Emotional risk work during the pandemic: Healthcare professionals' perceptions from a COVID-19 ward

In March 2020, COVID-19 wards were established in hospitals in Denmark. Healthcare professionals from a variety of specialities and wards were transferred to these new wards to care for patients admitted with severe COVID-19 infections. Based on ethnographic fieldwork in a COVID-19 ward at a hospital in Copenhagen, Denmark, including focus group interviews with nursing staff, we intended to explore practices in a COVID-19 ward by seeking insight into the relation between the work carried out and the professionals' ways of talking about it. We used a performative approach of studying how the institutional ways of handling pandemic risk work comes into being and relates to the health professionals' emerging responses. The empirical analysis pointed at emotional responses by the nursing staff providing COVID-19 care as central. To explore these emotional responses we draw on the work of Mary Douglas and Deborah Lupton's concept of the ‘emotion-risk-assemblage'. Our analysis provides insight into how emotions are contextually produced and linked to institutional risk understandings. We show that work in the COVID-19 ward was based on an institutional order that was disrupted during the pandemic, producing significant emotions of insecurity. Although these emotions are structurally produced, they are simultaneously internalised as feelings of incompetence and shame.

P158 A nurse-led model for tuberculosis services delivers safe and effective care

P158 Table 1 2018–2019 2020–2021 No: of patients 33 38 Disease site Pulmonary Extra-pulmonary Pulmonary Extra-pulmonary 45.5% 55.5% 23.6% 76.4% Single site Multi-Site Single Site Multi-Site 87.9% 12.1% 78.9% 21.1% Sensitivity Sensitive Drug Resistant Sensitive Drug Resistant 62.5% 37.5% 81.2% 18.8% Treatment started by: Doctor Nurse Doctor Nurse Inpatient Outpatient Inpatient Outpatient 24.1% 75.9% 0% 7.9% 71.1% 21% Days from symptom onset to treatment(median) 73 65 Total clinic appointments Face to face Virtual Face to face Virtual 503 1 339 11 Clinic appointments per patient (median) 13 13 Follow-up appointments led by Doctor Nurse Doctor Nurse 52% 48% 28% 72% Patients lost to follow-up 3 1 Hospital admissions 7 1 Patient deaths 0 1 ConclusionA nurse-led model for TB services provides safe, effective, and timely care.An expanded TBSN role with the support of a proactive, easily-accessible consultant may present a good model for TB service provision going forward.Further research is needed to test this model outside of the pandemic context.ReferencesBritish Thoracic society. Tuberculosis services during the Covid-19 pandemic. Available at https://www.brit-thoracic.org.uk/covid-19/covid-19-information-for-the-respiratory-community/

A Curious Case of New-Onset Diabetes

New-onset type 1 diabetes most frequently presents with diabetic ketoacidosis in young patients. A subset of patients with autoimmune type 1 diabetes may present with a slower progression to insulin deficiency and are frequently misdiagnosed with type 2 diabetes. Clinicians should screen for type 1 diabetes in patients who present with hyperglycemia and do not have obvious signs of insulin resistance or obesity. This case report presents an adult patient with hyperglycemia after a hospital admission for coronavirus disease 2019 and the evidence used to diagnose type 1 diabetes with atypical presentation.

FINANCIAL SUCCESS OF COMMUNITY HOSPITALS: THE ROLE OF THE EMERGENCY DEPARTMENT

Admissions are critical for the financial survival of community, acute care hospitals. Through the review of multiple peer-reviewed articles, research is conducted on the critical role of an Emergency Department ("ED") for the success of a hospital. The review of literature supports the monitoring and continuous improvement of ED quality measures, and it finds the common belief that the ED is a loss leader to be false. Next, potential solutions to the problem are discussed, including the need for increased volume and prevention of patients leaving without being seen. To conclude, a proposed plan to implement the solutions is discussed in detail.

