Having vision: The role of quality improvement in sustaining rates of corneal donation in a hospice, and the impact of this through the COVID pandemic

Understanding patients' wishes regarding organ and tissue donation is an important aspect of advance care planning (ACP). Many patients with life-limiting illnesses are still eligible to be corneal donors. A quality improvement (QI) approach has promoted a positive change in culture at an inpatient hospice, making the discussion of patients' wishes on corneal donation the norm. This cultural change led to a sustained high rate of such discussions, despite the multitude of challenges presented by the COVID-19 pandemic.Copyright © Royal College of Physicians 2023. All rights reserved.

Putting coastal communities at the center of a sustainable blue economy: A review of risks, opportunities, and strategies

New approaches to ocean governance for coastal communities are needed. With few exceptions, the status quo does not meet the diverse development aspirations of coastal communities or ensure healthy oceans for current and future generations. The blue economy is expected to grow to USD2.5–3 trillion by 2030, and there is particular interest in its potential to alleviate poverty in Least Developed Countries and Small Island Developing States, and to support a blue recovery from the COVID-19 pandemic. This paper presents a selective, thematic review of the blue economy literature to examine: (i) the opportunities and risks for coastal communities, (ii) the barriers and enablers that shape community engagement, and (iii) the strategies employed by communities and supporting organizations, which can be strengthened to deliver a ‘sustainable' blue economy and improve social justice for coastal communities. Our review finds that under business-as-usual and blue growth, industrial fisheries, large-scale aquaculture, land reclamation, mining, and oil and gas raise red flags for communities and marine ecosystems. Whereas, if managed sustainably, small-scale fisheries, coastal aquaculture, seaweed farming and eco-tourism are the most likely to deliver benefits to communities. Yet, these are also the sectors most vulnerable to negative and cumulative impacts from other sectors. Based on our evaluation of enablers, barriers and strategies, the paper argues that putting coastal communities at the center of a clear vision for an inclusive Sustainable Blue Economy and co-developing a shared and accessible language for communities, practitioners and policy-makers is essential for a more equitable ocean economy, alongside mainstreaming social justice principles and integrated governance that can bridge different scales of action and opportunity. Copyright © 2023 Evans, Buchan, Fortnam, Honig and Heaps.

EQUITY PARTNERSHIPS IN ACTION Vaccines and Public Health

During the COVID-19 pandemic, partnerships to advance equity were critical in developing and implementing vaccine allocation and distribution plans. This chapter provides an overview of one recent equity partnership focused on COVID-19 vaccination equity in Virginia. Health inequities existed among racial groups and socially vulnerable populations before the COVID-19 pandemic. The pandemic exacerbated these inequities—disproportionately and negatively affecting communities of color. The primary task of this partnership was the development of a community-based approach that ensured Virginia's vaccine allocation strategy focused on equity. The partnership's contributions and activities positively impacted Virginia's vulnerable communities. Strong equity partnerships can offer robust solutions—increasing the positive effect on socially vulnerable groups by combining resources and knowledge while focusing on a shared goal. Although much work remains in the fight against the COVID-19 pandemic, the longer-term goal is to eliminate health disparities and disparate treatment of vulnerable communities. The partnership profiled in this chapter offers an instructive example that is widely applicable. © 2023 selection and editorial matter, Elsie L. Harper-Anderson, Jay S. Albanese and Susan T. Gooden;individual chapters, the contributors.

Representative Voices: Native American Representation, Political Power, and COVID-19 in US States

We examine predictors of COVID-19 cases in Native nations during the early months of the pandemic. We find that where Native American representation and Native American political power in state politics were greater, COVID-19 cases on tribal lands were fewer. We expand the literatures on descriptive representation and on tribal-state relations by demonstrating consequences of powerful Native American voices in the statehouse. We find that Native American voices on tribal lands are also vital Tribal lands that had extensive networks of community-based health facilities and tribally controlled health facilities recorded fewer COVID-19 cases. The broader lesson here is that if Native nations are to protect their citizens, they need outside governments that support, not thwart. Our findings draw on unique, original quantitative analysis.

