Shakespeare through Trauma: Teaching in 2020 and Beyond

This chapter explores the impact of the COVID-19 pandemic on postgraduate students at the Shakespeare Institute. Through an analysis of responses to an open, anonymous, optional survey, it explores the emotional and practical challenges that isolation from lockdowns created for students;the value of community and a sense of purpose during challenging times;and the way the pandemic affected some students' understanding of Shakespeare's works. While it makes no claims for Shakespeare as a universal panacea, it highlights the solace that can be found in gathering around a shared passion during times of uncertainty and the way Shakespeare's writings can resonate during moments of hardship and even trauma. © 2023 selection and editorial matter, Pamela Bickley and Jenny Stevens;individual chapters, the contributors.

Strategic Roadmapping Framework for Disaster Response: Case of COVID-19 Pandemic Vaccine Rollout Program in the UK

Strategic planning in response to disasters is distinctly different from strategic planning in normal situa-tions. The experience of the coronavirus disease 2019 (COVID-19) pandemic has shown that a vaccine roll-out program as a disaster response requires a different approach from current routine vaccination and disaster response frameworks. A holistic conceptual framework for planning vaccine rollout disaster response programs is proposed, building on the experience of COVID-19. The customizable framework was developed to have high dynamicity, flexibility, and applica-bility, incorporating key decision-making factors and suitable time frames (phases and transitions), based on roadmapping principles and techniques. In this re-search, we focus on the COVID-19 pandemic vaccine rollout program in the United Kingdom (UK) as a rep-resentative case of disaster response planning due to the availability of public data and access to the rel-evant stakeholders. We applied Platts' process approach as a methodology and used various sources of information including an extensive literature re-view, expert interviews, and retrospective roadmap-ping (mapping past experience). As a result, we propose a strategic roadmapping framework for the COVID-19 vaccine rollout program to support visual planning of time-based strategies with the integration of various resources and demand environments. Apart from this practical contribution, we demonstrate that the concept of roadmapping can be applied beyond technology and innovation management domains to a novel research domain such as disaster response. © Fuji Technology Press Ltd. Creative Commons CC BY-ND.

Burnout Among Missouri Primary Care Clinicians in 2021: Roadmap for Recovery?

Rates of burnout among clinicians have been exacerbated by the COVID-19 (COVID)pandemic. A survey of Missouri primary care professionals at federally qualified health centers was conducted during a COVID surge in August 2021 to assess burnout, stress, and job satisfaction as well as if respondents had sought assistance for burnout or attended resiliency training. Despite respondents reporting rates of burnout (56%) that exceed those reported nationally (48%), only 17% sought help for burnout. Most (81%) had not attended resiliency training;of those who did, 16% said sessions "make me feel less alone," while an equivalent number found sessions not useful, identifying an absence of resources within their organization. Comments focused on the need for dedicated time to receive support, including time to seek assistance during working hours, time to take breaks, and time for self-care. The data suggest one path forward to remediate burnout: provide the workforce with time to access support. Copyright 2022 by the Missouri State Medical Association.

Nutrition Support in the Intensive Care Unit during the COVID19 pandemic

The aim of this analysis was to determine nutrition support needs and characteristics of COVID19 patients assessed by critical care dietitians during the COVID19 pandemic. Nutrition parameters were collected for all patients admitted to the intensive care unit (ICU) with COVID19 with length of stay (LOS) >48hrs. Data was compared from March-June 2020 (T1) to January-April 2021 (T2). The patients who met the inclusion criteria (n=64 in T1 and n=77 in T2) were assessed by a critical care Dietitian: 100% required nutrition support. Mean age in T1 was 60.6yrs (66% male) compared to 63.1yrs in T2 (62% male). Mean BMI was 29.6kg/m2 vs. 30.2kg/m2. In T1 72% required mechanical ventilation vs. 78% in T2, remainder on non-invasive ventilation (NIV). Average ICU LOS was 16days in T1 and 25days in T2. During T1 78% transferred to ward level care, 48% in T2 and all these patients required on going dietetic input at ward level. In T1 41% were discharged from ICU on enteral nutrition which increased to 48% in T2. Type of nutrition support during ICU stay is described in the table below. [Formula presented] All COVID19 patients with and ICU LOS >48hours were assessed by a critical care Dietitian. Patient profile was similar in both cohorts and all required nutrition support either by ONS, EN, PN or a combination of these. All patients on NIV required ONS with increasing numbers being commenced on supplementary EN in T2. More patients also required supplementary PN in T2. On transfer to ward level care 100% of patients required nutrition support highlighting the need for on-going dietetic input. Disclosure of Interest: None Declared

