Evaluating the use of the respiratory-rate oxygenation index as a predictor of high-flow nasal cannula oxygen failure in COVID-19.

BACKGROUND: It can be challenging for clinicians to predict which patients with respiratory failure secondary to coronavirus disease 2019 (COVID-19) will fail on high-flow nasal cannula (HFNC) oxygen and require escalation of therapy. This study set out to evaluate the association between the respiratory rate-oxygenation index (ROX) and HFNC failure in such patients and to assess whether ROX trajectory correlates with treatment failure. METHODS: This was a single-centre, retrospective, observational study of patients with COVID-19 requiring HFNC, conducted over a 3-month period. ROX was calculated as "pulse-oximetry oxygen saturation (SpO2) over the fractional inspired oxygen concentration (FiO2)/respiratory rate" for each patient at 2, 4, and 12 hours from starting HFNC. HFNC failure was defined as escalation to continuous positive airway pressure ventilation or invasive mechanical ventilation (IMV). Time-to-event analyses were performed to account for the longitudinal data set and time-dependent variables. RESULTS: We included 146 patients. Ninety-three (63.7%) experienced HFNC failure, with 53 (36.3%) requiring IMV. Higher ROX values were associated with a lower subhazard of HFNC failure on time-to-HFNC failure analysis (subhazard ratio, 0.29; 95% confidence interval [CI], 0.18-0.46; P<0.001). This remained true after controlling for informative censoring. Median ROX values changed differentially over time, increasing in the HFNC success group (0.06 per hour; 95% CI, 0.05-0.08; P<0.001) but not in the HFNC failure group (0.004 per hour; 95% CI, -0.05 to 0.08; P=0.890). CONCLUSIONS: A higher ROX is associated with a lower risk of HFNC failure. Monitoring ROX trajectory over time may help identify patients at risk of treatment failure. This has potential clinical applications; however, future prospective studies are required.

Psychological distress and morbidity of family members experiencing virtual visiting in intensive care during COVID-19: an observational cohort study.

PURPOSE: During the coronavirus disease 2019 (COVID-19) pandemic, intensive care units (ICUs) around the world introduced virtual visiting to mediate the psychological impact of in-person visiting restrictions. Our objective was to evaluate levels of distress, depression, anxiety, and stress among family members experiencing virtual visits. METHODS: Multi-centre prospective observational study recruiting adult family members of critically ill patients in the United Kingdom (UK) using a bespoke virtual visiting solution (aTouchAway). We recruited participants and administered validated questionnaires digitally via their aTouchAway account. Prior to first virtual visit, participants completed the Distress Thermometer (score range 0-10) and the Depression, Anxiety and Stress Scale (DASS)-21. Following first and subsequent virtual visits, participants repeated the Distress Thermometer and completed the Discrete Emotions Questionnaire. RESULTS: We recruited 2166 adult family members of ICU patients in 37 UK hospitals. Most were grown up children (33%) or spouses/partners (23%). Most (91%) were ≤ 65 years. Mean (SD) pre-virtual-visit Distress Thermometer score was 7 (2.6) with 1349/2153 (62%) reporting severe distress. Pre-visit Distress Thermometer scores were associated with relationship type (spouse/partner OR 1.65, 95% CI 1.27-2.12) but not family member age, or length of ICU stay. Mean (SD) post-visit Distress Thermometer score provided by 762 (35%) participants was 1.6 (3.2) points lower than pre-visit (P < 0.001). Of participants experiencing multiple visits, 22% continued to report severe distress. Median (IQR) pre-visit DASS-21 score was 18 (2-42) (1754 participants). Severe-to-extremely severe depression, anxiety, or stress were reported by 249 (14%), 321 (18%), and 165 (9%) participants, respectively. Participants reported a range of emotions with reassurance being the most common, anger being the least. CONCLUSION: Family members exposed to COVID-19 pandemic ICU visiting restrictions experienced severe distress. One fifth of family members reported severe-to-extremely sever anxiety or depression. Distress score magnitude and prevalence of severe distress decreased after undertaking one or more virtual visits.

