Developing a transfer risk assessment tool for the Midlands Critical Care Network

Introduction: Inter-facility critical care transfers are a high-risk activity, with a significant reported critical incident rate.1 The 2019 ICS Transfer of the Critically Ill Adult Patient guideline2 recommends a consultant-led risk assessment is performed in order to provide a rationale for the make-up of the transfer team. Prior to our project, there was no formalised risk assessment process at our unit. Objective(s): We wished to assess whether any 'informal' risk assessment process was already being performed prior to transfers. We then aimed to implement a clear assessment process, initially for our unit but ultimately for our critical care network. Method(s): We performed a baseline audit of adult inter-facility critical care transfers undertaken by a team from our unit between 1st December 2019 and 28th February 2020. Notes were analysed for evidence of any risk assessment performed in discussion with the responsible consultant We then locally piloted a new risk assessment tool for our Critical Care Network's transfer documentation. It included the required elements from ICS guidance, and followed a systems-based approach to facilitate completion in time-critical situations. Colour coding enabled easy identification of potential high-risk transfers and guided team formation. Initial re-audit of the new tool was performed between 16th September and 16th October 2020, after which it was implemented across the network. A further re-audit was performed between 1st October and 31st December 2021. Result(s): Fifteen transfers occurred during the initial audit period. All were clinical. No risk assessments were documented (0% compliance), although all were accompanied by a transfer-trained, airway competent doctor and all but one by an ODP. Our second audit cycle identified 10 transfers, of which 4 had risk assessments completed (40% compliance). All transfers had been undertaken with a dual doctor/ODP team. We identified that there was limited knowledge of the risk assessment process among clinicians, so introduced the topic into our unit's transfer training programme. Assessment completion was made a key performance indicator, fed back to team members following each transfer. Our final cycle covered 14 clinical transfers. Eight had a fully completed risk assessment (57% compliance), 2 had partially completed risk assessments (14% partial compliance), 4 had no risk assessment and 2 cases were excluded due to incomplete data. Conclusion(s): Our tool is now used for all inter-hospital transfers across the Midlands Critical Care Network. It enabled risk assessments to be performed appropriately for transfers originating from our unit. Introduction was initially hampered by limited training for clinicians during the first wave of the Covid pandemic, and compliance improved once this was implemented. The recent introduction of a regional critical care transfer service means that the majority of transfers undertaken by our unit's staff are now time-critical clinical transfers. This may contribute to the failure to complete risk assessments in some cases, however these assessments are likely to be of higher importance since such transfers may be higher risk. We now aim to collect feedback from transferring staff to identify any barriers to correct completion.

Nurses with workplace violence in pneumology settings during Covid-19

Background: Workplace violence (WPV) has consequences both for healthcare workers and healthcare organizations. Nurses are the most exposed healthcare workers to vertical WPV. Aims and Objectives: Describe the Italian WPV and identify its predictive factors. Method(s): This is a secondary analysis conducted in hospital pneumology settings from a larger study between January and April 2021. Data were collected through the Practice Environment Scale of the Nursing Work Index (PES-NWI;Likert scale 1 to 4) and the Violence in Emergency Nursing and Triage (VENT) Questionnaire. Result(s): The analysis was conducted on 484 pulmonary nurses (72.9% female;mean age 38.9 years, SD 9.8). Thirty-four per cent (n=164) of them have had an experience of WPV in last year and/or their last week and 16.7% (n=81) only in their last week. Comparing main results between nurses with WPV vs no WPV the number of patients was higher for nurses with WPV (MD +4.8;p<.001). The PES-NWI results were significantly worse for nurses with WPV: global mean scores (MD +0.2;p<.001);nurse participation in hospital affairs (MD +0.3;p<.001);nurse manager ability leadership, and support of nurses (MD +0.2;p<.001);physician-nurse relationship (MD +0.2;p<.001). Conclusion(s): Public health companies should reduce WPV by investing in resources for the management and prevention of the phenomenon. Integrated and multimodal programs of prevention and management of WPV are useful to combat it. Improving the work environment and job satisfaction should reduce WPV.

