Adoption of open innovation in the COVID-19 emergency: developing a process-based information coordination system

Purpose: The COVID-19 pandemic has stimulated a global movement of open innovation initiatives aimed to provide knowledge and tools to support policy decisions and actions in the emergency scenario. The authors describe an open innovation process aimed to build an information coordination system to reduce the infection diffusion within the population. Design/methodology/approach: The authors use coordination theory principles to elaborate a framework of activities, resources and dependencies among information resources and producers in the COVID-19 emergency. The framework was applied to develop a case study aimed at describing a health emergency system implemented by Dyrecta Lab (a research laboratory on computer science) and CITEL (a medical research center). Findings: The authors describe the existence of relevant “flow,” “fit” and “share” dependencies within the activities of infection containment and medical treatment. The authors identify eight key resources and a number of actors involved in those activities, and describe a platform able to gather a multitude of epidemic-related metrics with the purpose to address dependencies and support decision making. Research limitations/implications: The authors provide insights for advancing the academic discussion on process coordination principles in time-constrained, volatile and highly demanding scenarios. Practical implications: The value of the authors’ research can be identified for practitioners engaged to develop innovative development projects for public utility. The authors provide a contribution also for first responders and health operators involved in management of the current and future emergencies. Originality/value: The adoption of process coordination principles is a relatively new and powerful approach to analyze and optimize the processes that characterize the management of emergency scenarios. Besides, the study and application of open innovation in healthcare are partially limited. © 2022, Emerald Publishing Limited.

Physicians' attitudes and perceptions of neuromuscular blocker infusions in ARDS

INTRODUCTION: With the COVID pandemic, and recently updated practice guidelines for neuromuscular infusion (NMBI) use during ARDS, the practices/perceptions of ICU physicians regarding NMBI use during ARDS may not be evidence-based. METHODS: We developed, tested, and electronicallyadministered a questionnaire (9 questions/70 subquestions) to medical and surgical ICU fellow and attending physicians at 3 geographically-diverse U.S. health systems (U Arizona, U Chicago, Mass General Brigham). The IRB-approved questionnaire focused on adults with moderate-severe ARDS (PaO2:FiO2 < 150) with critical hypoxemia where dyssynchrony causes were addressed and PEEP optimized. Weekly reminders were sent twice. RESULTS: Respondents [173/342(50.5%)] primarily worked as an attending 117(75%) in a medical ICU 94(60%) for 12±8 weeks/year. COVID+ ARDS patients were twice as likely to receive a NMBI (56±37 vs. 28±19%;p< 0.01). Respondents somewhat/strongly agreed a NMBI: should be reserved until after a trial of deep sedation 142 (82%) or proning 59 (34%), be dose-titrated based on trainof- four monitoring 107(62%);and effectively reduced dyssynchrony 149(86%), plateau pressure 106(62%) and barotrauma 102(60%). Few respondents [23(18%)] somewhat/strongly agreed a NMBI should be initiated at ARDS onset 20(12%) or administered at a fixed-dose 12(7%). Only 2/14 potential NMBI risks were frequently reported to be of high/very high concern: prolonged muscle weakness during steroids 135(79%) and paralysis awareness due to inadequate sedation 114(67%). Only absence of dyssynchrony 146(87%) was frequently reported to be a very/extremely important NMBI titration target. Train-of-four 78(46%) and BIS 39(23%) monitoring and plateau pressure 67(40%) or PaO2:FiO2 64(38%) evaluation were deemed less important. Absence of dysschrony 93(56%) and use ≥48 hours 87(53%) were preferred NMBI stopping criteria. For COVID+ patients, few felt reduced self-extubation and COVID aerosolization during reintubation 16(9%) or reduced ventilator adjustments 7(5%) were very/extremely important reasons for NMBI use. CONCLUSIONS: Most physicians agree NMBI infusions in ARDS should be reserved until after trials of deep sedation. Paralysis awareness and prolonged muscle weakness are the greatest NMBI use concerns. Unique considerations in COVID+ ARDS patients exist.

