Pre-hospital Management of COVID-19: Looking for a Future Perspective

Acute severe symptoms and long-term sequelae caused by the novel coronavirus disease (COVID-19) are still major concerns for public health. In particular, it is an emerging need to prevent the overburn of health workers as well as the collapse of health care systems. To reach this purpose, it should be necessary to evaluate a standardized pre-hospital management for COVID-19 patients, but data about it are lacking. Thus, the aim of the present chapter is to analyze the in-hospital gesture hypothesizing its reproducibility at bedside.Meta-analyses and randomized clinical trials assessed were focused on the following topics: (1) early diagnosis through viral demonstration and serological testing;(2) home setting evaluation;(3) standardized multidimensional assessment of COVID-19 patients, including an early identification of specific clinical symptoms as well as a prognostic stratification through laboratory biomarkers and portable imaging techniques;(4) safe and easily administrable drugs, considering both new medications and repurposed molecules;(5) protocols regarding bedside oxygen therapy, prone positioning, and pulmonary rehabilitation.To date, several procedures for the in-hospital management of COVID-19 patients could be easily and safely applied in the outpatients' care. The institution of dedicated international open-access data banks could be useful to realize standardized pre-hospital protocols, and the implementation of remote approaches could provide the possibility to guarantee a continuous follow-up for these patients. Global efforts focused on this goal could represent the only way to decrease the pressure on health care systems and to restore their essential function, still allowing an effective management of mild-to-moderate COVID-19 stages. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Recent Developments in Pharmacotherapy of Depression: Bench to Bedside.

For the last 70 years, we did not move beyond the monoamine hypothesis of depression until the approval of the S-enantiomer of ketamine, an N-methyl-D-aspartate (NMDA) receptor blocker and the first non-monoaminergic antidepressant characterized by rapid antidepressant and antisuicidal effects. A similar profile has been reported with another NMDA receptor antagonist, dextromethorphan, which has also been approved to manage depression in combination with bupropion. More recently, the approval of a positive allosteric modulator of GABA-A receptors, brexanolone, has added to the list of recent breakthroughs with the relatively rapid onset of antidepressant efficacy. However, multiple factors have compromised the clinical utility of these exciting discoveries in the general population, including high drug acquisition costs, mandatory monitoring requirements, parenteral drug administration, lack of insurance coverage, indirect COVID-19 effects on healthcare systems, and training gaps in psychopharmacology. This narrative review aims to analyze the clinical pharmacology of recently approved antidepressants and discuss potential barriers to the bench-to-bedside transfer of knowledge and clinical application of exciting recent discoveries. Overall, clinically meaningful advances in the treatment of depression have not reached a large proportion of depressed patients, including those with treatment-resistant depression, who might benefit the most from the novel antidepressants.

Bedside naso-jejunal placement is more difficult, but successful in patients with COVID-19 in critical care: A retrospective service evaluation of a dietitian-led service

The COVID-19 pandemic presented clinical and logistical challenges in the delivery of adequate nutrition in the critical care setting. The use of neuromuscular-blocking drugs, presence of maxilla-facial oedema, strict infection control procedures, and patients placed in a prone position complicated feeding tube placement. We audited the outcomes of dietitian-led naso-jejunal tube (NJT) insertions using the IRIS (Kangaroo, USA) device, before and during the COVID-19 pandemic. NJT placement was successful in 78% of all cases (n = 50), and 87% of COVID-19 cases. Anaesthetic support was only required in COVID-19 patients (53%). NJT placement using IRIS was more difficult but achievable in patients with COVID-19.Copyright © The Intensive Care Society 2023.