A series of diabetic ketoacidosis associated with the use of sodium-glucose co-transporter-2 inhibitors in secondary care

Background and aims: Sodium-glucose co-transporter-2 inhibitors (SGLT-2i) are associated with diabetic ketoacidosis (DKA), though limited real-world case series are published. The aim of this study is to examine the number and characteristics of patients admitted with SGLT2i-associated DKA to our hospital over a 4-month period. Method(s): Patients were identified retrospectively following referral to the diabetes team with SGLT2i-associated DKA between September-December 2021. Medical notes were reviewed and data related to the patients' characteristics, diabetes control, usual medications and previous medical comorbidities were collected. Result(s): Twenty-two patients with SGLT2i-associated DKA were iden tified;21 (95.5%) were hyperglycaemic and 1 (4.5%) was euglycaemic. Patients had a mean age (+/-standard deviation) 60.8+/-12.3 years and HbA1c 89.2+/-29.2 mmol/mol (10.3%). Of these patients 45.5% were diagnosed with DKA alone, though some had concurrent bacterial (27.3%) or COVID-19 (18.2%) infection. There was significant treatment heterogeneity;nine (40.9%) patients were treated with insulin and 13 (59.1%) patients with other agents. Thirteen (59.1%) patients had no significant medical co-morbidity, though nine (40.9%) patients had underlying cardiovascular, respiratory and/or malignant co-morbidity. Of the 22 patients admitted with DKA, 19 (86.4%) were discharged alive, and three patients (13.6%) died during the admission. Conclusion(s): We observed no specific characteristics which predisposed to SGLT2i-associated DKA or more severe ketoacidosis in this cohort, consistent with previous studies. Most cases were in hyperglycaemic DKA, and people with SGLT2i-associated euglycaemic DKA may have been missed. Given the number of cases observed in our hospital and the associated mortality, greater awareness of the condition is essential.

Pediatric Acute Lung Injury and Sepsis Investigators (PALISI): Evolution of an Investigator-Initiated Research Network.

The Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network originated over 20 years ago to foster research to optimize the care of critically ill infants and children. Over this period, PALISI has seen two major evolutions: formalization of our network infrastructure and a broadening of our clinical research focus. First, the network is unique in that its activities and meetings are funded by subscriptions from members who now comprise a multidisciplinary group of investigators from over 90 PICUs all over the United States (US) and Canada, with collaborations across the globe. In 2020, the network converted into a standalone, nonprofit organizational structure (501c3), making the PALISI Network formally independent of academic and clinical institutions or professional societies. Such an approach allows us to invest in infrastructure and future initiatives with broader opportunities for fund raising. Second, our research investigations have expanded beyond the original focus on sepsis and acute lung injury, to incorporate the whole field of pediatric critical care, for example, efficient liberation from mechanical ventilator support, prudent use of blood products, improved safety of intubation practices, optimal sedation practices and glucose control, and pandemic research on influenza and COVID-19. Our network approach in each field follows, where necessary, the full spectrum of clinical and translational research, including: immunobiology studies for understanding basic pathologic mechanisms; surveys to explore contemporary clinical practice; consensus conferences to establish agreement about literature evidence; observational prevalence and incidence studies to measure scale of a clinical issue or question; case control studies as preliminary best evidence for design of definitive prospective studies; and, randomized controlled trials for informing clinical care. As a research network, PALISI and its related subgroups have published over 350 peer-reviewed publications from 2002 through September 2022.

Substance Use Behaviors Among LGBTQ Youth of Color: Applying a Novel Method in Two Large Samples to Identify Intersecting Social Positions Bearing the Greatest Burden

