ABSTRACT
The Montgomery vs. Lanarkshire case of March 2015 is one of the most important UK judgments on informed consent. The ruling dictated that any intervention should be based on a shared decision, whereby patients are aware of all options and supported in making an informed decision. There is debate over whether patients requiring a procedure after a store-andforward teledermatology consultation need a preoperative face-to-face (F2F) appointment to comply with this consent. We evaluated patient experiences of our skin cancer teledermatology pathway, whereby patients had a telephone consultation before a surgical appointment and their first visit to the hospital was for the procedure. On average, we receive 9000 2-week-wait referrals a year. In March 2020, following the UK's nationwide lockdown, our dermatology department had 700 new referrals pending without any opportunity of F2F appointments. To meet this demand and the subsequent restrictions of the COVID-19 pandemic, we established a teledermatology service. Patients attended a community hub where a detailed history was taken and lesions photographed by a medical photographer, including dermoscopic images. Clinical images were subsequently reviewed by a consultant dermatologist. For those requiring surgical procedures, preoperative telephone consultations were conducted. Patients requiring complex procedures and those with likely highgrade malignant melanoma were offered F2F appointments. During the telephone consultation, the planned procedure was explained, with risks, benefits and alternative treatments discussed. The first 50 patients were sent a survey comprising eight questions pertaining to their experience of the new pathway. Over a 4-week period, 34 responded. Mean age was 67 years (range 29-93). Ninety-seven patients felt photographs were taken in a timely manner. All patients reported that appropriate safety and social distancing precautions were taken. All patients described an overall positive experience, felt that sufficient information was provided throughout the pathway and were happy to engage with this service should they require a similar procedure in the future. In this cohort of patients, their first visit to hospital was for a procedure. There are many benefits in reducing F2F hospital attendances. As well as reducing footfall during the pandemic, there is less lost work time and cost of travel for patients or their relatives, more efficient use of hospital facilities and reduced carbon footprint. Our survey suggests that preoperative telephone consultations are liked by patients and appropriate in meeting the requirements of Montgomery consent for a teledermatology service.
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SESSION TITLE: Optimizing Resources in the ICU SESSION TYPE: Original Investigations PRESENTED ON: 10/16/2022 10:30 am - 11:30 am PURPOSE: The COVID-19 pandemic has exposed worldwide heterogeneity in the application of fundamental critical care principles and best practices. New methods and strategies to facilitate timely and accurate interventions are needed. If built on a robust foundation of physiologic principles, a virtual critically ill patient (aka digital twin) could better inform decision making in critical care. When used in clinical practice, a digital twin may allow bedside providers to preview how organ systems interact to cause a clinical effect, providing the opportunity to test the effects of various interventions virtually, without exposing an actual patient to potential harm. Building on our previous work with a digital twin model of critically ill patients with sepsis, this current project focuses specifically on the respiratory system. METHODS: We assembled a modified Delphi panel of 36 international critical care experts. We modeled elements of respiratory system pathophysiology using directed acyclic graphs (DAG) and derived several statements describing associated ICU clinical processes. Panelists participated in three Delphi rounds to gauge agreement on 71 final statements using a 6-point Likert scale. Agreement was defined as >80% selection of a 5 (“agree”) or 6 (“strongly agree”). RESULTS: The first Delphi round included statements of pulmonary physiology affecting critically ill patients, eg pulmonary edema, hypoxemic and hypercapnic respiratory failure, shock, acute respiratory distress syndrome (ARDS), airway obstruction, restrictive lung disease, and ventilation-perfusion mismatch. Agreement was achieved on 60 (84.5%) of expert statements after completion of two rounds. After partial completion of the third round, agreement increased to 62 (87%). Statements with the most agreement included the physiology and management of airway obstruction decreasing alveolar ventilation and the effects of alveolar infiltrates on ventilation-perfusion matching. Lowest agreement was noted for the statements describing the interaction between shock and hypoxemic respiratory failure due to increased oxygen consumption and ARDS increasing dead space. CONCLUSIONS: An international cohort of critical care experts reached 87% agreement on our rule statements for respiratory system pathophysiology. The Delphi approach appears to be an effective way to refine content for our digital twin model. CLINICAL IMPLICATIONS: Expert consensus can be used to strengthen the respiratory physiology statements used to direct the ICU digital twin patient model. With a digital twin based on refined respiratory physiology statements, bedside providers may preview how organ systems interact to cause a clinical effect without exposing an actual patient to various interventions. DISCLOSURES: No relevant relationships by Ognjen Gajic, value=Royalty Removed 06/06/2022 by Ognjen Gajic No relevant relationships by Amos Lal No relevant relationships by John Litell No relevant relationships by Amy Montgomery