A critical care outreach team under strain - Evaluation of the service provided to patients with haematological malignancy during the Covid-19 pandemic.

PURPOSE: Critical Care Outreach Teams (CCOTs) have been associated with improved outcomes in patients with haematological malignancy (HM). This study aims to describe CCOT activation by patients with HM before and during the Covid-19 pandemic, assess amny association with worse outcomes, and examine the psychological impact on the CCOT. MATERIALS AND METHODS: A retrospective, mixed-methods analysis was performed in HM patients reviewed by the CCOT over a two-year period, 01 July 2019 to 31 May 2021. RESULTS: The CCOT increased in size during the surge period and reviewed 238 HM patients, less than in the pre- and post-surge periods. ICU admission in the baseline, surge and the non-surge periods were 41.7%, 10.4% and 47.9% respectively. ICU mortality was 22.5%, 0% and 21.7% for the same times. Time to review was significantly decreased (p = 0.012). Semi-structured interviews revealed four themes of psychological distress: 1) time-critical work; 2) non-evidence based therapies; 3) feelings of guilt; 4) increased decision-making responsibility. CONCLUSIONS: Despite the increase in total hospital referrals, the number of patients with HM that were reviewed during the surge periods decreased, as did their ICU admission rate and mortality. The quality of care provided was not impaired, as reflected by the number of patients receiving bedside reviews and the shorter-than-pre-pandemic response time.

Improving the intensive care experience from the perspectives of different stakeholders.

The intensive care unit (ICU) is a complex environment where patients, family members and healthcare professionals have their own personal experiences. Improving ICU experiences necessitates the involvement of all stakeholders. This holistic approach will invariably improve the care of ICU survivors, increase family satisfaction and staff wellbeing, and contribute to dignified end-of-life care. Inclusive and transparent participation of the industry can be a significant addition to develop tools and strategies for delivering this holistic care. We present a report, which follows a round table on ICU experience at the annual congress of the European Society of Intensive Care Medicine. The aim is to discuss the current evidence on patient, family and healthcare professional experience in ICU is provided, together with the panel's suggestions on potential improvements. Combined with industry, the perspectives of all stakeholders suggest that ongoing improvement of ICU experience is warranted.

Family perspectives on facilitators and barriers to the set up and conduct of virtual visiting in intensive care during the COVID-19 pandemic: A qualitative interview study.

OBJECTIVE: To gain perspectives from family members about barriers and facilitators to virtual visit set up and conduct across intensive care unit settings in the United Kingdom to inform understanding of best practices. METHODS: We conducted a qualitative descriptive study recruiting a purposive sample of family members of adult intensive care unit patients experiencing virtual visiting during Jan to May 2021 of the COVID-19 pandemic. We used semi-structured qualitative interviews and a standard Thematic Analysis approach. RESULTS: We recruited 41 family-member participants from 16 hospitals in the United Kingdom. Facilitators to successful virtual visit set-up were preparation of the family, negotiating a preferred time, and easy-to-use technology. Facilitators to successful conduct were intensive care unit team member presence; enabling family involvement in care; inclusivity, accessibility, and flexibility; and having a sense of control. Barriers that created distress or conflict included restrictive virtual visiting practices; raising expectations then failing to meet them; lack of virtual visit pre-planning; and failing to prepare the patient. Barriers to visit conduct were incorrect camera positioning, insufficient technical and staff resources, issues with three-way connectivity, and lack of call closure. Recommendations included emotional self-preparation, increased technology availability, and preparing conversation topics. CONCLUSION: These data may guide virtual visiting practices during the ongoing pandemic but also to continue virtual visiting outside of pandemic conditions. This will benefit family members suffering from ill health, living at a distance, unable to afford travel, and those with work and care commitments, thereby reducing inequities of access and promoting family-centered care.

Virtual visiting in intensive care during the COVID-19 pandemic: a qualitative descriptive study with ICU clinicians and non-ICU family team liaison members.

