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1.
Neurocrit Care ; 35(2): 577-589, 2021 10.
Article in English | MEDLINE | ID: covidwho-1516917

ABSTRACT

BACKGROUND: Multiple studies demonstrate that fever/elevated temperature is associated with poor outcomes in patients with vascular brain injury; however, there are no conclusive studies that demonstrate that fever prevention/controlled normothermia is associated with better outcomes. The primary objective of the INTREPID (Impact of Fever Prevention in Brain-Injured Patients) trial is to test the hypothesis that fever prevention is superior to standard temperature management in patients with acute vascular brain injury. METHODS: INTREPID is a prospective randomized open blinded endpoint study of fever prevention versus usual care in patients with ischemic or hemorrhagic stroke. The fever prevention intervention utilizes the Arctic Sun System and will be compared to standard care patients in whom fever may spontaneously develop. Ischemic stroke, intracerebral hemorrhage or subarachnoid hemorrhage patients will be included within disease-specific time-windows. Both awake and sedated patients will be included, and treatment is initiated immediately upon enrollment. Eligible patients are expected to require intensive care for at least 72 h post-injury, will not be deemed unlikely to survive without severe disability, and will be treated for up to 14 days, or until deemed ready for discharge from the ICU, whichever comes first. Fifty sites in the USA and worldwide will participate, with a target enrollment of 1176 patients (1000 evaluable). The target temperature is 37.0 °C. The primary efficacy outcome is the total fever burden by °C-h, defined as the area under the temperature curve above 37.9 °C. The primary secondary outcome, on which the sample size is based, is the modified Rankin Scale Score at 3 months. All efficacy analyses including the primary and key secondary endpoints will be primarily based on an intention-to-treat population. Analysis of the as-treated and per protocol populations will also be performed on the primary and key secondary endpoints as sensitivity analyses. DISCUSSION: The INTREPID trial will provide the first results of the impact of a pivotal fever prevention intervention in patients with acute stroke ( www.clinicaltrials.gov ; NCT02996266; registered prospectively 05DEC2016).


Subject(s)
COVID-19 , Brain , Critical Care , Humans , Prospective Studies , Randomized Controlled Trials as Topic , SARS-CoV-2
2.
Semin Neurol ; 41(5): 473-474, 2021 10.
Article in English | MEDLINE | ID: covidwho-1467170
3.
Clin Infect Dis ; 72(10): e566-e576, 2021 05 18.
Article in English | MEDLINE | ID: covidwho-1232195

ABSTRACT

BACKGROUND: Assessing the impact of coronavirus disease 2019 (COVID-19) on intensive care unit (ICU) providers' perceptions of resource availability and evaluating the factors associated with emotional distress/burnout can inform interventions to promote provider well-being. METHODS: Between 23 April and 7 May 2020, we electronically administered a survey to physicians, nurses, respiratory therapists (RTs), and advanced practice providers (APPs) caring for COVID-19 patients in the United States. We conducted a multivariate regression to assess associations between concerns, a reported lack of resources, and 3 outcomes: a primary outcome of emotional distress/burnout and 2 secondary outcomes of (1) fear that the hospital is unable to keep providers safe; and (2) concern about transmitting COVID-19 to their families/communities. RESULTS: We included 1651 respondents from all 50 states: 47% were nurses, 25% physicians, 17% RTs, and 11% APPs. Shortages of intensivists and ICU nurses were reported by 12% and 28% of providers, respectively. The largest supply restrictions reported were for powered air purifying respirators (56% reporting restricted availability). Provider concerns included worries about transmitting COVID-19 to their families/communities (66%), emotional distress/burnout (58%), and insufficient personal protective equipment (PPE; 40%). After adjustment, emotional distress/burnout was significantly associated with insufficient PPE access (adjusted relative risk [aRR], 1.43; 95% confidence interval [CI], 1.32-1.55), stigma from community (aRR, 1.32; 95% CI, 1.24-1.41), and poor communication with supervisors (aRR, 1.13; 95% CI, 1.06-1.21). Insufficient PPE access was the strongest predictor of feeling that the hospital is unable to keep providers safe and worries about transmitting infection to their families/communities. CONCLUSIONS: Addressing insufficient PPE access, poor communication from supervisors, and community stigma may improve provider mental well-being during the COVID-19 pandemic.