Quality of nursing care and its relationship to work environment from the perspective of bedside nurses

Quality of nursing care has become an important when looking at patient outcomes and the impact it has on long-term care of the patient. Quality can be defined in many ways. Defining quality of nursing care can be a diverse approach based on the perspective of many individuals, including the perspective of nurses. Quality of nursing care from the nursing perspective is complex and has many variables that influence that perspective. Variables include nursing work load, patient acuity, supportive administration, teamwork within the facility/unit, patient/family conflict, and overtime shifts. Patients are the individuals that nurses commit to caring for and throughout research;the patient identifies the quality nursing care provided. Facilities often utilize patient satisfaction and patient outcomes when evaluating nursing care. The purpose of this research is to explore how quality of nursing care is defined historically and how the nurse perceives quality of nursing care and its relationship to work environment. Additionally, how their perception may change based on the COVID-19 pandemic. Existing evidence indicates that if nurses have a supportive or positive work environment, then a nurse is motivated to provide quality of nursing care. Healthcare presents its own unique stressor to nurses in their attempt to provide quality care. Healthcare is constantly changing, and it impacts the work environment of the nurse. There is a significant shortage of the nursing workforce. More nursing jobs will be needed in the United States than any other profession through 2022. 11 million more nurses are needed to prevent a further shortage. The aging population, aging workforce, workforce burnout, violence in the health care setting, and growth in certain regions make it difficult to provide the support nurses need in health care facilities. Measuring quality from the nursing perspective is complex. Ways to measure quality address the connection of quality of nursing care and nurse work environment. The hypothesis is supportive that quality of nursing care is given if there is a supportive work environment. The challenge is what a nurse identifies as a barrier, in giving quality of nursing care and what their facilities identify as quality of nursing care. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Faculty perceptions of teaching clinical reasoning at the patient bedside

Nurse educators meet frequently in conference settings and peer groups seeking an answer to "How do you do clinical?". The purpose of this qualitative, phenomenological study was to explore faculty perceptions of clinical teaching experiences at the patient bedside at a level one or two associate's degree nursing program by faculty within the Virginia Community College System (VCCS) that teach a rural student population.Rural students struggle with work-life barriers that complicate their educational journey. This was compounded by the COVID-19 pandemic that presented new challenges to the way nursing education could be delivered creating a need for on line and blended learning environments. Many programs experienced a shutdown of clinical teaching facilities and were forced online. This new learning environment proved to be another educational challenge for rural healthcare communities. This study explored faculty perceptions with interview sessions addressing clinical teaching practice over the last five years at the patient bedside with eight nurse educators from VCCS rural community colleges. A literature review revealed gaps in the research;the utilization of a comprehensive clinical teaching model and an overall disagreement on any one "best" teaching method. Three research questions on the teaching of clinical reasoning, safe patient care outcomes, and the experiences of new teaching environments during the COVID -19 pandemic were developed. Following hermeneutic analysis, the primary themes of Collaborative Teaching Practices, Traditional Teaching Methods, and Pandemic Teaching emerged with secondary themes of Concept Based Curriculum and Blended Learning Environments. Academic nursing leaders and faculty should use this information to create a common clinical teaching model. Health care leaders should use this information to enhance bedside teaching practices to produce safe outcomes for patients in their care. Nursing educators should use this information to make strong clinical thinkers that will address the growing need for nurses in the United States in the wake of the most significant nursing shortage experienced in this profession. This hermeneutic phenomenology is the beginning of a much-needed change in clinical education. Nurse educators must develop critical reasoning skills in nurses that will care for an aging population using innovative methods for critical thought. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Peer Role-Play Simulation: A Valuable Alternative to Bedside Teaching During the COVID-19 Pandemic.

Purpose: The COVID-19 pandemic dramatically affected every aspect of life worldwide. Contact restrictions and social distancing during the epidemic has led to the suspension of bedside teaching (BST) and shifting to online didactic teaching and other methods of active learning. We implemented peer role-play simulation (PRPS) during the pandemic to compensate for the suspended BST. This study aims to explore the effectiveness of PRPS in developing the students' verbal communication, empathy and clinical reasoning skills compared to BST. Methods: This is a cross-sectional observational study conducted in Jazan University faculty of medicine with the study sample including all medical students enrolled in 5th and 6th year during the academic year 2020-21. Data collection involved using a web-based validated questionnaire. Results: Most of the students (84.1%) rated bedside teaching (BST) as extremely beneficial or beneficial in developing verbal communication skills compared to 73.3% for peer role-play simulation (PRPS). A similar pattern was found in empathy skills development with 84.1% for bedside compared to 72.2% for PRPS. The pattern is reversed with the development of clinical reasoning skills with 77.7% rating BST as beneficial or extremely beneficial compared to 81.2% for PRPS. Conclusion: Overall, peer role-play is generally a valuable and trustworthy method in the absence of bedside teaching for enhancing clinical reasoning skills of medical students during the COVID-19 pandemic from students' perspective. It is less efficient than bedside teaching in enhancing communication skills. It cannot wholly replace bedside teaching, although it can be used reliably for that purpose in exceptional circumstances when bedside teaching cannot be implemented.

