Hospital resilience during Covid-19: A single mixed-methods case study in Morocco

Background: During the Covid-19 pandemic, in low- and middle-income countries, hospital resilience was critical to the success of the pandemic response. In North Africa and Middle East region, little attention was paid to hospital resilience strategies. Objective(s): To explore hospital organizational resilience strategies in a Moroccan hospital. Method(s): Single case study with mixed methods. Ten interviews were conducted with managers and frontline healthcare workers. The concept of hospital resilience was assessed using a questionnaire given to 50 managers and frontline health workers. Result(s): Hospital resilience strategies included developing crisis preparedness plans, hiring professionals, and organizing care quickly. The challenges were: shortage of medication and human resources, lack of personal protective equipment, insufficient bed capacity and emotional and psychological impact of overwork on frontline professionals. Level of Evidence: 5.Copyright © 2022 Elsevier Masson SAS

Management of the COVID-19 pandemic in Rhineland-Palatinate hospitals of all levels of care : Results of the COVID-19 Registry RLP.

The COVID-19 pandemic placed a significant burden on the German healthcare system. Based on the experience of severe disease progression of the SARS-CoV­2 infection from neighboring European countries in the early 2020s, with ICU overload and high mortality rates, efforts were made in Germany to increase the capacity of available ICU beds. Subsequently, all documentation and reporting focused on the ICU capacities for COVID-19 patients. It was hypothesized that mainly a few large hospitals provided care for the majority of COVID-19 patients. The COVID-19 Registry RLP of Rhineland-Palatinate documented SARS-CoV­2 inpatients from daily mandatory queries of all hospitals throughout the pandemic from April 2020 to March 2023, distinguishing between patients in ICUs and normal wards. In its 18th Corona Ordinance, the state government required all hospitals to participate in the care of SARS-CoV­2 inpatients. We investigated the participation of hospitals at different levels of care in Rhineland-Palatinate in the management of the COVID-19 pandemic. Nine pandemic waves were documented during the pandemic and exemplary data on the respective pandemic peaks were evaluated. A distinction was made between the burden on hospitals at different levels of care: primary care hospitals, standard care hospitals, specialty hospitals, and maximal care hospitals. Analysis of the data showed that all hospital types participated equally in the care of SARS-CoV-2 patients. The requirement of the Ministry of Health of Rhineland-Palatinate to provide at least 20% of the available capacity was met by all levels of care and there were no disparities between hospitals of different levels of care in the management of the pandemic.Hospitals at all levels of care participated equally in the care of SARS-CoV­2 inpatients and thus contributed significantly to the management of the pandemic in Rhineland-Palatinate.

Do hospitals need to establish multiple hospital districts? A hospital-based perspective on the benefits of scale.

Background: During the fight against COVID-19, China's public hospitals played the main role in taking on the most urgent, dangerous and arduous medical treatment and work. Therefore, in order to promote the high-quality development of hospitals, it is necessary to support some potential public hospitals to build and develop a "One Hospital with Multiple Campuses System" (OHMC) based on controlling the size of single hospitals, and to quickly convert their functions in the event of a severe epidemic. Methods: The Cobb-Douglas production function and log-transformed production function were used to measure the appropriate hospital size for 22 public hospitals in a region of China. Results: The eight OHMC hospitals that planned to be build are basically qualified to handle the conditions and potential of multi-districts from the perspective of economy of scale. The OHMC hospitals in operation appear to have weakened incremental scale rewards, because they are in the process of development, but they are still higher than the overall level of single-campus hospitals. Conclusion: The expansion of hospital scale may bring the advantages of group development, but it may also bring about problems including rising hospital cost, increasing management and operation cost, inefficient allocation of medical resources and unbalanced development.