Predicting Hospital Admissions to Reduce Crowding in the Emergency Departments

Having an increasing number of patients in the emergency department constitutes an obstacle to the admissions process and hinders the emergency department (ED)'s ability to deal with the continuously arriving demand for new admissions. In addition, forecasting is an important aid in many areas of hospital management, including elective surgery scheduling, bed management, and staff resourcing. Therefore, this paper aims to develop a precise prediction model for admissions in the Integral Healthcare System for Public Use in Catalonia. These models assist in reducing overcrowding in emergency rooms and improve the quality of care offered to patients. Data from 60 EDs were analyzed to determine the likelihood of hospital admission based on information readily available at the time of arrival in the ED. The first part of the study targeted the obtention of models with high accuracy and area under the curve (AUC), while the second part targeted the obtention of models with a sensitivity higher than 0.975 and analyzed the possible benefits that could come from the application of such models. From the 3,189,204 ED visits included in the study, 11.02% ended in admission to the hospital. The gradient boosting machine method was used to predict a binary outcome of either admission or discharge.

Acute coronary syndrome (ACS) during corona virus disease-19 (COVID-19) pandemic: A single-center comparative study

Aim: To analyze the impact of corona virus disease-19 (COVID-19) pandemic and various containment measures taken for the pandemic control on hospital admissions of acute coronary syndrome (ACS). Materials and Methods: This study is a single-center, comparative study conducted at a tertiary care center situated in the southern part of India. The study period was from March 1, 2020 till May 31, 2020, including the first lockdown period in India. All patients admitted with a diagnosis of ACS to our hospital during the study period were included in the study (study group). This group was compared with the patients admitted with ACS into our hospital during the corresponding period of the previous year (control group). Patients with ST-elevation myocardial infarction (STEMI) were compared with the control group for clinical profile, treatment, hospital course, outcome, and incidence rate ratio (IRR) of admissions. Results: There was a significant reduction of mean daily admissions of ACS cases in the study group with IRR of 0.702;95% confidence interval (CI), 0.719–1.02;P < 0.001. The reduction rate of ACS cases was 29.74% (study period, n = 215;control period, n = 306), and it was mostly related to a decline in the number of non-ST-elevation myocardial infarction (NSTEMI) and unstable angina. No significant reduction of patients with STEMI was observed between the groups. However, patients with STEMI had more left ventricular (LV) dysfunction, LV thrombus, and a significantly higher incidence of mitral regurgitation (13.3% vs. 8.8%, P < 0.05). The impact of the COVID-19 outbreak on the patients with ACS revealed a parallel reduction of hospital admissions with an increasing number of COVID-19 cases in the community. Conclusion: The COVID-19 pandemic and concomitant social restrictions resulted in a significant decline in hospital admissions due to ACS in this tertiary care center, but without any effect on the number of admissions with STEMI. A parallel reduction of hospital admissions for ACS cases with a rising number of COVID-19 cases in the community was also observed in this study.

The winter bed pressure project

BackgroundSince the COVID-19 pandemic, health and care services have been under unprecedented pressure. The need to keep hospital admissions for urgent and emergency cases has never been greater. The Winter Bed Pressure Project looked at the role of specialist palliative care interventions in the community, in reducing hospital admissions and readmissions for patients with a palliative diagnosis, with particular focus on nursing homes.Aim(s)The project aims to examine the education and support needs of nursing homes and to look at how specialist palliative care intervention may support patients to remain within their preferred place of care and death.MethodsBetween January 1st and March 31st 2022, 14 Nursing Home Managers were interviewed and 49 patient reviews took place. 390 urgent unscheduled home reviews were made by the community specialist palliative care team for symptom management. 53 patients were admitted to hospital and 33 patients to the hospice in-patient unit. 140 calls were made to the hospice out of hours’ advice line.ResultsPotentially avoidable admissions in the community include lack of advance care planning and ceilings of care, intravenous antibiotic administration, safeguarding concerns and carer breakdown.The project has highlighted significant delays in obtaining medication in nursing homes. Education was lacking in communication, syringe driver and symptom management.ConclusionsMedication delays are being addressed through collaboration with the Clinical Commissioning Group to look at improving processes and wider use of Independent Nurse Prescribers involved with nursing home patients. Education needs are being addressed by the local practice development teams. A quality improvement project is being planned to look at improving access to the out of hours’ advice-line and plans for nurse-led admission to the hospice are underway.