Purpose: The global COVID pandemic, social uprisings, and a wave of discriminatory policy proposals have highlighted the ways in which structural oppression contributes to health disparities facing youth of color and those identifying as LGBTQ. Young people living at the intersection of multiple types of oppression face the greatest burden, yet also have unique strengths and supports. Existing research has demonstrated persistent substance use disparities across sexual orientation, gender identity, and racial/ethnic groups – as individual categories. However, very little research has examined substance use among those with multiple stigmatized identities. Capitalizing on two very large datasets and a novel analytic technique, this study seeks to identify groups with the highest prevalence of past 30-day alcohol, e-cigarette, and marijuana use. This first step in a larger project will determine key intersecting identities for qualitative interviews regarding interpersonal and community supports that can reduce health disparities. Methods: Data come from the 2019 Minnesota Student Survey and the 2017-2019 California Healthy Kids Survey, two surveillance programs with a combined sample of 892,664 students in grades 6-12. Data were harmonized across sources to create compatible variables including race/ethnicity (non-Hispanic Native American, Asian/Pacific Islander, Black/African/African American, White, Multiracial;Latina/x/o), sexual orientation (straight, gay/lesbian, bisexual, questioning, something else [e.g. pansexual, queer]), gender identity (cisgender, transgender/gender diverse [TGD], questioning), sex assigned at birth (male, female), state, and past 30-day substance use (yes/no for alcohol, e-cigarettes, marijuana). Exhaustive Chi-square Automatic Interaction Detection (CHAID) analysis, a decision tree approach, was used to examine all interactions among social positions with the goal of identifying distinct groups with significantly different rates of substance use behaviors (Bonferroni adjusted p<.05). The groups with the highest prevalence for each substance were examined. Results: The overall prevalence of past 30-day substance use was 10.4% for alcohol, 9.7% for e-cigarettes, and 9.7% for marijuana, with substantial disparities across intersecting groups. For example, although 10.5% of Latina/x/o-identified youth and 20.8% of TGD-identified youth reported drinking alcohol, Latina/x/o TGD youth were among those with the highest prevalence of use, particularly those who also identified with a newer sexual orientation label (e.g. pansexual, queer) and were assigned male at birth (26.2%) or Latina/x/o TGD youth who did not indicate their sexual orientation (31.7%). This pattern was also evident for e-cigarette and marijuana use. Similarly, Black TGD youth had significantly higher rates of alcohol (26.9%), e-cigarette (29.2%, in California), and marijuana use (24.4%, straight-identified;29.5%, missing sexual orientation). Conclusions: Using the power and diversity of large population-based datasets and an innovative analytic technique specifically recommended for studies of intersectionality, we found significant disparities in substance use, with the burden varying by unique intersecting marginalized identities. This approach is recommended to examine disparities in groups often treated as homogeneous, as a precursor to developing relevant and appropriate prevention strategies. Further research is needed to identify structural factors contributing to these high rates. Clinicians, educators, and others working with youth should address intersecting types of stigma and oppression that may contribute to substance use. Sources of Support: National Institute of Minority Health and Health Disparities grant #R01MD015722.

SARS-CoV-2-SPECIFIC T CELLS ASSOCIATED with LUNG DYSFUNCTION in LONG COVID-19

Background: After infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a significant number of individuals develop post-acute sequelae of COVID-19 (PASC) marked by prolonged symptoms, including persistent pulmonary dysfunction. An estimated 5-20% of those infected with SARS-CoV-2 will go on to develop PASC. T cells and inflammation contribute significantly to severe COVID-19 and similar chronic conditions;however, little is known about the role of persistent inflammation and SARS-CoV-2-specific immunity in PASC. The objective of this study is to compare inflammatory markers, frequencies of SARS-CoV-2-specific T cells, and pulmonary function in subjects who recovered from acute COVID infection (AC) and PASC. Methods: We collected blood samples from 35 individuals after recovery from SARS-CoV-2 infection and divided the cohort by symptom duration into AC or PASC. We measured T cell responses to SARS-CoV-2 surface proteins, assessed levels of inflammatory markers in the plasma and measured pulmonary function. The Mann-Whitney U test were utilized to examine differences between groups. Correlations were calculated using the nonparametric Spearman test. P values of <0.05 were considered statistically significant. Results: Compared to AC, subjects with PASC had significantly elevated plasma CRP and IL-6 and up to a hundred-fold increase in the frequency of IFN-γ-and TNF-α-producing SARS-CoV-2-specific CD4+ and CD8+ T cells in blood. Importantly, the frequency of SARS-CoV-2-specific, TNF-α-producing CD4+ and CD8+ T cells in PASC positively correlated with plasma IL-6 and negatively correlated with measures of lung function, including FEV1, while increased frequencies of IFN-γ-producing T cells were associated with the duration of respiratory symptoms during the post-acute period. Conclusion: Significant immunological differences exist between subjects with PASC and AC that are associated with increased inflammation and pulmonary dysfunction, suggesting that persistent immunologic differences may drive ongoing symptoms in PASC. The persistence of SARS-CoV-2-specific T cells in PASC suggests the presence of persistent viral reservoirs as a possible mechanism behind PASC etiology.