Is It Time to Call 'Code Blue' on Nursing Infrastructure? A Nurse's Perspective from the COVID-19 Front-line.

The COVID-19 pandemic has highlighted the significance of every role within the interdisciplinary team and has exacerbated the challenges posed to every member. From the nursing perspective, many of these challenges were present before the pandemic but have become significantly larger problems that continue to demand global attention. This has provided an opportunity to critically evaluate and learn from the challenges the pandemic has both highlighted and created. We conclude that the nursing infrastructure requires a revolution in order to support, grow and retain nurses, who are vital to the delivery of high-quality healthcare.

Quality of nursing care and its relationship to work environment from the perspective of bedside nurses

Quality of nursing care has become an important when looking at patient outcomes and the impact it has on long-term care of the patient. Quality can be defined in many ways. Defining quality of nursing care can be a diverse approach based on the perspective of many individuals, including the perspective of nurses. Quality of nursing care from the nursing perspective is complex and has many variables that influence that perspective. Variables include nursing work load, patient acuity, supportive administration, teamwork within the facility/unit, patient/family conflict, and overtime shifts. Patients are the individuals that nurses commit to caring for and throughout research;the patient identifies the quality nursing care provided. Facilities often utilize patient satisfaction and patient outcomes when evaluating nursing care. The purpose of this research is to explore how quality of nursing care is defined historically and how the nurse perceives quality of nursing care and its relationship to work environment. Additionally, how their perception may change based on the COVID-19 pandemic. Existing evidence indicates that if nurses have a supportive or positive work environment, then a nurse is motivated to provide quality of nursing care. Healthcare presents its own unique stressor to nurses in their attempt to provide quality care. Healthcare is constantly changing, and it impacts the work environment of the nurse. There is a significant shortage of the nursing workforce. More nursing jobs will be needed in the United States than any other profession through 2022. 11 million more nurses are needed to prevent a further shortage. The aging population, aging workforce, workforce burnout, violence in the health care setting, and growth in certain regions make it difficult to provide the support nurses need in health care facilities. Measuring quality from the nursing perspective is complex. Ways to measure quality address the connection of quality of nursing care and nurse work environment. The hypothesis is supportive that quality of nursing care is given if there is a supportive work environment. The challenge is what a nurse identifies as a barrier, in giving quality of nursing care and what their facilities identify as quality of nursing care. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Association between Level of Knowledge Gained, Confidence, Motivation and Flexibility on Types of Learning for Bedside Teaching among Clinical Students in Four Malaysian Medical Schools during COVID-19 Pandemic

Introduction: With the arise of the COVID-19 pandemic, higher institutions are forced to change the method of delivery for bedside teaching sessions from face-to-face to online learning. However, online learning was found not effective in delivering practical knowledge and skills to students. Hence, the objective of this study was to determine the association between level of knowledge gained, confidence, motivation and flexibility on types of learning for bedside teaching sessions among clinical students in four Malaysian medical schools during COVID-19 pandemic. Methods: A cross-sectional study involving medical students from Universiti Putra Malaysia (UPM), Universiti Sains Islam Malaysia (USIM), Universiti Islam Antarabangsa (UIA) and Universiti Sains Malaysia (USM) were conducted from 1st March 2021 until 6th June 2021. An online questionnaire was distributed and it consisted of 5 sections which cover sociodemographic information, level of knowledge gained, confidence, motivation, and flexibility from bedside teaching session. The data was analysed by using SPSS software program. Results: There is a significant association between the level of knowledge gained, level of confidence, level of motivation and level of flexibility with the type of learning (online or face-to-face) during bedside teaching sessions. Results revealed that students gained a higher level of knowledge (84.9%), higher level of confidence in physical examination (93.3%), higher motivation (82.2%) and higher flexibility (64.1%) during face-to-face bedside teaching sessions compared to online learning. Conclusion: Most of the medical students in four Malaysian medical schools prefer face-to-face learning compared to online learning for bedside teaching sessions. © 2022 UPM Press. All rights reserved.

A safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19: A quality improvement study.

Importance: The number of infections and deaths caused by the global epidemic of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) invasion is steadily increasing daily. In the early stages of outbreak, approximately 15%-20% of patients with coronavirus disease 2019 (COVID-19) inevitably developed severe and critically ill forms of the disease, especially elderly patients and those with several or serious comorbidities. These more severe forms of disease mainly manifest as dyspnea, reduced blood oxygen saturation, severe pneumonia, acute respiratory distress syndrome (ARDS), thus requiring prolonged advanced respiratory support, including high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIMV), and invasive mechanical ventilation (IMV). Objective: This study aimed to propose a safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19. Design: This is a single center quality improvement study. Participants: Tracheotomy is a necessary and important step in airway management for COVID-19 patients with prolonged endotracheal intubation, IMV, failed extubation, and ventilator dependence. Standardized third-level protection measures and bulky personal protective equipment (PPE) may hugely impede the implementation of tracheotomy, especially when determining the optimal pre-surgical positioning for COVID-19 patients with ambiguous surface position, obesity, short neck or limited neck extension, due to vision impairment, reduced tactile sensation and motility associated with PPE. Consequently, the aim of this study was to propose a safer and more practical tracheotomy, namely percutaneous dilated tracheotomy (PDT) with delayed endotracheal intubation withdrawal under the guidance of bedside ultrasonography without the conventional use of flexible fiberoptic bronchoscopy (FFB), which can accurately determine the optimal pre-surgical positioning, as well as avoid intraoperative damage of the posterior tracheal wall and prevent the occurrence of tracheoesophageal fistula (TEF).

Faculty perceptions of teaching clinical reasoning at the patient bedside

Nurse educators meet frequently in conference settings and peer groups seeking an answer to "How do you do clinical?". The purpose of this qualitative, phenomenological study was to explore faculty perceptions of clinical teaching experiences at the patient bedside at a level one or two associate's degree nursing program by faculty within the Virginia Community College System (VCCS) that teach a rural student population.Rural students struggle with work-life barriers that complicate their educational journey. This was compounded by the COVID-19 pandemic that presented new challenges to the way nursing education could be delivered creating a need for on line and blended learning environments. Many programs experienced a shutdown of clinical teaching facilities and were forced online. This new learning environment proved to be another educational challenge for rural healthcare communities. This study explored faculty perceptions with interview sessions addressing clinical teaching practice over the last five years at the patient bedside with eight nurse educators from VCCS rural community colleges. A literature review revealed gaps in the research;the utilization of a comprehensive clinical teaching model and an overall disagreement on any one "best" teaching method. Three research questions on the teaching of clinical reasoning, safe patient care outcomes, and the experiences of new teaching environments during the COVID -19 pandemic were developed. Following hermeneutic analysis, the primary themes of Collaborative Teaching Practices, Traditional Teaching Methods, and Pandemic Teaching emerged with secondary themes of Concept Based Curriculum and Blended Learning Environments. Academic nursing leaders and faculty should use this information to create a common clinical teaching model. Health care leaders should use this information to enhance bedside teaching practices to produce safe outcomes for patients in their care. Nursing educators should use this information to make strong clinical thinkers that will address the growing need for nurses in the United States in the wake of the most significant nursing shortage experienced in this profession. This hermeneutic phenomenology is the beginning of a much-needed change in clinical education. Nurse educators must develop critical reasoning skills in nurses that will care for an aging population using innovative methods for critical thought. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

The Great Realization: Nurses Are in the Driver's Seat!