Home injuries during lockdown: evidence from hospital records in 2019–2020, Victoria, Australia

BackgroundCovid-19 related lockdowns in Victoria, Australia, have increased the time spent at home. It is not known how this increased exposure to injury hazards around the home have affected injury rates.AimsTo provide an overview of the impact of COVID-19 on hospital-treated injury during the 2020 lockdown period in Victoria, compared to the same period in 2019.MethodsThis study is a retrospective analysis of Emergency Department (ED) and hospital admissions data. Cases were selected as injuries occurring in the home, based on ICD-10-AM coding or approximate equivalent in the ED data. To determine who was disproportionally at risk for home injury during lockdown, logistic regression modelling was applied, comparing sociodemographic factors associated with injuries in April-October 2020 vs. April-October 2019.ResultsHospital-treated home injury rates in Victoria were higher in lockdown months of 2020 compared to the control period;this was observed in ED presentations (annual rates 2332 vs. 2042 per 100,000 population, respectively) and hospital admissions (613 vs. 519 per 100,000). Lockdown period injuries were relatively common in younger age groups and relatively less common in older adults;they were also relatively common among those living in regional Victoria.ConclusionsThe results of this study demonstrate an increase in home injuries that required hospital treatment, during months of lockdown in Victoria, 2020.Learning outcomesYounger people in particular should be a focus for injury prevention in this setting. Home injuries should weigh into the decision making when lockdown is considered to reduce the spread of COVID-19.

Among the failures, credit is due

Mary Dixon-Woods has harsh words for the East Kent Hospitals University NHS Foundation Trust (doi:10.1136/bmj.o2755).1 An investigation into its maternity services concluded that outcomes would have been better in roughly half of the cases reviewed if minimum standards of care had been achieved. Most of the maternal and neonatal deaths were judged preventable. Bullying, harassment, and unprofessional behaviour by consultants were common and tolerated. These issues had been identified in a 2014 investigation, yet nothing has changed. Dixon-Woods condemns the trust’s decade long failure to tackle these problems as particularly egregious. The failures were cultural and institutional, she says, and solutions must be as well. “Diagnoses are useless unless effective treatment follows—and that requires leadership commitment and sound systems, both of which East Kent lacked.”

"We All had to Respond to the Pandemic and our Patient Needs": Social Workers' Perspectives of Integrated Healthcare Agencies' Response to COVID-19 Pandemic

[...]data comparison between pre-pandemic mental health studies and an analysis for the beginning of the pandemic showed a dramatic increase in prevalence of mental health problems that included depression and anxiety (Wu et al., 2020). According to Kamnitzer and colleagues (2020), social workers proactively supported patients when the pandemic hit. [...]the current study will add to the emerging literature by asking how did integrated healthcare agencies respond to behavioral health care needs during the pandemic from the point of view of social workers in these settings. [...]VAGLAHS used the combined efforts of interdisciplinary leaderships and a widespread laboratory surveillance program in their skilled nursing facility, inpatient psychiatry unit, inpatient admissions, temporary shelter units, residential rehabilitation treatment center, and dialysis patients (Jatt et al., 2020).

Morbidity and mortality of cirrhotic patients admitted to a large tertiary hospital in England

P35 Figure 1ConclusionsUnplanned hospital attendances are common amongst cirrhotic patients, particularly those from lower socioeconomic groups. Over half of patients with at least one liver-related admission died during the follow up period, with two thirds of these deaths occurring during or shortly after discharge.The data shows the true burden of liver disease and highlights the need for improved in-patient care for this vulnerable patient group.

