Best-practices for preventing skin injury beneath personal protective equipment during the COVID-19 pandemic: A position paper from the National Pressure Injury Advisory Panel.

COVID-19 has infected millions of patients and impacted healthcare workers worldwide. Personal Protective Equipment (PPE) is a key component of protecting frontline clinicians against infection. The benefits of PPE far outweigh the risks, nonetheless, many clinicians are exhibiting skin injury caused by PPE worn incorrectly. These skin injuries, ranging from lesions to open wounds are concerning because they increase the susceptibility of viral infection and transmission to other individuals. Early into the COVID-19 pandemic (April 2020), the U. S. National Pressure Injury Advisory Panel (NPIAP) developed a series of position statements to improve wear-ability of PPE and protect healthcare professionals and their patients as safe from harm as possible under the circumstances. The NPIAP positions, which were formed by conducting a systematic review of what was known at the time, include: (a) Prepare skin before and after wearing PPE with skin sealants, barrier creams and moisturisers; (b) Frequent PPE offloading to relieve pressure and shear applied to skin; (c) treat visible skin injuries immediately caused by PPE to minimise future infection; (d) non-porous dressings may provide additional skin protection, but lack evidence; (e) health systems should take care to educate clinicians about placement and personal hygiene related to handling PPE. Throughout all of these practices, handwashing remains a top priority to handle PPE. These NPIAP positions provided early guidance to reduce the risk of skin injury caused by PPE based on available research regarding PPE injuries, a cautious application of evidence-based recommendations on prevention of device-related pressure injuries in patients and the expert opinion of the NPIAP Board of Directors. Clinicians who adhere to these recommendations reduce the prospects of skin damage and long-term effects (e.g. scarring). These simple steps to minimise the risk of skin injury and reduce the risk of coronavirus infection from PPE can help.

A Cost-Utility Analysis of Remote Pulse-Oximetry Monitoring of Patients With COVID-19.

OBJECTIVES: Since 2020, COVID-19 has infected tens of millions and caused hundreds of thousands of fatalities in the United States. Infection waves lead to increased emergency department utilization and critical care admission for patients with respiratory distress. Although many individuals develop symptoms necessitating a ventilator, some patients with COVID-19 can remain at home to mitigate hospital overcrowding. Remote pulse-oximetry (pulse-ox) monitoring of moderately ill patients with COVID-19 can be used to monitor symptom escalation and trigger hospital visits, as needed. METHODS: We analyzed the cost-utility of remote pulse-ox monitoring using a Markov model with a 3-week time horizon and daily cycles from a US health sector perspective. Costs (US dollar 2020) and outcomes were derived from the University Hospitals' real-world evidence and published literature. Costs and quality-adjusted life-years (QALYs) were used to determine the incremental cost-effectiveness ratio at a cost-effectiveness threshold of $100 000 per QALY. We assessed model uncertainty using univariate and probabilistic sensitivity analyses. RESULTS: Model results demonstrated that remote monitoring dominates current standard care, by reducing costs ($11 472 saved) and improving outcomes (0.013 QALYs gained). There were 87% fewer hospitalizations and 77% fewer deaths among patients with access to remote pulse-ox monitoring. The incremental cost-effectiveness ratio was not sensitive to uncertainty ranges in the model. CONCLUSIONS: Patient with COVID-19 remote pulse-ox monitoring increases the specificity of those requiring follow-up care for escalating symptoms. We recommend remote monitoring adoption across health systems to economically manage COVID-19 volume surges, maintain patients' comfort, reduce community infection spread, and carefully monitor needs of multiple individuals from one location by trained experts.

