Repair of acute respiratory distress syndrome in COVID-19 by stromal cells (REALIST-COVID trial): 1 year follow up for safety and pulmonary dysfunction

S44 Table 1Summary of significant medical events, thoracic computed tomography (CT) and pulmonary function tests (PFTs) in ORBCEL-C and placebo groups at 1 year follow upORBCEL-C Placebo Number of patients followed up 20 21 Significant medical events Number of patients with SMEs 6/20 9/21 Total SME events 7 11 Classification Respiratory,thoracic and mediastinal disorders 4 6 Neoplasm - benign, malignant, unspecified 1 0 Infections and infestations 1 1 Cardiac disorders 1 0 Metabolism and nutrition disorders 0 1 Injury, poisoning and procedural complications 0 1 Renal and urinary disorders 0 1 Gastrointestinal disorders 0 1 Thoracic CT Number of CTs available 5 8 Time to CT (Median, IQR) 181 (157–198) 203 (95–233) Evidence of ILD on CT 4 6 PFTs Number of PFTs available 10 8 Time to PFTs (Median, IQR) 184.5 (117.5–292.75) 203.5 (118.25–242.5) FEV1 (Mean, SD) 84.9 (13.6) 80.5 (13.3) FEV1 <80% predicted (n,%) 4/10 (44%) 4/8 (50%) FVC (Mean, SD) 78.4 (13.2) 79.3 (16.5) FVC <80% predicted (n,%) 5/10 (55%) 5/8 (62.5%) FEV1/FVC ratio (Mean, SD, n) 0.88 (0.12) N=8 0.76 (0.05) N=5 FEV1/FVC <0.7 (n,%) 0 (0%) 0 (0%) TLCO (Mean, SD, n) 78.9 (14.8) N=9 61.9 (13.4) N=7 TLCO <80% (n,%) 6/9 (66.7%) 7/7 (100%) ConclusionsOne year follow up supports the safety of ORBCEL-C MSCs in patients with moderate to severe ARDS due to COVID-19. A similar incidence of pulmonary dysfunction is reported in both groups at long term follow up.Please refer to page A?? for declarations of interest related to this .

Staff experiences of working on a new Critical Care Unit during the COVID 19 pandemic

Introduction: Intensive Care Unit (ICU) design impacts staff well-being1 with relocation to a different ICU layout causing staff stress.2,3 During the COVID-19 pandemic our new critical care centre was opened expediently allowing increased patient capacity and providing a purpose-built environment for ICU patients. The new single-bed room layout differed to other open plan multi-bed ICUs in the hospital. New design features included large floor-to-ceiling windows with park views, modernised equipment such as computer screens on movable pendants and noise reduction features. The pandemic accelerated the opening of the new unit and practice was adapted to address surge conditions (e.g., there were two patients in each 'single' room, and PPE could only be worn in specific areas of the unit, restricting movement). Objectives: We sought to understand the impact of the ICU design on staff experiences during pandemic conditions. Methods: Following ethical approval, staff who had worked on the new unit were invited to participate in a semi-structured interview. The interview guide was based on the Theoretical Domains Framework (TDF),4 a framework to identify the determinants of behaviour change. Interviews were audio recorded, anonymised and transcribed verbatim. We used line-by-line coding and analysed data informed by the TDF. Results: 21 participants captured experiences of a wide range of multi-disciplinary staff members. The most common domain identified within the data was 'Environmental context and resources', including data pertaining to barriers and facilitators of the new unit to effective working: Having large bed spaces is perfect for getting people out [of bed]. They are soundproofed as well, so patients were sleeping really well at night. Also, 'social/professional role and identity' (including group identity, leadership), 'skills' (including competence, skills development), and 'beliefs about consequences' (perception of the effects of the new units) were frequently identified in positive and negative ways: .because of where it [the patient's room] is located you do not get to see people often. I got forgotten for rolls.It was a constant struggle Medical staff and allied health professionals described advantages over the old unit design including improved team-working, oversight of patients, and mood from the design features. Participants perceived patient benefits from improved lighting and views and stimulation due to access to social media. Conversely, nurse participants perceived less support, less team-working and increased levels of anxiety due to the single rooms. Nurse experiences improved as patient numbers reduced. However, changes in how nurse teams worked was an ongoing challenge: staffing breaks and things is quite tricky. You need a permanent floater that is never allocated to patients, to try and help people, because they cannot leave their bays. Conclusions: Our findings support previous research2 demonstrating increased nurses stress when transitioning to a single-bed room ICU layout. Providing systems to alleviate nurse isolation, promote teamworking and reduce stress in future relocations may significantly improve staff well-being (e.g., video-calling and messaging between patient rooms). A multidisciplinary awareness of the impact on nurses is vital to support strategies to ameliorate the impact of changes during relocation.