USE OF AN ADVANCE CARE PLAN CHECKLIST TO IMPROVE COMMUNICATION AND ASSESSMENT OF THE IMPACT ON HOSPITAL READMISSIONS

Introduction Advance care planning (ACP) is a vital part of holistic and person-centred care. It allows formalising of an individual’s wishes and best interests, and avoids unnecessary or unwanted interventions including, potentially, hospital admissions. It is crucial that any decisions or recommendations are communicated to all relevant healthcare professionals to ensure peoples’ wishes are upheld. We developed this project to review and improve documentation and communication on discharge when a decision had been made to limit care to the community and avoid admission. Method A checklist was developed comprising 11 criteria to be documented in the discharge letter and actions to disseminate information including;updating the ReSPECT form and alerting the hospital frailty and community out of hours teams. We carried out a closed loop audit of patients where admission should be avoided and reviewed discharge letters against the criteria. Where patients were readmitted we reviewed the notes to determine whether the admission was appropriate. Results We compared patients discharged between February 2020–February 2021 and then from March–September 2021. 161 and 27 patients were identified respectively. Average age was 84.6 and 87.3 years respectively. In cohort 2 48.1% of patients were readmitted, up from 8.7% during the previous cycle. 33% of admissions in cohort 2 and 38.9% of readmissions in cohort 1 were deemed appropriate. Documentation improved in 10 of the 11 criteria. Average length of stay for readmissions was reduced from 16.7 to 5.7 days. Conclusion As evidenced by our study utilising a checklist has improved documentation and dissemination of ACPs to the Community. This did not lead to a reduction in hospital admissions but this may have been skewed by factors relating to the Covid-19 pandemic. We did find a significant reduction in length of stay for those subsequently readmitted.

OLDER PERSON’S ASSESSMENT SERVICE (OPAS): DELIVERING COMPREHENSIVE GERIATRIC ASSESSMENT (CGA) IN THE EMERGENCY DEPARTMENT (ED)

Introduction Innovative models of service delivery are required to provide Comprehensive Geriatric Assessment for older patients presenting to the Emergency Department with frailty syndromes. Method In 2018, the Older Person’s Assessment Service began a liaison service to the ED, taking referrals from the medical and ED teams for patients who presented with frailty syndromes (falls, cognitive impairment, care dependence, polypharmacy). The service saw 437 patients April–August 2018. 76% of the patients assessed were discharged by utilising available community services, rapid access outpatient follow up and inpatient reablement off the acute site. The service was estimated to avoid 50–80 admissions per month to medicine (saving 17–23 beds a year) and was commissioned as a permanent service. Phase 2 In 2020, a dedicated unit within ED was allocated to OPAS, enabling the acceptance of patients directly from triage and from the Ambulance Service by direct referral. This provided rapid access to specialist assessment, continued access to Elderly Care services, avoided exposure to coronavirus related admissions and the risks of nosocomial infection associated with admission. The service operates from 8 am-4 pm on weekdays. Results Between June 2020 and October 2021, the service saw 1,173 new patients. 988 patients (84.5%) were discharged off the acute site on the day of assessment. 68 (5.79%) patients were admitted to other facilities run by the Health Board (e.g Inpatient Reablement). The average age of an OPAS patient was 83 yrs and had a CFS > 5. Readmission rate at 14 days was 4% (47).Of the 253 patients who were admitted to an inpatient setting, 13.5% (35) contracted nosocomial covid-19. Conclusion The service has been supported and funded to expand into extended weekday hours as a result of this success and there are plans for future 7 day working.