Applying learning from 1st to the 3rd wave of the COVID19 pandemic: nutritional provision in critical care

The aim of this analysis was to compare route and adequacy of nutrition support in patients with COVID19 admitted to an intensive care unit (ICU) between March-June 2020 (T1) compared to January-April 2021 (T2). Parameters related to nutrition support were collected from the records of all patients admitted to ICU with COVID19 with length of stay of ≥7days on mechanical ventilation requiring artificial nutrition support. Data was collected during the late acute phase which was defined as day 4-7 post intubation. Energy and protein intake was compared to calculated estimated nutritional requirements. 35 patients met the inclusion criteria in T1, 94% were on enteral nutrition (EN), 3% parenteral nutrition (PN) and 3% EN+PN. In T2, there were 54 patients (92% EN, 2% PN and 6% EN+PN). [Formula presented] Of patients who achieved <70% of energy and protein requirements in T1 (n=17) 35% had constipation or ileus and 47% had GI intolerance (high gastric residual volumes or vomiting). In T2 (n=19), 84% experienced constipation or ileus and 63% had GI intolerance. 35% of patients in T1 had hypernatraemia vs. 47% in T2 and 41% in T1 had hyperglycaemia vs. 100% in T2 despite only 12% and 32% of patients respectively having a history of diabetes. Despite a higher incidence of GI intolerance in T2, a statistically significant improvement in achieving energy targets was noted. Learning from T1 showed that where strategies to improve GI tolerance are unsuccessful supplementary PN should be considered without delay to optimise nutritional intake. There was a clinically significant trend in protein intake which may be attributed to prompt initiation of modular protein supplements or perhaps an earlier transition from fat-based sedation. Meeting protein requirements while preventing overfeeding remains a challenge in the ICU. Disclosure of Interest: None Declared

Nutrition in critical care: An audit of protein and energy intakes compared to international recommendations

Adequate protein and energy provision in critical care is associated with better clinical outcomes. The aim of this audit was to evaluate compliance with achieving recommended protein and energy targets in our Intensive Care Unit (ICU) and to explore the reasons for any deficits identified. Nutrition parameters were collected on patients admitted to our ICU between March and May 2021. Inclusion criteria were requirement for nutritional support and mechanical ventilation with an ICU length of stay ≥ 4 days. Patients with COVID19 were excluded. Protein and energy intakes were compared to best practice guidelines1. 51 patients met the inclusion criteria: 53% male, 47% female. Mean age was 59.6 years and mean length of stay was 19.9 days (range 5-61 days). Protein and energy intakes achieved as follows: [Formula presented] Of the patients who received < 80% of their nutritional requirements, the main barriers to achieving targets identified were fasting and constipation in this cohort. Cumulative deficit ranged from 0 - 903g protein and 0 - 12717kcal over duration of ICU stay. Mean deficit was 315g protein and 2945kcal. Of concern, 12 patients had a deficit of > 500g protein and 7 patients had > 5000kcal deficit. While 69% of patients met ≥ 80% protein requirements and 77% of patients met ≥ 80% energy requirements, we have identified areas to consider to improve nutritional adequacy including increasing awareness of minimising fasting times and the introduction of a bowel management protocol. References 1. Singer P, Blaser AR, Berger MM. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019 1;38(1):48-79. Disclosure of Interest: None Declared

