Using quality improvement to develop transition to adult care at a UK cystic fibrosis (CF) centre

Objective: Following the creation of a quality improvement (QI) lead in the Oxford adult CF service, key areas for development were identified. Increased use of virtual care and CFTR modulators highlighted a need to adapt our transition process to meet the changing needs of young people with CF (pwCF). Our aim was to facilitate collaboration across adult and paediatric teams to identify areas for improvement. Method: We led a process of stakeholder engagement including meeting with other CF and non-CF transition services. Multidisciplinary Team (MDT) QI meetings were held within the adult service to identify whatwas considered a successful transfer of care. We observed the first in-person transition clinic since the pandemic, and distributed electronic surveys of the clinic experience to pwCF, carers, and staff. Lastly, we held a virtual cross-service QI meeting to present findings, aiming to reach consensus on areas for change. Results: 5/5 pwCF and 5/5 carers completed the clinic surveys. Both identified their main priorities: to meet the adult team and receive a clinical review. Comments identified anxiety discussing future life plans too young or repetitively. 3/5 pwCF and 3/5 carers preferred the carer to be present throughout the visit. 7/9 staff completed the survey. There was general agreement of clinic objectives that 6/7 felt were met. Comments were around clinic location, pre-meeting, and coordinating MDTreviewcontent. Holding a face-to-face clinic was perceived as important. Overall, the MDTs agreed on 5 areas for improvement: documentation;patient information;clinic meetings;individual profession handovers;and identifying pwCF requiring bespoke transition. Conclusion: Protected time for QI provided a forum to bring paediatric and adult CF teams together to identify shared priorities for improvement of local transition care. A QI lead role has allowed us to drive service development during the COVID-19 pandemic and introduction of CFTR modulators.

What can we Learn from Patients who Died from Covid-19 Following Escalation to a Respiratory High Dependency Unit for Trial of Non-Invasive Respiratory Support?

Background: Covid-19 infection is associated with significant risk of death, particularly in older, comorbid patients. Emerging evidence supports use of non-invasive respiratory support (CPAP and high-flow nasal oxygen [HFNO]) in this context, but little is known about its use in patients receiving end-of-life care. Methods: This was a retrospective study of 33 patients who died of Covid-19 on the Respiratory High Dependency Unit at the John Radcliffe Hospital, Oxford between 28/03/20 and 20/05/20. Data was sourced via retrospective review of electronic patient records and drug charts. Results: Patients dying from Covid-19 on the Respiratory HDU were comorbid with median Charlson Comorbidity Index 5 (IQR 4-6); median age 78 (IQR 72-85). Respiratory support was trialled in all but one case with CPAP being the most common form of first line respiratory support (84.8%) however, was only tolerated in 44.8% of patients. Median time to death was 10.7 days from symptom onset (IQR 7.5-14.6) and 4.9 days from hospital admission (IQR 3.1-8.3). 48.5% of patients remained on respiratory support at the time of death. Conclusions: End-of-life care for patients with Covid-19 remains a challenge. Patients tend to be frail and comorbid with a rapid disease trajectory. Non-Invasive Respiratory Support may play a key role in symptom management in select patients, however, further work is needed in order to identify patients who will most benefit from Respiratory Support and those for whom withdrawal may prevent unnecessary distress at the end of life or potential prolongation of suffering.

Experiences of virtual cystic fibrosis clinics during the COVID-19 pandemic at one UK adult cystic fibrosis centre

Background: In response to the COVID-19 pandemic, the Oxford Adult CF Centre offered virtual clinics using the NHS Attend Anywhere platform from June 2020. We surveyed patient and staff experience. Methods: An anonymous online patient survey was added to appear at the end of all CF virtual consultations from July to November 2020. A separate anonymous staff survey was distributed by email to all members of the CF multidisciplinary team. Results: 136 responses were received (patient population of 141) and 12/19 (62%) of staff responded. 71% of patients rated a virtual review a very reasonable alternative to face-to-face and 83% felt all their clinical needs were met. 98% rated how comfortable they were to talk to clinicians as 4 or 5/5. 83% staff felt they could provide an acceptable standard of review to most patients. When asked if they could provide a high standard of review, 17% felt they could to most patients, with 58% feeling they could to some patients only. Time efficiency and patient attendance at virtual clinics were perceived as superior to face-to face. 86% of patients rated their satisfaction with the technology as 4 or 5/5, with 100% staff rating as 4/5. 11 negative patient comments related to technology. Poor sound quality and video lag were the main concerns identified by both patients and staff. 82% of patients would like to continue using virtual reviews in future and 100% staff wanted this to be an option for some appointments. Routine clinic visits were rated most popular appointments to be virtual in future by staff and patients. Conclusion: Virtual clinics have been well received by the majority of our adult CF patients during the COVID-19 pandemic. Patients and staff wanted to use virtual reviews in future, although both recognised this is not always suitable for all appointments.

Secondary infection rates and antibiotic prescribing in a COVID-19 hdu population

Introduction Secondary infection in COVID-19 has been associated with adverse outcomes and high mortality. The prevalence of secondary infection in COVID-19 and optimal antimicrobial strategies remain unclear. Methods Retrospective case-note review of patients with COVID-19 admitted to our institution's high dependency unit (HDU) from March to June 2020. Patients were PCR-positive for SARS-CoV-2 or had classical CT appearances and a compatible clinical presentation for COVID-19. Microbiological tests, antimicrobial prescriptions and clinical outcomes were recorded. Results 84 patients were identified. Median age was 68.5 years and 29/84 (34.5%) were female. Respiratory support included HFNO (n=39), CPAP (n=56), non-invasive ventilation (n=3) and invasive ventilation (n=14). Overall mortality was 36/84 (42.9%). 6/84 patients (7.1%) had evidence of secondary infection (>105 CFUs on bronchoalveolar lavage (BAL);positive sputum culture or positive blood culture excluding skin contaminants). 28/84 (33.3%) had a respiratory sample sent: BAL n=10;sputum culture n=2;Legionella antigen n=15;throat swab multiplex PCR n=3;Biofire respiratory viral panel n=7. BAL was positive in 3/10 cases (Enterococcus faecium;Serratia marcescens and Escherichia coli;Pseudomonas aeruginosa). One sputum culture was positive for M. abscessus. 71/84 (84.5%) had blood cultures. 8 (11.2%) were positive, of which 6 were considered skin contaminants and not deemed true secondary infection (coagulase negative Staphylococci n=5;Lysinibacillus sp. n=1;Proteus mirabilis n=1;Staphylococcus epidermidis and Serratia marcescens n=1). All 84 patients received antimicrobials. 32 (38.1%) received a macrolide, predominantly azithromycin. Macrolide usage was not associated with mortality or admission length, but was associated with increased intubation rate (28.1% vs 9.6%, p=0.027) Initial antibiotic treatment was monotherapy in 45 (53.6%) cases and dual therapy in 39 (46.4%). Initial treatment with two antibiotics versus monotherapy was not associated with mortality but was associated with increased intubation rate (25.6% vs 8.9%, p=0.040) and increased mean admission length (16.5 vs 11.6 days, p=.036). Discussion Robust evidence of secondary infection in patients with COVID-19 was uncommon in our cohort. Increased intubation rates in patients prescribed a macrolide and those initially prescribed dual antibiotic therapy is likely to reflect more severe disease. There is considerable potential for enhanced antimicrobial stewardship in further waves of COVID-19.