IMPACT OF TWICE-DAILY MULTIDISCIPLINARY ROUNDING IN DECREASING TIME TO EXTUBATION FROM MECHANICAL VENTILATION IN THE ICU

SESSION TITLE: Late Breaking Posters in Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Discontinuing mechanical ventilation is a difficult process and takes time. Some patients succeed while others fail and remain on full ventilator support for a longer period. Extubation failure can result in many complications for the patient and a prolonged stay in the ICU. It's a common practice to have an SAT and SBT protocol in the majority of ICUs. Spontaneous awakening trial (SAT) is a nurse-driven protocol for discontinuation of sedation hypnotic drug to facilitate recovery to her baseline level of consciousness/responsiveness and assessment of intrinsic respiratory drive in the critical care setting. In general SAT protocol is followed and most ICUs are in the morning hours. If the patient needs the initial safety screening for SAT the sedative infusion is interrupted with a goal to awaken the patient or SAS 3-4. If the patient is showing signs of SAT failure with either tachypnea or desaturation or cardiac dysrhythmia or unacceptable ventilator asynchrony that the patient is resumed sedation/analgesia at 50% of the previous dose and bolus as needed dose of sedation is also utilized to achieve stability. A spontaneous breathing trial (SBT) is a protocol for systematic weaning of a patient from a mechanical ventilator in preparation for extubation. Before SBT protocol again safety screening is done and if the patient meets the criteria for SBT protocol, the patient is placed on spontaneous breathing mode that his CPAP of 5 to 8 cm of water for 30 to 120 minutes at the same FiO2. Various tools are utilized to analyze the success of the SBT trials including the RSBI index. Each institution has its own assessment of the average length of ventilator stay and the average length of ICU stay. The majority of hospital does SAT/SBT trials once a day for evaluation and successful liberation from ventilator. This project was done with the assumption that if compliance of SAT/SBT huddle is improved and if it is done twice in a day rather than only once the outcome in terms of length of ventilator stay, length of ICU stay, and rate of successful extubation improves METHODS: This is a prospective quality improvement study done at Einstein Medical Center Philadelphia. This is a 16-bed MICU unit and we implemented twice daily hurdle from August 2021 to April 2022. ( Study Period) This project was happening during the COVID pandemic during which the average length of ICU stay and the average length of ventilator stay was already high due to the natural course of COVID ARDS. The SAT/SBT Huddle involved interaction between our respiratory therapist, ICU fellow, and the nurse involved in the patient care. It had a checklist of SAT SBT protocol which needed a signature (electronic or manual) to consider it completed. This was done twice a day from the period of August 2021 to April 2022 (STUDY PERIOD). This study period was compared to the control period (August 2020 to April 2021). The reason for selecting this control period was to remove outlier and increased length of stay due to the COVID pandemic itself with the assumption that the COVID pandemic was present throughout the study and control period. RESULTS: In the control period- ie August 2020 to April 2021 the average ventilator length of stay is 6.85 days. In the study period from August 2021 to April 2022, the average length of a ventilator was 6.21. There is a clear decrease in ventilator length of stay with the intervention and no other change in the sample size. It should be noted that the COVID pandemic with the third surge was happening in both the control and study period. This is approximately a 10% decrease in length of stay. This is a Pilot study and with better compliance with a huddle, the length of stay will decrease further is our assumption. Here the huddle compliance ranged from 60-65% and out estimate is for better power we need at least 70% or more compliance with huddle CONCLUSIONS: Conclusion- This q ality improvement project aims to improve communication amongst healthcare providers with the ultimate goal of patient safety and decreased length of ventilator stay for every patient in MICU. Clearly, the minimal intervention of documenting each huddle and doing it twice a day had a decrease in ventilator length of stay. The greatest challenge for this compliance project is to have documentation of having a twice-daily hurdle. During this period to improve her compliance we have done various methods that included paper signatures electronic signatures and also QR code signatures. Of this, the maximum Complan success rate was achieved with a QR code signature for the huddle members. CLINICAL IMPLICATIONS: Limitation to the study–due to the COVID pandemic the average length of ventilator stay has increased in all hospitals which are affected by the COVID pandemic. Though the reflection of decreased length of ventilator stay is small this gives a glimpse of how her daily communication between a respiratory therapist, nursing staff, and the physician taking care of the patient makes a difference in the patient's overall length of stay and mortality. DISCLOSURES: No relevant relationships by Raminder Cheema No relevant relationships by Megan Dondarski No relevant relationships by Yasmeen Hassan No relevant relationships by Mahwish Hussain No relevant relationships by Myriam Poindijour No relevant relationships by Arnaldo Rodriguez No relevant relationships by Kumar Sarvottam No relevant relationships by Bhavna Sharma No relevant relationships by Teresa Vizak

