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Objectives: The objectives of the study was to assess the level of work satisfaction, assess compliance of using PPE among shop assistants during COVID-19 and to find the factors influencing work satisfaction. Method(s): A quantitative approach with descriptive design was used for the study. Eighty samples were selected by using convenient sampling technique. The study was conducted in 4 districts of Kerala through online platform as well as through offline mediums. Result(s): From the study, it is evident that majority of the subjects (55%) were satisfied with their work at the time of COVID-19 and more than half (55%) of the samples have enough compliance with the use of PPE and only 7.5% have less compliance with the use of PPE. Demographic variables such age, relationship status, and work experience were found to be statically significant (p<0.05) with work satisfaction, and other variables did not have a significant association. Conclusion(s): This study provides a baseline for assessing the level of work satisfaction and compliance of PPE among shop assistants in selected areas. Periodic reinforcements, proper education, availability and trainings on the use of PPE can reduce the spread of Corona Virus and improve PPE compliance to an extend. Good working environment support from family and good rapport with colleagues can help to improve work satisfaction .Copyright © 2023 The Authors.
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BACKGROUND: A comprehensive screening at delivery revealed that roughly 14% of pregnant women who tested positive for COVID-19 did not exhibit any symptoms. The SARS-CoV-2 antigen swab test is frequently utilized as a diagnostic technique. Inadequate implementation of health protocol compliance can enhance the vulnerability of a community to the COVID-19 virus, according to previous findings. This suggests that these health protocol compliance and the vaccination program are important for preventing and controlling the spread of the virus. AIM: This study aims to determine the relationship of vaccination history and health protocol compliance with positive antigen swab results among pregnant women at the Community Health Center in Medan. METHOD(S): This is a cross-sectional and observational study that was conducted in February 2022 at the Community Health Center in Medan, North Sumatra, Indonesia. Two hundred pregnant women who met the inclusion and exclusion criteria make up the sample population. Antigen sampling for SARS-CoV-2 was performed in the Pramita laboratory. Following the collection and processing of sample and antigen swab data, IBM SPSS version was utilized to conduct statistical analysis. RESULT(S): The result showed that four of the pregnant women were infected with COVID-19, and they accounted for 2% of the sample population. The health protocol carried out by pregnant women was not significantly related to the swab results. Therefore, vaccination history had no significant association with COVID-19 symptoms, but people who received vaccines had more negative swab test results compared to those who did not, where three out of four positive samples were unvaccinated. CONCLUSION(S): Based on the results, only 2% of pregnant women were infected with COVID-19 at the Community Health Centre in Medan, because this study was carried out when COVID-19 cases had decreased. The statistical analysis results showed that the history of vaccination was not significantly related to SARS-CoV-2 antigen swab results. However, there was a clinical tendency that vaccines can reduce the number of positive cases, where three out of four positive samples were not vaccinated.Copyright © 2023 Sarma Nursani Lumbanraja, Reni Hayati, Khairani Sukatendel, Johny Marpaung, Muhammad Rusda, Edy Ardiansyah.
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Background and purpose: Adherence to the principles of personal protection and commitment to health guidelines and principles of prevention perform important roles in controlling COVID-19 in a community. In this re3search we studied necessary measures to prevent COVID-19 in university dormitories at Mazandaran University of Medical Sciences, 2021. Material(s) and Method(s): In this descriptive-analytical study, 114 students in active dormitories during the COVID-19 pandemic participated in an online survey and their views and knowledge about COVID-19 preventive measures in the dormitories were examined. The samples were recruited using census method and data were analyzed in SPSS. Result(s): The results of the Chi-square test showed a significant relationship between adherence to preventive measures and educational level (P=0.015). Following personal hygiene was found to be significantly different according to being a local student, having underlying diseases, and the number of students at rooms (P<0.05). Findings showed that physical distancing and screening had no significant relationship with any of the variables studied (P>0.05). Conclusion(s): The study showed that among the four areas investigated, personal hygiene practices and following the principles of prevention of COVID-19 were in a good condition, while physical distancing and screening were not satisfying. Therefore, university authorities should make serious changes to improve these issues at dormitories.Copyright © 2023, Mazandaran University of Medical Sciences. All rights reserved.
