Modification of Management Strategies During Sars COVID 2 Pandemic Improved the Quality, Criticality, and Outcomes of In-Patients

The second wave of the pandemic exposed many hospitals to their unpreparedness to handle sudden surge patients due to lack of infrastructure to handle the relentless inflow of pts whilst also running short of beds, o2, ventilators, trained HCW's, PPE, medications, and other essentials. The aim of the study was to use judiciously the available resources, fine-tune the patient care, reduce the workload and burden of HCW s, optimize pts care, and improve the outcomes. This observation was done at a tertiary care hospital. The following fine-tuning was done: 1. Oxygen: Robust O2 systems that would support the pandemic, would take time to put in place, so conducting training programmers in a short period for HCW regarding optimal usage and avoid misusing or wastage of O2 was done in a relatively short time. We selected an HCW as O2 provider, the only job to check o2 delivery and SPO2 around the clock. 2. Foleys Catheters and Diapers: Patients on high O2 requirements when mobilized, O2 delivery to patients were discontinued along with disruption of prone positions and derecruitment of lungs and had severe hypoxia. So we started catheterizing the pts on high O2 need. 3. Family Visit: Family visits made pts comfortable, more compliant to the care. And it also reduced the significant burden of HCW's who had to otherwise communicate multiple times with their relatives via audio or video phone calls. This also brought transparency of the care. 4. Simple Protocols: We simplified the charts with only two sheets, one for the doctor one for the staff. These simple changes made work easy and more efficient and also help in collecting data. 5. DRUG Boy: Drugs indenting and on-time delivery were challenging. We selected a person only for drug delivery and later with drugs becoming precious and anticipating problems, drug boy used to deliver medications to the patient in presence of family. 6. Continuous Monitoring by a Leader: COVID is a dynamic process and requires continuous monitoring, timely interventions. Leaders have to take complete charge continuously from admission to discharge. Fragmented care by multiple people worsens the situations. 7. DVT Stockings: COVID is a prothrombotic state for the prevention of clots all moderate to severe pts were applied DVT stockings, along with chemoprophylaxis which prevented DVT significantly. 8. Anxiolytics, Restricted Mobilization, and Spirometry: Mild anxiolytics reduced the stress, work of breathing, and good compliance to the NIV. Strict restriction in mobilizing and adequate spirometry was supervised in moderate to severe COVID patients in the early stages to help in early recovery from COVID-19. 9. Prone Position in COVID: In moderate and severe ARDS in patients on O2 with face mask, O2 by BIPAP support and in invasively ventilated patients were subjected to prone positioning for 16-18 hours/day, which helped in improving lung recruitment oxygenation of patients and better outcomes while reducing the oxygen requirements. Conclusion: COVID pandemic is very challenging. Conservative management and fine-tuning of the resources available will have multiple benefits and also improve outcomes. With these innovations, quality will improved was costeffective and easily replicable in any hospital.

Efficacy and Doses of Ulinastatin in Treatment of COVID-19: A Single Centre Study

Aim and objective: Ulinastatin is a glycoprotein extracted from fresh human urine. It inhibits the activity of various proteolytic enzymes. Patient with severe COVID-19 exhibit elevated serum levels of proinflammatory cytokines IL-6, tumour necrosis factor, IL-I beta, characterised as cytokine storm, which is believed to progress, leading to deterioration and death. Ulinastatin dampens inflammatory response. However, data on efficacy and the doses are limited. We evaluated the efficacy and doses of ulinastatin in the hospital all-cause mortality in patients with moderate to severe COVID-19. Materials and methods: This retrospective study was conducted between April 1 and June 30, 2021, at tertiary care centre. COVID-19 was confirmed with RT PCR by nasopharyngeal swab. Patients with moderate to severe COVID-19 (moderate SPO2<94%, severe SPO2<90%) on room air were included. This is the first study comparing the doses of ulinastatin in COVID-19. Results: In total 145 patients, 75 patients with moderate to severe COVID-19 were treated with ulinastatin + other standard treatment. 70 patients were treated only with standard treatment regime. Allcourse mortality was significantly lower in patients treated with ulinastatin (15.3% vs 20.5%). In a total of 75 patients treated with ulinastatin, 40 patients were given 200,000 units BD and 35 patients were given 200,000 units QID. There was not much difference in the all-cause mortality (15% vs 13%) between the two doses. No adverse effects were noted. Conclusion: Our observational data showed a beneficial effect in moderate-severe COVID-19 patients and there was not much difference in beneficial effects with regular doses 200,000 q12th hourly as compared to higher doses of 200,000 q 6th hourly. This is the first observational study comparing the doses and having highest number of patients treated with ulinastatin.