Comparison of Nutritional Pattern and Use Between Covid and Non-Covid ICU Patients

Introduction: Nutrition plays an important role in ICU patients, more so in hypercatabolic COVID-19 illness. Among other lifethreatening problems, nutrition seemed to have taken a backseat in many hospitals due to logistics, reduction of manpower, isolation practices, etc. Objectives: To study the pattern and use of nutrition in our tertiary care COVID ICU in comparison to the non-COVID ICU. Materials and methods: An observational study was performed of 941 consecutive patients from March 2020 to June 2021 by collecting data from the iNUTRIMON software.1 In view of the various challenges faced in the delivery of appropriate nutrition and the hypermetabolic nature of the disease a COVID-specific nutrition protocol was formulated at the start of the pandemic.2 It involved the use of enteral scientific feeding formula for all COVID patients tolerating an oral diet. The protocol can be accessed at https://www.opensciencepublications.com/fulltextarticles/IJN- 2395-2326-7-216.html. The energy was prescribed using simple predictive equations (i.e., 25 kcal/kg). In case of mechanically ventilated patients, indirect calorimetry-derived measures were used. All patients were prescribed 1.8 g/kg proteins. The protocol for nutrition patients remained the same with the exception that in non-COVID patients oral supplements were added only if 50% of the kitchen diet was not taken within 3 days. The use of TPN for both groups remained as per the protocol. The software iNutrimon calculated the scientific feeding formulae (product) based on the prescription of energy, proteins, and volumes, taking into account the viscosity and precise water requirement per scoop of formula feed. Results: The mean length of ICU stay of COVID patients was 9.31 days as compared to 6.8 days in non-COVID patients. 8.8% of the patients required TPN as compared to 1.4% of the non-COVID population. Only 0.6% of the total enteral feeding in the COVID ICU was with kitchen diet alone compared to 7.8% in the non-COVID ICU. The incidence of use of supplemental nutrition was 97% per patient as compared to 57.6% per non-COVID patient. Among the scientific feeding formulae, the use of peptamen (85%) was highest in COVID patients as compared to 25% in non-COVID patients. The per-day cost of nutrition for COVID patients admitted to the ICU was found to be comparable to non-COVID patients when a cost analysis was done. Conclusion: There was a 168% increase in the use of scientific feeding formula and a 60% increase in the use of TPN in COVID patients as compared to non-COVID patients. This is also reflected as an increase in the cost of feeding. The use of TPN seems to suggest the increased intolerance to enteral nutrition. The increased use of scientific feeding formulae may indicate the adherence to protocol and also seems to suggest that COVID patients needed to be supplemented as kitchen feeds were unable to meet the requirements.

Critically ill patients with and without SARS-CoV-2 better achieve energy and protein targets with a high-energy, high-protein peptide-based enteral tube feed;insights from a multicentre clinical audit performed during the COVID-19 pandemic