The postpandemic health care environment has reached a pivotal point requiring transformative change among professional nurses working in health care organizations. This article posits that the nurses at the bedside, the true innovators and influencers, are most able to develop solutions that will be effective in this transformation. Appreciative inquiry is offered as a co-creative and possibility-focused model to guide nurses and nurse leaders through the process of holding on to what is good, dreaming of what can be, and charting the course for their future.

Bed-side DR and computed tomography manifestations and prognosis of critical COVID-19 cases

Critical COVID-19 cases are patients who meet any of the following criteria: (1) they have respiratory failure requiring mechanical assistance;(2) they are in shock;and/or (3) they have extrapulmonary organ failure, which means intensive care unit is needed. This chapter illustrates bed-side DR and computed tomography manifestations in critical cases. Bed-side DR is frequently used for progression evaluation. The lung area involved is extensive. The prognosis of these patients is also shown.

Computed tomography manifestations and prognosis of severe COVID-19 cases

Severe COVID-19 cases are patients meeting any of the following criteria: (1) respiratory distress, respiration rate ≥ 30 breaths/min;(2) oxygen saturation <93% at rest;and (3) partial pressure of oxygen/fraction of inspired oxygen≤300mm Hg. Besides, patients with rapid progression (>50%) within 24–48h based on computed tomography (CT) imaging results are deemed as the severe type. The lung areas of pneumonia involved in the severe type are more extended than that in the common type. Besides plain radiography and CT, Positron Emission Tomography (PET)/CT images in seven cases and PET/MR images in one case are also illustrated in this chapter. Increased or normal metabolic activity is noticed in the pneumonia area. Increased metabolic activity is noticed in the mediastinal lymph nodes.

Bedside Lung Ultrasound as an Independent Tool to Diagnose Pneumonia in Comparison to Chest X-ray: An Observational Prospective Study from Intensive Care Units.

Background: Diagnosing pneumonia is challenging because of multiple differential diagnosis. Bedside lung ultrasound (BLUS) is a safe, portable, rapid and inexpensive new modality to diagnose pneumonia. This study was aimed to evaluate the sensitivity of BLUS vs chest X-ray (CXR) to diagnose community-acquired pneumonia (CAP) using computed tomography (CT) scans as the gold standard. Patients and methods: An observational cross-sectional study was conducted in selected intensive care units (ICUs). Eligible 85 adult patients with symptoms suggestive of pneumonia as per 2007 Infectious Disease Society of America (IDSA), American Thoracic Society (ATS) criteria, and 2D echocardiography were enrolled consecutively by using convenient sampling technique. Real-time reverse transcription-polymerase chain reaction (RT-PCR) assay for SARS-associated coronavirus was sent with in 1 hour followed by BLUS and CXR within 24 hours of ICU admission. The final confirmation of CAP was done by a thoracic CT scan. Results: Bedside lung ultrasound vs CXR could detect 74 vs 58 cases out of 84 confirmed cases. Sensitivity and specificity of BLUS vs CXR was 88.1% vs 67.8% and 100% vs 0%, respectively. Moreover, LR+ and LR- for BLUS was found to be 0 and 0.12 in comparison to 0.68 and 0 for CXR. The area under receiver operator characteristics (ROC) curve for BLUS vs CXR was 0.94 (95% CI 0.0-1.0) with p = 0.13 and 0.66 (95% CI 0.12-1.0) with p = 0.58. There was a significant agreement between diagnostic accuracy of BLUS and CT scan [kappa value (κ) = 0.14, p = 0.009], whereas CXR could not establish its diagnostic efficiency (κ = -0.023, p = 0.493). Sonographic features of pneumonia were B-lines, shred, and hepatization signs. Conclusion: It is observed that BLUS showed higher sensitivity, specificity, and diagnostic accuracy as compared to CXR to diagnose pneumonia. How to cite this article: Dhawan J, Singh G. Bedside Lung Ultrasound as an Independent Tool to Diagnose Pneumonia in Comparison to Chest X-ray: An Observational Prospective Study from Intensive Care Units. Indian J Crit Care Med 2022;26(8):920-929.

