing the usual face-to-face care.

COVID-19 pandemic: Preparing for the XXI century plague

Towards the end of 2019 in China, a new coronavirus produced acute respiratory infection appeared. It soon became a worldwide pandemic which has pushed all medical care systems to adopt protocols to manage the situation, adjust resources required and to adapt medical areas for patient care;Mexico declare national sanitary emergency on march 30, 2020. The response to this new infection requires to understand its disease mechanisms, design and evaluate treatments, control of medical resources and, above all, the contention and mitigation within the general population in order to reduce contagiousness as much as possible.

R/Coronavirus and the Viral Pandemic: A source of truth, comfort and companionship during COVID19

The COVID19 pandemic has unfolded alongside a concurrent g€infodemic' - defined by the World Health Organization as an overabundance of information, some accurate, some not, that occurs during an epidemic. Key to managing this is not only identifying, countering and debunking misinformation but also providing unbiased and factually correct information and signposting people towards it. However, during COVID19, the g€truth' has not always been clear. It has not always been easy to prepare public health messaging that is consistent, easily understood or practical for everyone to apply. This presents unique challenges, to which social media platforms need to be part of the solution. One such solution can be found on www.reddit.com where, in January 2020, a group of research scientists, students, academics and medics came together to create and moderate forums in which the pandemic can be discussed and questions about it answered. These forums provide case studies of how information can be generated, misinformation corrected and disinformation debunked on subreddits with, combined, more than 3 million subscribers. © 2021 Owner/Author.

Low Incidence and Mortality by SARS-CoV-2 Infection Among Healthcare Workers in a Health National Center in Mexico: Successful Establishment of an Occupational Medicine Program

Background: Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Healthcare workers (HCWs) constitute a population which is significantly affected by SARS-CoV-2 infection worldwide. In Mexico, the Instituto Nacional de Enfermedades Respiratorias (INER) is the principal national reference of respiratory diseases. Aim: To evaluate the efficiency of the INER-POL-TRAB-COVID19 program to mitigate the SARS-CoV-2 infection risk among the INER-healthcare workers (INER-HCW). Methods: Currently, the INER has 250 beds and 200 respiratory ventilators to support COVID-19 patients in critical condition. On March 1st, 2020, the INER-POL-TRAB-COVID19 program was launched to mitigate the SARS-CoV-2 infection risk among the INER-HCW. Findings: From March 1st to October 1st, 2020, 71.5% of INER-HCWs were tested for SARS-CoV-2 infection, and 77% of them were frontline workers. Among the tested INER-HCWs, 10.4% were positive for SARS-CoV-2 infection. Nonetheless, nosocomial infection represented only 3.8% of the cases and the mortality was null. Fifty-three of INER-HCWs positive to SARS-CoV-2 had a negative test 42-56 days post-diagnosis and were returned to service. Finally, although a change in the PPE implemented on May 11th, 2020, the incidence of SARS-CoV-2 infection was not affected. Conclusion: INER has a lower incidence of HCWs infected with SARS-CoV-2 as compared to the mean of the national report. The implementation of the INER-POL-TRAB-COVID19 program is efficient to decrease the risk of infection among the HCWs. Our findings suggest that the implementation of a similar program at a national level can be helpful to provide a safe environment to HCWs and to prevent the collapse of health institutions.

Spontaneous pneumomediastinum in COVID-19 patients. Case series

Spontaneous pneumomediastinum is defined as the presence of free air within the mediastinum without an apparent cause such as chest trauma. It is a benign, self-limiting condition that is conservatively treated. Clinical diagnosis is based on two symptoms: chest pain and dyspnea;and on a particular sign: subcutaneous emphysema. It has been reported in patients with influenza A (H1N1) and severe acute respiratory syndrome;however, it has been rarely observed in COVID-19 patients. In this work, we describe six male patients with COVID-19, aged between 27 and 82 years, who presented with spontaneous pneumomediastinum and subcutaneous emphysema;both conditions were completely resorbed with conservative management.