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Objective: To describe the evolution of respiratory antibiotic prescribing during the coronavirus disease 2019 (COVID-19) pandemic across 3 large hospitals that maintained antimicrobial stewardship services throughout the pandemic. Design: Retrospective interrupted time-series analysis. Setting: A multicenter study was conducted including medical and intensive care units (ICUs) from 3 hospitals within a Canadian epicenter for COVID-19. Methods: Interrupted time-series analysis was used to analyze rates of respiratory antibiotic utilization measured in days of therapy per 1,000 patient days (DOT/1,000 PD) in medical units and ICUs. Each of the first 3 waves of the pandemic were compared to the baseline. Results: Within the medical units, use of respiratory antibiotics increased during the first wave of the pandemic (rate ratio [RR], 1.76;95% CI, 1.38–2.25) but returned to the baseline in waves 2 and 3 despite more COVID-19 admissions. In ICU, the use of respiratory antibiotics increased in wave 1 (RR, 1.30;95% CI, 1.16–1.46) and wave 2 of the pandemic (RR, 1.21;95% CI, 1.11–1.33) and returned to the baseline in the third wave, which had the most COVID-19 admissions. Conclusions: After an initial surge in respiratory antibiotic prescribing, we observed the normalization of prescribing trends at 3 large hospitals throughout the COVID-19 pandemic. This trend may have been due to the timely generation of new research and guidelines developed with frontline clinicians, allowing for the active application of new research to clinical practice.
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Background: In March 2020, COVID-19 assessment centres were launched across the province of Ontario to facilitate COVID-19 testing outside of emergency departments. We aimed to study the degree to which assessment centres provide education and follow-up care for patients with suspected COVID-19. Methods: We conducted an online survey of Ontario COVID-19 assessment centre directors between September 15 and October 15, 2020. The primary outcomes studied were the types of educational modalities employed and information conveyed, methods and frequency of test result communication, and any follow-up care that was offered. Survey respondents were also asked to provide descriptions of barriers to patient education and test communication. Results: A total of 56 directors (representing 73 assessment centres) completed the survey. The most frequent educational modalities employed were educational handouts (92%), direct in-person counselling (89%), and referral to website (72%). Seventy-one percent of respondents indicated patients with positive test results would be notified, and 61% of respondents indicated that follow-up care would be offered. The most frequently reported barriers to patient education were insufficient time and high volume of tests, while the most frequently reported barriers to communication of test results were difficulty accessing online health portals and high volume of tests. Conclusion: The ability of many assessment centres to provide patient education is limited by both individual patient and system-level factors. Assessment centres may benefit from standardization of educational materials, improved accessibility to test results for patients in marginalized groups, and virtual pathways to facilitate additional counselling and care for individuals who test positive.
Historique : En mars 2020, des centres d'évaluation de la COVID-19 ont été lancés dans la province de l'Ontario afin de favoriser le dépistage de la COVID-19 hors des services d'urgence. Les chercheurs visaient à étudier dans quelle mesure ces centres transmettent de l'information et des soins de suivi aux patients chez qui on présume une COVID-19. Méthodologie : Les chercheurs ont réalisé un sondage en ligne auprès des directeurs des centres d'évaluation de la COVID-19 de l'Ontario entre le 15 septembre et le 15 octobre 2020. Le type de modalités pédagogiques utilisé et d'information transmise, les modes et la fréquence de communication des résultats des tests et les soins de suivi offerts étaient les résultats cliniques primaires à l'étude. Les répondants au sondage ont également été invités à décrire les obstacles à la transmission d'information aux patients et à la communication des résultats. Résultats : Au total, 56 directeurs (représentant 73 centres d'évaluation) ont rempli le sondage. Les principales modalités pédagogiques étaient la remise de document d'information (92 %), des conseils individuels directs (89 %) et l'orientation vers un site Web (72 %). Ainsi, 71 % des répondants ont indiqué que les patients obtenant un résultat positif en étaient avisés, et 61 %, que des soins de suivi seraient offerts. Les principaux obstacles à la transmission d'information aux patients étaient le manque de temps et le volume élevé de tests, tandis que les principaux obstacles à la transmission des résultats étaient la difficulté d'accès aux portails santé en ligne et le volume élevé de tests. Conclusion : La capacité de nombreux centres d'évaluation à transmettre de l'information aux patients est limitée à la fois par des facteurs liés aux patients eux-mêmes et par des facteurs systémiques. Les centres d'évaluation pourraient tirer profit de la standardisation des documents pédagogiques, d'un meilleur accès aux résultats des tests pour les patients de groupes marginalisés et de trajectoires virtuelles pour favoriser la transmission de conseils et de soins supplémentaires aux personnes dont les résultats sont positifs.