Handheld ultrasound as an adjunct to physical examination in the diagnosis of cardiopulmonary disease.

Handheld 2D ultrasound devices (HUDs) have become available as an adjunct to physical examinations, visualizing the heart and lungs in real time and facilitating prompt patient diagnosis and treatment of cardiopulmonar.y disorders. These devices provide simple and rapid bedside alternatives to repetitive chest x-rays, standard ultrasound examinations and thoracic CT scans. Two currently available HUDs are described. This paper discusses the use of HUDs in the diagnosis of patients with pericardial effusion and tamponade, ventricular dilation, aortic and mitral regurgitation, cardiogenic pulmonary edema, viral and bacterial pneumonia, pleural effusion and pneumothorax. The use of a HUD by physicians increases clinical diagnostic accuracy, adds quantitative information about cardiopulmonary disease severity and guides the use of medications and interventions.

Effectiveness of the CLUE protocol in COVID-19 triage

Purpose: The purpose of this study was to evaluate the effectiveness of the CLUE protocol in COVID-19 triage. Materials and Methods: Patients who presented to the emergency department due to dyspnea with oxygen saturation below 95 % and were diagnosed with COVID-19 by reverse transcription polymerase chain reaction (RTPCR) tests were included in this prospective, observational study. Patients included in the study underwent lung ultrasound (LUS) in the light of the CLUE protocol, and were accordingly given LUS scores of between 0 and 36, also within the scope of the protocol. Patients were placed under observation, and clinical outcomes of discharge from the emergency department, admission to the ward, and admission to intensive care or discharge were recorded. ROC analysis was applied in the calculation of threshold values for LUS scores predicting discharge, admission to intensive care, and mortality. Results: Forty-five patients with a mean age of 63 +/- 18 years were included in the study. Fifteen patients (33 %) were treated on an outpatient basis and discharged, while 12 (27 %) were admitted to the ward and 18 (40 %) to the intensive care unit. Mortality occurred in 15 (33 %) patients. An LUS score lower than 3 was 97 % sensitive and 80 % specific for discharge, a score greater than 10 was 94 sensitive and 78 % specific for admission to the intensive care unit, and a score higher than 11 was 93 % sensitive and 87 % specific for mortality. Based on regression analysis, an LUS score higher than 10 emerged as an independent risk factor for intensive care requirement, a score lower than 3 for discharge, and a score over 11 for mortality. Conclusion: The CLUE protocol may be a useful bedside test in COVID-19 triage, and one that does not involve radiation or require laboratory tests.

Teaching Evidence-Based Physical Diagnosis: A Workshop for Hospitalists.

Introduction: Teaching on physical examination, especially evidence-based physical diagnosis, is at times lacking on general medicine rounds. We created a hospitalist faculty workshop on teaching evidence-based physical diagnosis. Methods: The workshop included a systematic approach to teaching evidence-based physical diagnosis, multiple teaching resources, and observed peer teaching. A long-term follow-up session was offered several months after the workshop. Participants completed questionnaires before and after the workshop as well as after the long-term follow-up session. Results: Four workshops were conducted and attended by 28 unique participants. Five hospitalists attended long-term follow-up sessions. Due to the COVID-19 pandemic, repeat sessions and long-term follow-up were limited. In paired analyses compared to preworkshop, respondents after the workshop reported a higher rate of prioritizing ( p = .008), having a systematic approach to ( p < .001), and confidence in ( p = .001) teaching evidence-based physical diagnosis. Compared to before the workshop, participants after the workshop were able to name more resources to inform teaching of evidence-based physical diagnosis ( p < .001). Informal feedback was positive. Respondents noted that the workshop could be improved by allowing more practice of the actual physical exam maneuvers and more observed teaching. Discussion: We created and implemented a workshop to train hospitalists in teaching evidence-based physical diagnosis. This workshop led to improvements in faculty attitudes and teaching skills. Long-term outcomes were limited by low participation due in part to the COVID-19 pandemic.