The Clinical Effectiveness of Dynamic Electronic Tracking and Escalation to Reduce Critical Care Transfers (the Detect Study)

BACKGROUND AND AIM: Physiological surveillance systems significantly reduced adult mortality in two large UK hospitals. In hospitalised children mortality is low, but there may be potential to reduce the morbidity associated with critical deterioration (CD). However, the risk models for adults are unsuitable for use in children because the signs associated with deterioration [heart rate, breathing rate, blood pressure], alter significantly across the age range. The aim is to evaluate whether this technology improves clinical outcomes for in-hospital deterioration, including sepsis in children. METHOD(S): ISRCTN61279068. https://bit.ly/36HtEGF Participants: Paediatric in-patients, aged less than 18 years at a tertiary hospital (240 beds). Intervention(s): Careflow Vitals and Connect app platform configured to incorporate the Alder Hey age-specific Paediatric Early Warning score (PEWS) and modified National Institute of Health and Clinical Excellence (NICE) Sepsis screening. The documentation of vital signs and clinical observations occur at the patient's bedside at intervals determined by the PEWS risk model. PEWS categorised CD risk as low, moderate, high and critical and provided targeted escalation advice and automated alerts to the Nurse in Charge of the shift and the responsible Clinical Teams. Primary Outcome:Emergency transfers to Critical Care (PICU/ HDU). RESULT(S): Prospective data collection baseline year March 2018 - February 2019 compared with 2 years postintervention March 2020-February 2022 (Extended due to COVID). Summary of results in Figure 1. CONCLUSION(S): The absolute number of CD and patients affected reduced by 29%. Associated review of the cases using the Predictability/Preventability framework showed reduction in the late recognition and CD with modifiable factors. (Figure Presented).

No beds available for transfer! Experience of life saving pancreatic necrosectomies at a non-pancreatic upper GI unit

Background: Infected necrotising pancreatitis (NP) has a high mortality. NICE recommends necrotising pancreatitis be managed at specialist pancreatic centres due to its challenging nature. However, timely transfer of patients from non-specialist centres to tertiary pancreatic units can be limited by critical bed availability. This problem is further compounded by the staffing issues and constraints on critical care facilities since the COVID19 pandemic. This situation places patients at high risk of mortality and poses the question as to whether lifesaving intervention can be offered within appropriate local upper GI non pancreatic units. We present our data from emergent pancreatic necrosectomies in a sub-set of critically ill patients for whom transfer to specialist care was not possible due to lack of availability of critical care beds. Method(s): A retrospective case series is presented over a two-year period at a non-pancreatic upper GI centre. Patients over a two-year period (2020-2022) were identified using clinical coding and operation note records. Data was collected on patient characteristics such as age, gender, and co-morbidities, as well as on their inflammatory markers on presentation, imaging modality used, nutritional status and duration of care in a high dependency unit. Complications, including death following pancreatic necrosectomy were also recorded. Only descriptive statistics were used in this audit. No advanced statistics were required. Data standards were assessed using fractions and then percentages for ease of understanding. Result(s): A total of six patients were identified as having undergone emergency pancreatic necrosectomies. Patients included were all male with a mean age of 48 and an average BMI of 25.6. The mean number of days patients were in hospital prior to their necrosectomy was 42.6. On average patients had 5.5 CT scans prior to their necrosectomy. 50% of patients had organ failure requiring ventilatory support and/or hemofiltration. Comorbidities included diabetes mellitus, rheumatoid arthritis and Covid-19. Social factors such as excess alcohol consumption and cigarette smoking were also present. As per NICE guidance, 100% of patients were administered enteral nutrition through a nasojejunal tube during their admission. 50% of patients received parenteral nutrition after failure of enteral nutrition, in keeping with best practice. 100% underwent a pancreatic necrosectomy and 50% had further operations. The mean number of re-operations per patient was 2.3. The average number of days between admission and pancreatic necrosectomy was 42 days. 100% of patients had complications with 50% suffering from AKI and 33% patients were readmitted with pancreatitis related complications. One death was from post operative haemorrhage. Overall survival rate at this tertiary care centre was 83.3%. These patients are currently still being followed up. Conclusion(s): The results of our audit have shown that necrotising pancreatitis can be managed outside of a specialist pancreatic centre providing there are appropriately skilled surgeons and critical care staff employed, who are confident in managing the condition. Complications at the centre, including death rates, were no higher than reported in the literature, suggesting patient safety was not adversely affected. Ideally, further audits will need to be carried out on a larger scale, potentially with multiple trusts involved, comparing specialist pancreatic centres to non-specialist facilities to ensure that the results of our audit are not limited to this tertiary care centre alone. The data in this audit stems from during the Covid-19 pandemic and therefore additional auditing will need to be done in case the pressures of the pandemic on healthcare services has impacted upon the results and findings, as well as the patient cohort.