Meeting energy and protein requirements in critically ill patients is important for prognosis, yet difficult to achieve as a consequence of disease, management and/or altered nutritional intake[1]. Improvements in achieving energy and protein requirements with a high-energy, high-protein peptide-based tube feed were observed in community patients with impaired gastrointestinal function[2]. To establish whether this remained true in the critical care setting, where feeding intolerance is observed frequently in patients with[3] and without SARS-CoV-2[4], a retrospective multicentre audit was performed. Adults (> 18years) with or without SARS-CoV-2, admitted to critical care across 6 UK hospitals between May 2020 and December 2020, were retrospectively included if they received a peptide-based enteral tube feed (Nutrison Peptisorb Plus HEHP®, Nutricia Ltd), containing 1.5kcal/ml and 7.5g protein/100ml (herein referred to as HEHP). Data were collected from 15 critically ill patients (52±12y;87% male), with mean length of hospital stay being 26days (range: 7-49days). Of these, 10 were SARS-CoV-2 positive, with the remainder having pancreatitis (n=3), delayed gastric emptying (n=1) or unconfirmed diagnosis (n=1). HEHP was used second line (after whole protein) and indications (multiple were cited for some) for use included tolerance issues (n=10), elevated energy and protein requirements (n=5) or due to primary diagnosis (n=2). Estimated energy and protein intakes (% of requirements achieved) were recorded before and during use of HEHP. In addition, Dietitians were asked whether HEHP allowed patients to better meet their nutrient target Mean intake of HEHP was 2008±461kcal/day and 100±23g protein/day provided over a mean of 12days (range: 3-29days). The percentage of estimated energy and protein targets achieved increased albeit non significantly with the use of HEHP (from 76% before vs 87% during use of HEHP for both) and the direction of effect remained true regardless of SARS-CoV-2 status. Two thirds (67%, n=10 of 15) of Dietitians reported HEHP helped patients better meet their nutrient targets and 87% (n=13 of 15) of Dietitians perceived the high protein content of HEHP as beneficial for this patient group. Gastrointestinal tolerance (anecdotal reports) remained largely unchanged in approximately half of SARS-CoV-2 positive patients when using HEHP yet improved for others including non-SARS-CoV-2 patients. Enteral tube feeding in critically ill patients poses numerous difficulties, especially in SARS-CoV-2 positive patients. This audit in critically ill patients demonstrates that a high-energy, high-protein, peptide-based enteral tube feed can help complex patients better achieve energy and protein targets in patients with and without SARS-CoV-2. References 1.Pullen K, Colins R, Stone T et al. Are energy and protein requirements met in hospital? Clin Nutr 2017;31(2): 178-187. 2.Green B, Sorensen K, Phillips M et al. Complex Enterally Tube-Fed Community Patients Display Stable Tolerance, Improved Compliance and Better Achieve Energy and Protein Targets with a High-Energy, High-Protein Peptide-Based Enteral Tube Feed: Results from a Multi-Centre Pilot Study. Nutrients. 2020, 12, 3538. 3.Liu R, Paz M, Siraj L et al. Feeding intolerance in critically ill patients with COVID-19. Clin Nutr 2021. 4.Gungabissoon U, Hacquoil K, Bains C et al. Prevalence, Risk Factors, Clinical Consequences, and Treatment of Enteral Feed Intolerance During Critical Illness. J. Parenter. Enteral. Nutr. 2015, 39, 441–448.

The Kuwait National Diabetes Registry (KDNR): Methodology and Pilot Results

Background: The rising incidence of diabetes mellites is a growing health concern in Kuwait, placing an overwhelming burden on the healthcare system. The overall prevalence of diabetes was estimated to be 19.1% according to last published data in 2020. As a result, the Kuwait National Diabetes Registry (KNDR) was established in the year 2018 by the Ministry of Health in collaboration with the Dasman Diabetes Institute to provide insight on the nature of the disease in this population. Aim: The aim of establishing the national web-based registry is to provide a sound database to investigate disease diagnosis, management, and outcomes and enable evaluation of clinical improvement focusing on identifying risk factors, treatment interventions and disease complications and assess morbidity in the adult and pediatric population. Method: Patients of all ages and nationalities residing in Kuwait diagnosed with any form of diabetes (type 1, type 2, gestational and atypical) were included in the KNDR. Data sources include electronic health records from primary healthcare centers (PHC), hospital outpatient clinics, Kuwait Diabetes Society (KDS) and patient self-register on the webpage. The register includes data on demographics, diabetes type, comorbidities, smoking habits, treatment modality, blood pressure, weight, height, and blood profile including glucose status, renal and lipid profile. Patient data was collected from one governorate as a pilot phase before extending the platform to other regions in Kuwait. Descriptive analysis was performed. Results: A sample of 36,447 patients with diabetes from PHCs in one Kuwaiti governorate, Al-Farwaniyah, collected from September 2019 to March 2020 (pre-SARS-CoV-2 pandemic) was studied. The median age was 54 years, most were men (63.4%), 33.4% were Kuwaiti and 11.3 % were smokers. The majority had type 2 diabetes (82.3%) and hypertension and dyslipidemia were found in 20.2% and 22.2% of the population, respectively. Over half the population (56.4%) with type 2 diabetes were on oral medication only, 3.7% on insulin only, 21.8% on oral and insulin medication and 18.1% were not on any medication and were recommended lifestyle modifications. Of the patients on insulin 60% were using long acting and 30% were using mixed insulin. In the registry, only 20% of those who have diabetes have a recorded HbA1c. Discussion: Creating a diabetes registry gathers invaluable information, aids as an essential tool for monitoring patients with diabetes and supports planning better healthcare services. However, the high missing data requires increased physician data entry training and improved and incorporated hospital information systems into the registry to ensure high ascertainment. The registry can be utilized to estimate incidence and prevalence, to translate into policy and improve standard of care.