Subject(s)
COVID-19 , Pandemics , Critical Care , Humans , Perception , SARS-CoV-2 , Surveys and Questionnaires , United States
5.
Chest ; 159(2): 619-633, 2021 02.
Article in English | MEDLINE | ID: covidwho-1049757

ABSTRACT

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has severely affected ICUs and critical care health-care providers (HCPs) worldwide. RESEARCH QUESTION: How do regional differences and perceived lack of ICU resources affect critical care resource use and the well-being of HCPs? STUDY DESIGN AND METHODS: Between April 23 and May 7, 2020, we electronically administered a 41-question survey to interdisciplinary HCPs caring for patients critically ill with COVID-19. The survey was distributed via critical care societies, research networks, personal contacts, and social media portals. Responses were tabulated according to World Bank region. We performed multivariate log-binomial regression to assess factors associated with three main outcomes: limiting mechanical ventilation (MV), changes in CPR practices, and emotional distress and burnout. RESULTS: We included 2,700 respondents from 77 countries, including physicians (41%), nurses (40%), respiratory therapists (11%), and advanced practice providers (8%). The reported lack of ICU nurses was higher than that of intensivists (32% vs 15%). Limiting MV for patients with COVID-19 was reported by 16% of respondents, was lowest in North America (10%), and was associated with reduced ventilator availability (absolute risk reduction [ARR], 2.10; 95% CI, 1.61-2.74). Overall, 66% of respondents reported changes in CPR practices. Emotional distress or burnout was high across regions (52%, highest in North America) and associated with being female (mechanical ventilation, 1.16; 95% CI, 1.01-1.33), being a nurse (ARR, 1.31; 95% CI, 1.13-1.53), reporting a shortage of ICU nurses (ARR, 1.18; 95% CI, 1.05-1.33), reporting a shortage of powered air-purifying respirators (ARR, 1.30; 95% CI, 1.09-1.55), and experiencing poor communication from supervisors (ARR, 1.30; 95% CI, 1.16-1.46). INTERPRETATION: Our findings demonstrate variability in ICU resource availability and use worldwide. The high prevalence of provider burnout and its association with reported insufficient resources and poor communication from supervisors suggest a need for targeted interventions to support HCPs on the front lines.


Subject(s)
COVID-19/therapy , Critical Care , Health Personnel/psychology , Health Resources , Health Workforce , Personal Protective Equipment/supply & distribution , Burnout, Professional/psychology , Critical Care Nursing , Female , Financial Stress/psychology , Health Care Rationing , Hospital Bed Capacity , Humans , Male , N95 Respirators/supply & distribution , Nurses/psychology , Nurses/supply & distribution , Physicians/psychology , Physicians/supply & distribution , Psychological Distress , Respiratory Protective Devices/supply & distribution , Resuscitation Orders , SARS-CoV-2 , Surveys and Questionnaires , Ventilators, Mechanical/supply & distribution
6.
Chest ; 159(2): 619-633, 2021 02.
Article in English | MEDLINE | ID: covidwho-938825

ABSTRACT

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has severely affected ICUs and critical care health-care providers (HCPs) worldwide. RESEARCH QUESTION: How do regional differences and perceived lack of ICU resources affect critical care resource use and the well-being of HCPs? STUDY DESIGN AND METHODS: Between April 23 and May 7, 2020, we electronically administered a 41-question survey to interdisciplinary HCPs caring for patients critically ill with COVID-19. The survey was distributed via critical care societies, research networks, personal contacts, and social media portals. Responses were tabulated according to World Bank region. We performed multivariate log-binomial regression to assess factors associated with three main outcomes: limiting mechanical ventilation (MV), changes in CPR practices, and emotional distress and burnout. RESULTS: We included 2,700 respondents from 77 countries, including physicians (41%), nurses (40%), respiratory therapists (11%), and advanced practice providers (8%). The reported lack of ICU nurses was higher than that of intensivists (32% vs 15%). Limiting MV for patients with COVID-19 was reported by 16% of respondents, was lowest in North America (10%), and was associated with reduced ventilator availability (absolute risk reduction [ARR], 2.10; 95% CI, 1.61-2.74). Overall, 66% of respondents reported changes in CPR practices. Emotional distress or burnout was high across regions (52%, highest in North America) and associated with being female (mechanical ventilation, 1.16; 95% CI, 1.01-1.33), being a nurse (ARR, 1.31; 95% CI, 1.13-1.53), reporting a shortage of ICU nurses (ARR, 1.18; 95% CI, 1.05-1.33), reporting a shortage of powered air-purifying respirators (ARR, 1.30; 95% CI, 1.09-1.55), and experiencing poor communication from supervisors (ARR, 1.30; 95% CI, 1.16-1.46). INTERPRETATION: Our findings demonstrate variability in ICU resource availability and use worldwide. The high prevalence of provider burnout and its association with reported insufficient resources and poor communication from supervisors suggest a need for targeted interventions to support HCPs on the front lines.


