COVID-19 Vaccination Among Healthcare Workers: Trend and Protection in a Tertiary Care Hospital in Northern India.

Background Coronavirus disease 2019 (COVID-19) is an infectious disease that poses health risks to everyone exposed to the virus and frontline healthcare workers (HCWs) are at very high risk. COVID-19 vaccines have been developed to offer protection from the disease and reduce the severity of illness. Objective This questionnaire-based cross-sectional survey aimed to determine COVID-19 vaccination trends and protection among HCWs in a dedicated COVID-19 tertiary care hospital in Northern India. Methods A printout of the questionnaire was distributed. Part 1 of the questionnaire included voluntary consent and demographics information, and part 2 dealt with COVID-19 vaccination, COVID-19 illness, and post-vaccination illness. The outcomes of the study comprised trends and protection offered by COVID-19 vaccination, post-vaccination side-effects, and reasons for vaccine hesitancy. The responses were analyzed using Stata version 15.0. Results: A total of 256 HCWs were approached to take the questionnaire, out of whom 241 consented to participate in the survey. One-hundred and fifty-five (64.3%) of these HCWs were fully vaccinated, 53 (21.9%) were partially vaccinated, and 33 (13.7%) were non-vaccinated. The overall rate of infection was 45.64% (110/241). The rate of infection was 58.18% among non-vaccinated HCWs, 21.81% after partial vaccination, and 20% after full vaccination. The odds of infection among vaccinated versus non-vaccinated HCWs was 0.338 (95% CI: 0.224 to 0.512; P<0.001). The overall hospitalization rate among infected HCWs was 6.36% and there was no incidence of hospitalization among fully vaccinated HCWs. Conclusions: Vaccination was shown to reduce the rates of infection and hospitalization among HCWs. A sizeable number of HCWs remained unvaccinated due to either recent COVID-19 infection or apprehension about vaccine-related side-effects.

Early Warning Scores at Time of ICU Admission to Predict Mortality in Critically Ill COVID-19 Patients.

OBJECTIVE: To assess ability of National Early Warning Score 2 (NEWS2), systemic inflammatory response syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA), and CRB-65 calculated at the time of intensive care unit (ICU) admission for predicting ICU mortality in patients of laboratory confirmed coronavirus disease 2019 (COVID-19) infection. METHODS: This prospective data analysis was based on chart reviews for laboratory confirmed COVID-19 patients admitted to ICUs over a 1-mo period. The NEWS2, CRB-65, qSOFA, and SIRS were calculated from the first recorded vital signs upon admission to ICU and assessed for predicting mortality. RESULTS: Total of 140 patients aged between 18 and 95 y were included in the analysis of whom majority were >60 y (47.8%), with evidence of pre-existing comorbidities (67.1%). The most common symptom at presentation was dyspnea (86.4%). Based upon the receiver operating characteristics area under the curve (AUC), the best discriminatory power to predict ICU mortality was for the CRB-65 (AUC: 0.720 [95% confidence interval [CI]: 0.630-0.811]) followed closely by NEWS2 (AUC: 0.712 [95% CI: 0.622-0.803]). Additionally, a multivariate Cox regression model showed Glasgow Coma Scale score at time of admission (P < 0.001; adjusted hazard ratio = 0.808 [95% CI: 0.715-0.911]) to be the only significant predictor of ICU mortality. CONCLUSIONS: CRB-65 and NEWS2 scores assessed at the time of ICU admission offer only a fair discriminatory value for predicting mortality. Further evaluation after adding laboratory markers such as C-reactive protein and D-dimer may yield a more useful prediction model. Much of the earlier data is from developed countries and uses scoring at time of hospital admission. This study was from a developing country, with the scores assessed at time of ICU admission, rather than the emergency department as with existing data from developed countries, for patients with moderate/severe COVID-19 disease. Because the scores showed some utility for predicting ICU mortality even when measured at time of ICU admission, their use in allocation of limited ICU resources in a developing country merits further research.

Development and implementation of a sustainable COVID-19 training package for healthcare workers: Experience from a teaching hospital of North India.

Background: With the impending threat of future COVID-19 waves, it is imperative that teaching hospitals develop, implement, and evaluate a systematic training program to render HCW elastic in delivering COVID-19 related services. We present our experience in developing, implementing, and evaluating a sustainable and scalable COVID-19 patient management training package for healthcare workers. Materials and Methods: A mixed-methods study design was used. Rapid assessment to understand the need of the trainees and identify the available resources was done followed by planning of the training module and its implementation. The program was evaluated for effectiveness and sustainability. Data analysis was done using descriptive statistics and qualitative data generated from open-ended questions in the feedback forms and the discussions were analyzed using rapid content analysis. Results: A total of 66.8% of the doctors and 18.9% of the nurses were trained by online synchronous mode while 55.0% of the nursing officers and 47.1% of the nursing orderlies and paramedical staff were trained in onsite skill development sessions. Need assessment identified that healthcare workers were ill-prepared to use medical devices such as Bipap machines, ventilators, and oxygen delivery devices. The participants mentioned that the multidisciplinary approach and video-based demonstrations facilitated their online learning while the incremental learning approach, easy-to-understand terminology and hands-on experience facilitated their onsite skill development sessions. Conclusion: The COVID-19 training package developed was multidisciplinary, effective, sustainable, and scalable in a resource-limited setting. We suggest that this model can be adapted by healthcare organizations to develop and implement such training packages for their healthcare workers.