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Introduction/Aim: Western Australia had its first wave of COVID-19 cases in March 2022. This retrospective study assessed the adherence to guidelines for prescribing COVID-19 disease modifying therapies (DMT), based on the National COVID-19 Clinical Evidence Taskforce Australian guidelines for the clinical care of people with COVID-19. Method(s): The first 100 cases admitted to the respiratory ward at Fiona Stanley Hospital (FSH) with confirmed COVID-19 were reviewed. Data was collected from the hospital Digital Medical Record to determine clinical severity on presentation and the need for DMT. Prescribing of DMT was assessed for adherence against the National guidelines and/or whether it was recommended by the infectious diseases (ID) team. Disease progression, length of stay, mortality and readmission rates were assessed within 28 days of admission. Result(s): During the audit period (11.03.2022 - 19.04.2022), the National guidelines underwent six updates. In the first 100 cases of COVID-19, the median (IQR) age was 65.11 years, the median (IQR) length of stay was 4 days and the mortality rate was 1%. There was a 7% readmission rate with 6% of patients treated with DMT having disease progression. 16% of patients were immunocompromised and 58% were partially vaccinated or unvaccinated. 63% of unvaccinated patients had severe disease. 84% of patients were recommended a DMT, of which, 63% received the correct combination of DMT. 14% of cases were recommended and not prescribed a DMT, though 71% of these cases were recommended budesonide alone. 12% were not recommended and not prescribed a DMT and 4% were not recommended, yet prescribed a DMT. Conclusion(s): Overall adherence with the National guidelines/ID advice for DMT was >80% excluding inhaled budesonide. The continually evolving nature of the National guidelines added complexity to prescribing. A dedicated medical proforma would aid with risk stratification and DMT prescribing for patients with COVID-19.
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Following the recent adjustments to coronavirus disease 2019 (COVID-19) prevention and control policies, an increasing number of medical staffs, especially those in primary care facilities are confront-ed with rapid growth of COVID-19 patients. Peking Union Medical College Hospital (PUMCH) has therefore compiled this recommendation for COVID-19 primary care practices based on a patient-centered perspective and following recommendations from domestic and international guidelines as well as the latest Chinese government policies. Further, PUMCH.s conception and compilation of this recommendation strictly adhere to evidence-based, concise and clinically applicable principles of practice. For the critical clinical questions with insufficient medical evidence, the recommendation offers insights on the basis of experience from PUMCH multi-disciplinary expert team and first-line medics.practices. Emphasizing on screening community residents with higher risk of severe illness, implementing early interventions including pharmaceutical treatment, enhan-cing nutritional support and improving sleep quality, we aim to construct a "Household-Community-Hospital" tertiary defense, with the hope of promoting health and reducing severe cases.Copyright © 2023, Peking Union Medical College Hospital. All rights reserved.
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With the adjustment of China's COVID-19 policies and measures, the treatment of infected patients, especially the severe and critically ill patients, has become the focus of all medical staff at this stage. Since the outbreak of the pandemic, Peking Union Medical College Hospital has accumulated rich experience in this field. Based on the updated international evidence-based knowledge, the multidisciplinary expert group of COVID-19 at Peking Union Medical College Hospital has compiled a set of operational recommendations. Adhering to the evidence-based, concise, and clinically operable principles, these recommendations for diagnosis and treatment integrate the latest research evidence. For clinical issues that lack evidence, certain recommendations are given based on the frontline clinical working experience and expert opinions. The purpose is to enhance medical staff's understanding of COVID-19 infection and its critical illness and improve patient care.Copyright © 2023, Peking Union Medical College Hospital. All rights reserved.