Experiences of female academics in Australia during COVID-19: Opportunities and challenges

An online survey collected data on a range of female academic experiences globally gaining 260 responses with 144 Australian specific academics' responses (55% of total responses). The pandemic has highlighted positive opportunities such as online teaching and skill development, flexibility, time efficiency, increased collaboration, and time for research. In terms of challenges identified responses indicate an increased workload, less motivation for career progression, and perceptions of greater and obvious gender disparity and bias against female academics. Australia is often referred to as a 'lucky country' which can further be enriched though fostering its rich and diverse female academic community into the future. Rapid measures to support women immediately and with a longer-term solutions that address gender equity is critical for female academics to ensure future engagement of female academics for positive economic and social growth as a nation.

Parenchymal involvement on CT pulmonary angiography in SARS-CoV-2 Alpha variant infection and correlation of COVID-19 CT severity score with clinical disease severity and short-term prognosis in a UK cohort.

AIM: To determine if there is a difference in radiological, biochemical, or clinical severity between patients infected with Alpha-variant SARS-CoV-2 compared with those infected with pre-existing strains, and to determine if the computed tomography (CT) severity score (CTSS) for COVID-19 pneumonitis correlates with clinical severity and can prognosticate outcomes. MATERIALS AND METHODS: Blinded CTSS scoring was applied to 137 hospital patients who had undergone both CT pulmonary angiography (CTPA) and whole-genome sequencing of SARS-CoV-2 within 14 days of CTPA between 1/12/20-5/1/21. RESULTS: There was no evidence of a difference in imaging severity on CTPA, viral load, clinical parameters of severity, or outcomes between Alpha and preceding variants. CTSS on CTPA strongly correlates with clinical and biochemical severity at the time of CTPA, and with patient outcomes. Classifying CTSS into a binary value of "high" and "low", with a cut-off score of 14, patients with a high score have a significantly increased risk of deterioration, as defined by subsequent admission to critical care or death (multivariate hazard ratio [HR] 2.76, p<0.001), and hospital length of stay (17.4 versus 7.9 days, p<0.0001). CONCLUSION: There was no evidence of a difference in radiological severity of Alpha variant infection compared with pre-existing strains. High CTSS applied to CTPA is associated with increased risk of COVID-19 severity and poorer clinical outcomes and may be of use particularly in settings where CT is not performed for diagnosis of COVID-19 but rather is used following clinical deterioration.

Physiotherapist-led online exercise session for People with cystic fibrosis (cf) during the Covid-19 pandemic: A service evaluation

Background Public Health England guidance advised people with CF to shield during the COVID-19 pandemic. We were concerned about patients struggling with isolation, lack of team contact and the inability to exercise. As such, we set up interactive exercise sessions for patients attending our unit, with the aim of supporting our patients to remain active while complying with the guidance and creating a holistic support network. Methods Over the 4 months of shielding, we developed eleven interactive online sessions per week, with different levels of intensity, and delivered these simultaneously to inpatients and outpatients. All patients at the Leeds Adult CF Unit, regardless of session attendance, were invited to answer an evaluation questionnaire for the service. Feedback from the multidisciplinary team (MDT) was also collated. Results Overall 75 patients attended the sessions at least once, and 36% of them provided feedback. 70% of patients found it harder to motivate themselves without the sessions and 83% reported exercising more frequently as a result. Over 75% of patients thought the sessions were enjoyable and would continue after shielding. Among those who did not attend the sessions, 22% of patients responded to our survey and the majority reported that they already achieved the minimum activity levels. Feedback from the MDT was very positive as the sessions allowed staff to identify patients needing greater input to optimise care and enable individualised reviews. Staff morale and well-being was also positively affected by the sessions. Conclusion The interactive online exercise sessions gave our patients the opportunity to engage in a physiotherapy-led exercise programme during shielding. Both active and inactive patients participated as a result of offering different intensity training options. Through the medium of live online classes, we were able to give people in shielding social contact, peersupport from others in the same situation and enhancement of physical health. Direct contact with the familiar physiotherapy team allowed advice to be given as required. This service will be monitored and reviewed in a further 3 and 6 months post cessation of shielding.