Evaluation of adverse effects with COVID-19 vaccination in Pakistan

Objectives: Vaccinations work with different mechanisms to offer protection against disease;however, process of immunity building can cause symptoms. Therefore, this study aimed to determine the immediate side effects of COVID-19 vaccination in the Pakistani Population. Methods: This cross-sectional analytical study was conducted at Foundation University College of Dentistry, Islamabad from February to April 2021. 0.5 mL per dose of the Covid-19 vaccine was administered to the candidates. These 205 candidates receiving vaccination were then interviewed investigating the adverse effects of the vaccine. Post-vaccination side effects were compared among categorical groups using the Chi-Square test, whereas post-vaccination side effects were compared with age using independent samples T-test. A p-value of ≤0.05 was statistically significant. Results: Among post-vaccination side effects, fever was reported by 69 participants, while 56 of 205 reported soreness, redness, and swelling at the injection site. It was reported by 42/205 participants to have felt chills and rigor, whereas gastrointestinal disturbance and flu-like symptoms were reported in 55/205 and 28/205 participants, respectively. Younger participants were more likely to develop gastrointestinal disturbance and flu-like symptoms following vaccination as compared to older participants. Conclusion: Malaise, headache, and fever were observed to be the most common side effects of the vaccine, moreover there was a linear relationship between manifestations of adverse effects and history of comorbidities.

Completion of an advance care plan (ACP) with patients with advanced neurological conditions, the evidence

BackgroundAs a result of service development through COVID-19, a community based Speciality Doctor was recruited to write ACPs for patients with progressive advanced neurological conditions through domiciliary visits. This study seeks to understand how their ACP may benefit patients and their primary health care providers (PHCP).MethodsRetrospective cohort study, examining electronic hospital records 3 months pre-ACP/3 months post-ACP of 36 patientsOnline survey of patient’s named PHCPResults36 patients were reviewed, diagnoses included advanced Parkinson’s disease/Parkinson’s plus, secondary multiple sclerosis, NF1 and superficial siderosis. 2 of these patients were known to hospice services before ACP commencement.5 patients died since their ACP was made, all in their preferred place of care (home), with anticipatory medications, and without hospital or hospice input at end of life. Comparing 3 months pre to 3 months post ACP, ED attendances reduced from 35 to 9, and acute hospital inpatient stays reduced from 16 to 5 (136 to 21 bed days). 9 of 26 PHCPs surveyed replied. 89% (8) knew about the ACP but none had used it so far to make a clinical decision. 89% (8) felt confident of what an ACP is (8+/10 self scoring) with 33% (3) very confident to complete/review themselves. All responders felt happy for an ACP to be completed on behalf of them, concluding that it should be done by the ‘most appropriate’ ‘experienced clinician’ who ‘knows the patient best’.ConclusionsThis study demonstrates the benefit from ACP in terms of achieving PPOC and avoiding hospital admissions. For these 36 patients, there were potentially 11 acute hospital admissions avoided, with a reduction in 115 bed days.Data will be extended by a further 3 months by the time of the PCC. Future work gauging patient’s and carer’s opinion of ACP is planned.

Pharmacological factors related to hospital admissions in polymedicated elderly patiens

6ER-022 Table 1Odds ratio results from logistic regression analysisFactor OR Lower 95% CI Upper 95%CI Factor OR Lower 95% CI Upper 95%CI A02B 1.46 0.427 4.991 N02B 0.814 0.513 1.291 A10B 1.246 0.816 1.904 N03A 0.715 0.443 1.154 A11C 0.875 0.535 1.431 N05A* 0.353 0.137 0.91 A12A 1.192 0.73 1.948 N05B 0.98 0.649 1.482 B01A* 1.95 1.004 3.824 N06A 1.002 0.671 1.497 C03C 1.088 0.72 1.642 R03A 0.997 0.628 1.583 C07A 1.206 0.8 1.818 R03B 0.881 0.541 1.435 C10A 0.988 0.626 1.561 Total prescribed drugs* 1.182 1.078 1.297 H02A 0.875 0.431 1.778 Gender 1.011 0.651 1.57 M05B 1.016 0.581 1.776 Age 1.022 0.991 1.054 N02A 0.819 0.524 1.279 CI, confidence interval;OR, odds ratio. *p<0.05.Conclusion and relevanceIn this preliminary analysis of 930 PEP, B01A (antithrombotic drugs) and a number of total prescribed drugs were SS factor associated with a higher risk of admission, meanwhile N05A (antipsychotics) showed a protective trend.References and/or acknowledgementsConflict of interestNo conflict of interest