Stroke Service Redesign to Facilitate Hospital Flow during the Covid-19 Pandemic

Introduction: During the Covid-19 pandemic it was recognised by MTW, a reconfiguration of the acute hospital would be required to create extra bed capacity and protect vulnerable patient groups. Alongside the pandemic the Kent and Medway stroke reconfiguration occurred (Winidbank, 2015). Since July 2020, MTW Stroke Unit admission data shows an average rise of 107% in activity. In December 2020, 'The Hilton Stroke Pathway' (HSP) was developed as a 6 month rehabilitation pilot to increase the MTW bed-base away from the acute site . The pathway consisted of an innovative virtual and homecare rehabilitation service in collaboration with Hilton Nursing Partners. Method(s): The pilots were evaluated using 5 key criteria: financial performance, clinical service delivery, quality of care, patient experience and stakeholder feedback. The pathway is overseen by MTW therapists, discharge liaison services and Hilton care. The aim of the pathway: Enable safe discharge home for stroke patients requiring specialist rehabilitation as soon as they were medically fit. Ensure patients rehabilitation was delivered safely and effectively. Provide a flexible service supporting patients with a range of therapy need. Provide nursing and care support as required. There are 3 levels of support: recovery, moderate and intensive. The MDT discussed which level was most appropriate for the patient. This was then reviewed as patients improved. Initially the therapy was overseen virtually by the OT, PT and SALT team. However, due to complexity of some of the patients' rehabilitation needs, therapy staff shifted to face-to-face therapy sessions. Due to the success of the pilot phase MTW decided to transition the pathway to business as usual. As part of this the pathway was reviewed in collaboration with KCFHT and therapy outcome measures were collected. Monthly monitoring meetings continue with Hilton, to ensure ongoing quality of care and effectiveness of the pathway Results: Since the beginning of the pilot the pathway has achieved positive results in SSNAP. Between January and June 2021 92.2% required OT, 84.4% required PT and 63.3% required SALT. The results in chart 1-2 are from Jan - April 2022. Chart 1 shows patient outcomes for destination on discharge. Chart 2 shows the difference in Therapy Outcome Measure (TOMs) admission and discharge scores. There has been a significant difference in the TOMS in three domains (significant difference=0.5)(Enderby and John, 2019), impairments, activity and participation. The biggest improvements has been seen in activity and participation meaning the HSP are enabling patients to integrate back into society and their occupational roles in life. The pilot evidenced using multi-organisational working has enabled earlier and safer discharges home. The new pathway has allowed for flexible acute bed capacity following the closure of stroke services at Medway hospital and during the challenges that accompanied the Covid-19 pandemic. The HSP has shown significant improvement with functional outcomes and integration back into occupational roles. In 2022 52% of the patients did not require further social care at the end of the pathway. SSNAP data shows a higher intensity of therapy was provided with an average of 34 minutes of OT, 37 minute of PT and 14 mins of SALT per day, whilst on the pathway. Therefore, MTW and Hilton Nursing Partners are keen for continuation of this pathway into future stroke development. Additionally, collaboration with KCHFT community neurorehabiliation team enabled the West Kent stroke rehabilitation pathways to be defined seen in Chart 3. The integration of Hilton Nursing Partners and the MTW MDT enabled safe and effective facilitation for stroke patients into their homes, whilst achieving high levels of independence. Conclusion(s): The stroke service demonstrated what can be achieved in a short timeframe and in challenging circumstances. The implementation was robust and a positive use of NHS resources to proactively enable changes in stroke service provision required across West Kent The pathway was well received by patients and staff, providing a direction of travel towards community-based stroke rehabilitation services which reflect the national guidelines for stroke services (RCP, 2016;NICE, 2013).

Impact of Covid-19 Wave 3 Paediatric Inpatient Unit Closures on Transfers to Tertiary Care Paediatric Hospital

BACKGROUND: During Wave 3 of the COVID-19 pandemic, 15 community hospital paediatric inpatient units (comprising 167 beds) in Toronto were directed to close by the Greater Toronto Area (GTA) Hospital Incident Management System (IMS) Command Centre to increase adult inpatient bed capacity. All paediatric patients from closed inpatient units were redirected to a single tertiary care paediatric hospital, which increased capacity to accommodate these additional patients through activation of surge plans, while community hospitals redeployed resources to fill much needed gaps in adult care. OBJECTIVE(S): The objective was to describe patient characteristics of all transfers during the closure to explore the impact of community paediatric inpatient unit closures on transfers to the tertiary hospital. DESIGN/METHODS: A chart review of all transferred patients was conducted during the mandated closure and subsequent reopening. Transfers excluded ICU-level transfers as these were not impacted by IMS mandated closures. All transfers were categorized as requiring tertiary care (i.e. would typically be transferred) or not requiring tertiary care (i.e. only transferred due to the closure). Variables collected included sending hospital, admitting diagnosis, patient age, hospital disposition, and length of stay. Data was collected until the last paediatric unit reopened. Quality improvement project approval was granted by the institution. RESULT(S): A total of 858 patients were transferred to the tertiary hospital during the 67 day closure;of those, 530 were transferred solely to increase adult bed capacity (i.e. were categorized as patients requiring non-tertiary care). The majority of patients were admitted to general paediatrics (52%), and 39% went to a surgical inpatient unit. Most patients (68%) admitted had a length of stay between 24 and 72 hours. A third of patients admitted were under 2 years old, and a third were over 12 years old. The top three diagnoses for admission were infections, gastrointestinal issues, and general surgery. Two-thirds (60%) of transfers from closed sites came from three sites. CONCLUSION(S): More than half of the transfers occurred solely due to the mandated closures, and transfers returned to a stable volume once all sites re-opened. The GTA hospital system was able to respond to the mandated closure effectively through clear high-level communication, escalation processes and structures as well as responsive, real-time problem solving. Closures increased potential adult inpatient capacity by 6740 bed days and demonstrated an unprecedented system-wide approach to the provision of integrated paediatric care across the region.

