Strategies to achieve adherence to prone positioning in awake COVID-19 patients with high-flow nasal oxygen. A case series.

Introduction: The use of high-flow nasal oxygen (HFNO) is a simple method that can reduce intubation in patients with hypoxemic acute respiratory failure (ARF). Early and prolonged prone position has demonstrated benefits on mortality in mechanically ventilated patients and on intubation in awake patients with ARF. However, strategies to achieve adherence to awake prone positioning (APP) have not been previously described. Case and outcomes: We present six patients with ARF due to COVID-19 treated with HFNO and APP. The median (p25-75) of PaFiO2 upon admission was 121 (112-175). The average duration of APP on the first day was 16 h (SD 5 h). Duration (median p25-75) in APP for the following 20 days was 13 (10-18) h/day. Several strategies such as the presence of a health care team, recreational activities, adaptation of the circadian rhythm, oral nutritional support, and analgesics were used to improve prone tolerance. None of the patients suffered from delirium, all were ambulating on discharge from the ICU and none require intubation. Conclusion: The case series presented show the feasibility of prolonged use of HFNO and APP in patients with COVID-19 and severe persistent hypoxemia and described strategies to enhance adherence.

Characteristics of Post-ICU and Post-COVID Recovery Clinics in 29 U.S. Health Systems

OBJECTIVES: The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States. DESIGN: Cross-sectional survey. SETTING: Thirty-nine RCs, representing a combined 156 hospitals within 29 health systems participated. PATIENTS: None. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: RC demographics, referral criteria, and operating characteristics were collected, including measures used to assess physical, psychologic, and cognitive recoveries. Thirty-nine RC surveys were completed (94% response rate). ICU-RC teams included physicians, pharmacists, social workers, physical therapists, and advanced practice providers. Funding sources for ICU-RCs included clinical billing (n = 20, 77%), volunteer staff support (n = 15, 58%), institutional staff/space support (n = 13, 46%), and grant or foundation funding (n = 3, 12%). Forty-six percent of RCs report patient visit durations of 1 hour or longer. ICU-RC teams reported use of validated scales to assess psychologic recovery (93%), physical recovery (89%), and cognitive recovery (86%) more often in standard visits compared with COVID-RC teams (psychologic, 54%;physical, 69%;and cognitive, 46%). CONCLUSIONS: Operating structures of RCs vary, though almost all describe modest capacity and reliance on volunteerism and discretionary institutional support. ICU- and COVID-RCs in the United States employ varied funding sources and endorse different assessment measures during visits to guide care coordination. Common features include integration of ICU clinicians, interdisciplinary approach, and focus on severe critical illness. The heterogeneity in RC structures and processes contributes to future research on the optimal structure and process to achieve the best postintensive care syndrome and postacute sequelae of COVID outcomes.

Adherencia Al Paquete De Medidas Abcdef Durante La Pandemia De Covid-19 ABCDEF bundle implementation in Argentina during COVID-19 pandemic

INTRODUCCIÓN: El objetivo de este estudio fue describir el conocimiento y el uso reportado del paquete de medidas ABCDEF en las unidades de cuidados intensivos (UCI) de adultos de la República Argentina durante la pandemia por SARS-CoV-2. MÉTODOS: Se realizó un estudio cualitativo a través de una encuesta nacional dirigida a profesionales de la salud. RESULTADOS: Se recibieron 396 cuestionarios completos de profesionales de 21 provincias argentinas y la Ciudad Autónoma de Buenos Aires. El 66% de los participantes contestó que conoce el paquete y lo aplica con diferentes grados de implementación. El 42,9% informó que usa al menos una herramienta validada para evaluar el dolor. Más de la mitad de los encuestados afirman realizar vacaciones de sedación y pruebas de ventilación espontánea diariamente. Las escalas de sedación fueron utilizadas por el 66,6% de los participantes en forma rutinaria. El 62% utiliza herramientas validadas para la detección de delirium. Respecto de la movilización temprana y ejercicio de los pacientes, el 91,8% de los profesionales entrevistados comunicaron que realizan rehabilitación neuromuscular en su UCI. Finalmente, sólo el 6,8% informó que su unidad estaba abierta las 24 horas para las visitas familiares. Las principales barreras a la aplicación del paquete de medidas fueron los recursos humanos y hospitalarios limitados, la resistencia al cambio, la falta de información y el aislamiento por COVID-19. CONCLUSIÓN: El 66% de los participantes contestó que conoce el paquete y lo aplica con diferentes grados de implementación.

Adherencia Al Paquete De Medidas Abcdef Durante La Pandemia De Covid-19

RESUMEN INTRODUCCIÓN: El objetivo de este estudio fue describir el conocimiento y el uso reportado del paquete de medidas ABCDEF en las unidades de cuidados intensivos (UCI) de adultos de la República Argentina durante la pandemia por SARS-CoV-2. MÉTODOS: Se realizó un estudio cualitativo a través de una encuesta nacional dirigida a profesionales de la salud. RESULTADOS: Se recibieron 396 cuestionarios completos de profesionales de 21 provincias argentinas y la Ciudad Autónoma de Buenos Aires. El 66% de los participantes contestó que conoce el paquete y lo aplica con diferentes grados de implementación. El 42,9% informó que usa al menos una herramienta validada para evaluar el dolor. Más de la mitad de los encuestados afirman realizar vacaciones de sedación y pruebas de ventilación espontánea diariamente. Las escalas de sedación fueron utilizadas por el 66,6% de los participantes en forma rutinaria. El 62% utiliza herramientas validadas para la detección de delirium. Respecto de la movilización temprana y ejercicio de los pacientes, el 91,8% de los profesionales entrevistados comunicaron que realizan rehabilitación neuromuscular en su UCI. Finalmente, sólo el 6,8% informó que su unidad estaba abierta las 24 horas para las visitas familiares. Las principales barreras a la aplicación del paquete de medidas fueron los recursos humanos y hospitalarios limitados, la resistencia al cambio, la falta de información y el aislamiento por COVID-19. CONCLUSIÓN: El 66% de los participantes contestó que conoce el paquete y lo aplica con diferentes grados de implementación. INTRODUCTION: The aim of this study was to assess the knowledge and use of the ABCDEF bundle in the intensive care units (ICU) from Argentina during COVID-19 pandemic. METHODS: A nationwide online survey was conducted on physicians, nurses and physiotherapists. RESULTS: 396 complete questionnaires were received from professionals from 21 Argentine provinces and the Autonomous City of Buenos Aires. 66% of the participants answered that they knew the bundle and applied it with different degrees of implementation. 42.9% reported using at least one validated tool to assess pain. Spontaneous awakening trials and spontaneous breathing trials are performed by the majority of the responders. Sedation scales were used by 66.6% of the participants routinely. Delirium monitoring was implemented by 62%. Regarding early mobilization and exercise of patients, 91.8% of the professionals interviewed reported that they perform neuromuscular rehabilitation in their ICU. Finally, only 6.8% reported that their unit was open 24 hours for family visits. Main barriers for bundle implementation were limited human and hospital resources, resistance to change, lack of information and isolation due to COVID-19. CONCLUSION: 66% of the participants answered that they know the package and apply it with different degrees of implementation.