Effective Dose of Prophylactic Oxytocin Infusion During Cesarean Delivery in 90% Population of Nonlaboring Patients With Preeclampsia Receiving Magnesium Sulfate Therapy and Normotensives: An Up-Down Sequential Allocation Dose-Response Study.

BACKGROUND: Oxytocin administration during cesarean delivery is the first-line therapy for the prevention of uterine atony. Patients with preeclampsia may receive magnesium sulfate, a drug with known tocolytic effects, for seizure prophylaxis. However, no study has evaluated the minimum effective dose of oxytocin during cesarean delivery in women with preeclampsia. METHODS: This study compared the effective dose in 90% population (ED90) of oxytocin infusion for achieving satisfactory uterine tone during cesarean delivery in nonlaboring patients with preeclampsia who were receiving magnesium sulfate treatment with a control group of normotensives who were not receiving magnesium sulfate. This prospective dual-arm dose-finding study was based on a 9:1 biased sequential allocation design. Oxytocin infusion was initiated at 13 IU/h, on clamping of the umbilical cord, in the first patient of each group. Uterine tone was graded as satisfactory or unsatisfactory by the obstetrician at 4 minutes after initiation of oxytocin infusion. The dose of oxytocin infusion for subsequent patients was decided according to the response exhibited by the previous patient in the group; it was increased by 2 IU/h after unsatisfactory response or decreased by 2 IU/h or maintained at the same level after satisfactory response, in a ratio of 1:9. Oxytocin-associated side effects were also evaluated. Dose-response data for the groups were evaluated using a log-logistic function and ED90 estimates were derived from fitted equations using the delta method. RESULTS: The ED90 of oxytocin was significantly greater for the preeclampsia group (n = 27) than for the normotensive group (n = 40) (24.9 IU/h [95% confidence interval {CI}, 22.4-27.5] and 13.9 IU/h [95% CI, 12.4-15.5], respectively); the difference in dose requirement was 10.9 IU/h (95% CI, 7.9-14.0; P < .001). The number of patients with oxytocin-related hypotension, defined as a decrease in systolic blood pressure >20% from baseline or to <90 mm Hg, was significantly greater in the preeclampsia group (92.6% vs 62.5%; P = .030), while other side effects such as ST-T depression, nausea/vomiting, headache, and flushing, were not significantly different. There was no significant difference in the need for additional uterotonic or uterine massage, estimated blood loss, and need for re-exploration for uncontrolled bleeding. CONCLUSIONS: Patients with preeclampsia receiving preoperative magnesium therapy need a greater intraoperative dose of oxytocin to achieve satisfactory contraction of the uterus after fetal delivery, as compared to normotensives.

Covid-19 Pandemic: Resumption of Orthopedic Care and Medical Education.

Covid-19 is a respiratory disease caused by coronavirus 2 (SARS-CoV-2) first identified in Wuhan, China (December 2019). The disease rapidly crossed the barrier of countries, continents and spread globally. Non-pharmaceutical measures such as social distancing, face mask, frequent hand washing and use of sanitizer remained the best available option to prevent the spread of disease. OPD, IPD admissions, elective O. Ts were curtailed. Orthopedic care was only limited to emergency and semi-urgent procedures like necrotizing fasciitis, open fracture, and compartment syndrome. These measures were taken to preserve infrastructure and manpower to manage covid-19 pandemic. The children were thought to have a low susceptibility to covid-19 as compared to an adult. Deferring the patient during pandemic has led to high orthopedic disease burden, morbidity and disease-related sequelae, hence elective care must be resumed with modified hospital infrastructure. Resumption of elective/emergent orthopedic care should be slow, phasic and strategic, much similar to unlocking. Cases must be stratified depending on covid status and severity. Dedicated O.Ts with neutral/negative pressure and HEPA filter for covid positive and suspected patients are to be used. All symptomatic and suspected patients should be investigated for covid-19 by RT-PCR, blood counts and CT scan. Regional anaesthesia should be preferred to General anaesthesia. Power drill/saw/burr/pulse lavage should be minimized to avoid aerosol generation. Postoperatively continuous surveillance and monitoring to be done for covid related symptoms. Medical institutes rapidly shifted to the online mode of education. Blended learning (virtual & physical) and imparting skills have to be continued in post covid phase with equitable distribution of teaching hours to students of different years.

Correlates of In-Hospital COVID-19 Deaths: A Competing Risks Survival Time Analysis of Retrospective Mortality Data.

INTRODUCTION: Several aspects of the coronavirus disease 2019 (COVID-19) pandemic remain ambiguous, including its transmission, severity, geographic, and racial differences in mortality. These variations merit elaboration of local patterns to inform wider national policies. METHODS: In a retrospective analysis, data of patients treated at a dedicated COVID hospital with moderate and severe illness during 8 wk of the pandemic were reviewed with attention to mortality in a competing risks framework. RESULTS: A total of 1147 patients were hospitalized, and 312 (27.2%) died in hospital. Those who died were older (56.5 vs 47.6 y; P < 0.0001). Of these, 885 (77.2%) had tested positive on reverse transcriptase polymerase chain reaction (RT-PCR), with 219 (24.2%) deaths (incidence rate, 1.9 per 100 person-days). Median time from onset of symptoms to death was 11 days. A competing risks analysis for in-hospital death revealed an adjusted cause-specific hazard ratio of 1.4 for each decade increase in age. CONCLUSIONS: This retrospective analysis provides broad patterns of disease presentation and mortality. Even COVID test-negative patients will receive treatment at dedicated facilities, and 33% presenting cases may die within the first 72 h, most with comorbid illness. This should be considered while planning distribution of services for effective health-care delivery.