The implementation of a digital group intervention for individuals with subthreshold borderline personality disorder

Context: Systems Training for Emotional Predictability and Problem Solving for Emotional Intensity (STEPPS-EI), a 13-week skills-based group intervention for individuals with subthreshold borderline personality disorder (BPD) has been deemed feasible and clinically effective in primary care [1] [2]. To modernize the service, STEPPS-EI lesson content has recently built onto an eHealth platform (Minddistrict). Due to Covid-19 restrictions, group sessions were additionally delivered remotely via Zoom. This project evaluates the implementation of this digitally blended version of STEPPS-EI within two Sussex Partnership NHS Foundation Trust (SPFT) primary care services. Methods: Service users and pracitioners who participated in the first two groups from March to July 2021 were invited to take part in a feasibility evaluation investigating recruitment, retention, and attendance rates, in addition to self-reported symptoms (BSL-23, QuEST), quality of life (ReQoL), system usability, and qualitative and quantitative measures designed to shed light on the experience and opinions of service users and practitioners during the intervention. Service users participating in following groups (from July to December 2021) were invited to share their symptom and quality of life outcome data only. Results: 14 service users and 5 practitioners agreed to take part in the primary evaluation. Results suggested that 86% of these service users attended at least 75% of the group sessions, and that service users completed on average 70% of the online material. Usability ratings revealed good gradings for Zoom from all participants, yet lower gradings for Minddistrict. Further analyses revealed a generally positive attitude towards digital STEPPS-EI from all parties and practical suggestions on how to improve the intervention. 11 service users from following groups agreed to share their data. Bayesian analyses were conducted for the data of service users who provided ratings at both timepoints. Evidence was found for a decrease in BSL-23 scores and an increase in ReQoL ratings from baseline to post-intervention. Incomplete self-report data-sets limits conclusions. Conclusions: It was found that the implementation of STEPPS-EI delivered in a blended digital format was feasible. The online delivery might increase service users' engagement with the material and group sessions. Yet more training and support on the use of Minddistrict may be required to increase usability. Implications: It may be possible to effectively implement digital interventions for individuals with subthreshold BPD. However, more research on the effect of these on symptom outcomes should follow. © 2022 Elsevier B.V.. All rights reserved.

