ABSTRACT
Learning Objectives: Virtual Morning Reports was created as a practical replacement for traditional morning report, in order to create a space for interactive case based learning. Multiple additional benefits were realized after our one-year pilot. : Introduction/Background: The requirement for physical distancing during COVID has led to challenges in education. Emergency Medicine (EM) residencies pivoted to online educational conferences, however a need for interactive education previously met through Morning Report remained. Third-year Teaching Residents (TRs), who historically supervised these sessions, also lost this opportunity for facultyobserved peer teaching. Educational Objectives: VMR aims to fill the gap left by the cancellation of in-person educational activities. These goals are as follows: Allow for a venue for interactive discussion between students and faculty in a non-clinical space. Create an opportunity for TRs to hone teaching skills during their block. Create a model which is easily accessible to learners. Curricular Design: VMR is held twice weekly using Zoom software, for strictly 30 minutes. The end time was enacted to ensure that participants can reliably schedule around VMR and see the entire presentation. Cases are presented by the TR, except for one monthly case by a pediatric EM fellow and one by a toxicology resident. Presentations encourage participation from the audience to develop a differential and discuss management. Residents on shifts have this half-hour protected and are expected to join, but sessions are optional for other residents. Individual feedback on session design is given by core faculty to the TR at the conclusion sessions. Impact/Effectiveness: The first VMR occurred on May 12 and has continued without interruption all year. Participation ranges between 20-60 learners. VMR allows for off-service residents to stay in touch with our department. Faculty from multiple sites, who previously would not have venue to interact, discuss management with learners. Student participation includes pre-clinical as well as EM-bound students. “Virtual” clerkship students and interviewees are invited to VMR engage with our residency. This model is easily reproducible.
ABSTRACT
Rationale: High patient volume and limited ICU resources associated with the COVID-19 pandemic have exacerbated ICU capacity strain, leading to longer pre-ICU lengths-of-stay (LOS). We examined the patient- and hospital-level predictors of pre-ICU LOS, and the association of pre-ICU LOS on in-hospital mortality for patients with COVID-19. Methods: Data were derived from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID), a multicenter cohort study of critically ill adults with COVID-19 admitted to 68 US hospitals. All patients had a minimum of 28-day follow-up;those discharged from hospital were presumed alive. The primary outcome was pre-ICU LOS, dichotomized into brief (≤1 day) vs. prolonged (>1 day). We constructed a multivariate mixed effects model, adjusting for patient factors (e.g., demographics, comorbidities, and pre-hospital symptom duration) and hospital factors (pre-COVID ICU beds number, countylevel case rates of COVID-19 (number of cases per 100,000 residents), and the hospital site itself) to determine predictors of pre-ICU LOS. Using 1:3 propensity score matching for pre-ICU period, we used multivariate mixed effect modelling to examine the association between pre-ICU LOS and in-hospital mortality. Results: A total of 4738 patients with complete data were admitted to the ICU, 36.6% were female, with median age 62 years (IQR 52-71). The majority (85.5%) were admitted from the ED or wards, with 62.5% classified as having a brief pre- ICU LOS. While demographics and co-morbidities (cancer, diabetes, and end-stage renal disease) were not associated with pre-ICU LOS, pre-existing lung disease (OR 1.33, 95% CI 1.02-1.74) was a patient-level predictor of a brief pre-ICU LOS as compared to a prolonged LOS. Having more available ICU beds (>100 vs. 0-48 ICU beds, OR 1.41, 95% CI 1.03-1.92) was a hospital-level predictor of a brief pre-ICU LOS. More patients were intubated at the time of ICU arrival in the prolonged pre-ICU LOS group, compared to the brief LOS group (64.6% vs. 59.2%, p≤0.001). In the mixed model, propensity matched for pre-ICU LOS, and adjusted for patient/hospital characteristics, differential pre-ICU LOS was not predictive of in-hospital mortality (OR 1.22, 95%CI 0.81-1.87), though oxygen support modality was associated with mortality. Conclusion: Patient- and hospital-level factors, such as ICU capacity, had an impact on pre-ICU duration, with more patients requiring a higher level of oxygen support at ICU arrival if admitted later in their course. However, once adjusting for clinical and hospital factors, pre-ICU LOS was not associated with in-hospital mortality.