A constructive crisis: complex system adaptability during the COVID-19 pandemic

PurposeThis study aims to investigate the response by a multi-campus private higher education provider to a major crisis. This study examined what elements of complex adaptive systems (CAS) were activated and/or developed within the organization during the onset of the COVID-19 global pandemic, through a retrospective analysis of organizational responses. Design/methodology/approachA retrospective qualitative approach has been used. The theory of CAS has been used as the theoretical lens to explore the organizational context, responses and behaviours during the first year of the COVID-19 crisis. A series of semi-structured interviews were conducted with 12 senior leaders across the major functions of the organization spread over multiple campuses. FindingsFindings point to coverage of the main CAS characteristics in the organizational responses to the pandemic, however, in varying degrees. There was strong evidence for the application of guiding principles, for self-organizing, for micro-diversity coupled with independent actors and new generative relationships, all brought about by the chaos the pandemic generated. This study concludes that the global pandemic presented this organization with the impetus for rapid and agile responses to what ultimately has become a constructive crisis, paving the way for key elements of CAS theory to be enacted. This study recommend embedding the conscious creation of an adaptive space within ongoing strategic organizational transformation initiatives. Originality/valueThere is scant literature on CAS as applied to crises from organizations in the higher education sector and notably from outside of the health/medical fields. As a result, this study offers a novel and original approach to applying CAS theory during a major crisis. In addition to the findings above, this study also found an emergent characteristic, that of agility, which could be further tested as a potential theoretical addition to CAS theory.

Service Evaluation Audit of Virtual Outpatient Clinics in the Post-COVID-19 era

Introduction: The COVID-19 pandemic has significantly changed outpatient clinic services which now involve virtual (telephone/video) rather than face-to-face consultations. For both new clinic patients or follow-up patients after a recent emergency admission, these changes may impact on their perceptions and confidence in The outpatient service. The aim of this service provision audit is to ascertain both patient satisfaction and confidence in virtual consultations in our unit. Method(s): A retrospective evaluation of all General Surgery virtual clinic appointments between January and March 2021 was undertaken. Patients were contacted for feedback about their surgical consultation based on questions from The National Health Service Outpatient Department Survey (2011). Result(s): In total, 151 patients were contacted. Overall satisfaction regarding telephone consultations was significantly higher when compared to survey results of face-to-face appointments in The pre-COVID era. The majority of patients were confident (51%) or confident to some extent (27%) of being listed for Surgery without further examination. only 8% of patients were not confident at The way Surgery was explained and 10% were not confident of The risks of surgery. Finally, more than a third were not happy to be discharged from clinic following a telephone consultation. Conclusion(s): Follow-up appointments are an integral part of The patient journey following an emergency admission. The COVID-19 recovery phase has necessitated a service reconfiguration towards virtual appointments. We show that patients were satisfied with virtual consultations, although further quality improvement should be undertaken to ensure outpatient discharge is satisfactory for all patients following an emergency admission.

