ABSTRACT
Background: Hospitals are the most frequent place of death in Germany (47%), but at the same time, the least preferred one - for both patients and their relatives. To optimize care in the dying phase by using a bottom-up approach, the StiK-OV project aims to implement and evaluate specific measures on different non-palliative wards at two university hospitals. In the first phase of the project, we assess the current state of care in the dying phase on different wards. Method(s): We conducted an online survey with national health care professionals consisting of seven open questions on important aspects, facilitators, barriers and needs for improvement as well as Covid-19 pandemic specifics regarding care in the dying phase. Qualitative data was analyzed thematically. Result(s): Of 67 participants, 66% work in clinical practice as nursing staff (52%) and physicians (30%) and 34% in management or administration. As relevant topics of care in the dying phase, we identified involvement of relatives, symptom control, patient-centeredness, professional competencies, as well as time, space and human resources. Participants state a need for improvement regarding these topics. During the pandemic, involvement of relatives and patient-centeredness were difficult to maintain due to visiting restrictions and higher workload, resulting in patient isolation and dying in loneliness. Discussion(s): The survey revealed common topics of importance which should be targeted by ward-specific measures. Difficulties due to the pandemic have to be accounted for to achieve optimal care in the dying phase under exceptional circumstances. Conclusion(s): The survey gave insights on care in the dying phase from the perspective of health care professionals that can help to develop and implement situation-specific measures to significantly improve the quality of care during the dying phase in hospitals. A bottom-up approach aims to increase the staff motivation to implement respective measures.
ABSTRACT
Background/aims: Hospitals are the most frequent place of death in Germany (47%) but also the least preferred one - for both patients and relatives. The project 'StiK-OV' aims to optimize care for dying patients in hospitals using a bottom-up approach. Therefore specific measures on non-palliative wards at two university hospitals will be implemented and evaluated. In the first project phase, the current state of non-specialist inpatient care in the dying phase was assessed. Methods: Online survey with national health care professionals in the field of care in the dying phase. The survey consisted of seven open-ended questions on important issues, facilitators, barriers and needs for improvement regarding the care for patients dying in hospitals as well as COVID-19 pandemic specifics. Qualitative data was analyzed thematically. Results: Of 67 participants, 66% worked in clinical practice, 34% in managerial positions. We identified five relevant topics of care in the dying phase: involvement of relatives;symptom control;patient-centeredness;professional competencies;as well as time, space and human resources. Participants aimed to uphold patient-centeredness as a priority in the dying phase despite reporting needs for improvement in all topics: 'Everything that is good for the patient is allowed.' This contrasts with the experience during the pandemic, when involvement of relatives and patient-centerednesswere hard to maintain due to visiting restrictions and high workload - leading to patient isolation and dying in loneliness. Conclusions: The survey revealed common topics on care in the dying phase from the perspective of health professionals to be targeted by ward-specific measures. Difficulties due to the pandemic have to be considered for optimal care in the dying phase under exceptional circumstances. The results can help to develop and implement context-specific measures to improve quality of hospital care during the dying phase.
ABSTRACT
TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema have been described as rare life-threatening complications of COVID-19. Reports of pneumoperitoneum or pneumoretroperitoneum are extremely rare. We present a patient with COVID-19 pneumonia who developed spontaneous pneumomediastinum and subcutaneous emphysema with subsequent progression to pneumoretroperitoneum, without evidence of pneumothorax. CASE PRESENTATION: A 61 year old man with HIV and Addison's disease presented to the emergency department with worsening dyspnea, cough, and diarrhea. On admission, his oxygen saturation was 80% on room air, and he had diffuse bilateral lung rhonchi. Nasopharyngeal swab was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Chest x-ray showed bilateral interstitial opacities. He was treated with dexamethasone, remdesivir, enoxaparin and supplemental oxygen. On hospital day three, he developed worsening hypoxia with pO2 of 41mmHg on 15L non-rebreather oxygen. He was transferred to the intensive care unit (ICU) and placed on non-invasive positive pressure ventilation but was quickly weaned to high-flow oxygen. On hospital day 17, he developed worsening hypoxia and reported neck swelling and tenderness. Computed tomography (CT) of the neck and chest confirmed extensive subcutaneous emphysema and pneumomediastinum and diffuse granular lung opacities without any normally aerated lung parenchyma, without evidence of pneumothorax. He was placed on mechanical ventilation after failing non-invasive positive pressure ventilation. Despite supportive care and lung protective ventilation, he remained hypoxic with worsening subcutaneous emphysema. CT of the chest, abdomen and pelvis showed development of pneumoperitoneum and pneumoretroperitoneum. Due to the patient's refractory hypoxia with progression to multi-system organ failure, his family opted for compassionate extubation and he expired on hospital day 34. DISCUSSION: Common causes of pneumoretroperitoneum include perforated viscous or iatrogenic introduction of air. As this patient had neither surgical procedures or evidence of perforation, his pneumoretroperitoneum was likely due to prolonged positive end expiratory pressure (PEEP) in setting of acute respiratory distress syndrome due to COVID-19. Mechanical ventilation likely acted as a shearing force intensifying air leak into the mediastinum which tracked inferiorly into the retroperitoneum. CONCLUSIONS: In conclusion, pneumomediastinum is a possible complication of COVID-19 pneumonia that can progress to pneumoretroperitoneum despite lung protective ventilation causing acute decompensation that can worsen patient prognosis. REFERENCE #1: Salehi, S., Abedi, A., Balakrishnan, S., & Gholamrezanezhad, A. (2020). Coronavirus Disease 2019 (COVID-19): A Systematic Review of Imaging Findings in 919 Patients. AJR. American journal of roentgenology, 215(1), 87–93. https://doi.org/10.2214/AJR.20.23034Zhou, C., Gao, C., Xie, Y., & Xu, M. (2020). COVID-19 with spontaneous pneumomediastinum. The Lancet. Infectious diseases, 20(4), 510. https://doi.org/10.1016/S1473-3099(20)30156-0 REFERENCE #2: Ahmed, A., Mohamed, M., & Ahmed, K. (2021). Severe COVID-19 Pneumonia Complicated by Pneumothorax, Pneumomediastinum, and Pneumoperitoneum. The American journal of tropical medicine and hygiene, tpmd210092. Advance online publication. https://doi.org/10.4269/ajtmh.21-0092Hillman K. M. (1983). Pneumoretroperitoneum. Anaesthesia, 38(2), 136–139. https://doi.org/10.1111/j.1365-2044.1983.tb13932. REFERENCE #3: Okamoto, A., Nakao, A., Matsuda, K., Yamada, T., Osako, T., Sakata, H., Yamaguchi, Y., Terashima, M., Iwano, J., & Kotani, J. (2014). Non-surgical pneumoperitoneum associated with mechanical ventilation. Acute medicine & surgery, 1(4), 254–255. https://doi.org/10.1002/ams2.52 DISCLOSURES: No relevant relationships by Christopher Ignatz, source=Web Response No relevant relationships by Bao Nhi Nguyen, source=Web Res onse No relevant relationships by Navitha Ramesh, source=Web Response