A Novel Approach to Post-Transplant Care of Kidney and Pancreas Transplant Recipients, Inpatient Level Care in the Home

Purpose: Demonstrate safe and cost effective care of early kidney and pancreas post-transplant complications through the Advanced Care at Home (ACH) inpatient home-based care program. Method(s): 5 abdominal transplant patients were admitted into ACH over a 1-month period. Each recipient underwent transplant less than a year prior to admission. These recipients received ACH and transplant standard of care including 24-hour access to a physician-led virtual monitoring center, telehealth and home-based provider visits, skilled nursing care, rehabilitation, nutrition, pharmacy, laboratory, imaging, social work, and other individualized healthcare services in the comfort of the patients own home. Result(s): 5 Recipients, all within 1 year of transplant were admitted with diagnoses of CMV Viremia, Bacteremia, AKI, pancreas rejection, COVID 19 and volume overload. Two patients required escalation back to the brick-and-mortar hospital, one for a biopsy to rule out rejection, the second for new onset sepsis and progressive renal failure requiring hemodialysis. A total of 33 brick and mortar bed days were saved, freeing hospital capacity during a time of critical bed shortage. None of the patients were re-admitted within 30 days of discharge from ACH. Conclusion(s): Advanced care at home is a safe alternative to the traditional Brick an Mortar(B &M) hospitalization for patients admitted with complications post abdominal solid organ transplant. We improved bed capacity in the midst of the COVID 19 pandemic and minimized cost associated with a traditional B & M stay.

Changes in the Number of Physicians and Hospital Bed Capacity in Europe.

OBJECTIVES: Our aim was to examine the numbers of practicing physicians and total numbers of hospital beds in European Organisation for Economic Co-operation and Development countries. METHODS: Data analyzed were derived from the "Organisation for Economic Co-operation and Development Health Statistics 2020" database between 1980 and 2018. The selected countries were compared according to the type of healthcare system and geographical location by parametric and nonparametric tests. RESULTS: In 1980, Bismarck-type systems showed an average number of physicians of 2.3 persons/1000 population; in Beveridge-type systems, it was 1.7 persons. By 2018, it leveled out reaching 3.9 persons in both healthcare system types. In 1980, average physician number/1000 was 2.5 persons in Eastern Europe; in Western Europe, it was 1.9 persons. By 2018 this proportion changed with Western Europe having the higher number (3.7 persons; 3.9 persons). In 1980, average number of hospital beds/1000 population was 9.6 in Bismarck-type systems whereas in Beveridge-type systems it was 8.8. By 2018, it decreased to 5.6 in Bismarck-type systems (-42%) and to 3.1 in Beveridge-type systems (-65%). In 1980, the average number of hospital beds/1000 population in Eastern Europe was 10.3; in Western Europe, it was 8.5. By 2018, the difference between the 2 regions did not change. CONCLUSIONS: Although the number of physicians was 33% higher in 1980 in Eastern Europe than in Western Europe, by 2018 the number of physicians was 5% higher in Western Europe. In general, regardless of the healthcare system and geographical location, the proportion of physicians per 1000 population has improved due to a larger decrease in the number of hospital beds.

CARE HOME DESIGNATED TO TAKE COVID-19 PATIENTS - PALLIATIVE CARE SUPPORT

Background Three Acute NHS Trusts were reaching maximum bed capacity by January 2021 due to the COVID-19 Pandemic. A local recently refurbished care home was identified as a suitable COVID-19 discharge facility for COVID-19 positive and COVID-19 contact patients whose ceiling of care could be managed in this setting (including oxygen therapy) to help ease bed pressures. Aims•To support primary care and care home staff with symptom control and decision making for those patients who were end-of-life.•To help avoid readmission back into the Acute NHS Trusts who were already at capacity.•To support the relatives of these patients Method From January until the end of March 2021 support was provided to the designated care home in the form of:•A weekly virtual ward round. Members on the virtual ward round included a GP, the Lead Nurse from the care home, an Advanced Nurse Practitioner, a paramedic and a Palliative Care Nurse Specialist.•The provision of regular telephone calls throughout the week was dependant on need from the care home.•If there were any particular patients that the care home staff had concerns about a clinical nurse specialist would be available at weekends and bank holidays for advice and support.•Telephone calls to relatives. Results•Prevention of patients being readmitted to the Acute NHS Trusts following the input from specialist palliative care.•Quality symptom control provided for patients not for escalation.•Quality end-of-life care.•Support for care home staff. Conclusion The specialist palliative care input made a positive contribution to the care of patients and also to the symptom control of those patients who were end-of-life. Staff felt supported in looking after these patients at a time when care home staff were generally feeling very isolated.

