Reset - the First Step in the Clinical Wellbeing Pathway

Background The COVID-19 pandemic has highlighted the importance of wellbeing support for frontline clinical staff. The newly introduced Great Ormond Street Hospital (GOSH) Clinical Wellbeing Pathway aims to provide consistent support to clinical teams following challenging or distressing events at work. RESET is the initial step in this pathway. It is a brief, facilitated conversation between clinical team members, taking place during the shift in which the clinical event has occurred. 'RESET' is an acronym that encompasses five key themes: Recognise, Evaluate, Stuff still to do, Elevate staff, Taking things forward. Method We used an action research methodology, where the design and clinical outcomes were co-created with the relevant staff groups. This comprised of an e-survey on existing clinical practices, expert consultation, facilitator training and pilot with ongoing qualitative feedback from staff on two pilot wards. Results Limited responses from our E-survey on existing hot debrief practices at GOSH highlighted that debriefs did not occur consistently but when they did, they were beneficial. Respondents indicated that training on facilitating debriefs would be well received. Feedback from the expert consultation (n= 14) highlighted the impact of terminology on clinical staff. Therefore, the language of the acronym was adapted accordingly. Feedback also highlighted the important role of the RESET facilitator, being able to respond flexibly and organically to the uncertain and potentially emotive conversations. Preliminary feedback from two facilitator training sessions with senior clinical staff (n= 11) identified the RESET tool and facilitator training is beneficial. Conclusion This phased introduction of the RESET tool has demonstrated that the proforma and accompanying training is viable to assist in the structure of post-event conversations. Clinical impact has yet to be assessed and we continue to pro-actively gather feedback on the utility and barriers to RESET conversations throughout our ongoing pilot study.

Increased Comorbidity Burden Among Hip Fracture Patients During the COVID-19 Pandemic in New York City.

BACKGROUND: The coronavirus disease 19 (COVID-19) pandemic had a devastating effect on New York City in the spring of 2020. Several global reports suggested worse early outcomes among COVID-positive patients with hip fractures. However, there is limited data comparing baseline comorbidities among patients treated during the pandemic relative to those treated in non-pandemic conditions. MATERIALS AND METHODS: A multicenter retrospective cohort study was performed at two Level 1 Trauma centers and one orthopedic specialty hospital to assess demographics, comorbidities, and outcomes among 67 hip fracture patients treated (OTA/AO 31, 32.1) during the peak of the COVID-19 pandemic in New York City (March 20, 2020 to April 24, 2020), including 9 who were diagnosed with COVID-19. These patients were compared to a cohort of 76 hip fracture patients treated 1 year prior (March 20, 2019 to April 24, 2019). Baseline demographics, comorbidities, treatment characteristics, and respiratory symptomatology were evaluated. The primary outcome was inpatient mortality. RESULTS: Relative to patients treated in 2019, patients with hip fractures during the pandemic had worse Charlson Comorbidity Indices (median 5.0 vs 6.0, P = .03) and American Society of Anesthesiologists (ASA) scores (mean 2.4 vs 2.7, P = .04). Patients during the COVID-19 pandemic were more likely to have decreased ambulatory status (P<.01) and a smoking history (P = .04). Patients in 2020 had longer inpatient stays (median 5 vs 7 days, P = .01), and were more likely to be discharged home (61% vs 9%, P<.01). Inpatient mortality was significantly increased during the COVID-19 pandemic (12% vs 0%, P = .002). CONCLUSIONS: Patients with hip fractures during the COVID-19 pandemic had worse comorbidity profiles and decreased functional status compared to patients treated the year prior. This information may be relevant in negotiations regarding reimbursement for cost of care of hip fracture patients with COVID-19, as these patients may require more expensive care.

Telemedicine in an Outpatient Arthroplasty Setting During the COVID-19 Pandemic: Early Lessons from New York City.