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Recognizing emergency department overcrowding during the COVID-19 pandemic, a pathway to facilitate direct admissions for outpatients with worsening COVID-19 infection was created using the COVID-19 expansion to outpatients (COVIDEO) virtual care program. Outpatients appropriate for direct admission had oxygen saturations consistently <92% without severe respiratory distress. Pulse oximeters were proactively delivered to high-risk patients, and patients contacted the program in the event of worsening symptoms or desaturation persistently <92%. Over a 15-month period, 9,116 outpatients were managed by the program, 164 of whom were hospitalized, and 83 of those hospitalized (50.6%) were directly admitted through this pathway. Of those directly admitted, 10 (12.0%) patients required ICU admission, occurring a median of 4 days from hospital admission. The mortality rate among directly admitted patients was 3.6% (3/83). Implementation of a virtual care program to facilitate direct admissions in outpatients with COVID-19 created a safe, efficient, and patient-centered pathway of care.
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BACKGROUND: The pandemic has affected hundreds of millions of people; early reports suggesting high rates of prolonged symptoms may be prone to selection bias. METHODS: In a program caring for all SARS-CoV-2 positive inpatients and outpatients between March to October 2020, and offering universal 90-day follow-up, we compared those who died prior to 90 days, not responding to follow-up, declining, or accepting follow-up. Among those seen or declining follow-up, we determined the prevalence and predictors of persistent symptoms. RESULTS: Among 993 patients, 21 (2.1%) died prior to 90 days, 506 (50.9%) did not respond, 260 (26.1%) declined follow-up because they were well, and 206 (20.7%) were fully assessed. Of 466 who responded to follow-up inquiry, 133 (28.5%) reported ≥1 persistent symptom, including constitutional (15.5%), psychiatric (14.2%), rheumatologic (13.1%), neurologic (13.1%), cardiorespiratory (12.0%), and gastrointestinal (1.7%). Predictors differed for each symptom type. Any persistent symptom was more common in older patients (adjusted odds ratio [aOR] 1.11, 95% CI 1.04 to 1.18/5 years), those diagnosed in hospital (aOR 2.03, 95% CI 1.24 to 3.33) and those with initial constitutional and rheumatologic symptoms. Patients not responding to follow-up were younger and healthier at baseline. CONCLUSION: Persistent symptoms are common and diverse 3 months post-COVID-19 but are likely over-estimated by most reports.
HISTORIQUE: La pandémie touche des centaines de millions de gens. Les rapports précoces laissant croire à des symptômes prolongés pourraient être assujettis à un biais de sélection. MÉTHODOLOGIE: Dans un programme de soins auprès de tous les patients ambulatoires et hospitalisés ayant reçu un résultat positif au SRAS-CoV-2 entre mars et octobre 2020, assorti d'un suivi universel de 90 jours, les chercheurs ont comparé les personnes qui ont succombé avant 90 jours, n'ont pas répondu au suivi ou ont décliné ou accepté le suivi. Chez celles qui ont été vues ou ont décliné le suivi, ils ont déterminé la prévalence et les prédicteurs de symptômes persistants. RÉSULTATS: Chez les 993 patients, 21 (2,1 %) sont décédés avant les 90 jours, 506 (50,9 %) n'ont pas répondu, 260 (26,1 %) ont décliné le suivi parce qu'ils se sentaient bien et 206 (20,7 %) se sont soumis à une évaluation complète. Des 466 qui ont répondu à l'offre de suivi, 133 (28,5 %) ont signalé ressentir au moins un symptôme persistant, y compris d'ordre constitutionnel (15,5 %), psychiatrique (14,2 %), rhumatologique (13,1 %), neurologique (13,1 %), cardiorespiratoire (12,0 %) et gastro-intestinal (1,7 %). Les prédicteurs différaient en fonction de chaque type de symptômes. Les symptômes persistants étaient courants chez les personnes âgées (rapport de cotes corrigé [RCc] 1,11, IC à 95 %, 1,04 à 1,18/cinq ans), les personnes diagnostiquées à l'hôpital (RCc 2,03, IC à 95 %, 1,24 à 3,33) et celles dont les manifestations initiales comportaient des symptômes constitutionnels et rhumatologiques. Les patients qui ne répondaient pas au suivi étaient plus jeunes et en meilleure santé au départ. CONCLUSION: Les symptômes persistants sont courants et diversifiés trois mois après la COVID-19, mais sont probablement surestimés dans la plupart des rapports.