High incidence of barotrauma in critically ill patients with COVID-19

INTRODUCTION: Intubated patients with acute respiratory distress syndrome are thought to have a 5-12% incidence of barotrauma, even with protective ventilation. However, little is known about the incidence of barotrauma in COVID-19. Due to high rates of observed barotrauma at this center, this retrospective cohort study aims to better characterize the incidence of barotrauma and identify predisposing factors such as inflammatory markers and disease severity indices for this high-mortality complication. METHODS: Inclusion criteria were as follows: age over 18 years, positive RT-PCR for SARS-CoV2, admission to the ICU between 03/15/2020 and 06/15/2020, and a score of 5 or higher on the World Health Organization's Ordinal Scale or respiratory rate over 30 breaths per minute on admission. Data were collected for the following categories developed by an internal committee of pulmonary/critical care faculty and housestaff based on similar studies: age, sex, body mass index, ferritin, d-dimer, APACHE II score, SOFA score, blood gas, ventilation mode and settings. Patients with evidence of barotrauma (pneumothorax, pneumomediastinum, pneumopericardium, subcutaneous emphysema) on imaging had additional respiratory data points collected. RESULTS: 78 patients met inclusion. Among 38 patients who received invasive mechanical ventilation (IMV) 12 had barotrauma (32%). Of 40 patients who did not receive IMV 3 had barotrauma (8%). Of 15 cases of barotrauma, 8 had pneumothorax (2 bilateral, 6 unilateral), 9 had pneumomediastinum, 4 had pneumopericardium, 6 had subcutaneous emphysema. 8 were found incidentally on imaging for non-respiratory indication. Mortality in the barotrauma group was 72% for IMV & 50% for non-IMV (3 patients transferred to other hospital, 3 remain hospitalized) compared to 50% for IMV & 8% for non-IMV in patients without barotrauma. Further analysis pending at submission, data to be finalized prior to presentation. CONCLUSIONS: Barotrauma may be an underappreciated complication of COVID-19, perhaps serving as an independent predictor of disease severity or low lung compliance. Many theories have been presented for the physiology of COVID-19 respiratory failure, but barotrauma could be evidence of or a herald sign for the low compliance phenotype.