OBJECTIVE: To understand the experiences and perceived benefits of virtual visiting from the perspectives of intensive care unit (ICU)-experienced clinicians and non-ICU-experienced family liaison team members. DESIGN: Qualitative descriptive study. SETTING: Adult intensive care setting across 14 hospitals within the UK National Health Service. PARTICIPANTS: ICU-experienced clinicians and non-ICU-experienced family liaison team members deployed during the first wave of the COVID-19 pandemic. METHODS: Semistructured telephone/video interviews were conducted with ICU clinicians. Analytical themes were developed inductively following a standard thematic approach, using 'family-centred care' and 'sensemaking' as sensitising concepts. RESULTS: We completed 36 interviews, with 17 ICU-experienced clinicians and 19 non-ICU-experienced family liaison team members. In the context of inperson visiting restrictions, virtual visiting offered an alternative conduit to (1) restoring the family unit, (2) facilitating family involvement, and (3) enabling sensemaking for the family. Virtual visits with multiple family members concurrently and with those living in distant geographical locations restored a sense of family unit. Family involvement in rehabilitation, communication and orientation activities, as well as presence at the end of life, highlighted how virtual visiting could contribute to family-centred care. Virtual visits were emotionally challenging for many family members, but also cathartic in helping make sense of their own emotions and experience by visualising their relatives in the ICU. Being able to see and interact with loved ones and their immediate care providers afforded important cues to enable family sensemaking of the ICU experience. CONCLUSIONS: In this UK qualitative study of clinicians using virtual ICU visiting, in the absence of inperson visiting, virtual visiting was perceived positively as an alternative that promoted family-centred care through virtual presence. We anticipate the perceived benefits of virtual visiting may extend to non-pandemic conditions through improved equity and timeliness of family access to the ICU by offering an alternative option alongside inperson visiting.

Communication and Virtual Visiting for Families of Patients in Intensive Care during the COVID-19 Pandemic: A UK National Survey.

Rationale: Restriction or prohibition of family visiting intensive care units (ICUs) during the coronavirus disease (COVID-19) pandemic poses substantial barriers to communication and family- and patient-centered care. Objectives: To understand how communication among families, patients, and the ICU team was enabled during the pandemic. The secondary objectives were to understand strategies used to facilitate virtual visiting and associated benefits and barriers. Methods: A multicenter, cross-sectional, and self-administered electronic survey was sent (June 2020) to all 217 UK hospitals with at least one ICU. Results: The survey response rate was 54%; 117 of 217 hospitals (182 ICUs) responded. All hospitals imposed visiting restrictions, with visits not permitted under any circumstance in 16% of hospitals (28 ICUs); 63% (112 ICUs) of hospitals permitted family presence at the end of life. The responsibility for communicating with families shifted with decreased bedside nurse involvement. A dedicated ICU family-liaison team was established in 50% (106 ICUs) of hospitals. All but three hospitals instituted virtual visiting, although there was substantial heterogeneity in the videoconferencing platform used. Unconscious or sedated ICU patients were deemed ineligible for virtual visits in 23% of ICUs. Patients at the end of life were deemed ineligible for virtual visits in 7% of ICUs. Commonly reported benefits of virtual visiting were reducing patient psychological distress (78%), improving staff morale (68%), and reorientation of patients with delirium (47%). Common barriers to virtual visiting were related to insufficient staff time, rapid implementation of videoconferencing technology, and challenges associated with family members' ability to use videoconferencing technology or access a device. Conclusions: Virtual visiting and dedicated communication teams were common COVID-19 pandemic innovations addressing the restrictions to family ICU visiting, and they resulted in valuable benefits in terms of patient recovery and staff morale. Enhancing access and developing a more consistent approach to family virtual ICU visits could improve the quality of care, both during and outside of pandemic conditions.

The Role of a Liaison Team in ICU Family Communication During the COVID 19 Pandemic.