Subject(s)
COVID-19/therapy , Critical Care , Health Personnel/psychology , Health Resources , Health Workforce , Personal Protective Equipment/supply & distribution , Burnout, Professional/psychology , Critical Care Nursing , Female , Financial Stress/psychology , Health Care Rationing , Hospital Bed Capacity , Humans , Male , N95 Respirators/supply & distribution , Nurses/psychology , Nurses/supply & distribution , Physicians/psychology , Physicians/supply & distribution , Psychological Distress , Respiratory Protective Devices/supply & distribution , Resuscitation Orders , SARS-CoV-2 , Surveys and Questionnaires , Ventilators, Mechanical/supply & distribution
7.
Neurohospitalist ; 11(2): 125-130, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-788575

ABSTRACT

The COVID-19 pandemic has led to shifts in healthcare utilization for patients both with and without COVID-19. We aimed to determine how trends in neurology service admissions during the pandemic may aid in departmental planning by predicting future clinician staffing and other needs. We examined all admissions to the general neurology, stroke, and neurocritical care services from January 31 to May 16, 2020 at our tertiary-care hospital using an electronic health record query, comparing these to analogous data in 2019. We trended admission rates and projected future censuses using logarithmic regression, tracked changes in length of stay (LOS), and quantified shifts in presentations of specific diagnoses. Daily rates of admissions declined sharply during the week of March 13, 2020 (the week after pandemic status was declared by the World Health Organization). On the censoring date, we projected a return to pre-pandemic censuses in the week of June 21 and used this information to make decisions regarding neurology resident schedules. There was a trend toward increased LOS for general neurology and stroke patients between March 27 and April 9, 2020 compared to in 2019, with subsequent decline coinciding with early hospital initiatives. Since March 13, 2020, there has been a trend toward reduced presentations of ischemic stroke, suggesting a need for community education on stroke awareness. Characterizing early trends in neurology admissions may allow physician administrators to plan local and community-level responses to the pandemic.

8.
Neurology ; 95(15): 693-694, 2020 10 13.
Article in English | MEDLINE | ID: covidwho-690840

ABSTRACT

Coronavirus disease 2019 (COVID-19) may pose unique challenges to clinicians attempting to diagnose brain death in patients infected with the SARS-CoV-2. Among these challenges is the risk of aerosol generation during the traditional apnea testing using the insufflation technique in addition to the risk of complications due to SARS-CoV-2-related lung disease. In this article, we discuss these challenges and provide further guidance to minimize such risks to ensure safety of healthcare professionals and other patients. We also emphasize the importance of maintaining the standards of brain death determination in this critical time.


Subject(s)
Brain Death/diagnosis , Coronavirus Infections/prevention & control , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Neurologic Examination/methods , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Betacoronavirus , COVID-19 , Coronavirus Infections/transmission , Humans , Insufflation/methods , Pneumonia, Viral/transmission , SARS-CoV-2
9.
J Stroke Cerebrovasc Dis ; 29(9): 105010, 2020 Sep.
Article in English | MEDLINE | ID: covidwho-548353

ABSTRACT

Aneurysmal subarachnoid hemorrhage (SAH) patients require frequent neurological examinations, neuroradiographic diagnostic testing and lengthy intensive care unit stay. Previously established SAH treatment protocols are impractical to impossible to adhere to in the current COVID-19 crisis due to the need for infection containment and shortage of critical care resources, including personal protective equipment (PPE). Centers need to adopt modified protocols to optimize SAH care and outcomes during this crisis. In this opinion piece, we assembled a multidisciplinary, multicenter team to develop and propose a modified guidance algorithm that optimizes SAH care and workflow in the era of the COVID-19 pandemic. This guidance is to be adapted to the available resources of a local institution and does not replace clinical judgment when faced with an individual patient.


Subject(s)
Betacoronavirus/pathogenicity , Coronavirus Infections/therapy , Critical Pathways/organization & administration , Delivery of Health Care, Integrated/organization & administration , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Occupational Exposure/prevention & control , Personal Protective Equipment/supply & distribution , Pneumonia, Viral/therapy , Subarachnoid Hemorrhage/therapy , Algorithms , COVID-19 , Clinical Protocols , Coronavirus Infections/diagnosis , Coronavirus Infections/transmission , Coronavirus Infections/virology , Humans , Occupational Exposure/adverse effects , Occupational Health , Pandemics , Patient Safety , Pneumonia, Viral/diagnosis , Pneumonia, Viral/transmission , Pneumonia, Viral/virology , Risk Factors , SARS-CoV-2 , Subarachnoid Hemorrhage/diagnosis , Virulence , Workflow
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