ABSTRACT
Objective: To describe the evolution of respiratory antibiotic prescribing during the coronavirus disease 2019 (COVID-19) pandemic across 3 large hospitals that maintained antimicrobial stewardship services throughout the pandemic. Design: Retrospective interrupted time-series analysis. Setting: A multicenter study was conducted including medical and intensive care units (ICUs) from 3 hospitals within a Canadian epicenter for COVID-19. Methods: Interrupted time-series analysis was used to analyze rates of respiratory antibiotic utilization measured in days of therapy per 1,000 patient days (DOT/1,000 PD) in medical units and ICUs. Each of the first 3 waves of the pandemic were compared to the baseline. Results: Within the medical units, use of respiratory antibiotics increased during the first wave of the pandemic (rate ratio [RR], 1.76; 95% CI, 1.38-2.25) but returned to the baseline in waves 2 and 3 despite more COVID-19 admissions. In ICU, the use of respiratory antibiotics increased in wave 1 (RR, 1.30; 95% CI, 1.16-1.46) and wave 2 of the pandemic (RR, 1.21; 95% CI, 1.11-1.33) and returned to the baseline in the third wave, which had the most COVID-19 admissions. Conclusions: After an initial surge in respiratory antibiotic prescribing, we observed the normalization of prescribing trends at 3 large hospitals throughout the COVID-19 pandemic. This trend may have been due to the timely generation of new research and guidelines developed with frontline clinicians, allowing for the active application of new research to clinical practice.
ABSTRACT
OBJECTIVES: The majority of patients with mild-to-moderate COVID-19 can be managed using virtual care. Dyspnoea is challenging to assess remotely, and the accuracy of subjective dyspnoea measures in capturing hypoxaemia have not been formally evaluated for COVID-19. We explored the accuracy of subjective dyspnoea in diagnosing hypoxaemia in COVID-19 patients. METHODS: This is a retrospective cohort study of consecutive outpatients with COVID-19 who met criteria for home oxygen saturation monitoring at a university-affiliated acute care hospital in Toronto, Canada from 3 April 2020 to 13 September 2020. Dyspnoea measures were treated as diagnostic tests, and we determined their sensitivity (SN), specificity (SP), negative/positive predictive value (NPV/PPV) and positive/negative likelihood ratios (+LR/-LR) for detecting hypoxaemia. In the primary analysis, hypoxaemia was defined by oxygen saturation <95%; the diagnostic accuracy of subjective dyspnoea was also assessed across a range of oxygen saturation cutoffs from 92% to 97%. RESULTS: During the study period, 89/501 (17.8%) of patients met criteria for home oxygen saturation monitoring, and of these 17/89 (19.1%) were diagnosed with hypoxaemia. The presence/absence of dyspnoea had limited accuracy for diagnosing hypoxaemia, with SN 47% (95% CI 24% to 72%), SP 80% (95% CI 68% to 88%), NPV 86% (95% CI 75% to 93%), PPV 36% (95% CI 18% to 59%), +LR 2.4 (95% CI 1.2 to 4.7) and -LR 0.7 (95% CI 0.4 to 1.1). The SN of dyspnoea was 50% (95% CI 19% to 81%) when a cut-off of <92% was used to define hypoxaemia. A modified Medical Research Council dyspnoea score >1 (SP 98%, 95% CI 88% to 100%), Roth maximal count <12 (SP 100%, 95% CI 75% to 100%) and Roth counting time <8 s (SP 93%, 95% CI 66% to 100%) had high SP that could be used to rule in hypoxaemia, but displayed low SN (≤50%). CONCLUSIONS: Subjective dyspnoea measures have inadequate accuracy for ruling out hypoxaemia in high-risk patients with COVID-19. Safe home management of patients with COVID-19 should incorporate home oxygenation saturation monitoring.
Subject(s)
COVID-19 , Canada , Dyspnea/diagnosis , Humans , Hypoxia/diagnosis , Outpatients , Retrospective Studies , SARS-CoV-2 , Sensitivity and SpecificityABSTRACT
BACKGROUND: In patients who are discharged home to self-isolate while coronavirus disease 2019 (COVID-19) test results are pending, there is no formal method for physician assessments or counselling to occur if the result returns positive. Our aim was to develop and test the feasibility of a virtual care program for self-isolating outpatients diagnosed with COVID-19. METHODS: In preparation for this gap in health care, the COVID-19 Expansion to Outpatients (COVIDEO) program was developed at the Sunnybrook Health Sciences Centre, Toronto, Ontario, to provide ongoing care for outpatients diagnosed with COVID-19. As part of a feasibility study, we describe our experiences with the first 50 patients managed using this program from its inception (Mar. 1, 2020) until Mar. 27, 2020. RESULTS: All 50 people who tested positive for COVID-19 at the Sunnybrook Health Sciences Centre and were discharged home to self-isolation during the study period were assessed through the COVIDEO program. Thirty-two patients (64%) were assessed via the Ontario Telemedicine Network virtual care platform, and the remainder by telephone. The median time from viral swab collection to first COVIDEO program assessment was 2 (interquartile range [IQR] 1-2) days. Among the 26 patients for whom further follow-up care through the COVIDEO program was discontinued by the end of March 2020, the median duration of virtual care was 12.5 (IQR 8.75-16) days. During the study period, 6 patients required transfer to hospital for assessment, of whom 4 required admission. INTERPRETATION: We have shown that a virtual care program can be used in the management of outpatients diagnosed with COVID-19. Further studies evaluating its sustainability and impact on health outcomes are underway.