Analysis of nutrition support in COVID19 critical care patients

The aim of this analysis was to determine route and adequacy of nutrition support in patients with COVID19 during the first 7 days of admission to an intensive care unit (ICU). Nutrition parameters were collected for all patients admitted to ICU with COVID19 and compared to best practice guidelines1. Of the initial 64 patients admitted to ICU for management of COVID19, all patients were assessed by a critical care dietitian. Patients who were tolerating oral diet were commenced on oral nutrition support as appropriate. Forty eight patients (75%) required enteral nutrition (EN) or parenteral nutrition (PN). The feeding route of choice for the majority of patients was EN (89.5%). In patients with gastrointestinal (GI) intolerance where strategies to optimise tolerance were unsuccessful, supplementary or total PN was used (10.5%). Energy and protein intakes during the early and late acute phase are described below. [Formula presented] Energy intakes in the early acute phase were consistent with best practice guidelines while protein provision was a challenge in both phases. GI intolerance was common which compromised nutrition intakes, though proned position did not affect these outcomes. Where strategies to improve GI tolerance are unsuccessful supplementary PN should be considered without delay to optimise nutrition intake. References: 1Singer et al. Clinical Nutrition (2019) 38(1), 48-79. Disclosure of Interest: None Declared

A PROSPECTIVE STUDY OF SEX DIFFERENCES IN QUALITY OF LIFE, ANXIETY, AND ALCOHOL USE RESPONSE TO THE COVID-19 PANDEMIC

Purpose: The COVID-19 pandemic has affected psychological health related to quality of life, anxiety, and alcohol use. To assess differences in pandemic response related to clinical status and sex, we used prospective data collected in a clinical sample of adults with Alcohol Use Disorder (AUD), HIV infection, or both diagnoses (AUD+HIV) and a control group. Methods: Data were collected between 2015-2018 during pre-COVID laboratory visits and later with an online survey to assess psychological health during COVID. Change scores (COVID score - pre- COVID score) evaluated differences in quality of life (QoL;Short-Form-21), state anxiety (State- Trait-Anxiety Inventory), and alcohol use (Alcohol Use Disorders Identification Test, AUDIT). Of the 218 participants we attempted to contact, 89 completed the survey. The clinical sample included 18 AUD (9M, 9F), 22 HIV (15M, 7F), and 15 AUD+HIV (6M, 9F);the Control group included 17M and 17F. Results: All groups reported decreases in QoL during COVID (X2 = 8.26, p = .04). Women in the clinical sample (regardless of diagnosis) reported an even greater decrease in QoL during COVID than clinical men (Z = 2.12, p = .016), control women (Z = 2.38, p = .017), or control men (Z = 2.41, p = .034). The greater decrease in QoL in clinical women was supported by analysis of the separate AUD, HIV, and AUD+HIV sub-samples. Regarding state anxiety, the clinical sample showed a greater increase during COVID than the control group (X2 = 5.64, p = .018). Regardless of group or sex, however, participants did not report significant change in pandemic alcohol use. Nonetheless, for clinical women, correlational analyses indicated that greater decline in QoL was related to increased anxiety (rho = -.49, p = .03) and increased alcohol use (rho = -.49, p = .02), and that increase in anxiety was related to increase in alcohol use (rho = .46, p = .04). By contrast, in clinical men, change in anxiety was related to change in QoL (rho = -.49, p = .02) but not alcohol use (rho = -.26, p = .24). Conclusions: Clinical men and women reported greater increase in anxiety and decrease in QoL than controls during COVID vs. pre-COVID assessment. The relation between increase in self-reported alcohol use and increased anxiety and decline in QoL in the clinical women suggests greater drinking-to-cope motivation to relieve emotional distress during COVID in women already burdened with a clinical diagnosis.

