Harnessing the Affordances of Action Researchers to Address the Challenges of the COVID-19 Pandemic: Educational Leaders take Action Research Online

The unique affordances of Action Research, including flexibility, playfulness, accessibility, and a focus on practical problem solving provided crucial strategies for generating knowledge and developing solutions to the challenges created by the Covid-19 pandemic. The move to online research settings, in particular, required action researchers to find ways to adapt existing research methods and to devise new approaches. This article describes the work of a group of doctoral students in an Educational Leadership program and their instructor in carrying out action research methods in both synchronous and asynchronous online settings.If the months of the pandemic have taught us nothing else, it is that flexibility and willingness to innovate, which are central to action research, are valuable assets in times of uncertainty. The unique affordances of Action Research include creativity, playfulness, accessibility to multiple participants and audiences, transferability of findings, and a focus on the generation of knowledge designed to be pragmatic and problem-focused. These qualities can be harnessed to address the multiple challenges we have encountered during the pandemic including health equity and access, poverty and unemployment, and the interruption of education for vulnerable student populations. They also offer us hope that action research can continue to contribute to addressing the challenges we are sure to face in the future.As students in an educational leadership doctoral program, we focus on examining problems of practice in our schools and districts through action research. As we adapted to online learning in our own schools, we were able to bring these skills to bear in our doctoral studies by developing strategies for conducting these action research methods in both synchronous and asynchronous online settings. This paper describes some of the approaches we developed in the hope that this will enable other action researchers to implement these methods in their own schools, organizations, and communities. The specific action research methods described in this paper are Future Creating Workshops, Citizens' Juries, World Café, Nominal Group Technique, and Digital Storytelling.

COVID-19-Related Anxiety and Cognition in Middle-Aged and Older Adults: Examining Sex as a Moderator.

Aging populations experience disproportionate risk for cognitive decline, which may be exacerbated by coronavirus (COVID-19) illness, particularly among women. This study tested sex as a moderator of associations between COVID-19 state anxiety and cognition in middle-aged/older adults. Adults aged 50+ (N = 275; 151 men/124 women) completed the Coronavirus Anxiety Scale and Cognitive Failures Questionnaire online from remote locations in July/August 2020. A subset of participants (n = 62) completed an objective cognitive task (Stroop). Multiple regressions determined whether sex moderated associations between COVID-19 anxiety and cognitive outcomes. Sex was a significant moderator, such that for women (not men), greater COVID-19 anxiety was associated with more memory failures and blunders (subjective measures) and worse processing speed (objective measure). COVID-19 state anxiety is linked to everyday cognition and processing speed in women, but not men. Consistency across subjective and objective measures promotes the need for sex-specific understanding of the pandemic's behavioral and cognitive effects in mid-to-late life.

Facing COVID-19 in Liberia: Adaptations of the Resilient and Responsive Health Systems Initiative.

The 5-year Resilient and Responsive Health Systems (RRHS)-Liberia Initiative, funded by PEPFAR via HRSA, launched in 2017 and was designed to support the implementation of Liberia's National Health Workforce Program as a means to improving HIV-related health outcomes. The COVID-19 pandemic, arrived in Liberia just five years after Ebola and during RRHS-Liberia's fourth year, impacted educational programs and threatened the project's continued work. This paper presents the challenges that the COVID-19 pandemic posed to the RRHS partners, as well as adaptations they made to maintain progress towards project goals: 1) contributing to Liberia's 95-95-95 HIV targets via direct service delivery, and 2) building a resilient and responsive health workforce in Liberia via instruction and training. Direct health service impacts included decreased patient volumes and understaffing; adaptations included development of and trainings on safety protocols, provision of telehealth services, and community health worker involvement. Instruction and training impacts included suspension of in-person teaching and learning; adaptations included utilization of multiple online learning and virtual conferencing tools, and increasing clinical didactics in lieu of bedside mentorship. The RRHS team recommends that these adaptations be continued with significant investment in technology, IT support, and training, as well as close coordination among partner institutions. Ultimately, the RRHS Liberia consortium and its partners made significant strides in response to ensuring ongoing education during the pandemic, an experience that will inform continued service delivery, teaching, and learning in Liberia.

e-Health for COVID-19 Epidemic: The Arizona Poison and Drug Information Center Experience.