A Comparative Clinical Study To Evaluate the Effect between Deep Vein Thrombosis (DVT) Compression Stockings with Anticoagulants versus Anticoagulants Alone to Prevent Thromboembolism in SARS COVID-2 with ARDS in ICU Setting

Aim and background: COVID-19 is caused by the severe acute respiratory syndrome coronavirus (SARS-CoV-2). COVID-19 is associated with a prothrombotic state leading to adverse clinical outcomes. We aimed to compare DVT compression stockings with anticoagulants versus anticoagulants alone for the prevention of thromboembolism in severely ill ICU COVID patients. Materials and methods: A retrospective chart review of patients admitted to ICU of a tertiary care hospital in Bangalore to assess the incidence of thrombosis (DVT and/or pulmonary embolism) and requirement of thrombolysis in severely ill COVID-19 patients treated with DVT stockings with anticoagulation versus patients treated with anticoagulants alone. Results: A total of 154 patients were admitted to our ICU with severe COVID-19 symptoms, 54 (35.1%) were females, and 100 (64.9%) were males. 121 patients were treated with DVT stockings with anticoagulation and 33 patients were given anticoagulation alone. 8 patients developed thrombotic events, 6 patients developed DVT alone, and 2 patients developed DVT and pulmonary embolism requiring thrombolysis. Out of 8 patients, 6 patients developing thrombotic events were treated with anticoagulation alone for the prevention of thrombosis. Out of 121 patients who were treated with DVT stocking with anticoagulation, only 2 patients developed DVT and none of them developed pulmonary embolism. Conclusion: In patients, hospitalized in ICU with severe COVID-19, use of DVT compression stockings along with anticoagulants significantly reduced the incidence of thrombotic events (DVT and/or pulmonary embolism) and thus reducing the need for e proving eventually decreasing the financial burden.

Rising to the Occasion The Only Mantra for Success in the COVID-19 Pandemic

Introduction: The COVID-19 pandemic has been resulted in >2 million deaths globally. SARS COVID 2 is highly infectious and although most are either asymptomatic or mild to moderate, a substantial proportion face the severe life-threatening disease. The mortality risk with large population outbreaks has a major effect on lives, economies, and health care system across the world. The second wave of COVID-19 in India has had severe consequences in the form of increasing cases reduced supplies of the essential treatment and increased deaths, particularly in the young population. It was clearly misgovernance harming people more than lack of medical knowledge. Aim of the studies is to show how rising to the occasion by working together, prioritization, and the right level of resources utilization made things work smoothly with improved quality/outcomes. Background: COVID is a dynamic process. No ideal plan or model exists. We cannot wait for the nonmedical people or government to fix the problem, due to a lot of limitations. In our centre, we went on the extra mile for the benefits of patients including accommodating more ward/ICU patients, prioritization of experienced staff, and right level of resource utilization which helped to treat more patients with good outcome. Working together: 1. Infrastructure: Due to surge in the cases in need of beds with supporting equipment became the primary need. Due to the lockdown and demand, organizing these things was a challenge. Restrictions in place, workload pressures, limitations for regular meetings, things don't fall in place without hospital authority involvement. There are many smart ways of increasing beds in pandemic. From 20 ICU beds to 50 in short time was done without much civil work and cost. Most patients require a good basic care with supportive measures and time for healing, so we added extra beds. With single O2 port, attaching extensions, we were able to provide for more patients. With this expansion, the second challenge was O2 supply. We had 2 challenges one is better supplies and the other reduced the wastage. COVID-19 is a long game and best time to start implementing effective O2 systems. For better supplies, within short period oxygen generators were installed understanding a few limitations in O2 delivery with generator, we mixed with industrial O2 in lesser percentage. O2 misuse was significantly reduced with identifying O2 boys who works were to monitor O2 and saturation round the clock. This happened in short time with good training, and planning. 2. Second important thing was personale: Getting trained staff on time practically was not possible. Most trained staff have a notice period to serve. With few trained staff, making them leaders, were supported by junior staff in each shift. This system works well in pandemic, as there are minimal interventions by the staff, Charts were simplified. Responsibility of Ventilator/O2/Drugs was taken off from the staff. They had time for monitoring and troubleshooting. Interestingly, we also found less stress and anxiety among HCW with these models. We should have a few people who take complete charge of the situation. In pandemic only managing critical patients at a later stage doesn't improve outcomes, precious time will be lost if we delay early interventions. Third important thing is involving family;we involved families with precautions and consent. The results were very encouraging, and multiple benefits were seen. Fourth important thing is simple protocol and documentation. We made only two sheets for a couple of days with clear trends documented, it reduced the workload, time and improved the care. Fifth part is innovations. The learning experience was doing the basics right with supportive care and innovations if needed. Innovations play a big role in pandemics. Doing basics right and do not harm concept in mind, innovations can be done in clinical/non-clinical areas which can improve the outcomes. Conclusion: Working together, prioritising the staff and right level of recourses usage helps in better mana ement and outcomes. Innovations play a major role in a pandemic.