Countries with High Registered Nurse (RN) Concentrations Observe Reduced Mortality Rates of Coronavirus Disease 2019 (COVID-19)

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) pandemic has generated many questions on its screening, diagnosis and management. One important question emerging from this discussion of regional differences pertains to the healthcare workforce not just in absolute numbers but also in terms of skill-mix. As nurses comprise over half the skilled healthcare workforce worldwide, it is important to consider them as part of a health systems strengthening approach to quality improvement. We sought to investigate the influence of the registered nurse (RN) concentration and the impact on COVID-19 mortality between countries worldwide. METHODS: We conducted an observational cohort study to examine the association between COVID-19 mortality rates and concentrations of registered nurses. Data on nursing concentrations by country provided from the World Health Organization were merged with March 2020 COVID-19 mortality rates. Descriptive statistics, geographical information systems (GIS) mapping and multilevel linear regression with mixed effects were applied to examine this association with regional clustering of countries. FINDINGS: In total, 172 countries were included in the analysis. These results indicated that for every 1.0 increases in RN per 1,000 individuals in a country, there was a decrease in COVID-19 mortality of -1.98 per 1 million individuals (p=0.003). INTERPRETATION: High nursing concentrations are strongly associated with reduced mortality rates of COVID-19. The key to address the needs of current and future COVID-19 outbreaks, or for that matter, any infectious disease outbreak of this magnitude is to prepare a highly trained, versatile nursing workforce. Funding Statement: William Padula is supported by grants from the U.S. National Institutes of Health (KL2 TR001854) and the Bill & Melinda Gates Foundation. Declaration of Interests: None.

Economic value of vaccines to address the COVID-19 pandemic: a U.S. cost-effectiveness and budget impact analysis.

AIMS: The Novel Coronavirus (COVID-19) has infected over two hundred million worldwide and caused 4.4 million of deaths as of August 2021. Vaccines were quickly developed to address the pandemic. We sought to analyze the cost-effectiveness and budget impact of a non-specified vaccine for COVID-19. MATERIALS AND METHODS: We constructed a Markov model of COVID-19 infections using a susceptible-exposed-infected-recovered structure over a 1-year time horizon from a U.S. healthcare sector perspective. The model consisted of two arms: do nothing and COVID-19 vaccine. Hospitalization and mortality rates were calibrated to U.S. COVID-19 reports as of November 2020. We performed economic calculations of costs in 2020 U.S. dollars and effectiveness in units of quality-adjusted life years (QALYs) to measure the budget impact and incremental cost-effectiveness at a $100,000/QALY threshold. RESULTS: Vaccines have a high probability of reducing healthcare costs and increasing QALYs compared to doing nothing. Simulations showed reductions in hospital days and mortality by more than 50%. Even though this represents a major U.S. investment, the budget impacts of these technologies could save program costs by up to 60% or more if uptake is high. LIMITATIONS: The economic evaluation draws on the reported values of the clinical benefits of COVID-19 vaccines, although we do not currently have long-term conclusive data about COVID-19 vaccine efficacies. CONCLUSIONS: Spending on vaccines to mitigate COVID-19 infections offer high-value potential that society should consider. Unusually high uptake in vaccines in a short amount of time could result in unprecedented budget impacts to government and commercial payers. Governments should focus on expanding health system infrastructure and subsidizing payer coverage to deliver these vaccines efficiently.

Impact of Neighborhood Social and Environmental Resources on Medicaid Spending.

INTRODUCTION: In an era of COVID-19, Black Lives Matter, and unsustainable healthcare spending, efforts to address the root causes of health are urgently needed. Research linking medical spending to variation in neighborhood resources is critical to building the case for increased funding for social conditions. However, few studies link neighborhood factors to medical spending. This study assesses the relationship between neighborhood social and environmental resources and medical spending across the spending distribution. METHODS: Individual-level health outcomes were drawn from a sample of Medicaid enrollees living in Baltimore, Maryland during 2016. A multidimensional index of neighborhood social and environmental resources was created and stratified by tertile (high, medium, and low). Differences were examined in individual-level medical spending associated with living in high-, medium-, or low-resource neighborhoods in unadjusted and adjusted 2-part models and quantile regression models. Analyses were conducted in 2019. RESULTS: Enrollees who live in neighborhoods with low social and environmental resources incur significantly higher spending at the mean and across the distribution of medical spending even after controlling for age, race, sex, and morbidity than those who live in neighborhoods with high social and environmental resources. On average, this spending difference between individuals in low- and those in high-resource neighborhoods is estimated to be $523.60 per person per year. CONCLUSIONS: Living in neighborhoods with low (versus those with high) resources is associated with higher individual-level medical spending across the distribution of medical spending. Findings suggest potential benefits from efforts to address the social and environmental context of neighborhoods in addition to the traditional orientation to addressing individual behavior and risk.