Emergency Medicine Resident RVU Trends at an Academic Medical Center

Learning Objectives: To determine average RVUs per hour for emergency medicine residents at a tertiary-care, university-based academic medical center and to characterize change in mean RVUs per hour as residents advance in training. Background(s): Physician productivity is often reported in relative value units (RVU). However, RVUs are infrequently reported during residency. Studying RVUs in varied training settings may better define benchmarks for progression of resident productivity. Method(s): This was a retrospective, observational study of PGY 1-3 residents at an academic, tertiary-care center. PGY2s and PGY3s were considered equivalent in shift scheduling and responsibilities. From 07/2019 to 09/2021, RVUs were extracted from the electronic health record (Epic) using E&M billing codes (excluding procedures, which were not tied to specific residents). In the PGY1 year and continuing longitudinally, residents received individual productivity reports. Individual metrics were de-identified, coded, and analyzed. Result(s): The primary outcome was the measure of mean RVUs/hr per resident overall and by class. Secondary outcomes were the change in RVUs/hr between classes at the end of each year, as well as the change in RVUs/hr for the same class year to year. Descriptive statistics were reported in mean with standard deviations. One-way ANOVA was used to determine if PGY-level had a significant effect on RVUs generated;the remainder of comparisons were made with student's t-test. 60 RVU data points were obtained, representing 40 residents. Two classes were followed longitudinally (Table 2). Overall mean RVU/hr per resident was 2.89 RVU/hr (SD 0.89). Mean RVU/ hr per resident for PGY1s, PGY2s, and PGY3s were 1.97 RVU/ hr (SD 0.26), 2.67 (SD 0.77), and 3.35 (SD 0.36) respectively. Class year was predictive of RVUs generated (p<0.001). There was no significant difference in RVUs within a single class from PGY2 to PGY3 (p =0.528), but there was a significant increase from PGY1 to PGY2 (p<0.001). Conclusion(s): Resident RVUs in our academic ED were associated with training year, but longitudinally, the only statistically significant increase was from PGY1 to PGY2. Limitations include ongoing effects of the COVID-19 pandemic on productivity.

Weaving trauma awareness into museum education. (Special Issue: Snapshot: documenting museum education during intersecting pandemics.)

The COVID-19 pandemic is a global, collective, traumatic experience. Trauma-aware museum educators can play a therapeutic role in helping visitors reengage with life as the world reopens. This article explores the dynamics of what a trauma-aware approach to engaging with art may be, specifically detailing methods that can create new cognitive, emotional, and sensory experiences that contradict the experiences of trauma by replacing them with sensations rooted in agency and connection. Through their experiences working at different museums, the authors outline the main principles of trauma-aware art museum education (T-AAME) as it relates to visitors: orientation (setting a supportive tone);being with one another (regulation, attunement, and responsive pacing);choice and voice;and connection. The article also discusses museum-based art therapy as it compares to art museum education to highlight the overlaps and distinctions between the two and to show that museum experiences can be therapeutic without being therapy.

"I Hope to Hell Nothing Goes Back to The Way It Was Before": COVID-19, Marginalization, and Native Nations

We draw on new and original data to examine both partisan and systemic inequities that have fueled the spread of COVID-19 in Native America. We show how continued political marginalization of Native Americans has compounded longstanding inequalities and endangered the lives of Native peoples. Native nations have experienced disproportionate effects from prior health epidemics and pandemics, and in 2020, Native communities have seen greater rates of infection, hospitalization, and death from COVID-19. We find that Native nations have more COVID-19 cases if they are located in states with a higher ratio of Trump supporters and reside in states with Republican governors. Where there is longstanding marginalization, measured by lack of clean water on tribal lands and health information in Native languages, we find more COVID-19 cases. Federal law enables non-members to flout tribal health regulations while on tribal lands, and correspondingly, we find that COVID-19 cases rise when non-members travel onto tribal lands. Our findings engage the literatures on Native American politics, health policy within U.S. federalism, and structural health inequalities, and should be of interest to both scholars and practitioners interested in understanding COVID-19 outcomes across Tribes in the United States.