CONTEXT: In the name of public safety, a general suspension on hospital visiting was imposed in the U.K., prohibiting family and friends to visit hospitalized patients, even if they were critically ill. OBJECTIVES: we aimed to assess the impact of the FLT on the communication with patients' family and friends (PFF), especailly around end-of-life care, and their interaction with CC clinicians. METHODS: A retrospective, mixed-methods analysis of a family liaison team (FLT) formed by redeployed clinicians in critical care (CC) during the first surge of the 2020 COVID 19 pandemic. RESULTS: The FLT was constituted predominantly of non-ICU consultants (30/39, 77%). Following two one-hourly webinars around basic communication skills, the FLT facilitated over 12,000 video and telephone calls with 172 patients' family and friends (PFF). The majority of the PFF interviewed were mostly, very or extremely satisfied with the frequency, ease, understanding, honesty, completeness, and consistency of the information provided. Approximately 5% of the interviewees reported to be slightly or very dissatisfied in one or more of the following 3 categories: frequency, consistency, and ease of getting the information. The thematic analysis identified 3 themes: 1) being there with/ for the patient; 2) breakdown in communication; 3) disbelief at the speed of deterioration. In 14.9% of cases there was documented discrepancy between the information transmitted by the CC team and that by the FLT, particularly around the severity of the patient's illness and their imminent death. CONCLUSION: The formation of a dedicated FLT was feasible and associated with high levels of satisfaction by the PFF. Friction was created when communication was not consistent and did not convey the severity of the patient's condition, to prepare the PFF for a bad outcome.

Hospital Mortality and Resource Implications of Hospitalisation with COVID-19 in London, UK: A Prospective Cohort Study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) had a significant impact on the National Health Service in the United Kingdom (UK), with over 35 000 cases reported in London by July 30, 2020. Detailed hospital-level information on patient characteristics, outcomes, and capacity strain is currently scarce but would guide clinical decision-making and inform prioritisation and planning. METHODS: We aimed to determine factors associated with hospital mortality and describe hospital and ICU strain by conducting a prospective cohort study at a tertiary academic centre in London, UK. We included adult patients admitted to the hospital with laboratory-confirmed COVID-19 and followed them up until hospital discharge or 30 days. Baseline factors that are associated with hospital mortality were identified via semiparametric and parametric survival analyses. RESULTS: Our study included 429 patients: 18% of them were admitted to the ICU, 52% met criteria for ICU outreach team activation, and 61% had treatment limitations placed during their admission. Hospital mortality was 26% and ICU mortality was 34%. Hospital mortality was independently associated with increasing age, male sex, history of chronic kidney disease, increasing baseline C-reactive protein level, and dyspnoea at presentation. COVID-19 resulted in substantial ICU and hospital strain, with up to 9 daily ICU admissions and 41 daily hospital admissions, to a peak census of 80 infected patients admitted in the ICU and 250 in the hospital. Management of such a surge required extensive reorganisation of critical care services with expansion of ICU capacity from 69 to 129 beds, redeployment of staff from other hospital areas, and coordinated hospital-level effort. CONCLUSIONS: COVID-19 is associated with a high burden of mortality for patients treated on the ward and the ICU and required substantial reconfiguration of critical care services. This has significant implications for planning and resource utilisation.

Allocating scarce intensive care resources during the COVID-19 pandemic: practical challenges to theoretical frameworks.

The COVID-19 pandemic strained health-care systems throughout the world. For some, available medical resources could not meet the increased demand and rationing was ultimately required. Hospitals and governments often sought to establish triage committees to assist with allocation decisions. However, for institutions operating under crisis standards of care (during times when standards of care must be substantially lowered in the setting of crisis), relying on these committees for rationing decisions was impractical-circumstances were changing too rapidly, occurring in too many diverse locations within hospitals, and the available information for decision making was notably scarce. Furthermore, a utilitarian approach to decision making based on an analysis of outcomes is problematic due to uncertainty regarding outcomes of different therapeutic options. We propose that triage committees could be involved in providing policies and guidance for clinicians to help ensure equity in the application of rationing under crisis standards of care. An approach guided by egalitarian principles, integrated with utilitarian principles, can support physicians at the bedside when they must ration scarce resources.