ABSTRACT
Aim: To compare the reoperation and implant loss rates following implant breast reconstruction after 3 months and 5 years in a single unit cohort included in the large multicentre iBRA study1. Method: Patients undergoing implant breast reconstruction for breast cancer or risk reduction mastectomy were recruited as per the iBRA protocol. Electronic patient records were reviewed in December 2021 and reoperation and implant loss was recorded. Results: The records of 26 patients were analysed, all were recruited to the iBRA study. 3-month implant loss (9%) and reoperation rates (18%) were similar to the initial overall study. By 5 years, implant loss rates and reoperation rates had increased to 19% and 77% respectively. 10 patients (39%) underwent 2 or more further operations during this period, with 3 of these patients requiring 5 operations. We acknowledge this cohort is small and any revision procedures performed outside our trust would be missed. Conclusions: Following Montgomery Vs Lanarkshire2 and the Paterson Inquiry Report3, it is vital that patients are aware of any material risk during the consent process before surgery. Quoting 3-month implant loss and reoperation rates in isolation is potentially misleading and there is a need for robust real-life data to guide informed consent. Covid-19 related disruption to elective surgery is inevitable4 and difficult prioritisation decisions are required. Patients undergoing breast reconstruction in 2022 may experience similar complications to the 2016 cohort, however access to revision surgery is uncertain.
ABSTRACT
Patients receiving Continuous Positive Airway Pressure (CPAP) therapy for severe COVID-19 are at high risk of malnutrition1,2. This is related to poorer outcomes and longer durations of hospital stay3. British Dietetic Association guidance recommends nasogastric (NG) feeding for all COVID-19 patients on CPAP4. The aim of this Quality Improvement Project (QIP) was to optimise nutrition in COVID-19 patients receiving CPAP therapy in a ward-based setting at a UK District General Hospital. The QIP included 222 patients in total across four QI cycles. Four domains: meeting nutritional requirements (outcome measure), dietitian review, accurate weight and NG feeding (process measures) were studied. Whether patients were reviewed by dietitians, weighed and NG fed was determined for all 222 patients. Meeting of estimated nutritional requirements could be determined in 108 patients. Interventions included use of a local nutrition pathway, COVID-19 diet sheet, NG feeding and involvement of dietitians at a daily multi-disciplinary meeting. Descriptive statistical analysis in the form of a Chi- Squared test was used to compare the first two COVID19 waves. No ethical approval was required. Results showed significant improvement in the proportion of patients reviewed by dietitians, accurately weighed and NG fed between the first two waves of COVID19 (p<0.05). Comparing the 1st to the 4th QI cycle;meeting requirements improved from 50% to 68%, dietitian review from 29% to 91%, accurate weights from 44% to 87% and NG feeding from 6% to 65%. These improvements were achieved through novel approaches, rapid implementation of new guidance and multi-disciplinary working. Next steps should include introduction of a standardised care proforma and study in future QI cycles. These interventions could be trialled in other inpatient wards to deliver wider benefit. This QIP was successful in optimising nutrition in this cohort of patients and thereby delivering better patient care. References 1. Turner P, Montgomery H, Stroud M, et al. (2021) Malnutrition risk in hospitalised COVID-19 patients receiving CPAP. Lancet 397:1261. 2. Terzi N, Darmon M, Reignier J, et al. (2017) Initial nutritional management during noninvasive ventilation and outcomes: a retrospective cohort study. Crit Care 21:293. 3. Singer P, Blaser AR, Berger MM, et al. (2019) ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 38:48–79. 4. BDA Critical Care Specialist Group COVID-19 Best Practice Guidance: Feeding Patients on Critical Care Units in the Prone Position (awake and sedated). Second Edition. [accessed 31st May 2021]