Impact of COVID-19 on patients undergoing neoadjuvant therapy: A pre/post pandemic analysis and assessment of quality of care delivered

Background: When the first wave of COVID-19 hit globally in early 2020, concerns were raised about access to surgical interventions for cancer patients. It was considered that neoadjuvant therapy (NAT) although conventionally given to locally advanced breast cancer may need to also be provided to earlier-stage disease. In addition, due to the temporary closure of breast cancer screening programs during the pandemic, concerns were raised about patients presenting with later-stage disease at initial diagnosis. This project aims to assess the impact of COVID-19 on the volume of neoadjuvant referrals at a large cancer centre, as well as any stage migration, impact on treatment timelines and impact on outcomes for breast cancer patients compared to the pre-pandemic population. Methods: The BC Cancer Vancouver centre has a neoadjuvant breast cancer program to ensure high quality of care is maintained. This program's prospective database of breast cancer patients referred for and treated with NAT between the years 2012-2021 was queried to assess data on neoadjuvant referrals, clinical stage, receptor status, treatment timelines, and outcomes between January 1, 2019-December 31, 2020. Data from the years 2019 and 2020 were compared to evaluate the impact of COVID-19 on NAT. Summary data available from earlier years were also utilized as reference. Results: The COVID-19 pandemic resulted in a 51% increase in Sthe number of patients referred to the neoadjuvant program, with 102 patients referred for NAT in 2019, whereas 154 patients were referred in 2020. This proportional increase in referrals is higher than any other year since the database inception. Of note, during 2020 there were no COVID related closures for cancer surgeries in the province. The proportion of patients referred who received NAT remained similar between 2019 and 2020 (69.1% vs 70.8% in 2020). The trend in referrals by month varied between the two years. In 2019, the majority of patients were referred between April to July with the lowest proportion of referrals in October to December. In 2020, the opposite occurred with the lowest proportion of referrals transpiring between January-June, and the greatest proportion in October to December. The proportion of patients who presented with de-novo metastatic disease was consistent between the two years (7.8% in 2019 vs 9.7% in 2020). Despite the closure of all screening mammography programs between March-June of 2020, the clinical stage and receptor status are equivalent between 2019 and 2020. With regards to treatment timelines, there was a 3 day increase in the median time between referral date and medical oncology consultation in 2020 compared to 2019. No other treatment timeline delays were found between 2019 and 2020. With regards to outcomes, 34.9% of patients achieved pCR in 2019, but only 24.1% achieved pCR in 2020, despite similar stage and receptor subtypes. Conclusion: During the COVID-19 pandemic in 2020, a higher volume of patients were referred for NAT than had ever before been referred, despite the fact that there were no closures of operating rooms in our province for COVID-19. From a quality of care perspective there was a delay in referral to consultation for medical oncology, but no delay on referral to treatment, treatment to surgery, or surgery to radiation. However, and a significantly lower pCR rates was seen in 2020 compared to 2019. The 10% decrease in pCR rates may have resulted from increased complexity in breast cancer cases. This trend may continue, as the impact of COVID-19 on breast cancer outcomes will likely take many years to fully appreciate. Attention should be paid to encouraging women to return to regular breast screening programs to decrease the number of patients needing neoadjuvant therapy.

eP490: A united front on tackling a pandemic – the true value of industry and government partnerships