MAKING AN IMPACT ON THE COVID PANDEMIC

STATEMENT OF PROBLEM/QUESTION: When hospitals and skilled nursing facilities (SNF) were impacted during the COVID surge, what healthcare delivery model can be used to increase hospital bed capacity while maintaining quality care for marginalized patients with no access to a SNF? DESCRIPTION OF PROGRAM/INTERVENTION: Background - Santa Clara Valley Medical Center is the second largest public safety net healthcare system in California. During the COVID surge, our hospitals experienced a significant demand for hospital beds. At this time, SNFs were impacted and did not accept patients with barriers in discharge planning. Problem: How to safely discharge non-acute patients with no accepting SNF to increase hospital bed capacity. Intervention: Develop a post-acute care team (PACT) for marginalized, non-acute patients. These patients were initially hospitalized for severe medical conditions but could not be safely discharged once stabilized. During the COVID surge, Santa Clara County operationalized a 36-bed, lowacuity hospital called DePaul Health Center (DPHC) through an emergency state-issued alternative care license. DPHC implemented a novel healthcare model for post-acute transitions of vulnerable, non-acute patients during a resource-constrained time period. Of the 131 admissions to DPHC, 42% had unstable housing, 29% had active substance use, and 100% had no accepting SNFs. The operationalization involved: - Training volunteer outpatient providers to work in an inpatient setting with COVID-positive patients. - Building a referral model to include all hospitals in our county. - Transition of care services including: direct transition to drug treatment programs, linkage to medical respites, COVID vaccinations, specialty care followup, and medication delivery/teaching at bedside. MEASURES OF SUCCESS: - Number of hospital bed days saved. - Number of additional potential hospital admissions. - Implementation of high-quality inpatient services for non-acute patients. FINDINGS TO DATE: Over six months, DPHC admitted 127 patients across three county hospitals. DPHC allowed for a potential 446 additional hospital admissions (based on 2232 potential bed days saved and an average hospital LOS of 5 days per hospital admission). KEY LESSONS FOR DISSEMINATION: - Establishing a post-acute care team addresses structural inequities prevalent in our healthcare system for marginalized patients. - Incorporating a post-acute care team improves access to SNF for marginalized patients.

A study of the evacuation and allocation of hospital beds during the Covid-19 epidemic: a case study in Iran.

BACKGROUND: Shortage of resources, such as hospital beds, needed for health care especially in times of crisis can be a serious challenge for many countries. Currently, there is no suitable model for optimal allocation of beds in different hospital wards. The Data Envelopment Analysis method (DEA) has been used in the present study to examine the evacuation and allocation of hospital beds during the covid-19 pandemic in order to contribute to effective planning for fighting the spread the covid-19 virus. METHODS: The present study was conducted in two stages in hospitals affiliated with Urmia University of Medical Sciences (UUMS) in 2021. First, the number of excess beds was determined by calculating the technical efficiency using the DEA method and Deap2.1 software. To reallocate excess beds to covid-19 patients, the types of hospital wards were considered. As a result of this analysis, the inefficient hospitals with excess beds in different wards, which could be used for covid-19 patients with more serious symptoms, were identified. RESULTS: The results of the study show that the average technical efficiency of the studied hospitals was 0.603. These hospitals did not operate efficiently in 2021 and their current output can be produced with less than 61% of the used input. Also, the potential of these hospitals, over a period of 1 year, for the evacuation of beds and reallocation of them to covid-19 patients was calculated to be 1781 beds, 450 of which belonged to general wards and 1331 belonged to specialized wards. CONCLUSIONS: The DEA method can be used in the allocation of resources in hospitals. Depending on the type of hospital wards and the health condition of patients, this method can help policy-makers identify hospitals with the best potential but less emergency services for the purpose of reallocation of resources, which can help reduce the severe effects of crises on health resources.

HEALTHCARE IN THE TIME OF A PANDEMIC AND BEYOND: THE INNOVATIVE LARGE-SCALE AND INTEGRATED SAUDI NATIONAL HEALTH COMMAND CENTRE

Background The increasing frequency of pandemics, and costs of healthcare services requires integrative, efficient and effective health systems. Aim Describe the framework and distinctive outcomes of the Saudi National Health Command Centre (NHCC). Method: A review was performed to describe the system-based engineering approach utilised to design the Saudi NHCC. This smart centre creates a new model of care delivery which impacts clinical and operational indicators by adopting integrative and interdisciplinary methods to analyse, disseminate, manage, and measure outcomes. Results The NHCC is structured into four main departments with data integration and real-time data visualisation to allow for rapid assessment of available resources. It's organised to support technical incubators and empower several initiative. This enhanced the proactive capacity management in the centre and collectively contributed to several favourable outcomes. These included rapidly deploying medical staff and mechanical ventilators during its response to coronavirus disease (COVID-19);bending the curve early of the first wave of COVID-19 resulting in a low mortality rate (<2%);and reducing ICU lengths of stay by 10%, average lead-time of the supply chain from 60 days to 25 days, and surgery waiting times. It also supported the increment bed capacity from 6,000 to10,400, and maintaining the percentage of patients receiving care within 4 hours in emergency departments above 85%. Conclusion The NHCC replaces the traditional reliance on the subjectivity of information-based processes with actionable data, which helps building fairer systems to tackle structural inequalities in healthcare access and outcomes, eliminating waste, and allocating resources more effectively and efficiently. Importantly, a command centre to healthcare design and delivery creates synergy between people, processes, and technology facilitating substantial improvements in both patient and service outcomes.