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Osteoradionecrosis has considerable morbidity and can adversely affect the quality of life of patients who undergo radiotherapy as part of the treatment for their head and neck cancer. This can be reduced by a thorough dental assessment and extractions of teeth with poor prognosis prior to radiotherapy, ideally at least ten days before radiotherapy commences. Aim and objectives: The dental department at Charing Cross Hospital has an established pathway to assess patients prior to radiotherapy. The aim of the audit was to evaluate whether during the coronavirus pandemic there was timely dental assessment prior to radiotherapy and extractions carried out in sufficient time before start of radiotherapy in accordance with the Royal College of Surgeons 2012 guidelines. Method(s): Data was collected retrospectively from patient records over two eight monthly periods (May 2019 -Jan 2020 prior to the pandemic and April 2020 - November 2020 during the pandemic). Parameters analysed included: the number of patients referred;time interval between referral and assessment;number of patients requiring extractions and time interval between extraction completion and commencement of radiotherapy. Result(s): Seventy-six patients with head and neck cancer were referred for dental assessment over the audit period. The most recent audit showed 96.4% of patients were assessed within ten days of referral. Extractions were undertaken on 63.6% of patients, 92.9% were in excess of ten days before radiotherapy, 42.9% over 20 days. Conclusion(s): National guidelines for extractions are being met in 92.9% of cases and the majority in excess of minimum timing recommended. The dental clinic is providing quality care for this patient group as measured by this audit, showing a positive service outcome.Copyright © 2021 The Authors
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Background: The Covid-19 pandemic has brought new challenges to the health systems of Latin America. However, the institutions and mechanisms created by the Social State of Law were unable to confront these new risks. As a result of that, populist governments have used this crisis as an opportunity to deepen the high levels of inequalities through the appropriation of power, wealth and social welfare. Courts have also reacted in order to guarantee the right to health;however, many challenges remain. Objective: To examine the challenges and opportunities of the judicial protection of the right to health in the context of Covid-19 and Populism in Brazil. Methodology: Qualitative, descriptive and exploratory. Documentary research was carried out by reviewing databases such as Scholar, PubMed, and Scopus. Indexed articles, jurisprudence, legislation, and literature were also reviewed. Additional publications were also identified through other sources. Results: There is an inversely proportional relationship between the intensity of the crisis and the level of judicial activism on the part of the Courts. Therefore, the more the scale and intensity of the crisis generated by populist governments in the context of pandemics, uncertainty, and inequality the more reflexive, and strategic courts should be and the more protection, defense and monitoring should be promoted in order to ensure the fulfilment of the right to the highest attainable level of health especially of the most vulnerable. On the other hand, the more compliance through the availability of health goods and services, and the more availability of health workers with better salaries, social security and working conditions the more resilient the State will be to face emergencies, which at the same time will promote fewer restrictions on fundamental rights. Conclusions: Courts play a special role in protecting the right to health, especially in the context of emergencies and crises. States must adopt measures by using the maximum available resources in order to protect the right to the highest attainable standard of health.
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Polymerase chain reaction (PCR) invented by Kary Mullis (1983), has become the centrepiece of molecular detection of various infectious diseases including coronavirus disease 2019 (COVID-19). Many developing countries like Nepal faces various challenges and grab many future opportunities during and after establishment of molecular PCR laboratories throughout the country. This viewpoint describes the involvement of laboratory employees, development and adoption of new protocols or framework, deliberate partnership with national and international community is very efficient for the establishment of PCR laboratories. Beside this, continued alliance and nation leadership is crucial to generate a unified and sustainable PCR laboratory network in the country like Nepal. In future the established PCR laboratories can be utilized for the diagnosis of others pandemic diseases and can be used for multipurpose like in verification of infectious diseases;Oncology;Blood test;Genetic testing. Copyright © 2020, Kathmandu University. All rights reserved.