Background: The early months of the coronavirus disease 19 (COVID-19) pandemic in New York City led to a rapid transition of non-essential in-person health care, including outpatient arthroplasty visits, to a telemedicine context. Questions/Purposes: Based on our initial experiences with telemedicine in an outpatient arthroplasty setting, we sought to determine early lessons learned that may be applicable to other providers adopting or expanding telemedicine services. Methods: A cross-sectional study was performed by surveying all patients undergoing telemedicine visits with 8 arthroplasty surgeons at 1 orthopedic specialty hospital in New York City from April 8 to May 19, 2020. Descriptive statistics were used to analyze demographic data, satisfaction with the telemedicine visit, and positive and negative takeaways. Results: In all, 164 patients completed the survey. The most common reasons for the telemedicine visit were short-term (less than 6 months), postoperative appointment (n = 88; 54%), and new patient consultation (n = 32; 20%). A total of 84 patients (51%) noted a reduction in expenses versus standard outpatient care. Several positive themes emerged from patient feedback, including less anxiety and stress related to traveling (n = 82; 50%), feeling more at ease in a familiar environment (n = 54; 33%), and the ability to assess postoperative home environment (n = 13; 8%). However, patients also expressed concerns about the difficulty addressing symptoms in the absence of an in-person examination (n = 28; 17%), a decreased sense of interpersonal connection with the physician (n = 20; 12%), and technical difficulties (n = 14; 9%). Conclusions: Patients were satisfied with their telemedicine experience during the COVID-19 pandemic; however, we identified several areas amenable to improvement. Further study is warranted.

Pulmonary exacerbtions in the desert: A quality improvement project of the university of arizona adult cystic fibrosis center

Pulmonary exacerbations (PEx) are associated with significant morbidity and decreased quality of life in patients with cystic fibrosis. Many patients fail to return to their previous lung function baseline following a PEx (1). At present there is no standardized definition of a PEx in cystic fibrosis and there is significant variability among CF centers and providers regarding the identification and treatment of PEx. In the STOP study which assessed practices surrounding exacerbations treated with inpatient intravenous IV antibiotics (abx), 85% of patients reported increased symptom burden at least 7 days before admission and 32% had symptoms 21 days prior to admission. Only half of the patients received oral antibiotics prior to admission (2). This highlights the need for earlier recognition and effective treatment of pulmonary exacerbations. We implemented a quality improvement project in our CF center to better understand our practices surrounding pulmonary exacerbations. We sought to improve recognition and treatment of pulmonary exacerbations during outpatient clinic visits and to ensure timely clinic follow-up to assess response to exacerbation treatment. To do so, we created a PEx scoring sheet that combines systemic signs and symptoms, respiratory specific signs and symptoms, and objective measurements. The symptoms and objective measurements have an assigned score value in order to quantify exacerbation scores. On the same sheet, providers report the management plan or document the rationale behind “no change” in management if the patient's score is suggestive of a PEx. Finally, a follow-up appointment date is documented. Over a 16-month period from September of 2018 through December of 2019, we collected 140 PEx scoring sheets which captured 35 PEx in our adult clinic. Twenty-five of these patients received oral abx, 2 received home IV abx, 1 received inhaled abx, 2 had changes in pulmonary clearance therapy, and 5 were directly admitted to the hospital for treatment. Our center is involved with the Cystic Fibrosis Learning Network (CFLN) in an active multi-center quality improvement project assessing the implementation and role of the FEV1-indicated exacerbation score (FIES) which defines a PEx as an absolute reduction in FEV1 of >10%. If we were to apply this definition to our population, only 14/35 exacerbations would have met criteria for PEx based on the FIES score alone. Furthermore, in the era of COVID-19 where much of our clinic has transitioned to televisits, we have adapted our PEx scoring sheet to function without measured FEV1 as a telephone/virtual PEx scoring sheet and are actively tracking virtually diagnosed exacerbations. We plan to continue collecting PEx sheets and have several active plan-do-study-act cycles ongoing in our clinic in order to better inform our practice and improve PEx management.

Universal Testing for COVID-19 in Essential Orthopaedic Surgery Reveals a High Percentage of Asymptomatic Infections.

