ABSTRACT
Introduction: The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation into focus. This study aims to analyse Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic. Methods: This was a retrospective repeated cross-sectional study. Data including comorbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1st toMay 31 s t 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID- 19 admitted during the same period. Pre-COVID-19 pandemic DNACPR documentation rates were also examined. Factors associated with DNACPR order instatement during the first wave of the COVID-19 pandemic were identified. Results: Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. 50% of DNAR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of 131 patients aged 65 years or over within the cohort admitted with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 patients ≥65 without COVID-19 (p<0.0001). During a comparable time period prepandemic, 15.4% of 130 older patients had a DNACPR order in place (p<0.0001). Independent associations with DNACPR order documentation included increasing age (Odds Ratio [O.R.] 1.12;95% CI 1.05-1.21);nursing home resident status (O.R. 3.57;95% CI 1.02-12.50);frailty (O.R. 3.34;95% CI 1.16-9.61) and chronic renal impairment (O.R. 5.49;1.34-22.47). The case-fatality-rate of older patients with COVID-19 was 29.8% versus 5.4% without COVID-19. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived. Conclusion: The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain clinical practice despite the pandemic.
ABSTRACT
Background: The COVID19 pandemic has necessitated innovative ways to provide safe healthcare remotely for large numbers of infected patients. We implemented a COVID Virtual Clinic (CVC) in a tertiary referral centre allowing such patients to be monitored in the community. This study describes the CVC's remote monitoring experience and explores the predictors of need for specialist intervention. Methods: We included all patients enrolled in the CVC at the Mater Misericordiae University Hospital, Dublin between March 1st and June 1st 2020. Patients received a Bluetooth-enabled pulse oximeter and smartphone application (Patient-M-Power®) and uploaded twice-daily SpO2 readings, heart rate and dyspnoea score (1-10). A team of 2-14 healthcare providers monitored results. Abnormal or absent data triggered calls from the CVC, with assessments and/or admission as required. We collected data on demographics, calls received from/made to patients, outcomes and readmissions. Descriptive analysis of the CVC was performed as well as simple logistic regression to explore factors associated with the likelihood of readmission. Results: 502 patients were included (179 (36.4%) male, median age 39 (IQR 50-3) years, 360 (73.2%) staff). Outcomes are illustrated in Figure 1. Median time in CVC was 12 days (IQR 13-10). 1902 calls were made to patients by CVC staff prompted by abnormal data: dyspnoea (41 patients, 8.2%), low SpO2 (133, 26.5%), tachycardia, (99, 19.7%), technical issues (81, 16.1%), absent results (255, 50.1%). This resulted in 45 (9%) patients requiring re-assessment and 42 (8.4%) being readmitted. Of those readmitted, 3 (7%) required critical care admission. Median length of stay was 2 (IQR 6.75-1) days. Those readmitted were more likely to be older (odds ratio [OR] per year older 1.03 (1.01, 1.05), P=0.0050, have an abnormal SpO2 (<94%, OR 5.43 [2.93, 11.1], P<0.001), a high dyspnoea score (>7, OR 4.33 (2.04, 9.3), P<0.001) and be staff (OR 6.08 (3.11, 11.87), P<0.001). Neither gender nor abnormal HR were associated with higher likelihood of readmission. 22.2% of presenting patients were hypoxic in the absence of dyspnoea, of which 70% required admission and one patient required intensive care. Conclusion: We describe the largest remotely monitored cohort of COVID19 patients to date. The low frequency of readmissions and value of SpO2 monitoring and dyspnoea scores as predictors of readmission highlights the value of this model in providing safe care whilst minimising unnecessary admissions.
ABSTRACT
AIM: To report an audit of the evaluation of suspected, unconfirmed cases of COVID-19 including chest computed tomography (CT), as compared to World Health Organization recommendations. METHODS: A clinical audit was undertaken examining the evaluation of patients with suspected COVID-19 with negative SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) results, with comparison to WHO recommendations. A retrospective chart review was undertaken for 90 patients examining investigations, in particular CT, used to clarify the diagnosis. RESULTS: Ninety patients underwent additional investigation. Seventy-five per cent adherence to WHO recommendations was observed. Fifty-two men (57.78%) and 38 (42.22%) women were investigated, with a median age of 69 years (range 20-96 years). Seventy-nine chest CT examinations demonstrated positive, indeterminate, and negative rates for COVID-19 of 3.79%, 24.1%, and 72.15% respectively. Three patients had discordant swab results with initially negative and subsequently positive results for SARS-CoV-2, resulting in false-negative rates of 5.1% for those retested. Combining discordant RT-PCR swab results, positive radiology, and patients treated as COVID-19-positive due to indeterminate radiology and highly consistent symptoms, resulted in a false-negative rate for initial SARS-CoV-2 RT-PCR swabs of 16.67%. CONCLUSION: Seventy-five per cent compliance with relevant WHO guidance and a false-negative rate for initial swabs of 16.67% was demonstrated. Further evidence is needed to fully determine the utility of chest CT in the diagnosis of COVID-19 in the context of initial false-negative RT-PCR results.