Introduction: The emergence of the SARS-CoV-2 virus, the cause of the COVID-19 pandemic, in late 2019 put every country on high alert and led to major changes in global diagnostic testing capability in infectious disease. From the outset it was apparent that local health authorities were under-prepared and under-staffed to cope with the rapid onset and spread of the disease. Demand for SAR-CoV-2 testing soared, highlighting the limitations of capacity in existing infectious disease laboratories along with requests from governments to support growing testing need. We partnered with US and UK Governments to establish, supply, staff and operate three large-scale, high-throughput SARS-CoV-2 testing facilities. These were ultimately established in Valencia, CA, offering testing of up to 150k samples per day, and in Loughborough and Newport, UK, offering a combined testing of up to 70k samples per day. The biggest challenge faced globally was the unprecedented scale of testing required and the timeframe to deliver a reliable and sensitive high-throughput assay. The benefits of industry and government partnerships become evident along with having a dedicated supply chain to feed the reagent and consumable needs for high-throughput testing as well as a highly accurate test with a fast turnaround time. Experts from multiple divisions, including R&D, Genomics, Enterprise, and regional centres were bought into the project, resulting in the establishment of SARS-CoV-2 testing within the three facilities in approximately eight weeks. Clinical testing experts in high-throughput, newborn screening, and rare disease testing, built molecular testing pipelines for the facilities based around the use of real-time polymerase chain reaction (RT-PCR) assays and sequencing. Laboratories were setup to meet the requirements set by various regulatory and accreditation agencies such as Clinical Laboratory Improvement Amendments, College of American Pathologies, the UK National Health Service validation group and ISO15189. Methods: Underpinning the testing was the massive IT and bioinformatics effort to enable reporting of the testing outcomes to the relevant authorities. We were able to deploy a novel LIMS system that is used throughout the laboratories to maintain sample chain of custody from arrival at the facility to reporting of results and incorporating interpretive software to support clinical interpretation of the resulting RT-PCR data. The LIMS systems are constantly undergoing improvement to support interpretation and troubleshooting. Local experts in clinical interpretation and reporting were onboarded to augment data analysis and ensure high-quality and reliable reporting whilst ensuring that clinical governance remains at the centre of all activities. Results: Before any SARS-CoV-2 testing was able to commence, several significant challenges were overcome by combining the expertise of our global teams with the local knowledge and support of the respective Governments. Experts in logistics and program management were able to convert three empty facilities with no pre-existing laboratory infrastructure into fully functional clinical testing laboratories within eight weeks. Our assay manufacturing capacity was majorly expanded to accommodate the requirements of SARS-CoV-2 testing, with all three facilities operating on automated platforms and utilizing chemistry with a dedicated secure supply chain. The final major challenge was rapid onboarding and training of staff for the facilities, and a year out, the two active facilities are currently employing over 600 individuals. Conclusion: To date the three facilities have performed over 12 million SARS-CoV-2 RT-PCR assays and SARS-CoV-2 testing will continue into 2022. The number of cases is again growing globally, and with the emergence of new variants and continual uncertainty about the impact on existing vaccines, there is an ongoing requirement for this scale of testing. From the experience of the SARS-CoV-2 global pandemic, the benefits of industry and government collaboration or the public has become much clearer, including greater access to large-scale testing options, significant reductions in time-to-testing and reporting and the rapid deployment of modern, cutting edge technology in diagnostic and monitoring programmes and eventually reduced costs to health services from mass-production. Ultimately the longevity of the individual testing facilities is unclear, but the future of large-scale clinical testing has changed forever and the legacy of this is the clear benefit to everybody when industry and governments work together to provide the public high quality and reliable testing operations.

A remote OASIS: Implementing clinical guidelines over a virtual platform

Keywords: OASIS;Clinical guidelines;Virtual Purpose: The OsteoArthritis Self-management & Independent-living Support Group (OASIS Group) was set up in response to NICE Guidance CG177 in 2014, to create a cost effective yet high quality and efficient treatment pathway for people living with hip and knee osteoarthritis (Roberts & Busby 2020). The world was then changed dramatically with the appearance of the COVID-19 pandemic, which forced significant changes to ways of professional working. After the closure of non-essential services, the OASIS team were forced to revisit the NICE Guidelines in order to develop a virtual service for people with osteoarthritis (OA). Methods: During the restoration of services, the OASIS group was developed into a virtual programme to focus on the core treatment of enhancing understanding OA and its management, alongside a home exercise plan and weight loss advice. Converting to a virtual platform still required safeguards to be in place to protect patient's information and maintain confidentiality. The following documents needed to be created to ensure Information Governance principles were observed and were approved by Health & Safety and Legal teams within the trust: • Standard Operating Procedures (SOP) for managing unwell patients • SOP for using Microsoft Teams for group consultations • Risk assessment • User-agreement • Safe-home checklist • Screening tool Patient educational material from the OASIS group was converted to a virtual format to be presented to patients at each session. Patients have also been involved in the co-creation of an educational guidebook alongside the team to develop appropriate tools to aid self management. Digital versions of outcome measures, working within licencing restrictions, were also created to monitor the effectiveness of the programme. Results: The move to a virtual platform for the delivery of the OASIS programme has allowed the most vulnerable patients to access services safely. In a time when they are shielding to protect their health, the remote OASIS group provides them with a tailored treatment programme to educate and empower them to self manage their long-term condition. Conclusion(s): Moving forwards, the virtual platform is now a viable option even with the return of face-face appointments, for those people who struggle to access the service. It remains a sustainable and cost effective service to tackle the ever-growing problem of OA. Patient satisfaction and feedback will be collected after each group to ensure high quality care that meets the needs of its users. Following pilot groups, outcomes will be collected and analysed to monitor the effectiveness of the programme and compare to the original OASIS group. Impact: Development of the remote OASIS group removes the restraints of location and facility availability allowing access from a wider proportion of the population. It maintains group interactions and provides a service that keeps people safe whilst still addressing their health care needs. The foundation of processes and documents that have been developed for use with the remote OASIS programme have formed a template for future groups to be based upon. Work is underway with Keele University to develop a lower back pain virtual group, using the experiences and expertise of OASIS at its core. Funding acknowledgements: This work was not funded.