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BACKGROUND: It is important to adhere to infection control measures in dental procedures due to direct contact with blood and saliva. During the Coronavirus disease 2019 pandemic, regular surveillance is imperative to ensure adherence to the standards. AIM: This study aimed to assess the level of adherence to infection control guidelines in specialized dental clinics in different working shifts. MATERIALS AND METHODS: This study assessed the level of adherence of 45 selected dental departments to three main guidelines released by (I) the center for disease control (CDC), (II) the Ministry of Health (MOH), and (III) armed forces organization (AFO) in three different working shift. The CDC checklist had eight domains. Thus, the items of each domain were individually scored, and considering the weighting coefficient of each item, the total score was calculated. The same procedure was carried out for the two remaining guidelines. The possible effect of working shifts and different specialties on infection control practice was also calculated. RESULT(S): The mean rate of adherence was 70.7% to the CDC, 93.8% to the MOH, and 84.4% to the AFO guidelines indicating that adherence to the CDC guidelines was lower than the other two domestic guidelines. Individual assessment of each item revealed that hand hygiene (39%) and safe handling and disposal of sharp instruments (46%) acquired the lowest, while sterilization (79%) and safe injection (97%) acquired the highest score according to the CDC checklist. There was no relationship between working shifts and dental specialties regarding the adherence to infection control standards. CONCLUSION(S): Dental clinics had different performances regarding infection control guidelines. Further emphasis should be placed on hand hygiene and disposal of sharp instruments. Copyright © 2022 Mohammad Ali Keshvad, Mohammad Taghi Vatandoust, Elahe Tahmasebi, Mohsen Yazdanian, Hormoz Sanaeinasab, Mahmood Salesi, Esmaeil Rafiei.
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Background: With COVID-19, online opportunities to support families living with dementia are becoming increasingly important. However, academic institutions are typically not prepared to develop and test online platforms. We present a case study to describe steps for creating an infrastructure to test an online platform, WeCareAdvisor (WCA). WCA provides caregivers disease education and tailored strategies to manage dementia-related behavioral symptoms using the DICE Approach. WCA was previously tested in a small, randomized trial demonstrating positive caregiver outcomes. To advance its evidence-base, WCA is being tested in a NIA-funded Stage III efficacy trial with a national sample of 326 caregivers. Method(s): To test WCA, an infrastructure in the academic institution had to be created to address HIPAA compliance, privacy considerations, integrate user and developer input, and support rigorous trial methodologies. Through key informant interviews and literature reviews, we established a six-step process: 1) Identifying and engaging key stakeholders (legal, Information Technology offices, research team, software company);2) Creating software development agreement with stakeholder input;3) Detailing scope of work and an oversight structure of software company, 4) Developing formal agreements with the software company, 5) Conducting security assessments with university IT offices;and 6) Establishing formal vendor status of the software company. This also necessitated new roles and responsibilities of research team members. Result(s): The six-step process was labor intensive, transpired over 12 months, and involved over 15 iterative meetings with investigators, project staff, and stakeholders. Careful coordination of stakeholders to provide practical and iterative guidance at each of the six steps was essential. Deliberations resulted in app store access, URLs and domains, and compliance and privacy statements reviewed and approved by various university offices, and then launching WCA on app stores for access by study participants. Conclusion(s): Researchers and academic institutions have varying levels of understanding and readiness to engage in infrastructure development to rigorously test online platforms. Our approach resulted in an effective infrastructure for testing WCA which can be used by other researchers. Development of an infrastructure requires new skills for investigators, engaging multiple stakeholders, appropriately budgeting for this activity, and allocating sufficient start-up time. Copyright © 2022 the Alzheimer's Association.