Outcomes for severe COVID-19 disease following ICU

Rationale: Severe SARS Co-V2 (COVID-19) infections are characterized by ARDS, cytokine storm, and multisystem organ failure. Longterm outcomes of these patients requiring long-term acute care (LTAC) have not been clarified. Given the severity of the initial acute illness, poor longterm outcomes are likely. We hypothesized that patients with severe COVID-19 infections would have outcomes worse than non-COVID-19 patients with multisystem organ failure. We tested this by comparing LTAC outcomes in patients having severe COVID-19 disease with patients without COVID-19 who required LTAC after critical illness. Methods: We conducted a chart review of the 275 COVID-19-positive patients requiring intensive care unit (ICU) care discharged from the Brigham and Women's hospital from January 1-July 31, 2020 and compared them to a cohort of 241 ICU patients requiring LTAC who are part of a quality improvement program to enhance care continuity (CC). Statistical analyses used Student-t tests and Chi-square analyses, with P < 0.05 accepted as statistically significant. Results: 65 of 279 COVID-19 patients required LTAC, with 57 patients discharging to the same LTAC used for CC patients. Similar to prior reports, the proportion of Black (28%) and Hispanic (10%) patients were significantly (P < 0.05) greater in COVID-19 patients compared to the CC patients (9% Black and 6% Hispanic). There were no differences between groups in the average patient age: COVID-19 patients (62 ±14.2) and CC patients (60 ±15) or the proportion of males: COVID-19 patients (37, 64%) compared to the CC patients (137, 57%). At transfer to LTAC, 25% CC patients but only 7% COVID-19 patients required mechanical ventilation (MV), although 90% of the COVID-19 patients had required MV during their acute hospitalization. After LTAC transfer, significantly (P < 0.05) fewer COVID-19 patients (12%) compared to CC patients (28%) required readmission to an acute hospital within 30 days of the acute hospital discharge. Additionally, significantly more (P < 0.05) COVID-19 patients (41, 71%) compared to CC patients (73, 30%) were discharged to home after LTAC. Conclusions: The low rates of early readmission and the high rates of home discharge in the COVID patients compared to the CC patients were unexpected and indicate that COVID-19 patients requiring LTAC have outcomes that are comparable, and possibly better than, similar patients without COVID-19. The possible contributing factors for improved outcomes in COVID-19 patients are unknown but may include a lower burden of comorbid disease in these patients and better pre-morbid functional status.

Analysis of nutrition support in Covid19 critical care patients

Rationale: The aim of this analysis was to determine route and adequacy of nutrition support in patients with COVID19 during the first 7 days of admission to an intensive care unit (ICU). Methods: Nutrition parameters were collected for all patients admitted to ICU with COVID19 and compared to best practice guidelines1. Results: Of the initial 64 patients admitted to ICU for management of COVID19, all patients were assessed by a critical care dietitian. Patients who were tolerating oral diet were commenced on oral nutrition support as appropriate. Forty eight patients (75%) required enteral nutrition (EN) or parenteral nutrition (PN). The feeding route of choice for the majority of patients was EN (89.5%). In patients with gastrointestinal (GI) intolerance where strategies to optimise tolerance were unsuccessful, supplementary or total PN was used (10.5%). Energy and protein intakes during the early and late acute phase are described below. [Formula presented] The most common reason for suboptimal nutrition intake in the late acute phase was GI intolerance, affecting 27% of patients. Compared with those without GI intolerance, patients who experienced feed regurgitation, vomiting or high gastric residual volumes achieved significantly less energy and protein intakes (p≤0.05). Proned position did not affect GI tolerance in our cohort (p=0.65). Conclusion: Energy intakes in the early acute phase were consistent with best practice guidelines while protein provision was a challenge in both phases. GI intolerance was common which compromised nutrition intakes, though proned position did not affect these outcomes. Where strategies to improve GI tolerance are unsuccessful supplementary PN should be considered without delay to optimise nutrition intake. References: 1Singer et al. Clinical Nutrition (2019) 38(1), 48-79. Disclosure of Interest: None declared.