Background: A significant challenge of the COVID-19 epidemic was the dissemination of accurate and timely information to the public, health care providers, and first responders. We describe the expansion of the Arizona Poison and Drug Information Center (APDIC) to fill such a need for residents of Arizona. Methodology: The original mission of the APDIC was recognition and management of chemical exposure, poisoning, envenomation, and drug-related medical problems. In response to COVID-19, APDIC expanded its personnel and facilities to accommodate telephone calls and teleconsults regarding COVID-19. Thirteen different topics dealing with COVID-19 were addressed and tracked and included: testing information, isolation, prevention, personal protective equipment, travel, vaccines, therapies, antibody testing, contact tracing, exposure to the virus and what to do in businesses, at work or at school regarding isolation and quarantine. Results: Responding to the public health needs, APDIC accepted >320,000 telephone calls and completed 48,346 teleconsults from March 3, 2020 to March 3, 2021. This represented a 15-fold increase in calls and twice the number of consults over 2019. Upon release of the vaccine, calls increased sharply with >7,000 calls in 1 day (February 7, 2021). Conclusion: In conclusion, the APDIC, rapidly expanded to address urgent public health information needs surrounding COVID-19 while still accomplishing its founding mission.

Impact of Sex on COVID-19 Media Exposure, Anxiety, Perceived Risk, and Severity in Middle-Aged and Older Adults.

OBJECTIVES: To examine associations between COVID-19 media exposure and anxiety/perceived risk/severity and investigate their dependency on sex in middle-aged/older adults. METHODS: Adults aged 50+ years completed online surveys: Coronavirus Anxiety Scale, COVID-19 media exposure, COVID-19 media dependency for health information, and COVID-19 perceived risk and severity. Multiple regressions examined independent and interactive (with sex) associations between COVID-19 media exposure/dependency and COVID-19 anxiety/perceived risk and severity. Analyses controlled for age, education, race, total medical conditions, and COVID-19 status. RESULTS: Higher COVID-19 media exposure was associated with higher COVID-19 anxiety among men (not women) and higher perceived risk/severity in both sexes. Higher COVID-19 media dependency was associated with higher COVID-19 anxiety and perceived risk/severity in both sexes. CONCLUSION: In middle-aged/older adults, the use/dependency of media for COVID-19 information may be linked to negative psychological health and increased COVID-19 perceived risk and severity. Men may be at increased risk of anxiety related to media exposure.

Pharmacological strategies used to manage symptoms of patients dying of COVID-19: A rapid systematic review.

BACKGROUND: COVID-19 has tragically resulted in over 2.5 million deaths globally. Despite this, there is a lack of research on how to care for patients dying of COVID-19, specifically pharmacological management of symptoms. AIM: The aim was to determine the dose ranges of pharmacological interventions commonly used to manage symptoms in adult patients dying of COVID-19, establish how effectiveness of these interventions was measured, and whether the pharmacological interventions were effective. DESIGN: This was a rapid systematic review with narrative synthesis of evidence, prospectively registered on PROSPERO (ID: CRD42020210892). DATA SOURCES: We searched MEDLINE, EMBASE, CINAHL via the NICE Evidence Health Databases Advanced Search interface; medRxiv; the Cochrane COVID-19 Study Register; and Google Scholar with no date limits. We included primary studies which documented care of patients dying of COVID-19 under the care of a specialist palliative care team. RESULTS: Seven studies, documenting the care of 493 patients met the inclusion criteria. Approximately two thirds of patients required a continuous subcutaneous infusion with median doses of 15 mg morphine and 10 mg midazolam in the last 24 h of life. Four studies described effectiveness by retrospective review of documentation. One study detailed the effectiveness of individual medications. CONCLUSIONS: A higher proportion of patients required continuous subcutaneous infusion than is typically encountered in palliative care. Doses of medications required to manage symptoms were generally modest. There was no evidence of a standardised yet holistic approach to measure effectiveness of these medications and this needs to be urgently addressed.

