ABSTRACT
The Pando app is UK based and part of the NHS Clinical Communication Procurement Framework, which is designed to provide continuity of care with virtual patient management (https://www.bad.org.uk/healthcare-professionals/covid-19/re mote-dermatology-guidance), and drive tech-enabled connectivity across the National Health Service (NHS). This has also been used in the British Army to help defence medical staff connect with and seek advice from their colleagues in the UK while in the field (www.hellopando.com). Lack of on-site medical illustration, the COVID-19 pandemic and plastic surgeons operating in a NHS-funded private setting with no access to Picture Archiving and Communication System (PACS) in our Trust prompted use of the Pando app to capture prebiopsy pictures, avoid wrong-site surgery and improve interdepartmental communication. We present our multidisciplinary quality improvement project, involving dermatology and plastic surgery, evaluating the use of the Pando app from September to December 2020, mostly from 2-week-wait skin cancer clinics. All dermatology and plastic surgery colleagues downloaded the Pando app to their mobile phones and created a group entitled 'Dermatology/Plastics' to share their patient photos with identity labels. Patient photos could also be emailed to the clinicians' NHS email addresses - all done with patient consent. We evaluated our project with pre-and post-Pando feedback questionnaires. In the pre-Pando questionnaires, the majority of 14 colleagues involved were concerned with the varying quality of photos emailed by patients, the time lag in photos being uploaded to PACS and any likelihood of compromising patient safety. With post-Pando questionnaires, the majority found the app to be user-friendly, that the photographs taken were of superior quality, that there were no reported concerns with patient consent and they preferred using the app to the previous pathway. Comments suggested the Pando app to be invaluable for site recognition in patients with cognitive impairment, multiple lesions, difficult-to-see areas, medicolegal, educational and audit purposes, and local cancer multidisciplinary discussions. The drawbacks were the lack of seamless connection between the app and PACS, the inability to search for pictures in the app with patient identification and lack of access to previously shared pictures for new users. Despite some limitations, the Pando app has immensely improved patient safety and proved to be invaluable for our joint dermatology and plastic surgery interactions. However, there is an unmet need for a system with the ability to instantly transfer pictures to PACS and patient electronic records, to improve things further.
ABSTRACT
SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) pandemic has displayed heterogeneity in disease manifestations and complications;cardiac, renal, neurological complications and coagulopathy are reported. We present a case of COVID-19 with pneumomediastinum. CASE PRESENTATION: A 59-year-old male was admitted after a reverse transcriptase polymerase chain reaction (RT-PCR) test- confirmed COVID19. He was confused and was intubated for hypoxia. Laboratory investigation showed white blood cells of 2.8x1000/mm3 (normal: 3.4-9.4x1000/ mm3) [differential: 59%(normal: 47-67%) neutrophils and 39% ( normal: 25-45%) lymphocytes], aspartate aminotransferase 1174 IU/l(normal:13-39IU/l), alanine aminotransferase 598 IU/l(normal:7-52IU/l), ferritin > 7500 ng/ml (normal: 20-200 ng/ml), C reactive protein 306.1 mg/l (normal: 0-5 mg/l) and D-dimer 10 mcg/ml (normal: 0-0.50 mcg/ml). Arterial blood gases showed pH 7.14 (normal: 7.35-7.45), PCO2 59 mmHg (normal: 34-46 mmHg) and PO2 54 mmHg (normal: 80-97 mmHg) on 100% oxygen. Computed tomography of the chest (CT chest) showed diffuse groundglass opacities. Diagnosis of acute respiratory distress syndrome (ARDS) was made. On day 5, given low lung compliance (static compliance 13.5 ml/CmH2O), mode was switched to airway pressure release ventilation(APRV). On day 8, subcutaneous emphysema was noted with worsening hemodynamics. CT chest showed pneumomediastinum, pneumopericardium and subcutaneous air without pneumothorax. APRV was changed to conventional mode and infraclavicular incisions completed. Patient‘s status continued to decline;he died on the 13th day of admission. DISCUSSION: COVID-19 causes pulmonary involvement ranging from atypical pneumonia to ARDS. Few cases of COVID-19-associated pneumomediastinum are reported in the literature. Barotrauma from mechanical ventilation accounts for one third cases of pneumomediastinum. Although, large tidal volumes are thought to predispose to barotrauma, these associations are related to the severity of lung disease. ARDS is most associated and is the only independent risk factor for barotrauma[1]. APRV does not demonstrate any difference regarding the onset of barotrauma when compared to conventional modes used in ARDS[2]. Different pathological patterns ranging from interstitial lymphocytic infiltrates to organizing pneumonia to diffuse alveolar damage are reported in COVID-19[3]. These possibly define the spectrum of COVID-19 and hence the increasing rate of severe complications with worsening injury. CONCLUSIONS: COVID-19 patients display diverse complications;pneumomediastinum is an emerging one. Further research is needed to study COVID-19 and barotrauma within the clinical and pathological phenotypes of the disease. Reference #1: Airway pressures and early barotrauma in patients with acute lung injury and acute respiratory distress. Eisner MD, Thompson BT, Schoenfeld D, et al. Am J Respir Crit Care Med. 165:978-982 2002. Reference #2: Airway pressure release ventilation during acute hypoxemic respiratory failure: a systematic review and meta-analysis of randomized controlled trials. Carsetti et al. Ann. Intensive Care (2019) 9:44. Reference #3: Time to consider histologic pattern of lung injury to treat critically ill patients with COVID-19 infection. Marie-Christine Copin, Erika Parmentier, […], and The Lille COVID-19 ICU and Anatomopathology Group. Intensive Care Med. 2020 Apr 23 :1–3. DISCLOSURES: No relevant relationships by Moses Hayrabedian, source=Web Response No relevant relationships by Faraaz Nayeemuddin, source=Web Response No relevant relationships by Rajagopal Sreedhar, source=Admin input