Preliminary Results From an Emergency Department Pain Coach Service and Discharge Toolkit Pilot Project During COVID-19

Study Objectives: Amid the US opioid epidemic, emergency providers and patients are searching for non-opioid or nonpharmacologic pain treatment options. The challenge of managing pain without opioids was escalated by the COVID-19 pandemic with opioid related overdoses and deaths increasing by 20-40%. Most healthcare professionals have limited knowledge, resources or time for pain education, especially in the emergency department (ED). To address these needs a novel pain coaching program was designed including a menu of nonpharmacologic patient discharge toolkit materials. Study objectives were to determine descriptive patient and toolkit utilization data and challenges in the first 4 months of a novel pain program. Methods: Target population consisted of patients ≥14 years of age seen by a new ED Pain Coaching staff from January 4, 2021- April 30, 2021. The two ED sites consisted of an urban, academic center with trauma center, pediatric ED, etc. and an affiliated community ED. Patients were determined by ED rounding, ED census review and consultation by ED staff, physicians, physical therapy, palliative care and pharmacy. Summary statistics for patient demographics, pain type, REALM-SF score, educational topics, toolkit materials, challenges and other data were ed from coaching and patient notes on a daily basis using a REDCap database for analysis. Upon request, there were select inpatient and repeat coaching encounters. Results: During this 4-month pilot, 296 coaching sessions were completed on 276 unique patients;20 screen outs for severe pain, procedures, violent behavior or other obstacles. Average age was 43 with 85% between 20-70 years of age;62% female;60% African American. Pain was 46% acute, 50% acute on chronic and 4% chronic with patients often having multiple pain etiologies: musculoskeletal (74%), inflammatory (71%), post-trauma (15%), headache (14%), post-surgical (4%) and neuropathic (3%). Education topics provided with accompanying toolkit items: hot/cold gel packs (90%), car with 4 flat tires analogy (90%), pain neuroscience education (88%), aromatherapy inhalers (82%), breathing techniques (69%), virtual reality (51%), exercise (38%), stretching (35%), diet (20%), acupressure (11%). The majority of patients were seen in 2 EDs or associated trauma center (87%);however, the coach received referrals for selected inpatients (13%). Seventeen educational brochures were made available to patients with aromatherapy, managing pain, pain and stress, and nonpharmacologic management being most utilized. Challenges to coaching included medical condition (14%), too much pain (11%), time constraints (7%);52% had no challenges. Regarding patient feedback, 61% indicated the session was helpful and 39% were unsure at the time. Conclusion: Results from this novel ED pain coach and discharge toolkit model provide valuable insights for development of a national pain coach model. Coaching scripts, note template, brochures, videos, inventory and other programmatic materials will be published for further implementation. Future plans include longitudinal patient follow-up, staff satisfaction assessment and addition of new modalities.

Effects of Stress from COVID-19 on chronic central serous retinopathy

Purpose : It was hypothesized that stress from COVID-19 would have a negative effect on Central Serous Retinopathy (CSR), a stress associated condition. The purpose of this study was to evaluate the effects of stress from COVID-19 on chronic CSR using a retrospective chart review. Methods : Charts from 45 patients, 67 eyes, with chronic CSR were evaluated. Data were collected pre COVID-19 shutdown (January 1, 2019 to March 15, 2020) and during COVID19 shutdown (March 15, 2020 to September 1, 2020) for visual acuity, central subfield thickness (CST), pigment epithelial detachment (PED), and subretinal fluid. Clinical change (improved, stable, or worsened) status was determined by the treating retinal specialist. The data were determined to not be normally distributed via the Shapiro-Wilk test. Statistical significance of the CST and vision data was determined by the sign test. The McNemar Exact test was used to determine statistical significance of PED and subretinal fluid. Results : Differences in data in pre vs post COVID-19 shutdown were not statistically significant. Clinically, 69% of patients were stable, 14% improved, and 17% worsened. Visual acuity pre COVID-19 shutdown averaged 20/37 (SD 20/46) and during the COVID-19 shutdown averaged 20/37 (SD 20/43);these changes were not statistically significant. CST pre COVID-19 shutdown averaged 281 μm (SD 57 μm) and during the COVID-19 shutdown averaged 288 μm (SD 83 μm);these changes were also not statistically significant. The majority of patients did not change in their presence or absence of PED (94%) or subretinal fluid (85%). Conclusions : Patients with chronic CSR did not see significant changes to their clinical status, vision, CST, subretinal fluid, or PED when assessed during the COVID-19 pandemic. Stress from onset of the COVID-19 did not appear to have a significant effect on patients with chronic CSR.