BACKGROUND: The long incubation period and asymptomatic spread of COVID-19 present considerable challenges for health-care institutions. The identification of infected individuals is vital to prevent the spread of illness to staff and other patients as well as to identify those who may be at risk for disease-related complications. This is particularly relevant with the resumption of elective orthopaedic surgery around the world. We report the results of a universal testing protocol for COVID-19 in patients undergoing orthopaedic surgery during the coronavirus pandemic and to describe the postoperative course of asymptomatic patients who were positive for COVID-19. METHODS: A retrospective review of adult operative cases between March 25, 2020, and April 24, 2020, at an orthopaedic specialty hospital in New York City was performed. Initially, a screening questionnaire consisting of relevant signs and symptoms (e.g., fever, cough, shortness of breath) or exposure dictated the need for nasopharyngeal swab real-time quantitative polymerase chain reaction (RT-PCR) testing for all admitted patients. An institutional policy change occurred on April 5, 2020, that indicated nasopharyngeal swab RT-PCR testing for all orthopaedic admissions. Screening and testing data for COVID-19 as well as relevant imaging, laboratory values, and postoperative complications were reviewed for all patients. RESULTS: From April 5, 2020, to April 24, 2020, 99 patients underwent routine nasopharyngeal swab testing for COVID-19 prior to their planned orthopaedic surgical procedure. Of the 12.1% of patients who tested positive for COVID-19, 58.3% were asymptomatic. Three asymptomatic patients developed postoperative hypoxia, with 2 requiring intubation. The negative predictive value of using the signs and symptoms of disease to predict a negative test result was 91.4% (95% confidence interval [CI], 81.0% to 97.1%). Including a positive chest radiographic finding as a screening criterion did not improve the negative predictive value of screening (92.5% [95% CI, 81.8% to 97.9%]). CONCLUSIONS: A protocol for universal testing of all orthopaedic surgery admissions at 1 hospital in New York City during a 3-week period revealed a high rate of COVID-19 infections. Importantly, the majority of these patients were asymptomatic. Using chest radiography did not significantly improve the negative predictive value of screening. These results have important implications as hospitals anticipate the resumption of elective surgical procedures. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hip Fracture Outcomes During the COVID-19 Pandemic: Early Results From New York.

OBJECTIVE: To evaluate inpatient outcomes among patients with hip fracture treated during the COVID-19 pandemic in New York City. DESIGN: Multicenter retrospective cohort study. SETTING: One Level 1 trauma center and one orthopaedic specialty hospital in New York City. PATIENTS/PARTICIPANTS: Fifty-nine consecutive patients (average age 85 years, range: 65-100 years) treated for a hip fracture (OTA/AO 31, 32.1) over a 5-week period, March 20, 2020, to April 24, 2020, during the height of the COVID-19 crisis. MAIN OUTCOME MEASUREMENTS: COVID-19 infection status was used to stratify patients. The primary outcome was inpatient mortality. Secondary outcomes were admission to the intensive care unit, unexpected intubation, pneumonia, deep vein thrombosis, pulmonary embolus, myocardial infarction, cerebrovascular accident, urinary tract infection, and transfusion. Baseline demographics, comorbidities, treatment characteristics, and COVID-related symptomatology were also evaluated. RESULTS: Ten patients (15%) tested positive for COVID-19 (COVID+) (n = 9; 7 preoperatively and 2 postoperatively) or were presumed positive (n = 1), 40 (68%) patients tested negative, and 9 (15%) patients were not tested in the primary hospitalization. American Society of Anesthesiologists' scores were higher in the COVID+ group (d = -0.83; P = 0.04); however, the Charlson Comorbidity Index was similar between the study groups (d = -0.17; P = 0.63). Inpatient mortality was significantly increased in the COVID+ cohort (56% vs. 4%; odds ratio 30.0, 95% confidence interval 4.3-207; P = 0.001). Including the one presumed positive case in the COVID+ cohort increased this difference (60% vs. 2%; odds ratio 72.0, 95% confidence interval 7.9-754; P < 0.001). CONCLUSIONS: Hip fracture patients with concomitant COVID-19 infection had worse American Society of Anesthesiologists' scores but similar baseline comorbidities with significantly higher rates of inpatient mortality compared with those without concomitant COVID-19 infection. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.