Living donor liver transplant outcomes during the COVID-19 pandemic: does a decrease in case volume impact the overall outcomes?

Background: High-volume centers (HVCs) are classically associated with better outcomes. During the coronavirus disease 2019 (COVID-19) pandemic, there has been a decrease in the regular liver transplantation (LT) activity at our center. This study analyzed the effect of the decline in LT on posttransplant patient outcomes at our HVC. Methods: We compared the surgical outcomes of patients who underwent LT during the COVID-19 pandemic lockdown (April 1, 2020 to September 30, 2020) with outcomes in the pre-pandemic calendar year (April 1, 2019 to March 31, 2020). Results: During the 6 months of pandemic lockdown, 60 patients underwent LT (43 adults and 17 children) while 228 patients underwent LT (178 adults and 50 children) during the pre-pandemic calendar year. Patients in the pandemic group had significantly higher model for end-stage liver disease (MELD) scores (24.39±9.55 vs. 21.14±9.17, P=0.034), Child-Turcotte-Pugh scores (11.46±2.32 vs. 10.25±2.24, P=0.03), and incidence of acute-on-chronic liver failure (30.2% vs. 10.2%, P=0.002). Despite performing LT in sicker patients with COVID-19-related challenges, the 30-day (14% vs. 18.5%, P=0.479), 3-month (16.3% vs. 20.2%, P=0.557), and 6-month mortality rates (23.3% vs. 28.7%, P=0.477) were lower, but not statistically significant when compared to the pre-pandemic cohort. Conclusions: During the COVID-19 pandemic lockdown the number of LT procedures performed at our HVC declined by half because prevailing conditions allowed LT in very sick patients only. Despite these changes, outcomes were not inferior during the pandemic period compared to the pre-pandemic calendar year. Greater individualization of patient care contributed to non-inferior outcomes in these sick recipients.

ICU Structures and Protocols in Ecuador: A Peri-Pandemic Nationwide Assessment

Rationale: Ecuador was among the top fifth of countries affected by the COVID-19 pandemic worldwide. Intensive care units (ICUs), and health system resilience form key elements of the health system to prepare for meeting needs of its population, both during surge needs, and for postpandemic planning. There is limited evaluation of the existing ICU infrastructure, processes and protocols within ICUs. Our study sought to perform an assessment of the ICU practices across Ecuador. Methods: During December, 2020, we conducted an observational, cross-sectional study using questionnaires developed in Spanish, that were deployed in 42 Ecuadorian medical facilities, using trained physicians. The questionnaires were developed by experts, covering domains including hospital characteristics, utilization, and structural factors, such as human resources, and staffing practices. ICUs were categorized by the degree of global resource availability. The primary outcomes were availability and access to equipment, personnel, protocols, and therapies relevant to the practice of critical care. Secondary outcomes were mortality, admissions in the emergency department and ICU annually. Results: Thirty-six hospitals (85.7%) agreed to participate and were enrolled in the study. Annual average ICU mortality in 2019 was 20% (IQR: 14-30), which in 2020 increased to 40.5% (IQR 28.9-49.8), in the facilities evaluated. Annual average ICU admissions were 311 (154-404), with an average annual bed capacity of 120 (82-221.5). Sepsis, deep venous thromboprophylaxis, and glucose monitoring protocols were most commonly reported (96%), while protocols for massive transfusion (48%), targeted temperature management (41%), and palliative care (30%) were less common. In a multivariable linear regression adjusting for ICU level, annual ICU mortality was significantly lower in hospitals that reported higher use of respiratory protocols (- 3.4%, 95% CI-5.4 to -1.3;p=0.003) and sepsis protocols (-8.4%, 95% CI -14.1 to -2.7);p= 0.006). Conclusions: To our knowledge, this is the first study describing the ICU structure, process and components of different facilities across Ecuador. These may help guide decision-making policymakers, and health service communities to understand Ecuador's health system resilience, and key avenues for improvement and planning.

Intensive care unit treatment for patients suffering from COVID-19: The second wave Neuchâtel experience

Between mid-October 2020 and mid-January 2021, during the second wave of COVID-19 pandemia, 125 patients have been admitted in the intensive care units of Neuchâtel network hospitals. To manage this flow, the bed capacity of intensive care unit increased by 240%. Each patient received corticosteroids, an increased prophylactic anticoagulation and an antibiotic. Similarly to the first wave, 51% patients received mechanical ventilation, 55% of which in prone position. Concerning the drug treatments, 16 patients were treated with tocilizumab and 4 with remdesivir. Despite an unprecedented rise in the number of ventilated beds, 15 patients were transferred out of the region of Neuchâtel in order to prevent a saturation point of the system. The mortality rate in the intensive care unit reached 16% of the admitted and non-transported patients.