26 The end-of-life experiences for cancer patients with COVID-19;reflections from 2 UK cancer centres

BackgroundThe COVID-19 pandemic has seen a wealth of research examining the features of the disease. While large multicentre studies have detailed the implications of a cancer diagnosis and systemic anti-cancer therapy on mortality, little has been published regarding the end-of-life experiences for cancer patients dying COVID-19.AimsTo review the end-of-life care (EOLC) for patients with COVID-19 at 2 UK cancer centres.MethodsPrescriptions of anticipatory medications, opioids and continuous subcutaneous infusions of all non-ventilated inpatient deaths, n=28.ResultsThe mean age was 67 (45–89), most patients were male and white British (18). 10 patients had recognised risk factors of cardiovascular disease and diabetes. 18 patients had metastatic disease and 23 were receiving palliative treatment. The most commonly recorded tumour type was GI (8). 12 patients were referred to palliative care (PC) for symptom control, while 10 were referred for EOLC. The mean number of PC reviews was 3.29 (range 0–10). Baseline IPOS scores on initial assessment at one centre (N=15), recorded the main symptoms as breathlessness, weakness and anxiety. Family anxiety was the highest scoring aspect of the IPOS. The medical management at the end-of-life was, however, generally uncomplicated;the total opioid (oral morphine equivalent) and benzodiazepine doses administered in last 24 hours before death were relatively low, median dose(range) 31.25 mg (5–160 mg) and 15 mg (0–30 mg) respectively.ConclusionsShould a further surge of COVID-19 cases occur, many cancer patients dying with COVID-19 could be appropriately managed by non-specialist physicians supported by comprehensive guidelines, ward-based teaching and specialist palliative care input for more complex cases. High levels of family anxiety could be improved by enhanced family support and communication about end-of-life wishes and priorities;healthcare services should have a particular focus on supporting the shadow pandemic of loss.

22 What can we learn from patients who died from SARS-CoV2 following escalation to a respiratory high dependency unit for trial of non-invasive respiratory Support?

SARS-CoV-2 is associated with significant risk of death, particularly in older patients and those with comorbidities. Emerging evidence supports use of non-invasive respiratory support;however, it is uncertain whether and when this should be stopped in patients who fail to respond to treatment. The experience of teams caring for awake patients who died from SARS-CoV2 infection on Non-Invasive Respiratory Support in a Respiratory High Dependency Unit has not been documented.This was a retrospective study of 33 adult patients who died of SARS-CoV2 on the Respiratory High Dependency Unit at the John Radcliffe Hospital, Oxford between 28/03/20 and 20/05/20. The population had multiple comorbidities (median Charlson Index 5 (IQR 4–6);median age 78 (IQR 72–85)) and respiratory support was trialled in all but one case, with CPAP the most common form (84.8%). Median time to death was 10.7 days from symptom onset (IQR 7.52–14.6), 4.8 days from hospital admission (IQR 3.1–8.3) and 21.5 hours from documented decision to cease active treatment. 48.5% of patients remained on respiratory support at the time of death, the reasons for this included ongoing active treatment (n=8), patient distress (n=6), awaiting further family discussions (n=1) and was undocumented in one case.Data collected included: demographic and comorbidity data;timings of symptom onset and disease course;use of respiratory support;community and hospital Advance Care Planning;palliative care input and medication use and communication with families.Non-Invasive Respiratory Support may play a key role in symptom management in select patients, however, further work is needed in order to identify patients who will most benefit from Respiratory Support and those for whom withdrawal may prevent unnecessary distress at the end of life or potential prolongation of suffering. For those with a poor prognosis early assessment of palliative needs and premorbid wishes should be encouraged.