Weight status of patients admitted to an Intensive Care Unit for management of COVID19

Rationale: Obesity has been proposed as a risk factor for severe illness and invasive ventilation in patients with COVID191. Additionally, malnutrition is highly prevalent in critically unwell patients, regardless of baseline weight status2. The aim of this analysis was to determine the baseline weight status and weight change in patients admitted to an intensive care unit (ICU) for management of COVID19. Methods: Baseline weight on admission to ICU was collected from the records of all patients admitted with COVID19. Weight change during ICU admission was calculated for patients who survived and had an ICU length of stay (LOS) ≥ 5 days. Results: Sixty four patients were admitted to the ICU for management of COVID19 (mean age 60.6yrs (range 21-90yrs), 66% male, mean ICU LOS 16.5 days (range 1-71days)). Weight status in this cohort is presented below. [Formula presented] 69% of patients experienced at least 5% weight loss during ICU admission and 31% had greater than 10% weight loss, despite provision of nutrition support. Conclusion: Overweight and obesity were prevalent in patients admitted to our ICU for management of COVID19. Significant weight loss in this cohort confirms that malnutrition and obesity co-exist in critically unwell patients. These findings are consistent with emerging data from other centres internationally3 and inform appropriate nutritional management of this cohort of critically ill patients. References: 1Simonnet et al. Obesity (2020) 28: 1195-1199, 2Lew et al. JPEN (2017) 41(5):744–58, 3House et al., ICNARC 2020. Disclosure of Interest: None declared.

Mental health plan for workers of the London Nightingale Hospital: following the evidence to support staff.

The COVID-19 pandemic has extracted an enormous physical health toll on many millions worldwide, and the wider societal impact from economic turmoil, unemployment, social isolation and so forth continue to be measured. A less explored aspect has been the psychological impact on treating healthcare staff, with emerging evidence of 'moral injury' and mental illness for some. This review explores the evidence base for implementing a tiered model of care to minimise this and foster 'post-traumatic growth', and describes the authors' implementation of this in the London Nightingale hospital, with lessons for the armed forces.

Airway management guidance for the endemic phase of COVID-19.

It is now apparent that severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19) will remain endemic for some time. Improved therapeutics and a vaccine may shorten this period, but both are far from certain. Plans must be put in place on the assumption that the virus and its disease will continue to affect the care of patients and the safety of staff. This will impact particularly on airway management due to the inherent risk to staff during such procedures. Research is needed to clarify the nature and risk of respiratory aerosol-generating procedures. Improved knowledge of the dynamics of SARS-CoV-2 infection and immunity is also required. In the meantime, we describe the current status of airway management during the endemic phase of the COVID-19 pandemic. Some controversies remain unresolved, but the safety of patients and staff remains paramount. Current evidence does not support or necessitate dramatic changes to choices for anaesthetic airway management. Theatre efficiency and training issues are a challenge that must be addressed, and new information may enable this.

Risks to healthcare workers following tracheal intubation of patients with COVID-19: a prospective international multicentre cohort study.

Healthcare workers involved in aerosol-generating procedures, such as tracheal intubation, may be at elevated risk of acquiring COVID-19. However, the magnitude of this risk is unknown. We conducted a prospective international multicentre cohort study recruiting healthcare workers participating in tracheal intubation of patients with suspected or confirmed COVID-19. Information on tracheal intubation episodes, personal protective equipment use and subsequent provider health status was collected via self-reporting. The primary endpoint was the incidence of laboratory-confirmed COVID-19 diagnosis or new symptoms requiring self-isolation or hospitalisation after a tracheal intubation episode. Cox regression analysis examined associations between the primary endpoint and healthcare worker characteristics, procedure-related factors and personal protective equipment use. Between 23 March and 2 June 2020, 1718 healthcare workers from 503 hospitals in 17 countries reported 5148 tracheal intubation episodes. The overall incidence of the primary endpoint was 10.7% over a median (IQR [range]) follow-up of 32 (18-48 [0-116]) days. The cumulative incidence within 7, 14 and 21 days of the first tracheal intubation episode was 3.6%, 6.1% and 8.5%, respectively. The risk of the primary endpoint varied by country and was higher in women, but was not associated with other factors. Around 1 in 10 healthcare workers involved in tracheal intubation of patients with suspected or confirmed COVID-19 subsequently reported a COVID-19 outcome. This has human resource implications for institutional capacity to deliver essential healthcare services, and wider societal implications for COVID-19 transmission.