Did the UK's public health shielding policy protect the clinically extremely vulnerable during the COVID-19 pandemic in Wales? Results of EVITE Immunity, a linked data retrospective study.

INTRODUCTION: The UK shielding policy intended to protect people at the highest risk of harm from COVID-19 infection. We aimed to describe intervention effects in Wales at 1 year. METHODS: Retrospective comparison of linked demographic and clinical data for cohorts comprising people identified for shielding from 23 March to 21 May 2020; and the rest of the population. Health records were extracted with event dates between 23 March 2020 and 22 March 2021 for the comparator cohort and from the date of inclusion until 1 year later for the shielded cohort. RESULTS: The shielded cohort included 117,415 people, with 3,086,385 in the comparator cohort. The largest clinical categories in the shielded cohort were severe respiratory condition (35.5%), immunosuppressive therapy (25.9%) and cancer (18.6%). People in the shielded cohort were more likely to be female, aged ≥50 years, living in relatively deprived areas, care home residents and frail. The proportion of people tested for COVID-19 was higher in the shielded cohort (odds ratio [OR] 1.616; 95% confidence interval [CI] 1.597-1.637), with lower positivity rate incident rate ratios 0.716 (95% CI 0.697-0.736). The known infection rate was higher in the shielded cohort (5.9% vs 5.7%). People in the shielded cohort were more likely to die (OR 3.683; 95% CI: 3.583-3.786), have a critical care admission (OR 3.339; 95% CI: 3.111-3.583), hospital emergency admission (OR 2.883; 95% CI: 2.837-2.930), emergency department attendance (OR 1.893; 95% CI: 1.867-1.919) and common mental disorder (OR 1.762; 95% CI: 1.735-1.789). CONCLUSION: Deaths and healthcare utilisation were higher amongst shielded people than the general population, as would be expected in the sicker population. Differences in testing rates, deprivation and pre-existing health are potential confounders; however, lack of clear impact on infection rates raises questions about the success of shielding and indicates that further research is required to fully evaluate this national policy intervention.

‘Every day was a learning curve’: implementing COVID-19 triage protocols in UK ambulance services – a qualitative study

BackgroundTRIM is an evaluation of the triage models used by emergency ambulance services caring for patients with suspected COVID-19 during the pandemic’s first wave in 2020. We aimed to understand experiences and concerns of staff about implementation of triage protocols.MethodResearch paramedics interviewed stakeholders from four ambulance services (call handlers, clinical advisors, paramedics, managers) and ED clinical staff from receiving hospitals. Interviews (n=23) were conducted remotely using MS Teams, recorded, and transcribed in full. Analysis generated themes from implicit and explicit ideas within participants’ accounts (Braun and Clarke 2021), conducted by researchers and PPI partners working together.ResultsWe identified the following themes:Constantly changing guidelines – at some points, updated several times a day.The ambulance service as part of the wider healthcare system - changes elsewhere in the system left ambulance services as the default.Peaks and troughs of demand - fluctuating greatly over time, and varying across the staff groups.A stretched system - resources were overextended by staff sickness and isolation, longer job times, and increased handover delays at ED.Emotional load of responding to the pandemic - including call centre staff. Doing the best they can in the face of uncertainty - a rapidly evolving situation unlike any which ambulance services had faced before.ConclusionImplementing triage protocols in response to the COVID-19 pandemic was complex and had to be actively managed by a range of frontline staff, dealing with external pressures and a heavy emotional load.Conflict of interestNone.FundingUKRI-DHSC Covid-19 Rapid Response Funding.

Covid-19 mortality review: Current smokers Are under-represented and cannot be Explained by ethnicity alone

Aim To compare demographic information between COVID-19 related deaths and those who died of another cause to identify any significant patient factors that may be contributing to COVID-19 deaths. Methods A retrospective systematic review of all medical (acute, general internal, specialty and critical care) mortality was undertaken from 01/03/2020 until 01/07/2020 in a large inner-city hospital. The electronic medical record from both the hospital and GP (where available) were reviewed to identify demographic information with particular reference to characteristics thought to be associated with COVID-19 illness including age, gender, ethnicity and co-morbidities. Death certificate information was used to establish direct cause of death (part 1 a, b or c). Only deaths where death certification was available were included. Results Death certification was available for 279 deaths (median age 77 years;IQR 67-83;133 (48%) female;76 (27%) BAME;67 (24%) admitted to critical care). 121 (43%) died as a direct consequence of COVID-19 illness (median age 77 years;IQR 67-83;61 (50%) female;47 (39%) BAME;31 (26%) admitted to critical care). Non-Caucasian (BAME) ethnicity was associated with increased COVID-19 mortality (RR 1.67;95% CI 1.30-2.15;p 0.0015). BMI, COPD, hypertension, chronic kidney disease and renal replacement therapy were not independent risk factors for COVID-19 deaths compared to deaths by another cause (see table 1). In comparison, type 2 diabetes was stastically associated with COVID-19 deaths (RR 1.3;CI 1.01-1.71;p 0.045). Current smoking status was negatively associated with COVID-19 mortality (RR 0.33;95% CI 0.16-0.65;p 0.0015) with 5.8% current smokers in COVID-19 deaths compared to 23.7% in those who died of another cause. Smoking status was not available for 4 persons (1.4%). Conclusion In our cohort, there appears to be increased mortality from COVID-19 associated with BAME ethnicity and type 2 diabetes. The signal from current smoking status is interesting and cannot fully be explained by ethnicity alone and should prompt further research.

PEP in the city - A new way of delivering post-exposure prophylaxis from the Emergency Department

Introduction: We present our contingency plan for the management of patients presenting to our Emergency Department (ED) requiring HIV (Human Immunodeficiency Virus) Post-Exposure Prophylaxis (PEP) during the COVID-19 pandemic. Method: The pre-COVID pathway relied on patients who needed PEP being dispensed a 5 day supply of PEP. A generic leaflet was included in each PEP pack. This contained a large amount of medical jargon and no contact details for local services. A handwritten fax referral was sent to Genitourinary Medicine (GUM) who would recall the patient for face to face (F2F) review in order to obtain baseline screening and supply an additional 23 days of medication. F2F follow up testing was arranged at 2 weeks and 8-12 weeks post-PEP. Results: An electronic PEP referral was introduced and the ED Clinical Decision Support Guideline (CDGS) was redesigned. Pharmacy was able to supply 28 days of PEP meaning that if a patient was required to self-isolate, they would have an adequate supply of treatment at home. The patient information leaflet was rewritten using simple terminology and details of local GUM services were included. Baseline bloods were taken within ED removing the need for F2F appointments. Upon receipt of the PEP referral, a Health Advisor would call the patient and arrange for confirmatory home testing kits to be sent at the required window period. Patients attending ED who were non-Manchester residents were eligible for the same service thus reducing unnecessary F2F contact at other clinics. 16 patients were successfully referred from ED to GUM between May/June 2020. Discussion: Our new pathway has helped us to substantially mitigate risk for patients requiring PEP via the ED. Following the success of this collaborative project, we have decided to adopt this pathway permanently as we predict demand for PEP will increase as the UK begins to ease lockdown restrictions.

S5 COVID-19 mortality review: current smokers are under-represented and cannot be explained by ethnicity alone

S5 Table 1Commonest co-morbidities for certified deaths related and not related to COVID-19 illness March to July 2020ConclusionIn our cohort, there appears to be increased mortality from COVID-19 associated with BAME ethnicity and type 2 diabetes. The signal from current smoking status is interesting and cannot fully be explained by ethnicity alone and should prompt further research.