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Introduction: 42% of patients in the intensive care unit (ICU) will suffer ocular damage during their stay.1 Multiple mechanisms that usually protect the eye are inhibited, whilst interventions such as positive airway pressure and muscle relaxants further expose the eye to harm.2 This became increasingly evident during the COVID-19 pandemic, where non-invasive ventilation and proning of patients exposed patients to risk of injury.3 Redeployment of Ophthalmologists to ICU during the first wave of the COVID-19 pandemic highlighted the need for a robust and sustainable intervention to reduce the frequency of eye complications in our unit. Objectives: Our objective was to reduce harm to eyes in all patients within the Royal Infirmary of Edinburgh (RIE) to zero ICU within nine months. Methods: Our QI project involved initial staff and patient data collection regarding current eye care practices. A fish-bone diagram facilitated group discussions with ICU clinical teams regarding prior eye care practices. A pareto chart identified categories to focus on, with a driver diagram identifying change ideas. Our primary intervention was the design and introduction of a bespoke eye care guideline. Specific outcomes, processes, and balancing measures were set out, and multiple PDSA cycles helped to prompt interventions to ensure consistent and standardised care was delivered. Run charts were regularly reviewed and a variety of interventions were introduced throughout the data collection period as tests of change. These included: 1. posters highlighting guideline enrolment 2. formal teaching at handovers and on the unit 3. educational emails to staff members 4. prompts on daily reviews to highlight eye care assessments. Between 28 Sept 2020 -28 June 21, twenty patients in RIE ICU were randomly selected by the data collection team weekly. Patient outcome -eyes were examined and noted if they had developed any ocular complications during their stay. Patients who had evidence of ocular damage on admission were excluded unless they developed further complications. A single episode was not counted twice. Process outcomes -Eye care guideline adherence was recorded, and non-compliance was rectified following data collection. The data was recorded on run charts, accessible via MS teams, allowing all project team members to review the data remotely. Results: During our data collection period, the introduction of our guideline and educational interventions reduced the median number of patients who suffered eye complications in ICU by 50% within nine months (Figure 1). Chemosis and evidence of dry eyes were the most common complications. Since initiation of the guideline, our educational interventions have maintained median guideline compliance at 80%. Conclusion: This is a comprehensive, patient-centred, QI project, utilizing a systematic methodology to introduce a new guideline within ICU. This project has resulted in a sustained improvement of eye care standards, and reduction of eye complications within RIE ICU. This project was ongoing during the second wave of the COVID-19 pandemic, where constant rotation of medical staff, unfamiliar with ICU, required education to ensure guideline compliance was achieved. Our eye care guideline is now part of a multicentre project to standardise care across NHS healthboards.
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Aim: The Enhanced Recovery After Surgery (ERAS) protocol for total laryngectomies was first implemented in our tertiary head and neck centre from November 2019. It includes pre-operative carbohydrate loading and an early swallow test which facilitates recommencement of oral intake to improve outcomes. Protocol adherence rate and patient outcomes were measured to determine the effectiveness and benefits of ERAS in laryngectomy patients. Method: 22 total laryngectomy patients from November 2019 to September 2021 were enrolled onto the ERAS protocol, 18 primary and 3 salvage cases. An analysis of the respective patient cohorts was performed to determine adherence to the ERAS protocol and outcomes such as complications and length of inpatient stay were measured. Results: 19 patients (86%) received pre-operative carbohydrate loading successfully, while 3 patients were contraindicated due to background of diabetes. Early swallow test was performed in 59% of patients. Potential reasons for delay were stoma dehiscence or clinical suspicion of neo-pharyngeal leak. 59% of primary cases were deemed medically fit for discharge within the target timeframe of 12-14 days whereas no target was set for salvage cases due to expected poor healing. Main complication in primary cases was neo-pharyngeal leak followed by stoma dehiscence with 28% and 11% respectively. Conclusion: Limitations of our study include small sample size due to the COVID-19 pandemic. Despite its infancy, the ERAS protocol has achieved good outcomes in early recommencement of oral intake post-laryngectomy and encouraging early safe discharge from hospital. Future plans include establishment of Prehab Clinic and application of ERAS to neck dissection patients.