Changes in faculty attendance at resident conferences after transitioning to a virtual format

Learning Objectives: Evaluate the effect of change from inperson to virtual resident conference on faculty attendance rates. Background: The COVID-19 pandemic has forced many graduate medical education programs to move from in-person educational activities to a virtual format. Academic faculty are typically encouraged to attend resident conferences, but it is unclear if faculty attendance could be affected by these format changes. Objectives: To examine changes in conference attendance after changing from in-person to virtual delivery. We hypothesized that faculty attendance would increase overall with the transition to virtual format. Methods: This is a retrospective, observational study of faculty attendance at resident conferences between July 2020 to November 2020, ed from routinely collected conference records for 24 faculty. To reduce bias, this period was chosen due to changes in how conference attendance was recorded for faculty. Our exposure groups included faculty attending in-person conference versus virtual conference via Zoom ©. The primary outcome was conference attendance. Calculations were performed using chi-squared testing. Results: Overall, there were 1920 hours of conference, with 447 hours attended by faculty (23.3%). Attendance for inperson and virtual formats were 23.7% and 22.1%, respectively (Table 1). Comparison revealed no significant difference between conference format and conference attendance (χ2= 0.51, p 0.47). Conclusions: Faculty attendance at resident conferences did not change significantly after transitioning from in-person conference to virtual format. Limitations included a small sample size.

Changes in resident conference attendance after transitioning to a virtual format

Learning Objectives: To examine changes in conference attendance across various methods of conference delivery: in-person, virtual conference, and virtual conference with a video-on requirement. We hypothesized that overall attendance would increase with the change to virtual format. Background: The COVID-19 pandemic has forced many graduate medical education programs to move from in-person educational activities to a virtual format. To our knowledge, little is known about how this format change impacts attendance. Objectives: To examine changes in conference attendance across various methods of conference delivery: in-person, virtual conference, and virtual conference with a video-on requirement. We hypothesized that overall attendance would increase with the change to virtual format. Methods: This is a retrospective, observational study of resident conference attendance from July 2019 to November 2020, ed from routinely collected records for all emergency medicine residents (n=30). Groups included residents attending in-person conference, virtual conference, and virtual conference with a camera-on requirement (Table 1). The primary outcome was conference attendance. An a priori subgroup analysis was performed to examine changes in attendance for the in-person format before onset of the pandemic versus during the pandemic. Chi-squared analyses were performed. Results: Overall, there were 7800 hours of conference, with 5936 hours attended (76.1%). Attendance for inperson, virtual, and virtual with camera-on formats were 75.7%, 80.1%, and 69.5%, respectively (Table 2). A 3-way chi-squared analysis showed significant association between conference format and conference attendance ( χ2= 29.3, p < 0.005), with each 2-way comparison also being significant. There was no difference in in-person attendance before versus during the pandemic (75.1% vs 76.9%, χ2= 2.1, p = 0.14). Conclusions: Resident conference attendance significantly increased after transitioning from in-person to virtual format, but then decreased after adding a camera-on requirement. Limitations include crossing over academic years as well as smaller sample size of the virtual with camera-on format.

Navigating a Calculus Course During a Pandemic: A USMA Perspective

In this article we analyze publications written about different teaching modalities and evaluate how each applies to a calculus class during the on-going COVID-19 pandemic. We focus on the positives and negatives of teaching and learning in a virtual, classroom, or HyFlex environment. Although arguments could be made for each environment, especially given different institutional objectives, this work aims to explain why we eventually preferred teaching our Fall 2020 multivariable calculus course in a face-to-face classroom setting at the United States Military Academy at West Point. We also offer measures of performance to compare the current COVID-19 semester with previous semesters. The results support two major conclusions drawn from our decision to teach in-person under in a time constrained environment: learning modality matters in mathematics and this pandemic will influence student-teacher interaction for semesters to come.