Global digital social learning as a strategy to promote engagement in the era of COVID-19.

AIMS AND OBJECTIVES: To assess formative and summative milestones in a digital course and the reach to low- and middle-income countries of a Massive Open Online Course focussing on supporting nurses dealing with an emerging pandemic. BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has ravaged the globe and increased the need for timely and accurate information from reliable sources. Access to reliable and accurate information, as well as support, is important in achieving health systems strengthening. Using a Massive Open Online Course format, an educational resource aimed at large-scale interactive participation via the Internet, and participants were engaged in a course focussing on nursing in a time of crisis and involved using social learning principles. DESIGN: Observational descriptive study. METHOD: Routinely collected data were collated during the period of 18 May-18 July 2020 focused on both formative and summative milestones in the course. Data were separated and classified by income in accordance with the publicly accessible 2020 World Bank Open Dataset. RESULTS: During the 2-month period of observation (18 May-18 July 2020), 10,130 individuals from 156 countries enrolled in the course. More than 51% of participants were Active Learners. Thirty per cent completed over 90% of the course content by the end. There was widespread distribution of learners in low- and middle-income countries across Asia, Africa and Latin America. CONCLUSION: The COVID-19 pandemic has underscored the importance of reliable and valid information sources. The use of Massive Open Online Course format can facilitate dissemination. RELEVANCE TO CLINICAL PRACTICE: In the context of a dynamic global pandemic, leveraging digital resources to allow access to reliable information and resources is important. Incentivising participation through recognition of learning is important. Engaging in a social learning platform also has the power for reflection, promotion of resilience and capacity for health systems strengthening.

Countries with High Registered Nurse (RN) Concentrations Observe Reduced Mortality Rates of Coronavirus Disease 2019 (COVID-19).

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) pandemic has generated many questions on its screening, diagnosis and management. One important question emerging from this discussion of regional differences pertains to the healthcare workforce not just in absolute numbers but also in terms of skill-mix. As nurses comprise over half the skilled healthcare workforce worldwide, it is important to consider them as part of a health systems strengthening approach to quality improvement. We sought to investigate the influence of the registered nurse (RN) concentration and the impact on COVID-19 mortality between countries worldwide. METHODS: We conducted an observational cohort study to examine the association between COVID-19 mortality rates and concentrations of registered nurses. Data on nursing concentrations by country provided from the World Health Organization were merged with March 2020 COVID-19 mortality rates. Descriptive statistics, geographical information systems (GIS) mapping and multilevel linear regression with mixed effects were applied to examine this association with regional clustering of countries. FINDINGS: In total, 172 countries were included in the analysis. These results indicated that for every 1.0 increases in RN per 1,000 individuals in a country, there was a decrease in COVID-19 mortality of -1.98 per 1 million individuals (p=0.003). INTERPRETATION: High nursing concentrations are strongly associated with reduced mortality rates of COVID-19. The key to address the needs of current and future COVID-19 outbreaks, or for that matter, any infectious disease outbreak of this magnitude is to prepare a highly trained, versatile nursing workforce. Funding Statement: William Padula is supported by grants from the U.S. National Institutes of Health (KL2 TR001854) and the Bill & Melinda Gates Foundation. Declaration of Interests: None.