Promoting Telehealth Equity Through Strategiesto Address Social Determinants of Health

Background: Due to the COVID-19 pandemic, health systems rapidly embraced telemedicine for a range of health services. Prior to COVID, approximately 15% of physicians offered telehealth services and less than 10% of patients utilized it. By Spring 2020, 85% of physicians and 46% of patients reported using telehealth, encouraged by federal and state emergency actions. However, without explicit efforts to ensure equity, broad reliance on telemedicine can perpetuate and increase disparities in health care access for vulnerable populations such as patients with Limited English Proficiency (LEP). Methods: We leveraged an implementation sciences framework to improve telehealth equity for patient families whose preferred language was not English. Our project included 1) pre-intervention planning to define the problem, summarization of the organizational evidence-practice gap and involvement of stakeholders;2) implementation of change interventions;and 3) postimplementation evaluation at quarterly intervals (Q1, Q2 and Q3). Our project team assembled Health Information Technology (HIT) solutions to support redesigned clinical workflows that included universal screening for self-reported English proficiency and on-demand integrated video interpretation services. The package of interventions included decision supports to recommend language services utilization, an interpretation platform integrated with our video software, and analytic reports to monitor performance metrics. Data were collected at baseline and for 9 months post-intervention defined as implementation of the HIT intervention package. We calculated a “Telemedicine Care Gap” by comparing the proportion of non-English-speaking telemedicine encounters to the proportion of non-Englishspeaking in-person encounters. We tracked the percentage of non-English-speaking patient telemedicine encounters with receipt of documented language services as well as the percentage of non-English-speaking patients with an activated patient portal, which is a prerequisite to conducting a telemedicine visit at our institution. Results: Shortly after implementation of telemedicine throughout the health system, use of telemedicine favored English-speaking families. At baseline, our “Telemedicine Care Gap” was 2.9%. Overall, the introduction of integrated telemedicine interpretation services did not significantly increase adoption of telemedicine for nonEnglish-speaking patients. However, significant progress was made in the uptake of integrated interpretation services for eligible encounters, which steadily increased from 0% at baseline to 23.9% by the end of Q3. Despite outreach efforts, the percentage of non-English-speaking patients with an active patient portal is much lower at 51.9% than patients who are English-speaking at 69.4%. Conclusion: The promotion of telehealth equity requires deliberate attention and a commitment to iterative problem-solving by healthcare organizations. Identifying populations at risk of poor access to telemedicine and monitoring access disparities are both critical to overcoming societal and systems barriers to care. We plan to eliminate the patient portal requirement for telemedicine which disproportionately burdens non-English speaking patient families.

Impact of COVID-19 on critical care nosocomial infection rates

Introduction: Critical care nosocomial infection (CCNI) increases risk of patient mortality and morbidity [1,2]. The impact of the Coronavirus 19 (2019-nCoV) pandemic on CCNI in terms of increased strain and infection control measures, is uncertain. Departmental strain has the potential to confound impact of infection control measures aimed to reduce CCNI incidence. This study will describe the impact of 2019-nCoV on non-COVID CCNI incidence and mortality. Methods: A retrospective cohort study of adult patients admitted to critical care in one Central London teaching hospital. CCNI incidence, (diagnosed ≥ 48 h post critical care admission), was compared between pre (Jan 2019-Feb 2020) and peak COVID (Mar 2020-Jun 2020). Results: Of 2,266 patients, 1788 were admitted pre and 478 peak COVID. Mean age was 57.2 years and 56.1 years pre and peak COVID respectively, with 35.5% and 37.4% of patients, female. There was a significant increase in rate of total CCNI incidence (1.6% to 3.6%) in the pre and peak period respectively. There was a significant increase in rate of incidence of gram negative bacterium and C. diff, but not in gram positive bacterium, MRSA, VRE and fungus. The increase in rate of peak (23.5%) compared to pre COVID (13.5%) CCNI non-COVID mortality, was not significant (Table 1). Conclusions: Increased infection control measures did not protect against non-COVID CCNI and mortality across all infection types. Increased strain is likely to confound additional infection control measures and resulted in excess patient non-COVID CCNI and mortality, secondary to the pandemic. Greater emphasis is needed to protect other patients from expected CCNIs. (Table Presented).

Challenges of tracheostomy in COVID-19 patients in a tertiary centre in inner city London.

The rapid global spread of SARS-CoV-2, the causative agent of COVID-19, has dominated healthcare services, with exponential numbers requiring mechanical ventilation in the intensive care unit (ICU). Tracheostomy facilitates respiratory and sedative weaning but risks potential viral transmission. This study reviewed the tracheostomy provision, techniques, and outcomes for a single-centre prospective cohort during the resource-pressured COVID-19 period. Seventy-two of 176 patients underwent tracheostomy at a median 17 days: 44 surgical (open), 28 percutaneous. Their median age was 58 years, the male to female ratio was 2.4:1, 75.1% were of BAME backgrounds, 76% had a BMI≥25kg/m2, and 65% had ≥2 major co-morbidities. Seventy-nine percent of patients were weaned from sedation at a median 2 days, 61% were weaned from mechanical ventilation at a median 10 days, 39% were discharged from the ICU at a median 11.5 days, and 19.4% were discharged home at a median 24 days. All patients survived the procedure. The mortality rate was 9.7% at a median 12 days. No clinician reported COVID-19 symptoms within 14 days of the procedure. The role of tracheostomy in COVID-19 is currently unclear. Delivery of tracheostomy by maxillofacial surgeons relieved the workload pressure from ICU clinicians. The choice of technique was influenced by the patient and resource factors, resulting in a mixed cohort of open and percutaneous tracheostomy in COVID-19 patients. Preliminary data suggest that open tracheostomy is as favourable as percutaneous tracheostomy for COVID-19 patients, and is safe for clinicians.