Fine Tuning of Simple Things During Pandemic Improves Quality, Criticality, and Outcomes

COVID pandemic has made the health care system difficult to prepare for demanding situations. Second wave of the pandemic made many hospitals unable to handle the relentless inflow of patients whilst also running short of beds, oxygen cylinders, health care workers, and other essentials, with limited resources, we had two challenges to secure better supplies and judiciously use the resources. The aim of the study was to use judiciously the resources, fine tune the patient care, reduce the work load/burden of HCW and improve the outcomes and to see whether these fine tuning will sustain better care and improve the outcomes This observation is done at tertiary care centre. The innovation or fine-tuning were done as follows, 1. Oxygen Boy: The O2 is lifesaving in COVID-19 and its a long game. The neglect of O2 systems have been partly market failure, partly lack of knowledge and anticipation, and misuse Robust O2 systems that would support the pandemic take time to put in place, so conducting training programmes in short period for HCW regarding using or misusing O2 can be done in the relatively short times if there is good planning and management. We selected an HCW as O2 boy;his job was only checking O2 delivery and monitoring SPO2. He was given SPO2 targets to maintain. He would adjust the O2 depending on the targets, we found care was better, reduced O2 misuse, and less burden on HCW including hospital authorities. He also used to monitor continuous prone positions. 2. Foleys Catheters and Diapers: Due to the shortage of ICU/HDU beds during the peak of pandemic, moderate to severe patients were managed in wards with close monitoring. In the initial stages, we faced problems in patients on high o2 when they were mobilized to restrooms. Continuous o2 awake prone was disturbed and derecruited and had severe hypoxia with symptoms and few near codes. So we started catheterizing the patients on high o2 requirements/ elderly, and diapers used if very hypoxic. After these changes the surprises were less, compliance for care was more, and complaints from the patients were very less. 3. Family Visit: Allowing family person visit with precautions was very useful. Family visits made patients comfortable, more compliant with the care, families were happy and reduced the significant burden of HCW's and brought transparency of the care. Complaints of misusing of the drugs were less. 4. Simple Protocols: Due to scarcity of HCW and over working, we analyzed the work flow and found more time was taken for documenting and following the reports than actual patient care. So we simplified the charts with only two sheets, one for the doctor one for the staff. These simple changes made work easy and more efficient and also help in collecting data. 5. 'Drug' Boy: Drugs indenting and on-time delivery was challenging with limited staff and a high workload. We selected a person only for drug delivery and later with drugs becoming precious and anticipating problems, drug boy used to deliver in family presence. This reduced the further burden of HCW's. 6. Continuous Monitoring by a Leader: COVID is a dynamic process and requires continuous monitoring, timely interventions. Leaders have to take complete charge continuously from admission to discharge. Fragmented care by multiple people worsens the situation. 7. Support from the Other Specialities: With above mentioned fine tuning, we found rounds by any specialists doctors was comfortable, less time-consuming, and could manage many patients. This reduces the burden of intensivists and physicians. 8. Monitored Hydration: Most patients were hydrated in view of reduced appetite, druginduced, third spacing, and on NIV. This simple regime significantly reduced acute kidney injuries. 9. DVT Stockings: COVID is a prothrombotic state for the prevention of clots all moderate to severe patients were applied DVT stockings, this prevented DVT significantly. 10. Anxiolytics, Restricted Mobilization, and Spirometry: Mild anxiolytics reduce the stress, work of breathing, and good compliance to the NIV. Stric restriction in mobilizing and no spirometry in moderate to severe COVID in early stages. Conclusion: COVID pandemic is very challenging, till data no proper pharmacological treatment available. So fine tuning of the resources available will have multiple benefits and also improve outcomes. With these innovations, quality improves, cost-effective, and can easily be replicable in any centre.

Shorter Course of Remdesivir in Moderate COVID-19 is as Efficacious as Compared to Standard Regime: Observational Study

Aims and objectives: Remdesivir is an RNA polymerase inhibitor with potent antiviral activity in vitro. It is the current recommended antiviral treatment in moderate to severe COVID-19. However, data on shorter durations of treatment and the adverse effects are limited. Studies have not shown a significant difference between a 5-day course and 10-day course of the remdesivir in severe COVID- 19. We evaluated the efficacy of the shorter durations of 3 days vs 5 days on time to recovery and adverse reactions in a patient with moderate COVID-19. Materials and methods: This retrospective study was conducted between April 15 and March 30, 2021, at a tertiary care centre. Patients with moderate COVID-19 (SPO2- 90-94%) were included. Results: In total 56 patients were included and began treatment. The median duration of the treatment was 3 days for 30 patients and 5 days for 26 patients. The time recovery in 3-day course and 5-day course was 8 days and 9 days. After adjustment for baseline clinical status, patients treated for 3 days and 5 days were similar. The most common adverse event nausea and altered liver enzymes were less in 3 days course (6% vs 8%). Conclusion: In patients with moderate COVID-19, our study did not show a significant difference between 3-day course and 5-day course of remdesivir and adverse effects were less in 3 days course.