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Background: Physical activity (PA) is an important component in the management of people with rheumatoid arthritis (RA) (1). Interventions incorporating Behaviour Change (BC) theory are needed to target physically inactive people with RA. The study Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis (PIPPRA) was designed using the Behaviour Change Wheel (BCW) and a pilot study of feasibility undertaken (ClinicalTrials.gov Identifer: NCT03644160). Objectives: To obtain reliable estimates regarding recruitment rates;participant retention;protocol adherence and possible adverse events, and to producing estimates of the potential effect sizes of the BC intervention on changes in outcomes of physical activity;fatigue;disability and quality of life. Methods: Participants were recruited at University Hospital (UH) rheumatology clinics and randomly assigned to control group (physical activity information leafilet) or intervention group (four BC physiotherapy sessions in eight weeks). Inclusion criteria were diagnosis of RA (ACR/EULAR 2010 classifcation criteria), aged 18+ years and classifed as insufficiently physically active. Ethical approval was obtained from the UH research ethics committee. Participants were assessed at baseline (T0), 8-weeks (T1), and 24-weeks (T2). Descriptive statistics and t-tests were used to analyse the data with SPSS v22. Results: 320 participants were identifed through chart review with direct contact then with people meeting the inclusion criteria at rheumatology clinics. Of the clinic attendees n=183 (57%) were eligible to participate and n=58 (55%) of those consented to participate. The recruitment rate was 6.4 per month and refusal rate was 59%. Due to impact of COVID-19 on the study n=25 (43%) participants completed the study (n=11 (44%) in intervention and n=14 (56%) in control). Of the 25, n= 23 (92%) were female, mean age was 60 years (sd 11.5). Intervention group participants completed 100% of BC sessions 1 & 2, 88% session 3 and 81% session 4. No serious adverse events were reported. Secondary outcome measures data is Table 1. Conclusion: The PIPPRA study designed using the BCW to improve promote physical activity was feasible and safe. This pilot study provides a framework for larger intervention studies and based on these fndings a fully powered trial is recommended.
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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.
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Early enteral feeding is important in maintaining the integrity of the gastrointestinal tract mucosal barrier and associated with less bacterial translocation and decreased stimulation of the systemic inflammatory response and subsequent improved outcomes in intensive care (ICU) patients. Enteral feeding by nasogastric (NG) tubes is the preferred route of nutritional support for most ICU patients. However, ICU patients with delayed gastric emptying and poor intestinal motility may not tolerate gastric feeding and may therefore benefit from post-pyloric feeding via nasojejunal (NJ) tubes1. We reviewed the effectiveness of 35 NJ tube placement in 24 patients on ICU between January and March 2021. The M:F ratio was 4:1, median age 69 years (30–80 years) and 54% of patients were non-White British. 10 patients (42%) had diabetes and 54% had COVID-19 as part of their admitting diagnoses. The median BMI was 25 (range 20 – 32.3) and none of the patients were identified as high risk for refeeding syndrome at the time of NJ tube insertion. Nutritional information was unavailable on 5 patients. Of the remaining 19 patients, 26% of patients (n=5) were commenced on parenteral nutrition (PN) within 48 hours of NJ insertion. Only 1 patient was able to meet their nutritional requirements enterally via NJ tube at 5 days;a further 2 patients had their nutritional requirements met with supplemental PN. In 8 of 22 referrals the indication for NJ tube insertion was because an NG tube could not be passed. The evaluation revealed discrepancies in adherence to protocols for high gastric residual volumes and prokinetic use. Documentation surrounding decision making, requesting and inserting an NJ tube was poor and probably reflects the complexity of the patients, involvement of multiple clinical teams, and various documentation modalities (i.e., verbal, written and different electronic systems). There was clinical dispute regarding the indication for NJ tube insertion in 23% of cases (documented in 3 of 13 referrals for NJ tube insertion). Where documentation was available 43% of patients (n=10) had an NJ tube placed on the day of request;the median time from request to insertion was 1 day (range 0-10). 5 patients had more than one NJ tube inserted (median 3;range 2–5). There was variation in experience and expertise of the endoscopists placing the NJ tubes. NJ tube feeding is considered to be less expensive and have less complications than PN2. However, our evaluation has revealed a range of issues relating to both the insertion and use of NJ tubes in an ICU setting. The true resource ‘cost’ of NJ tube insertion is probably underestimated in the literature and the complications of PN probably overestimated in the context of modern ICU and nutrition support team clinical practices. We suspect that our clinical experience is not unique and that more research is needed in this area. We are using this work to educate clinical teams, standardise documentation, provide better support and supervision for endoscopists, and raise awareness of the benefit and need for supplemental PN where nutritional requirements are not consistently reached enterally. 1 Schröder S, Hülst S V, Claussen M et al. Postpyloric feeding tubes for surgical intensive care patients. Anaesthetist 2011;60 (3): 214-20. 2 Lochs H, Dejong C, Hammarqvist F et al. ESPEN Guidelines on enteral nutrition: Gastroenterology. Clin Nutr 2006;25(20: 260-74.