VENTILATOR ALARM TRENDS IN A MEDICAL ICU

SESSION TITLE: Actionable Improvements in Safety and Quality SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Ventilator alarms are an audible and visual safeguard within a system which alerts clinicians to potentially critical changes within the patient or ventilator unit. They are a crucial aspect of patient care;however, not every alarm that is generated by the ventilator will provide actionable information. Unfortunately, this can contribute significantly to the overall alarm burden in the intensive care unit. This has been especially true with the marked increase in ventilator use during the COVID-19 pandemic. The individual impact of each alarm can easily become dampened due to the sheer quantity of alarms, ventilator-related and others. Excessive alarming may lead to cognitive overload and alarm fatigue for providers, and eventually, adversely impact patient outcomes. This potentially can lead to missed life-sustaining interventions and medical errors. METHODS: As part of a quality improvement initiative, we evaluated ventilator alarms through the month of October 2021 in the medical intensive care unit within Bellevue Hospital Center in New York City. Respiratory therapists recorded ventilator parameters and extracted alarm data daily from every ventilator within the medical intensive care unit. Ventilator logs were exported from each individual Servo-U ventilator unit in use onto a USB flash drive and the captured data was uploaded to a secure network for review. For each ventilator, data regarding specific alarm type and priority as defined by the manufacturer, as well as time, frequency, and duration was obtained for review. RESULTS: From October 4, 2021, to October 31, 2021, a total of 30,230 ventilator alarms were initiated over 672 hours in the MICU. This provided an approximate mean of 45 alarms per ventilator hour. Data was collected daily from all MICU ventilators in use which averaged about 12 ventilators per day (between 6-16). The top four alarms as defined by the ventilator were “airway pressure high,” “respiratory rate high,” “PEEP [positive end expiratory pressure] low,” and “expiratory minute volume low.” 18,451 alarms over the month were “airway pressure high.” 3,982 alarms were defined as “respiratory rate high.” 2,220 alarms were “PEEP low” and 2,041 alarms were “expiratory minute volume low.” CONCLUSIONS: Ventilator alarms, both nuisance and actionable alarms, contribute significantly to the alarm burden in the medical intensive care unit. Dedicated research is necessary to ensure safer alarm practices. CLINICAL IMPLICATIONS: Evaluating baseline alarm data allows for assessments as well as analyses of trends and patterns that are contributing to the excessive noise within the intensive care units. This gives hospitals an opportunity to provide targeted multidisciplinary educational initiatives and create standardized protocols to enhance the quality and safety surrounding ventilator alarms within intensive care units. DISCLOSURES: No relevant relationships by Kerry Hena No relevant relationships by Charmel Rogers no disclosure on file for Amit Uppal;No relevant relationships by Tatiana Weinstein

Tele-rehabilitation for people with dementia in the COVID-19 pandemic: A case-study

Introduction The Promoting Activity, Independence and Stability in Early Dementia (PrAISED) is delivering an exercise programme for people with dementia. The Lincolnshire partnership NHS foundation Trust successfully delivered PrAISED through a video-calling platform during the COVID-19 pandemic. Objectives This qualitative case-study identified participants that video delivery worked for, and highlighted its benefits and challenges. Methods Interviews were conducted with participants with dementia, caregivers and therapists, and analysed through thematic analysis. Results Video delivery worked best when participants had a supporting carer, when therapists showed enthusiasm and had an established rapport with the client. Benefits included time-efficiency of sessions, enhancing participants’ motivation, caregivers’ dementia awareness and therapists’ creativity. Limitations included users’ poor IT skills and resources. Conclusions The COVID-19 pandemic required innovative ways of delivering rehabilitation. This study supports that people with dementia can use tele rehab, but success is reliant on having a caregiver and an enthusiastic and known therapist.

A novel Collaborative Online Robotics Platform to address engagement and social emotional challenges in remote learning environment

In this WIP-Innovation Practice, the authors present a shared Collaborative Online Robotics platform embedded in Google Slides application for students from primary grades to University to enhance the learning and teaching process in online and blended/hybrid environments. This Computer Supported Cooperative Work (CSCW) system is intended to facilitate an immersive experience in a collaborative virtual environment by combining physical digital artifacts with remote STEM-based instruction. Particularly relevant during COVID-19, it also helps connect students potentially isolated by other factors (geographic, economic, environmental, health limitations, etc.). In this paper we present a first approach to the performance, acceptance, and adherence to a novel remote collaborative platform that facilitates STEM and Social Emotional Learning (SEL) enhanced by the interaction of a multiple-users with a LEGO MINDSTORM EV3 Robotic platform based on the Positive Technological Development (PTD) framework.