Orodispersible and transmucosal alternative medications for symptom control in adults.

BACKGROUND: Paediatric palliative care makes frequent use of orodispersible and transmucosal drug delivery routes. The limited published experience of this practice suggests that it enables the delivery of needle-free symptom relief, with the potential to train family carers to administer anticipatory medications without reliance on trained health professionals. AIMS: To identify orodispersible and potential transmucosal alternatives that may be used in adults in the event of a patient having no oral or intravenous route and no access to subcutaneous injections. METHODS: The author panel identified medications through review of multiple drug formularies, review of the published evidence and their experience. Where possible, licensed alternatives were identified and any 'off label' or unlicensed medications clearly highlighted. RESULTS: A list of 27 medications is provided, which could be used either via the orodispersible or transmucosal alternative route for healthcare professionals delivering end of life care to consider when the licensed alternative routes are unavailable. All users of this guide are encouraged to use their professional judgement whenever selecting a medication for a patient, recognising that this review is neither a guideline nor a systematic review, and taking account of licensing considerations, adverse effects, potential unpredictability of time to effect and contraindications. CONCLUSION: Should it be necessary to use these orodispersible or transmucosal alternatives then any experience gained should be reported in the literature. Combined with further research, this experience offers the possibility of reducing injection frequency and inherent delays in medication administration, particularly in the community setting during the COVID-19 pandemic.

Palliative Care During COVID-19: Data and Visits From Loved Ones.

OBJECTIVES: A vital component of the coronavirus response is care of the dying COVID-19 patient. We document the demographics, symptoms experienced, medications required, effectiveness observed, and challenges to high-quality holistic palliative care in 31 patients. This will aid colleagues in primary and secondary care settings anticipate common symptoms and formulate management plans. METHODS: A retrospective survey was conducted of patients referred to the hospital palliative care service in a tertiary hospital, south east of England between March 21 and April 26, 2020. Patients included had a confirmed laboratory diagnosis of COVID-19 via reverse transcription polymerase chain reaction nasopharyngeal swab for SARS-Cov-2 or radiological evidence of COVID-19. RESULTS: The thirty-one patients included were predominantly male (77%), elderly (median [interquartile range]: 84 [76-89]), and had multiple (4 [3-5]) comorbidities. Referral was made in the last 2 [1-3] days of life. Common symptoms were breathlessness (84%) and delirium (77%). Fifty-eight percent of patients received at least 1 "as required" dose of an opioid or midazolam in the 24 hours before death. Sixty percent of patients needed a continuous subcutaneous infusion and the median morphine dose was 10 mg S/C per 24 hours and midazolam 10 mg S/C per 24 hours. Nineteen percent of our cohort had a loved one or relative present when dying. CONCLUSION: We provide additional data to the internationally reported pool examining death arising from infection with SARS-CoV-19. The majority of patients had symptoms controlled with low doses of morphine and midazolam, and death was rapid. The impact of low visitation during dying needs exploring.

Fan therapy for cough: case report and literature review

This case report describes the care of a 59-year-old woman with metastatic small cell lung cancer and chronic obstructive pulmonary disease who was highly symptomatic with an intractable cough. The patient reported a subjective benefit from a table fan. The authors observed an objective improvement with a marked reduction in cough frequency when the fan was in use. A literature review was undertaken and identified one randomised controlled trial assessing the use of fan for cough. The proposed underlying mechanism of cough relief is stimulation of the trigeminal nerve, possibly by cooling. This mechanism is well described in breathlessness. It presents the possibility of a novel therapeutic approach to managing cough. Further studies of both the role of nasal receptors in cough pathophysiology and the role of fan therapy in cough, where there is no concern of an airborne infectious pathogen such as COVID-19, are warranted.