Nosocomial or not? A combined epidemiological and genomic investigation to understand hospital-acquired COVID-19 infection on an elderly care ward.

BACKGROUND: COVID-19 has the potential to cause outbreaks in hospitals. Given the comorbid and elderly cohort of patients hospitalized, hospital-acquired COVID-19 infection is often fatal. Pathogen genome sequencing is becoming increasingly important in infection prevention and control (IPC). AIM: To inform the understanding of in-hospital SARS-CoV-2 transmission in order to improve IPC practices and to inform the future development of virological testing for IPC. METHODS: Patients detected COVID-19 positive by polymerase chain reaction on Ward A in April and May 2020 were included with contact tracing to identify other potential cases. Genome sequencing was undertaken for a subgroup of cases. Epidemiological, genomic, and cluster analyses were performed to describe the epidemiology and to identify factors contributing to the outbreak. FINDINGS: Fourteen cases were identified on Ward A. Contact tracing identified 16 further patient cases; in addition, eight healthcare workers (HCWs) were identified as being COVID-19 positive through a round of asymptomatic testing. Genome sequencing of 16 of these cases identified viral genomes differing by two single nucleotide polymorphisms or fewer, with further cluster analysis identifying two groups of infection (a five-person group and a six-person group). CONCLUSION: Despite the temporal relationship of cases, genome sequencing identified that not all cases shared transmission events. However, 11 samples were found to be closely related and these likely represented in-hospital transmission. This included three HCWs, thereby confirming transmission between patients and HCWs.

Training Primary Care Physicians on Electronic Health Record Use During COVID-19

Providing training on critical practice management issues such as using your EHR appropriately and efficiently has become challenging during the COVID-19 pandemic. As organizations look for ways to decrease the burden of updating EHR systems and addressing physician burnout due to the demands of EHR use, innovative training methods are needed to educate physicians on ways to optimize EHR use. Physicians are a diverse learning audience, and may have not only an inhomogeneous baseline level of technical savvy but also individual preferences for various learning methods (e.g., lectures, videos, email, tutorials), potentially necessitating employment of a variety of training methods. This article discusses three innovative ways to successfully train physicians at their practices: short Zoom training sessions;peer remote trainers;and personalized optimization sessions. These strategies are tailored to the physicians and their practice needs as well as learning styles.

Implementing a change in practice in a different specialty via the chief registrar (CR) role

Junior doctor feedback from the General Medical Council (GMC) survey and quality panels has consistently highlighted poor handover in Acute Medical Unit (AMU) as a concern. Neglected handover practice has been identified as a key component of poor outcomes in root cause analyses within the unit. There was no formal handover of patients between the incoming and outgoing medical teams. Resolution of this problem was tasked to the chief registrar (CR). As an obstetrics and gynaecology registrar in the CR role there were potential benefits and barriers to taking on a project in a different specialty.The information gathering occurred over six months (surveys, focus groups, incident reporting). The implementation coincided with the COVID-19 surge. All staff were notified of the finalised plans the week before handover was implemented and key staff were individually approached to be champions. Feedback was encouraged and actively sought to highlight teething problems.The results show a clear improvement in handover practice, junior doctor support and multi-professional team working. There had been resistance from some senior clinicians to attend an evening handover in the planning stages, however, implementing change at the height of the pandemic meant that staff had to adapt rapidly to new ways of working and as a result this change was widely accepted and implemented. The next stage is to incorporate more teaching into handover practice by including ‘teaching bites.’Upon starting the CR job this was presented as an unsolvable project. However, by a thorough analysis and formation of a plan for change with buy-in from the entire team we were able to affect a successful change. This demonstrates the value of seconding middle grade doctors to management roles as they can provide a crucial link between medical and management staff and coordinate vital change to improve patient safety.