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Purpose/Objectives: Effective management of childhood obesity is critical to prevent long-term medical and psychosocial sequelae. In 2015, the AAP issued guidelines on monitoring body mass index (BMI) and providing comprehensive obesity care based on risk factors. However, literature demonstrates that physician adherence to these guidelines is often poor. Electronic health record (EHR) clinical decision support tools can be effective in standardizing weight management. Utilizing EPIC SmartSets to improve physician adherence to AAP obesity management guidelines, we aimed to increase by 30% in 6 months the following: formal diagnosis of elevated BMI, frequency of weight follow-up visits, adherence to recommended lab screening, and subspecialty referrals. Design/Methods: Pre- and post-intervention surveys were distributed to residents/faculty at an academic primary care clinic to identify variability in practice and barriers to guideline adherence, which informed intervention designs. Cycle 1: SmartSets were implemented in July 2020 with diagnosis codes, note templates, readiness to change surveys, recommended lab and referral orders, patient handouts/questionnaires, and follow-up visit suggestions. Education was completed for providers. Cycle 2: Based on end-user input, SmartSets were integrated into preexisting well-visit templates rather than requiring separate workflow. Analysis metrics included the percentage of: well-visits with an appropriate diagnosis of elevated BMI, acute visits designated as weight follow-ups, and weight or well-visits in which labs were ordered or subspecialty referrals placed. All patients with BMI 85-94.9%ile (overweight) and BMI ≥95%ile (obese) ages 2-17.9 years old seen from 7/1/2019 to 3/31/2021 were included. Data was plotted on run/control charts to assess trends after implementation and revision. Results: A total of 748 overweight patients and 669 patients with obesity were seen during this timeframe. There was a sustained increase in appropriate diagnosis of elevated BMI from an average of 49% pre-intervention to 71% postintervention (Fig. 1), surpassing our aim. There were no significant trends in the percentage of weight visits, labs, or referrals. Appropriate utilization of the implemented EHR tools for well-visits improved after second cycle revisions (39% to 88%). Provider-perceived barriers to AAP guideline adherence included lack of family willingness to participate in management, lack of visit time, and socioeconomic factors out of the provider's control (Fig. 2). Conclusion/Discussion: The first step to instigate practice changes is through problem identification. By utilizing end-user feedback and preserving clinical workflows, the incorporation of AAP guidelines into EPIC SmartSets improved the diagnosis of elevated BMI during well-visits. However, due to COVID-19, it is unclear whether lab orders, referrals, or weight follow-ups improved. Additional EPIC modifications, such as auto-populated lab results, could minimize the need to chart review and thus improve these behaviors. While we demonstrated improved physician recognition, more studies are warranted to address the complex challenges primary care providers and families face regarding weight management. - Control Chart for BMI Diagnoses Made at Applicable Well Child Checks (WCC) by Month Percent of patients with elevated BMI seen at a well-visit from July 2019 through March 2021 who were formally given the diagnosis of elevated BMI. Goal to increase appropriate diagnoses by 30%. -Pareto Chart of Perceived Barriers to Adherence to AAP Guidelines for Weight Management Based upon surveys of residents and faculty at the academic pediatrics clinic studied.