The journey of Malta's public healthcare service during the first 12 months of the COVID-19 pandemic

BACKGROUND COVID-19 was a global shock, causing challenges to many countries’ healthcare services. This paper provides a summary of Malta’s healthcare system journey during the COVID-19 pandemic with its initial preparedness for COVID-19 pandemic and the impact of COVID-19 on the service during the first 12 months of the pandemic. METHODS A literature search was conducted using Google and reviewing Maltese online newspapers. A comprehensive summary of internal operations conducted at Mater Dei Hospital, the country’s only acute general hospital, was provided by the Chief Operating Officer. RESULTS Several infrastructural changes including the increase in bed capacity and ITU areas were instituted in preparation for the pandemic. The health system showed resilience during the first wave. However, the situation was more precarious during the second wave. The end of December 2020 saw the start of the Covid-19 vaccination rollout, with over 30 health system hubs offering this service across the islands. Simultaneously health professional’s burnout is on the rise as resources and workforce are overstretched. CONCLUSION The collaborative effort between the guidance provided by the Public Health Authorities and the hospital’s multi-disciplinary team have been pinnacle during the pandemic. However, the future of the healthcare system is heavily dependent on the population’s behaviour, timely measures, the vaccination rollout and the type of immunity acquired through vaccination or infection.

The impact of COVID-19 pandemic on intensive care workload at Mater Dei Hospital in Malta

Introduction: The aim of the study was to determine the impact of COVID-19 pandemic on intensive care workload [1,2] at our only acute main general hospital on the island. During the pandemic surge in March 2021, our intensive care was running at 200% capacity. Mater Dei Hospital has a 20-bedded adult intensive care catering for a population of 500,000. Methods: This is a prospective cohort study conducted in the COVID- 19 Intensive Care Unit at Mater Dei Hospital, Malta. Data analysed is from March 2020 to May 2021. Data collected daily from admission until death or discharge from ICU. Results: A total of 261 patients with severe acute respiratory distress syndrome coronavirus 2 (SARS-Cov-2) required admission to our intensive care. ICU facilities required expansion into a total of 5 Intensive Care Units, therefore reaching a capacity of 44 intensive care beds during the peak month of March 2021. A maximum of 21 patients were admitted per week culminating to a total of 33 COVID-19 Intensive Care beds during the month of March 2021. A total of 179 patients (68.6%) required mechanical ventilation for a median duration of 11 days per patient. Proning was required in 124 mechanically ventilated patients (70.5%). 50 patients (20%) required CRRT with a maximum number of 7 patients per day requiring CRRT. Conclusions: COVID-19 pandemic transformed the way how we provide critical care with improved bed capacity, ICU triage and ICU devices. This study highlighted the need for more clinical guidelines and their availability for online use. This will positively impact the care of non-COVID patients. It also highlighted the need for more training of non-ICU staff to allow for surges in ICU capacity. The COVID-19 pandemic has seen Mater Dei hospital already investing in ICU personnel and equipment as this cannot be reactive to large scale events but must be a proactive planned strategy to enhance resilience of our ITU.

The impact of implementing a multicomponent recovery pathway for patients undergoing unicompartmental knee replacement on length of stay

Keywords: unicompartmental, pathway, outcomes Purpose: Unicompartmental knee replacement (UKR) is the gold standard surgical management of patients with unicompartmental osteoarthritis of the knee. As UKR surgery is less invasive, this potentially allows patients to be discharged quicker than those patients undergoing total knee replacement. During the COVID-19 pandemic, elective surgeries were postponed and new ways of working were required to restart procedures. In order to minimise the risk of exposure to COVID-19, we established a new multicomponent recovery pathway (MRP) for patients undergoing UKR to facilitate earlier discharge. Objective: To evaluate the impact of the MRP on length of stay. Methods: The MRP was introduced in August 2020 to provide day-case surgery where possible. All patients undergoing UKR at St Cross Hospital, Rugby were eligible for inclusion in the trial. Exclusion criteria was lack of support at home and uncontrolled co-morbidities. Patients who were assessed preoperatively, but unsuitable for the day-case service followed all other aspects of the enhanced recovery pathway (ERP). The ERP included a new anaesthetic protocol of prilocaine spinal anaesthesia, limiting tourniquet use, and multimodal postoperative analgesia. From a physiotherapy perspective, new individualised pre-operative assessment and education sessions were introduced, with mobilisation commencing on the day of surgery. Patients were discharged with their knee in full extension and returned at day 4 for postoperative review and initiation of flexion. Data was collected prospectively for patients receiving the MRP and compared to a historical cohort from the previous year. Primary outcome was hospital length of stay (LOS). LOS data was assessed for normality and analysed using the students t-test. Results: Following introduction of the MRP 30 patients underwent UKR and were included in the analysis. Patients in the MRP group were significantly older (65.6 vs. 60.1 years, p < 0.05), although no other baseline differences were observed. Whilst there was a reduction in the use of general anaesthesia (30% vs 59%, p = 0.0917) and tourniquets (53% vs 68%, p = 0.3925), this did not reach statistical significance although there was a significant increase in the use of Prilocaine (30% vs 0%, p < 0.01). Following the introduction of the MRP, LOS reduced significantly (1.4 vs 2.9 days, p < 0.001), with no significant differences observed in joint range of motion (ROM) between groups. Within the MRP group, 9 patients (30%) received all key components (prilocaine spinal anaesthesia, no tourniquet and enhanced physiotherapy), 8 of which were discharged as day-case. Conclusion(s): The MRP was successful in reducing LOS in patients undergoing UKR, with no impact on joint ROM. The biggest impact was observed for those patients who received all components. Future work should explore methods to improve compliance with the pathway to maximise patient benefit. Impact: The positive results seen through introducing the MRP has a number of potential benefits. Alongside a reduction in LOS with benefits to patients and cost savings to the trust, the additional bed capacity released will allow increased throughput of patients which could be significant for the waiting list accrued as a result of the cessation of elective surgery due to Covid-19. Funding acknowledgements: n/a