Severe acute respiratory infection-preparedness (Sari-Prep): A multicenter prospective study

OBJECTIVES: We designed a prospective cohort study to systematically study patients with severe acute respiratory infection (SARI) and improve hospital preparedness (SARI-PREP). The goal of this project is to evaluate the natural history, prognostic biomarkers, and characteristics, including hospital stress, associated with SARI clinical outcomes and severity. METHODS: In collaboration with the Society of Critical Care Medicine Discovery Research Network and the National Emerging Special Pathogen Training and Education Center (NETEC), SARIPREP is an ongoing, prospective, observational, multi-center cohort study of hospitalized patients with respiratory viral infections. We collected patient demographics, signs, symptoms, and medications;microbiology, imaging, and other diagnostics;mechanical ventilation, hospital procedures, and other interventions;and clinical outcomes. Hospital leadership completed a weekly hospital stress survey. Respiratory, blood, and urine biospecimens were collected from patients on days 0, 3, 7-14 after study enrollment and at hospital discharge. MEASUREMENTS AND MAIN RESULTS: SARI-PREP enrollment began on April 4, 2020 and currently includes 674 patients. Here we report results from the first 400 patients: 216 are from the University of Washington Hospitals, Seattle WA, 142 from New York University, New York NY and 42 from University of Southern California, Los Angeles, CA. Almost all tested positive for SARS-CoV-2 infection (n=397), whereas 3 patients tested positive for an alternative viral pathogen. The mean (±SD) age of the patients was 57±16 years;72% were men, 62% were White, 14% were Asian, 12% were Black, and 31% were Hispanic. Most of the patients were admitted to the intensive care unit (96%). The median (interquartile range) hospital length of stay was 22 (9-46) days. Rates of invasive mechanical ventilation (72%) and renal replacement therapy (19%) were common and the rate of hospital mortality was 35%. CONCLUSIONS: Initial SARI-PREP analysis indicates enrollment of a diverse population of hospitalized patients primarily with SARSCoV-2 infection. The demographics and clinical outcomes of our cohort mirror other large critically ill cohorts of COVID-19 patients. Results of a concomitant, weekly, hospital stress assessment are reported separately.

The Health and wellbeing impacts of Home and agile working in Wales: A HIA Approach

The SARS-COV-02 pandemic has globally resulted in a number of policies and interventions to address and reduce the transmission of the disease throughout the population. Mitigation measures have ranged from ‘Staying at Home' or ‘Lockdowns' to social distancing policies and requirements to work from home when you can. Whilst there are a number of papers which discuss the effects of home or remote working on employees and their families the large scale shift, accelerated pace and wider impacts of such a shift has not been well explored in the literature or has been focussed on specific topics, for example, productivity. HIA is promoted as a beneficial tool to identify the wider impacts of a policy, plan or intervention across a population and as such is well placed to examine and articulate who in a population may be affected and how, and the inequalities that may be created by an intervention such as home working. Using the lens of social determinants and equity focussed-HIA, this work examines the wider impact of home working in Wales during the COVID-19 pandemic. It provides a coherent overview of the major impacts on health and the particular populations affected. It articulates the process followed, the key evidence based findings, discusses the gaps in the evidence base that require further exploration and the impact and influence it has had to date. Finally, it shares the transferable learning, which will be of use to researchers, policy and decision makers, organisations and public health agencies.

Learning About Healthcare Resilience from the Initial Response to the COVID-19 Pandemic – A Physiotherapy Case Study

In April 2020, the UK’s initial response to the COVID-19 pandemic resulted in drastic and rapid changes to the way work was done within the National Health Service. Despite the difficult times, staff across this healthcare organisation adapted and developed methods of coping to keep the system functioning. This study aimed to capture the changes and adaptive ways of working specifically for one department, namely the physiotherapy service at one large acute NHS hospital trust in the UK. Eight online focus groups were held with a total of 26 physiotherapy staff to explore the changes in their work system as a result of the initial response to the COVID-19 pandemic. The SEIPS 2.0 model was used to provide a system structure for the analysis. The results report the staff’s experiences of work during this time, use a systems perspective to depict the changes in the system and new ways of working, and provide some recommendations for preparation for future ‘waves’ of this pandemic. Furthermore, by positioning the results within the resilience engineering paradigm, a larger theoretical basis is provided for developing recommendations. © 2021, The Author(s), under exclusive license to Springer Nature Switzerland AG.