ENT/Audiology Department of Samoa welcomes the introduction of the Pneumococcal Conjugate Vaccine (PCV) into the national childhood immunisation program

The Pacific Island region is estimated to have among the highest levels of otitis media (middle ear infections) and secondary hearing loss in the world [3], and a public health approach has already been advocated for its prevention, early identification, and management in the Pacific Islands [4]. The significant factors contributing to pneumococcal carriage and density continue to be young age, residential location, living with young children, low family income, and symptoms of upper respiratory tract infection [10]. Again, the lesson we can draw from the Papua New Guinean experience is that PCV is but one part of a package of public health care measures: childhood immunisations should not overshadow the role of environmental health measures in reducing the risk of infections. Ear disease, hearing loss, and PCV introduction in Samoa – the way forward At this time, the foreseeable challenge in Samoa is restoring public confidence in childhood immunisations and achieving optimal immunisation coverage rates through health promotion activities [14].

COVID outcome prediction in the emergency department (COPE): using retrospective Dutch hospital data to develop simple and valid models for predicting mortality and need for intensive care unit admission in patients who present at the emergency department with suspected COVID-19

ObjectivesDevelop simple and valid models for predicting mortality and need for intensive care unit (ICU) admission in patients who present at the emergency department (ED) with suspected COVID-19.DesignRetrospective.SettingSecondary care in four large Dutch hospitals.ParticipantsPatients who presented at the ED and were admitted to hospital with suspected COVID-19. We used 5831 first-wave patients who presented between March and August 2020 for model development and 3252 second-wave patients who presented between September and December 2020 for model validation.Outcome measuresWe developed separate logistic regression models for in-hospital death and for need for ICU admission, both within 28 days after hospital admission. Based on prior literature, we considered quickly and objectively obtainable patient characteristics, vital parameters and blood test values as predictors. We assessed model performance by the area under the receiver operating characteristic curve (AUC) and by calibration plots.ResultsOf 5831 first-wave patients, 629 (10.8%) died within 28 days after admission. ICU admission was fully recorded for 2633 first-wave patients in 2 hospitals, with 214 (8.1%) ICU admissions within 28 days. A simple model—COVID outcome prediction in the emergency department (COPE)—with age, respiratory rate, C reactive protein, lactate dehydrogenase, albumin and urea captured most of the ability to predict death. COPE was well calibrated and showed good discrimination for mortality in second-wave patients (AUC in four hospitals: 0.82 (95% CI 0.78 to 0.86);0.82 (95% CI 0.74 to 0.90);0.79 (95% CI 0.70 to 0.88);0.83 (95% CI 0.79 to 0.86)). COPE was also able to identify patients at high risk of needing ICU admission in second-wave patients (AUC in two hospitals: 0.84 (95% CI 0.78 to 0.90);0.81 (95% CI 0.66 to 0.95)).ConclusionsCOPE is a simple tool that is well able to predict mortality and need for ICU admission in patients who present to the ED with suspected COVID-19 and may help patients and doctors in decision making.

Bloodstream Infections During COVID-19

Researchers at the Imperial College Hospital and School of Public Health in London examined patterns of bloodstream infection (BSI), hospital stay, and mortality before and during two waves of COVID-19 between January 2020 and February 2021. Despite a decrease in the number of total hospital admissions by 65% during the surges, mostly because of the suspension of elective activities, blood cultures were obtained at a rate nearly double that of pre-COVID, up from 86.8/1,000 patient days pre-COVID to 150.7/1,000 patient days during both COVID surges. The authors believe both the higher rate of contaminated cultures and the increase in hospital-acquired BSI can be directly traced to the effect of both COVID surges on the hospital system, with disruptions in care and breakdown of usual infection prevention practices.