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Introduction: "Wake Up and Learn" (WUAL) is a population based preventative sleep screening and education program for 7th to 12th graders through an asynchronously delivered virtual platform. The program was intentionally developed to be completely virtually delivered for scalability, which was of advantage during COVID allowing for the program to continue to be implemented with modest delays related to school schedule changes. This is a descriptive summary of excessive daytime sleepiness over two time points during the academic school year. Materials and Methods: The 7th to 12th grade students of Montgomery school district (Pennsylvania) were given an opt-out option for participation in the WUAL program. The surveys were generated using REDcap and included the Epworth sleepiness scale-CHAD (ESS-CHAD) and the childhood sleep habits questionnaire (CHSQ). The surveys became available online via the WUAL website (wakeupandlearn.org) and the students were instructed to access the website and complete the surveys as part of class time. Surveys were completed in December 2020 for the first time and then again in April 2021 as part of the planned three times per year surveillance. Due to school schedule changes experienced related to COVID the first survey planned for beginning of the academic year was skipped. Results: A total of 344 students completed ESS-CHAD in December 2020. There were 57 students with ESS scores greater than 10 (16.5%). In April, a total of 321 students completed ESS-CHAD with 49 students (15%) having ESS scores greater than 10. Of those with abnormal scores in December 15 (26%) had persistent sleepiness, 28 (49%) improved, and 14 (25%) did not provide a completed survey in April 2021. With this said, 34 (69%) of the respondents in April 2021 were newly identified to have pathologic sleepiness. 31% with persistent EDS from December 2020. Conclusions: Excessive daytime sleepiness is common in this adolescent high school cohort, but may not remain persistent over time. The majority of students who provided follow up responses had resolution of complaints of excessive daytime sleepiness between the two time points. Alarmingly, however, 34 additional students endorsed new complaints of EDS. Further examination of trends of EDS over time in this age group is required to better determine if this pattern is replicated in different school districts. If this is replicated it will be important to further explore factors that contribute to development, persistence and recovery from EDS. It is important to note that COVID and varying school structures (i.e in-person, virtual, hybrid) may have played a role in these findings. Wake Up and Learn is an on going program with plans for further expansion into additional school districts that may provide further insights into these trends. Acknowledgements: Thank you to Jazz pharmaceuticals and Janet Weis Children's Hospital for their support of the development and growth of this program.
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Background. The Walter Reed National Military Medical Center (WRNMMC) established a consolidated COVID-19 screening area (CSA) beginning in March 2020 to provide beneficiary and staff testing via a drive-through site. Testing was available to all patients and WRNMMC staff regardless of beneficiary status. Presented is a descriptive analysis of our testing operations and positivity rates within a closed medical system from March 2020 to April 2021. Methods. For quality and process improvement, we compiled daily testing logs from March 2020 to April 2021 from the CSA. These logs included patient demographics, reason for testing, test result, testing platform, and occupational status at the hospital. We determined positivity rates in various subgroups -asymptomatic, symptomatic, pre-operative, in order to track testing use and access. Additionally, we compared the overall positivity rate to the surrounding civilian community by pulling data from the Maryland Department of Health's COVID database. Results. Over the course of nearly 14 months of testing availability, 34,694 beneficiaries were screened with 41,582 individual tests. After May 2020, the monthly overall positivity rate varied from 1.99% to 11.92%, peaking in December 2020 (with high rates in November 2020, 7.52% and January 2021, 9.53%), correlating with or exceeding elevated positivity rates in Montgomery County (November 2020: 4.91%;December 2020: 6.48%;January 2021: 6.51%). When examining only symptomatic individuals, the positivity rate is notably much higher, with monthly rates varying from 6.40% to 21.10%, with a similar peak in December 2020. After full implementation of pre-operative screening for procedures with aerosolization potential in June 2020, the range of positivity rates was 0.28%-1.66%. Since vaccination for COVID-19 became widely available beginning in Feb 2021, the preoperative positivity rate has remained below 0.85%. Conclusion. Our institutional experience is unique in its ability to offer universal access to COVID-19 testing for beneficiaries and staff of the DoD under direction of the ID service. Our process serves as a model for public and occupational health response, and may guide lab resource and real-time staffing management in support of COVID-19 diagnostics at a medical center.