Hospital in the Home Delivery of Supportive Care for Autologous Stem Cell Transplantation: A Novel Single Centre Patient Focused Approach

Introduction: High dose therapy with Autologous Stem Cell Transplantation (ASCT) has traditionally been performed as an inpatient procedure. However, with improvements in care and patient selection it is possible to safely deliver conditioning chemotherapy and supportive care in an Daytherapy setting (Kodad SG et al., 2019). While deemed an “outpatient procedure” this method is often delivered on large day units which requires the patient to attend daily, often only spending overnight at home. To reduce these daily visits the Clinical Haematology Department of Peter MacCallum and Royal Melbourne Hospital (CHD) in collaboration with the Hospital in the Home department (HIHD) at Royal Melbourne Hospital developed an innovative program to safely deliver supportive care for Myeloma Patients undergoing ASCT at home (HIH-ASCT). The HIHD is an acute inpatient unit that exists as a “virtual” inpatient ward. Patients are reviewed daily by a HIHD Doctor with twice daily visits by a HIHD Nurse for administration of supportive care measures (e.g. intravenous electrolyte and fluid replacement) in the comfort of their home. Here we report on the safety outcomes of our HIH-ASCT program, specifically patient complications and outcomes. Methods: A retrospective case note audit identified 54 consecutive HIH-ASCT patients who received HIH-ASCT for Myeloma between 2018 and 2021 under HIHD. Patients were eligible for our HIH-ASCT program if they had Myeloma requiring ASCT;an ECOG ≤1;had not been admitted to ICU previously;lived within 30 minutes drive of the hospital;had a safe home environment (for both the patient and visiting staff) and a carer who could stay with them throughout their HIH-ASCT. While undertaking HIH-ASCT patients did not receive prophylactic antibiotics and they were not routinely given GCSF to minimise the risk of engraftment fevers. Results: Of those treated as HIH-ASCT patients the median age was 60 years (range 33-72). 39% patients were female (n=21) and 61% male (n=33). Underlying disease groups included IgA (n=8;15%), IgG (n=35;64%), IgM (n=1;2%), Light Chain (n=9;17%) and Oligosecretory (n=1;2%). 43% had High-risk Cytogenetics. ASCT-1 (n=48;88%), ASCT-2 (n=5;9%) and one patient underwent a ASCT-Tandem (both under HIHD). Conditioning regimes included Melphalan200 (n=37;68%), Velcade-Melphan200 (n=13;23%) and Carfilzomib-Melphalan200 (n=5;9%). The average stem dose was 3.80 x10 6/kg (range 2.14-8.4). Median time to Neutrophil engraftment was 12 days (range = 10-21) and Platelet engraftment 12 days (range = 8-18). The total number of bed days saved through the HIH-ASCT program was 466, with a median length of stay (LOS) under the HIHD team of 9 days (Range = 3-14). In addition, 3 patients were not readmitted to the hospital (6%) and were discharged directly from the HIHD team. The most common reason for readmission was fever (n=43;80%), of which only 11 were culture positive, and diarrhoea (n=44;81%). Only 1 patient required intensive care support. There were no deaths. The median LOS as an inpatient once readmitted was 6 days (range = 2-27). In regards to cost savings, an acute inpatient bed under the CHD is approximately $1300 USD versus $900 USD per day for a HIHD bed. This equated to a potential cost saving for the CHD of approximately $186000 USD. Conclusion: The delivery of supportive care for patients undergoing HIH-ASCT in is both safe and effective with comparable outcomes for what would be expected for an inpatient cohort. It resulted in a median of 9 bed days saved per patient (total number of bed days saved = 466). This is important as it allowed our department to increase bed capacity across the unit without the associated costs of building a new ward. In addition, during our COVID-19 outbreaks the HIH-ASCT program has allowed us to continue to deliver optimal patient care, while minimising the infection risk for our patients. More recently we have introduced remote monitoring (e.g. temperature, heart rate, blood pressure and oxygen saturations) with video reviews with the aim of increasing the capacity of our HIHD and further improving the HIH-ASCT experience for our patients. Disclosures: Routledge: Amgen: Honoraria, Speakers Bureau;Sandoz: Consultancy, Honoraria, Speakers Bureau;BMS: Honoraria. Harrison: Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Abbvie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;GSK: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Eusa: Consultancy, Honoraria, Speakers Bureau;Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees;Celgene/ Juno/ BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Terumo BCT: Consultancy, Honoraria;Janssen Cilag: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Roche/Genentech: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Haemalogix: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Ritchie: CRISPR Therapeutics: Research Funding;Amgen Inc: Honoraria, Research Funding;Novartis: Honoraria;CSL: Honoraria;BMS: Research Funding;Takeda: Research Funding.