Impact analysis of virtual transplant ambulatory pharmacist during COVID-19

Purpose: During the COVID-19 pandemic, transplant centers were challenged to meet the demand for new telemedicine strategies. High-risk immunocompromised patients, such as lung transplant recipients (LTR) require close follow-up due to their medical complexity and need for frequent medication changes. The pandemic significantly limited the ability of lung transplant providers (LTP) to safely conduct face-to-face clinic visits. Transplant pharmacists, previously unable to provide medication management visits for all patients due to time and space restraints of clinic, were now able to conduct virtual telehealth visits to assist LTP in the transition to telemedicine. Methods: A retrospective chart review of telephone encounters from cardiothoracic pharmacists (CTRx) at our center from March to September 2020 was completed. LTR scheduled for clinic visits with LTP were called prior to the visit by CTRx who conducted chart reviews, medication reconciliations, adherence assessments, and medication access assistance. Clinical recommendations were then communicated directly to the LTP and documented in patient electronic medical records. The primary outcome was the number of pharmacist-driven clinical interventions made during COVID-19 virtual lung transplant visits. Secondary endpoints included the total number of medication discrepancies, average number of interventions, and average number of discrepancies found per visit. Results: From March to September 2020 the CTRx conducted 385 virtual visits on 157 LTR with an average of 23.4 minutes spent per visit. There were 864 total interventions made by CTRx and a total of 778 medication discrepancies identified. An average of 2.8 interventions were sent to LTP per visit. The most common interventions made were medication education (20.8%), adherence counseling (19.5%), update on adherence level (20.4%), and reinforcement of social distancing and COVID-19 precautions (17.1%). There was an average number of 2.5 medication discrepancies identified out from an average of 22.6 medications reconciled per visit. (Table 1) Conclusions: Implementation of CTRx telehealth visits has potential for increased patient access to pharmacy care, improved accuracy of medication lists and increased collaboration with LTP given the flexibility that telemedicine provides. Further investigation is needed to determine the significance of CTRx clinical interventions on clinical patient outcomes.

Risk of 30-day mortality and cardiopulmonary complications in patients undergoing emergency surgery with perioperative SARS-CoV-2 infection

INTRODUCTION AND OBJECTIVE: Continued vigilance of operative outcomes of COVID-19 patients is important given the relative novelty of the SARS-CoV-2 infection. We here sought to evaluate the 30-day mortality and cardiopulmonary adverse event rates in patients undergoing emergency surgery with perioperative COVID-19 infection, in comparison to a control group of medically managed COVID-19 patients that did not require surgical intervention. METHODS: A retrospective review of electronic medical data from a single tertiary-care center in Michigan was undertaken. Patients who had tested positive for SARS-CoV-2 infection either 7 days before or within 30 days after surgery during March-May 2020 were included in the study (n=52). Propensity score matched (1:6) patients who had been positive for SARS-CoV-2 infection during this time-period but did not undergo surgery were used as controls (n=314, Figure 1). The primary endpoint was 30-day mortality. Secondary endpoints included cardiac and pulmonary complications. Multivariable logistic regression analyses were utilized to account for baseline differences. A pvalue <0.05 was considered significant. RESULTS: The 30-day mortality (17.3% vs 13.1%, p=0.408) and cardiac (28.9% vs 19.1%, p=0.107) and pulmonary complication (55.8% vs 49.4%, p=0.392) rates were similar in patients in the surgical versus non-surgical group, respectively. Multivariable analyses confirmed that an emergency surgical intervention was not associated with increased odds for any of the studied adverse events (p >0.10 for all 3 endpoints). CONCLUSIONS: Patients undergoing emergency surgery with a co-diagnosis of SARS-CoV-2 infection in the perioperative period do not have an increased risk for short-term mortality or cardiopulmonary complications compared to the medically treated COVID-19 patients.

Tele-rehabilitation for people with dementia in the COVID-19 pandemic: A case-study

IntroductionThe Promoting Activity, Independence and Stability in Early Dementia (PrAISED) is delivering an exercise programme for people with dementia. The Lincolnshire partnership NHS foundation Trust successfully delivered PrAISED through a video-calling platform during the COVID-19 pandemic.ObjectivesThis qualitative case-study identified participants that video delivery worked for, and highlighted its benefits and challenges.MethodsInterviews were conducted with participants with dementia, caregivers and therapists, and analysed through thematic analysis.ResultsVideo delivery worked best when participants had a supporting carer, when therapists showed enthusiasm and had an established rapport with the client. Benefits included time-efficiency of sessions, enhancing participants’ motivation, caregivers’ dementia awareness and therapists’ creativity. Limitations included users’ poor IT skills and resources.ConclusionsThe COVID-19 pandemic required innovative ways of delivering rehabilitation. This study supports that people with dementia can use tele rehab, but success is reliant on having a caregiver and an enthusiastic and known therapist.

