Improving Picu Patient Safety by Implementing a Robust Supply Chain Management Process

INTRODUCTION: With recent gaps in the timely availability of critical pieces of intensive care-specific equipment, clinical care has been affected by the COVID-19 pandemic. Presently complex systems are in place for the essential supplies unique to the pediatric intensive care unit (PICU), such as endotracheal tube sizes, central line supplies, etc. A robust multidisciplinary process can ensure an adequate and timely supply of critically important ICU equipment. This quality improvement initiative's goal was to establish a supply chain management (SCM) process map to reduce elements of inefficiency and acquire resources that would enhance patient safety. METHOD(S): Our goal was to redesign the process that ensures an adequate supply of critical equipment in the PICU, ensures adequate communication during supply chain breakdowns, and minimizes waste by six months. We provided education to increase the patient safety event report (PSER) entries for missing supplies (process metric). We developed an SCM process map (PM) through collaboration with nursing, physicians, and central supply and identified key PM steps. Adherence >50% to the three key steps in the event of missing supplies (process metric) and a decline in days with missing critical supplies was the outcome metric (75% by 6 months). RESULT(S): In our 12-bed pediatric and cardiac intensive care unit, PSERs with missing critical supplies were measured over six months. 21 PSERs were reported compared to 9 over the preceding 2-year period. The three key steps identified in the PM were the Central Issues (CI) specialist sent a daily email to the group (nurse manager (NM), physician, CI Manager, Special order manager) regarding missing supplies. The 2nd step was the expected arrival time (ETA) provided by the special-order manager to the NM within 24 hours for back-ordered items. The 3rd step was a replacement item is expeditiously ordered if the ETA for the item is not acceptable to the PICU team. The three measures adhered to 79% of the time, and the number of days with missing critical supplies decreased to 9 in 6 months. CONCLUSION(S): Implementation of SCM strategies in healthcare has been slow despite the essential need. SCM PM increases productivity in critical care by enhancing safety, shortening product/service cycles, and can lower inventory costs.

SmRNA PRIME S+N DNA BOOST VACCINATION ELICITS ROBUST IMMUNE RESPONSES in MICE

Background: Currently available COVID-19 vaccination regimens in the US deliver either a homologous spike (S) mRNA prime-boost or a prime-only S DNA adenovirus-vectored antigen to elicit humoral and cell-mediated responses to confer protection against SAR-CoV-2 infection. Alternatively, heterologous vaccination using two different platforms has the potential to enhance and expand immune protection. Addition of a second SARS-CoV-2 antigen, the nucleocapsid (N) protein that is less subject to mutation and elicits vigorous T-cell responses, may also be advantageous. We report immunological responses to homologous and heterologous prime-boost vaccination regimens with a human DNA adenovirus serotype 5 S plus N (AdS+N) and/or a self-amplifying S-only mRNA vaccine (AAAH) delivered with a nanostructured lipid carrier (NLC). Methods: CD-1 mice received homologous or heterologous prime-boost combinations of AdS+N and AAAH. Priming doses were administered on Day 0, booster doses were delivered on Day 21, and mice were euthanized for blood and organ collection on Day 35. Serum was analyzed for anti-S (both wild type and variant) and anti-N IgG subtypes by ELISA. Spleen-resident CD4+ and CD8+ T cells were tested for IFN-γ, TNF-α, and IL-2 production in response to S-WT, S Delta variant and N protein overlapping peptides by intracellular cytokine staining (ICS). Splenocyte cytokine secretion upon stimulation with S-WT/N peptides was also assessed by IFN-γ and IL-4 ELISpot. Serum neutralization of the original Wuhan strain, Delta, and B.1.351 variants was assessed by a pseudovirus neutralization assay. Results: The highest humoral and T-cell responses were seen with the heterologous AAAH prime-AdS+N boost regimen, with a significant increase in T-cell responses relative to homologous vaccination. S protein-binding IgG was similar between wild type and Delta variant S proteins, with a strong/clear Th1/Th2 bias, and T cells responded to S wild type and S Delta peptides with similar levels of cytokine expression. Sera from AAAH prime-AdS+N boost mice showed the ability to neutralize Wuhan D614G, Delta, and B.1.351 (South Africa) variant pseudoviruses at high levels. Conclusion: Heterologous vaccination with the AAAH RNA vaccine prime and an AdS+N DNA boost may provide substantially improved humoral and cell-based immunity against SARS-CoV-2 variants by leveraging the advantages of each vaccine platform technology and by inclusion of immune responses to N.

Dual-antigen COVID-19 vaccination with oral boost protects NHP from viral challenge

Background: To address the need for an efficacious COVID-19 vaccine suitable for world-wide distribution, we have developed a dual-antigen vaccine incorporating genes for a modified SARS-CoV-2 spike protein (S-Fusion) and the viral nucleocapsid protein (N) with an Enhanced T-cell Stimulation Domain (N-ETSD) with the potential to increase MHC class I/II responses. The adenovirus serotype 5 platform used, hAd5 [E1-, E2b-, E3-] can be delivered in an oral formulation that overcomes cold-chain limitations. The hAd5 S-Fusion + N-ETSD vaccine was evaluated in rhesus macaques to determine both humoral and cell-mediated responses to vaccination, and protection from subsequent SARS-CoV-2 challenge. Methods: Non-human primates (NHP) received either a subcutaneous (SC) prime and two oral boosts at 2-week intervals, or one SC and one oral boost (each group n = 5). There was also a placebo group (n = 2). Humoral responses to spike (S) were determined by ELISA and T-cell responses to S and nucleocapsid (N) by ELISpot. Neutralization capability of sera was assessed by a surrogate assay and by a microneutralization assay. After SARS-CoV-2 challenge of 10e6 TCID50, genomic RNA (gRNA) and subgenomic RNA (sgRNA) were determined in nasal swab and bronchoalveolar lavage (BAL) samples by RT qPCR. Results: In response to hAd5 S-Fusion + N-ETSD vaccination, NHP generated SARS-CoV-2-neutralizing anti-spike (S) antibodies and demonstrated T-cell activation by both S and nucleocapsid (N). Both the subcutaneous (SC) prime followed by two oral boosts or an SC and oral boost protected the upper and lower respiratory tracts of non-human primates from high titer SARS-CoV-2 challenge. Notably, inhibition of viral replication began within 24 hours of challenge in both lung and nasal passages, becoming undetectable within 7 days post-challenge. Rapidly enhanced neutralization capability of sera in the two weeks after challenge suggests the presence of memory B cells that were activated by infection. Conclusion: The hAd5 S-Fusion + N-ETSD vaccine, when give as a subcutaneous prime with oral boosts, protects rhesus macaques from subsequent viral challenge. The decrease in subgenomic RNA seen at the first time point for sample collection post-challenge (24 hours) provides evidence that protection was almost immediate. The thermally-stable oral form of the vaccine has the potential to facilitate global distribution of vaccines, especially in developing nations.