ABSTRACT
Background: Patients with Covid-19 are under great psychological stress, which can lead to the development of various psychiatric symptoms and maladaptive responses, such as anxiety, fear, depression, and insomnia. Psychiatric and psychological support can play a fundamental role in the general control of the disease. During the pandemic, whenever possible, services must provide help through telemedicine approaches. Digital solutions such as “PLANO-A-SAÚDE-C19” that allow to evaluate and to monitor the signs of infection of the SARS-CoV-2 while monitoring the states of mind, allow to maximize the capacity of the services without compromising on the quality-of-service provision. Objectives: To present and describe a digital platform that is being developed to remote monitoring Covid-19 patients and their mental health status at different points of the infection, from diagnosis to recovery. Methods: A set of sensors, coupled with a small low-cost device, is used to acquire biometric data according to different profiles. The device is connected wirelessly to a patient's smartphone, which transfers the acquired data to a central platform. Doctors can remotely access the data to assess the patient's condition and make decisions. The application running on the patient's smartphone can generate alerts (such as medication time) and alarms in case of dangerous biometric signals. In the case of Covid-19, the monitored parameters include blood pressure, heart rate, weight, body temperature, peripheral oxygen saturation, blood glucose, and the respiratory cycle. Validated psychiatric scoring tools are also used (the Montgomery–Åsberg Depression Rating Scale, the Pittsburgh Sleep Quality Index, the Insomnia Severity Scale, and the World Health Organization Quality of Life - BREF). Results: In this work, we would like to provide some preliminary data related to the impact of SARS-CoV-2 on the mental health of individuals infected during the course of the disease. We will describe the signs and symptoms of the virus, highlighting its relevance in changing the infected person's mental health status. Through the use of the digital platform, we hope to guarantee the quality of health services, proactively and continuously, following the fluctuations in the conditions of each patient, and contribute to the Proximity of Health, through the easy access between the patient and the provider of health. Conclusion: Healthcare services are facing a dramatic change in demand related to the effects of COVID-19. Scarce resources have mandated maximal operational efficiency and productivity to ensure timely patient access to best-suited treatment. Many hospitals have already telemedicine and launched hotlines to provide some help to people in need. Digital solutions that allow a double control of the state of organic and mental health can benefit the long-term economic, social and clinical results. The translation of therapeutic strategies that improve coping responses to stress following the needs of infected patients, contributes to the relief of related signs and symptoms. Apart from the Covid pandemic, distant mood follow-up monitoring promises a lot of others benefits. No conflict of interest
ABSTRACT
Introduction: SARS-CoV-2 infection causes a pulmonary disease (COVID-19) which spread worldwide in 2020, leading the World Health Organization (WHO) to declare a pandemic [1] and the Italian government firstly to declare a state of emergency, then to impose restrictive measures lasting about two months. COVID-19 pandemic generated fear, anxiety, depression and post-traumatic symptoms in the general population [2,3] as well as among subjects affected by mental disorders [4]. Little is known about which different psychopathological changes the pandemic caused among individuals affected by different psychiatric disorders. Aims: To investigate potential psychopathological changes over time during the first wave of COVID-19 pandemic comparing different psychiatric disorders. Methods: Data about demographic/clinical variables and psychopathological status were retrospectively collected. Specific psychometric scales were administered at three time points: T0 as outbreak of pandemic, T1 as lockdown period, T2 as reopening. Primary outcomes: Brief Psychiatry Rating Scale (BPRS), Clinical Global Impression (CGI), Hamilton Anxiety Rating Scale (HAM-A). Secondary outcomes: Disability Scale (DISS), Positive and Negative Syndrome Scale (PANSS), Hamilton Depression Rating Scale (HAM-D), Montgomery and Åsberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Descriptive analyses and linear regression models were performed. Summary of results: A total of 166 outpatients were included. Overall, psychometric scores showed a significant worsening at T1 with a mild improvement at T2 (p<0.05). Only psychotic and OC symptoms did not significantly improve at T2. Primary outcomes: time had a significant effect on the change of BPRS (F=26.56;p<0.001), CGI-severity (F=8.29;p<0.001), CGI-improvement (F=41.88;p<0.001) and HAM-A (F=33.63;p<0.001) scores. BPRS and CGI-S scores were higher among subjects affected by personality disorders (PDs) than in the depressed (MDD) and anxiety/obsessive-compulsive (OC) groups (p<0.05). PD patients also showed higher HAM-A scores than schizophrenia (SKZ) ones (p=0.02). Secondary outcomes: Time had a significant effect on the change of DISS-stress (F=40.80;p<0.001), DISS-support (F=9.26;p<0.001), HAM-D (F=9.50;p<0.001) and MADRS (F=9.40;p<0.001) scores. The time effect was not significant for DISS-disability (F=1.23;p=0.29), PANSS (F=1.37;p=0.26), YMRS (F=2.84;p=0.06) and Y-BOCS (F=0.55;p=0.59) scores. DISS-disability scores were higher in the PD group with respect to bipolar disorder (BD) (p=0.009), MDD (p<0.001) and anxiety/OCD (p=0.03) groups;SKZ and BD patients had lower DISS-stress scores than PD ones (both p values = 0.02). Conclusions: Patients affected by PDs showed to be particularly affected by the negative effects of outbreaks on mental health and perhaps they require specific clinical attention in case of traumatic events such as pandemics. Moreover, although SKZ patients reported lower anxiety levels than PD ones, the worsening of psychotic and OC symptoms should be strictly monitored by clinicians, as these aspects did not improve with the end of lockdown measures. Further studies on larger samples would allow an in-depth comparison of the psychopathological impact of pandemics between the different psychiatric diagnoses. The study has been registered on ClinicalTrials.gov with the following ID number: NCT04694482 No conflict of interest