Outcomes for severe COVID-19 disease following ICU

Rationale: Severe SARS Co-V2 (COVID-19) infections are characterized by ARDS, cytokine storm, and multisystem organ failure. Longterm outcomes of these patients requiring long-term acute care (LTAC) have not been clarified. Given the severity of the initial acute illness, poor longterm outcomes are likely. We hypothesized that patients with severe COVID-19 infections would have outcomes worse than non-COVID-19 patients with multisystem organ failure. We tested this by comparing LTAC outcomes in patients having severe COVID-19 disease with patients without COVID-19 who required LTAC after critical illness. Methods: We conducted a chart review of the 275 COVID-19-positive patients requiring intensive care unit (ICU) care discharged from the Brigham and Women's hospital from January 1-July 31, 2020 and compared them to a cohort of 241 ICU patients requiring LTAC who are part of a quality improvement program to enhance care continuity (CC). Statistical analyses used Student-t tests and Chi-square analyses, with P < 0.05 accepted as statistically significant. Results: 65 of 279 COVID-19 patients required LTAC, with 57 patients discharging to the same LTAC used for CC patients. Similar to prior reports, the proportion of Black (28%) and Hispanic (10%) patients were significantly (P < 0.05) greater in COVID-19 patients compared to the CC patients (9% Black and 6% Hispanic). There were no differences between groups in the average patient age: COVID-19 patients (62 ±14.2) and CC patients (60 ±15) or the proportion of males: COVID-19 patients (37, 64%) compared to the CC patients (137, 57%). At transfer to LTAC, 25% CC patients but only 7% COVID-19 patients required mechanical ventilation (MV), although 90% of the COVID-19 patients had required MV during their acute hospitalization. After LTAC transfer, significantly (P < 0.05) fewer COVID-19 patients (12%) compared to CC patients (28%) required readmission to an acute hospital within 30 days of the acute hospital discharge. Additionally, significantly more (P < 0.05) COVID-19 patients (41, 71%) compared to CC patients (73, 30%) were discharged to home after LTAC. Conclusions: The low rates of early readmission and the high rates of home discharge in the COVID patients compared to the CC patients were unexpected and indicate that COVID-19 patients requiring LTAC have outcomes that are comparable, and possibly better than, similar patients without COVID-19. The possible contributing factors for improved outcomes in COVID-19 patients are unknown but may include a lower burden of comorbid disease in these patients and better pre-morbid functional status.

Evaluation of inhaled epoprostenol and nitric oxide for refractory hypoxemia in COVID-19

INTRODUCTION: Inhaled epoprostenol (iEPO) and nitric oxide (iNO), have been shown to improve oxygenation in patients with refractory hypoxemia and ARDS. The purpose of this analysis was to evaluate the efficacy and safety of iEPO and iNO in patients with COVID-19 and refractory hypoxemia. METHODS: This retrospective cohort study evaluated critically ill patients admitted to the ICU with respiratory failure secondary to COVID-19 from March to June 2020. Patients were included if they received at least one hour of iEPO or iNO for refractory hypoxemia. The primary outcome was the change in the partial pressure of oxygen [PaO2]/fractional concentration of oxygen [FiO2] ratio following initiation of iEPO or iNO. Secondary outcomes included changes in PaO2 and pulse oxygen saturation (SpO2), percentage of patients classified as ?responders? (increase PaO2/FiO2 > 10%), differences between responders and non-responders, and adverse events. Logistic regression was used to determine predictors of responsiveness to iEPO. RESULTS: Of 93 patients screened, 38 were included in the analysis, with mild (4, 10.5%), moderate (24, 63.2%) or severe (10, 26.3%) ARDS. All patients were initiated on iEPO as the initial pulmonary vasodilator and the median time from intubation to initiation was 137 (68 to 228) hours. The median change in PaO2/FiO2 was 0 (-12.8 to 31.6) immediately following administration of iEPO. Sixteen patients (42.1%) were classified as responders with a median increase in PaO2/FiO2 of 34.1 (24.3 to 53.9) with iEPO. The mean change in PaO2 and SpO2 was -0.55 ± 41.8 and -0.6 ± 4.7, respectively. Eleven patients transitioned to iNO with a median change of 11 (3.6 to 24.8) in PaO2/FiO2. No differences in outcomes or characteristics were seen between responders and non-responders. Minimal adverse events were seen in patients who received either iEPO or iNO. CONCLUSIONS: We found that the initiation of iEPO and iNO in patients with refractory hypoxemia secondary to COVID-19, on average, did not produce significant increases in oxygenation metrics. However, a small group of patients had significant improvement with iEPO and iNO.

THE HbA1c in COVID 19 patients

Purpose of the study: During the emergency period Covid-19 the glycosilate hemoglobin has been required for patients admitted to specialist wards suitable for metabolic control in diabetics and non-diabetics. Material and methods: The test HbA1c has been performed on Variant II Biorad, calibrated with standard Biorad for glycate hemoglobin, using EDTA whole blood samples after running two-tier Biorad controls. Results: The patients have been studied in the wave of coronavirus infection corresponding to the two months of loackdown. Thirty patients that have been hospitalized in covid area have been tested in our laboratory . In 12 females and 6 males with average age 50 years old the HbA1c has been resulted in the limits (up to 42 mmoli/moles) and in 10 patients ( 6 females and 4 males average age 48 years old ) higher values ( between 51 and 79 mmoli/molioli ) have been found. The patients have been so followed for the care of the case. Discussion and conclusion: Thus it has been possible to discern among patients with comorbidity and patients with lower degree of exposure to risks because in return to metabolic improvement and it has been possible to collaborate for the health of the sicks.