E. COLI PNEUMONIA WITH PNEUMATOCELE, EMPYEMA NECESSITANS, AND BRONCHOPLEURAL FISTULA IN A PATIENT WITH SEVERE COVID-19

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tocilizumab, an interleukin-6 inhibitor used in rheumatologic disease and cytokine release syndrome, is one of many investigational drugs used for coronavirus disease-19 pneumonia (COVID). While the safety profile has been well studied, there is little known about its effect on opportunistic infections (OI) risk in patients with COVID. We present a 43-year-old man with COVID who received tocilizumab and subsequently developed cavitating lung lesions suspicious for invasive aspergillosis. CASE PRESENTATION: A 43-year-old man with diabetes mellitus was admitted for hypoxemic respiratory failure (HRF). Nasopharyngeal swab polymerase chain reaction was positive for COVID. He was placed on high-flow nasal cannula (HFNC), and on day 10 he was intubated for worsening HRF. He was treated with ceftriaxone, azithromycin, methylprednisolone, convalescent plasma, and tocilizumab. Antibiotics later included ertapenem due to E. coli with extended-spectrum beta lactamase (ESBL) found in sputum culture. He was extubated on day 15 and oxygen requirements were weaned to HFNC. However, bronchial aspirate cultures from day 14 grew mold and subsequent serologies were positive for Aspergillus. Chest computerized tomography (CT) was notable for the development of multiple new cavitary lesions concerning for invasive pulmonary aspergillosis. The patient was initially treated with voriconazole and later with amphotericin B due to liver enzyme elevation. The patient’s oxygen requirements initially decreased, however on day 30 the patient suffered an aspiration event and was reintubated. Subsequent CT was concerning for worsening of cavitary lung disease. Bronchoalveolar lavage was collected, which tested positive for Aspergillus galactomannan. On hospital day 31, the patient suffered a left-sided tension pneumothorax requiring tube thoracostomy. At the time of submission the patient remains critically ill. DISCUSSION: Influenza-associated pulmonary aspergillosis (IAPA) is a known complication of severe influenza.1,2 Similarly, COVID-associated pulmonary aspergillosis (CAPA) may become an emerging problem given the overwhelming inflammation and use of experimental immunosuppressive therapies in COVID.1,2 While tocilizumab has not been shown to increase risk of Aspergillus infection in rheumatologic disease, it has not been studied in COVID and the risk of OI in an already-susceptible group may outweigh the benefits of using this drug in patients with COVID.3 If CAPA is similar to IAPA, BAL galactomannan is the gold standard for diagnosis.2 CONCLUSIONS: As the medical community searches for COVID treatments, these patients’ potentially inherent vulnerability to OI may be under-appreciated. When using immunosuppressive agents to curtail the inflammatory cascade, the risk of OI must be considered and agents like tocilizumab must be further studied in this context. Reference #1: Koehler P, Cornely OA, Böttiger BW, et al. COVID-19 associated pulmonary aspergillosis. Mycoses. 2020;63(6):528-534. Reference #2: van Arkel ALE, Rijpstra TA, Belderbos HNA, van Wijngaarden P, Verweij PE, Bentvelsen RG. COVID-19 associated pulmonary aspergillosis. Am J Respir Crit Care Med. 2020;online May 2020. Reference #3: Kourbeti IS, Ziakas PD, Mylonakis E. Biologic therapies in rheumatoid arthritis and the risk of opportunistic infections: a meta-analysis. Clin Infect Dis. 2014;58(12):1649-57. DISCLOSURES: No relevant relationships by Michael Kahn, source=Web Response No relevant relationships by Nader Kamangar, source=Web Response No relevant relationships by Jay Thetford, source=Web Response No relevant relationships by Richard Watson, source=Web Response

Chest CT screening for COVID-19 in elective and emergency surgical patients: experience from a UK tertiary centre.

AIM: To determine the incidence of possible COVID-19-related lung changes on preoperative screening computed tomography (CT) for COVID-19 and how their findings influenced decision-making. To also to determine whether the patients were managed as COVID-19 patients after their imaging findings, and the proportion who had SARS-CoV2 reverse transcriptionpolymerase chain reaction (RT-PCR) testing. MATERIALS AND METHODS: A retrospective study was undertaken of consecutive patients having imaging prior to urgent elective surgery (n=156) or acute abdominal imaging (n=283). Lung findings were categorised according to the British Society of Thoracic Imaging (BSTI) guidelines. RT-PCR testing, management, and outcomes were determined from the electronic patient records. RESULTS: 3% (13/439) of CT examinations demonstrated findings of classic/probable COVID-19 pneumonia, whilst 4% (19/439) had findings indeterminate for COVID-19. Of the total cohort, 1.6% (7/439) subsequently had confirmed RT-PCR-positive COVID-19. Importantly, all the patients with a normal chest or alternative diagnoses on CT who had PCR testing within the next 7 days, had a negative RT-PCR (92/407). There was a change in surgical outcome in 6% (10/156) of the elective surgical cohort with no change to surgical management was demonstrated in the acute abdominal emergency cohort requiring surgery (2/283). CONCLUSION: There was a 7% (32/439) incidence of potential COVID-19-related lung changes in patients having preoperative CT. Although this altered surgical management in the elective surgical cohort, no change to surgical management was demonstrated in the acute abdominal emergency cohort requiring surgery.