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American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927794


Rationale: Effective patient-clinician communication is a central component of high-quality patientcentered care in the intensive care unit (ICU). The Coronavirus Disease 2019 (COVID-19) pandemic has strained critical care delivery systems worldwide and considerably increased burnout symptoms experienced by frontline healthcare workers;however, its influence on patient-clinician communication and therapeutic relationships within the ICU is not well described. Methods: We purposively selected seven hospital dyads from regions in the United States that experienced early and/or large surges of patients hospitalized with COVID-19 during the winter or spring of 2020. Each dyad included a hospital from the national Veterans Affairs (VA) HealthCare System and its university-academic affiliate. We used semi-structured interviews of intensivists to explore facilitators and barriers to patient-clinician communication and the formation of therapeutic relationships during the COVID-19 pandemic. We then utilized inductive thematic analysis to identify themes describing the influence of the pandemic and hospitals' responses to it on patientclinician communication and therapeutic relationships in the ICU. Results: Overall, 24 intensivists from seven dyads of VA hospitals and academic-affiliate hospitals participated. We identified several barriers and facilitators of patient-clinician communication and the establishment of therapeutic relationships as perceived by intensivists. Barriers included physicians' fear of becoming infected with COVID-19, causing some to minimize contact with patients, and their use of personal protective equipment, which served as an obstacle to effective physical and verbal interactions. Additionally, intensivists noted the disproportionate effect of the pandemic on racial and ethnic minorities, describing how language barriers and restrictive visitation policies exacerbated institutional mistrust among patients and their families and compromised physicians' ability to develop therapeutic relationships. Facilitators to patient-clinician communication included the presence of on-site interpreters, use of virtual technology to interact with family members, and designation of a care team member or specialist service (e.g., palliative care) to provide consistent, daily updates to families. Conclusions: The COVID-19 pandemic has threatened patient-clinician communication and the development of therapeutic relationships in the ICU, particularly among racial and/or ethnic minority patients and their families. We identified several facilitators to improve patient-clinician communication as perceived by intensivists that may help improve trust and foster therapeutic alliances between patients, families, and clinicians in the ICU setting.

American Journal of Respiratory and Critical Care Medicine ; 205:1, 2022.
Article in English | English Web of Science | ID: covidwho-1880995
Open Forum Infectious Diseases ; 8(SUPPL 1):S453, 2021.
Article in English | EMBASE | ID: covidwho-1746390


Background. Clostridiodes difficile infection (CDI) is common and classified as an urgent threat by the US Centers for Disease Control and Prevention. Recurrence (rCDI) occurs in 30% of cases and increases with subsequent episodes. As part of a trial of fecal microbiota transplantation vs. placebo for the prevention of rCDI, rCDI is identified using a case-finding algorithm that screens for potential cases across all Veterans Affairs facilities, a key component of which is a stool test confirming the presence of C. difficile. With the emergence of Covid-19 in the Unites States in early 2020, study personnel observed a decreasing number of rCDI cases. We hypothesized that Covid restrictions and fear of transmission prevented patients from coming to a VA facility to submit a confirmatory stool sample, the standard method of diagnosing rCDI. Accordingly, the algorithm was modified to also identify cases where rCDI was empirically treated, without confirmatory testing. Here we report on the prevalence of empiric treatment of rCDI during the Covid pandemic and changes in lab-conformed cases over time. Methods. Cases of potentially rCDI are identified by a weekly query of VA data, using an algorithm that includes laboratory testing results, diagnostic codes, and prescriptions. The ource database is updated daily from every VA facility, encompassing over 8 million Veterans. Potential cases are reviewed by research coordinators using the medical record to determine study eligibility. Beginning June 2020, the algorithm was adjusted to also identify patients with lab confirmation of their first CDI episode but none for their recurrence and identified those who were prescribed treatment for rCDI. Results. We observed a reduction in both the number of weekly cases (22.2 vs. 17.4;P < 0.001) which is a 22% decrease after the Covid-19 emergency declaration (figure). Post-declaration, empiric treatment was prescribed to 159 Veterans (mean, 3.3/week). Potential cases of rCDI/week pre- and post Covid-19 pandemic declaration Conclusion. There was a significant drop in laboratory-confirmed rCDI associated with Covid-19. Recurrent CDI was frequently empirically treated during the Covid-19 pandemic, potentially exposing many patients with non-CDI diarrhea to unnecessary antimicrobial use and its attendant risks.