Ankle blocks: Improving day case efficiency

Introduction: The COVID pandemic has exerted unprecedented pressure on hospital resources. Resulting in cancellation of elective operative services, increased patient waiting lists, limited surgical training opportunities along with reduced availability of staff, theatre, and inpatient bed capacity. A novel approach for day case forefoot surgery under ankle block, to mitigate the pandemic service limitations without compromising care, was developed. Method: This is a 3-month, multi-centre, prospective cohort study evaluating the novel ankle block day case forefoot surgery pathway. Patients had a minimum of three months clinical follow up with outcome scores. They were matched to a cohort undergoing similar surgery prior to the COVID pandemic. Results: The utilisation of an ankle block pathway resulted in an average reduction of inpatient stay by 2 days per patient. Over the study period conservative savings of £26,659 were calculated. Anecdotally we observed a reduction in morbidity (wound complications, SSI's) although not statistically significant. Conclusions: Our novel surgical pathway has enabled continued elective operating for procedures that previously required hospital admission during a period of severe restrictions within the NHS. We observed significant reductions in cost, surgical inpatient bed utilisation and total operative time with staff, resource, and time savings. We hypothesise that prehabilitation with physiotherapy, ankle instead of thigh tourniquets and early mobilisation may have contributed to improved morbidity scores. The findings of this project have implications for training, upper limb services and are transferrable as a template to improve service efficiency while maintaining high quality care.

[Bed capacity management in times of the COVID-19 pandemic : A simulation-based prognosis of normal and intensive care beds using the descriptive data of the University Hospital Augsburg]. / Bettenkapazitätssteuerung in Zeiten der COVID-19-Pandemie : Eine simulationsbasierte Prognose der Normal- und Intensivstationsbetten anhand der deskriptiven Daten des Universitätsklinikums Augsburg.

BACKGROUND: Following the regional outbreak in China, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread all over the world, presenting the healthcare systems with huge challenges worldwide. In Germany the coronavirus diseases 2019 (COVID-19) pandemic has resulted in a slowly growing demand for health care with a sudden occurrence of regional hotspots. This leads to an unpredictable situation for many hospitals, leaving the question of how many bed resources are needed to cope with the surge of COVID-19 patients. OBJECTIVE: In this study we created a simulation-based prognostic tool that provides the management of the University Hospital of Augsburg and the civil protection services with the necessary information to plan and guide the disaster response to the ongoing pandemic. Especially the number of beds needed on isolation wards and intensive care units (ICU) are the biggest concerns. The focus should lie not only on the confirmed cases as the patients with suspected COVID-19 are in need of the same resources. MATERIAL AND METHODS: For the input we used the latest information provided by governmental institutions about the spreading of the disease, with a special focus on the growth rate of the cumulative number of cases. Due to the dynamics of the current situation, these data can be highly variable. To minimize the influence of this variance, we designed distribution functions for the parameters growth rate, length of stay in hospital and the proportion of infected people who need to be hospitalized in our area of responsibility. Using this input, we started a Monte Carlo simulation with 10,000 runs to predict the range of the number of hospital beds needed within the coming days and compared it with the available resources. RESULTS: Since 2 February 2020 a total of 306 patients were treated with suspected or confirmed COVID-19 at this university hospital. Of these 84 needed treatment on the ICU. With the help of several simulation-based forecasts, the required ICU and normal bed capacity at Augsburg University Hospital and the Augsburg ambulance service in the period from 28 March 2020 to 8 June 2020 could be predicted with a high degree of reliability. Simulations that were run before the impact of the restrictions in daily life showed that we would have run out of ICU bed capacity within approximately 1 month. CONCLUSION: Our simulation-based prognosis of the health care capacities needed helps the management of the hospital and the civil protection service to make reasonable decisions and adapt the disaster response to the realistic needs. At the same time the forecasts create the possibility to plan the strategic response days and weeks in advance. The tool presented in this study is, as far as we know, the only one accounting not only for confirmed COVID-19 cases but also for suspected COVID-19 patients. Additionally, the few input parameters used are easy to access and can be easily adapted to other healthcare systems.