Coccidioidomycosis in an Immunocompetent Host during the COVID-19 Era

Introduction: Coccidioides immitis and posadasii are dimorphic fungi endemic to the southwestern United States. Most immunocompetent hosts who contract coccidioidomycosis will clear the infection without symptoms. We detail the case of an immunocompetent, 56-year-old female who presented with symptoms of lower respiratory tract infection and concern for COVID-19 infection given significant exposure history. Case Description: The patient was referred to our advanced lung disease center (located in the southwestern United States) for subacute, productive cough associated with clear-yellow phlegm, dyspnea on exertion, infrequent night sweats, and abnormal chest x-ray (Figure A). The patient denied any history of fever, chills, hemoptysis, unintentional weight loss, or chest pain. Six-weeks prior to admission, the patient had significant exposure to multiple symptomatic persons with COVID-19. Two RT-PCR tests for COVID-19 to date were ruled negative, and a third test performed on admission was also negative. Computed tomography of the chest revealed right upper lobe cavitary consolidation with surrounding nodules bilaterally (Figure B). Sputum smear was negative for acid-fast bacillus or other bacterial organisms, prompting a bronchoscopy with bronchoalveolar lavage. Results demonstrated fungal cultures of Coccidioides immitis/posadasii. The patient also had significant IgG antibodies against Coccidioides species. She was started on therapeutic doses of fluconazole with a gradual improvement in symptoms. Discussion: History of significant exposure to COVID-19 warrants prompt and thorough investigation for disease status. Nonetheless, clinicians should still maintain a high suspicion and vigilance for excluding other, potentially treatable infectious etiologies, even regional endemic fungal infections that tend to manifest without symptoms.

Percutaneous dilational tracheostomy during the COVID-19 pandemic in New York City

INTRODUCTION: The COVID-19 pandemic overwhelmed New York City hospitals. Shortages of ventilators and sedatives prompted tracheostomy earlier than recommended by professional societies. The objective of this study was to determine the impact of percutaneous dilational tracheostomy (PDT) in COVID-19 patients on critical care capacity. METHODS: This is a single-institution prospective case series of SARS-CoV-2 infected patients undergoing PDT from April 1-June 4, 2020 with follow-up through June 25, 2020 at a public tertiary care center. Clinical data were obtained through medical record review. Mechanically ventilated COVID-19 patients were screened for intervention based on the following criteria: ≥ 6 days of intubation with further need for mechanical ventilation, a fractional inspired oxygen concentration of ≤ 60%, positive end expiratory pressure ≤12, no significant organ dysfunction except acute kidney injury, and minimal pressor requirements. The main outcomes measured were change in 48-hour periprocedural sedative/analgesia requirements, liberation from the ventilator, rate of transfer from the ICU, decannulation, PDT-related complications, and in-hospital survival. RESULTS: Fifty-five patients met PDT criteria and underwent PDT a median of 13 days from intubation. Patient characteristics are found in Table 1. Intravenous midazolam equivalents, fentanyl equivalents and cisatracurium equivalents were significantly reduced post- PDT (Table 2). Thirty-five patients were transferred from the ICU and liberated from the ventilator. Median time from PDT to ventilator liberation and ICU discharge was 10 and 12 days respectively. Decannulation occurred in 45.5% and 52.7% were discharged from acute inpatient care. Median follow-up for the study was 62 days. Four patients had bleeding complications postoperatively and 11 died during the study period. Older age was associated with increased odds of complication (OR 1.12, 95% CI 1.04, 1.23) and death (OR=1.15, 95% CI 1.05, 1.30). CONCLUSIONS: Mechanically ventilated COVID-19 patients undergoing PDT using standard criteria improves ventilator and medication utilization in areas strained by the SARS-CoV-2 pandemic. Long term outcomes after PDT in this population deserve further study.

When rent seeking smacks you in the face: tif and motivated reasoning

This article is a substitute for the Fellows Address that I did not get to present at the 2020 Southern Regional Science Association (SRSA) Conference due to the COVID-19 pandemic. Regional science research typically addresses real world problems in hopes of guiding better policy decisions. Why is it, then, that economic development plans often fail to reflect best practices? What do you do when you find that your own community is about to buy into a terrible plan? In this address, I share my observations and experience with a Tax Increment Financing (TIF) development plan implemented in Norman, OK. I point out how motivated reasoning leads policy makers to seek reasons to approve a plan rather than to evaluate if a plan is good. To make a meaningful impact on public policy decisions, scholars will need to step out of their comfort zones and engage in – sometimes contentious – community outreach education. © Southern Regional Science Association 2020.