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Elevated pro-inflammatory cytokines such as interleukin-6 (IL-6) have been observed in patients with COVID-19 and are associated with adverse clinical outcomes. Systemic immune response is co-regulated via the vagally-mediated cholinergic anti-inflammatory reflex. Specifically, a reduced release of pro-inflammatory cytokines such as IL-6 from acetylcholine-synthesizing T-cells in response to Vagus nerve stimulation has been demonstrated in animal and human studies. A known non-invasive and cost-effective way to stimulate efferent vagal activity is slow-paced breathing. The primary aim of this RCT was to determine if high-dose breath-assisted reflex stimulation results in a reduction of systemic inflammatory levels in COVID-19 patients. 48 hospitalized COVID-19 patients with moderate to severe symptoms from two isolation wards were randomized to intervention (3x20min app-assisted slow-paced breathing @6BPM) or TAU control group at the University Medical Center Ulm (Germany) during March & May 2021 (BEAT-COVID-study;DRKS00023971). Morning samples of IL-6, protocol adherence and self-reported total practice time (TPT) were collected bi-daily. Mixed effect linear regression models were used to explore groupXtime differences as well as dose-response analysis. Models were adjusted for age, ward, and TAU protocols. A total of 40 patients (age 55±14;67% male) were included to the final analysis. Feasibility of the applied breathing protocol was good, oxygenation was stable and no adverse events occurred. Adherence was closely monitored and sufficient in 17 out of 25 IG patients. Primary reason for non-adherence was worsening of symptoms with transfer to ICU. Reduction rate in inflammatory markers were not statistically different between IG and CG. Investigating the effect of categorized TPT on next morning IL-6 levels in 25 IG patients from 112 intervention days revealed significant lower IL-6 values when TPT exceeded 40min (b= -0.898ln[pg/ml];p=0.043). This is equivalent to a ratio of 59.3% reduction in circulating IL-6 compared to days with TPT <10min. This is the first clinical RCT to study immediate anti-inflammatory effects of a slow-paced breathing protocol in hospitalized COVID-19 patients. Although no between group differences were found in the reduction rate of systemic inflammatory markers, promising dose-response effects were observed.
ABSTRACT
Background: Nowadays, noninvasive ventilation is the mainstay of the ventilation strategy in the neonatal intensive care units (NICUs) and most of infants, especially preterm infants, having respiratory problems, are provided noninvasive ventilation (NIV) upon their demands. Nevertheless, complication of NIV device-related pressure injury was common, the incidence of nasal injury ranged from 20% to 60%. Limited studies were found evaluating the nursing care of preterm infants receiving NIV. Aims: This study aimed to develop an evidence-based clinical practice guideline for preterm infants receiving NIV, implement the guideline in a NICU of a regional hospital, and evaluate infant outcomes including comfort, incidence of NIV device-related pressure injury. Besides, improvement on nurse's knowledge and practice for caring infants under NIV were assessed. Study Design and Methods: The Iowa Model-Revised was adopted as the theoretical framework to guide the study process. A multidisciplinary workgroup consists of eight stakeholders in NICU was formed for the process and acted as the champions for the new practice. A before and after study design was adopted and included the preimplementation and post-implementation phases. An integrative review was conducted to identify relevant studies from eight electronic databases before the study. All eligible studies were appraised using the Johns Hopkins University's evidence appraisal tool. Neonatal Pain, Agitation and Sedation Scale (N-PASS) for pain assessment and two self-developed NIV care bundle knowledge test and audit tool were used for the study. Results: Due to the COVID-19 pandemic in 2020, the study was extended for a month and ended in January 2021. A total of 74 infants in Pre-implementation phase (before group) and 67 infants in Post-implementation phase (after group) were recruited. Logistic regression model was used to compare the incidence of pressure injury between groups after adjusted for all substantial covariates in the study. Infants in after group had an 84% decreased odds of acquiring pressure injury (adjusted OR=0.149, 95% CI 0.045-0.495, p=0.002). Infant's comfort level whilst receiving NIV was not determined in the study as the after group having a significantly lesser mean time (p<0.001) in calm state but lower N-PASS score. Regarding nurse participants, 71 nurses received the training programme on NIV care bundle, and overall nurses' knowledge level improved immediately (adjusted p<0.001) and at 12 weeks after the programme. Three audits were conducted to evaluate nurses' practice, nurses' compliance rate to the care bundle significantly improved at 12 (p<0.001) and 24 weeks (p<0.001) in comparison with baseline compliance rate in the pre-implementation phase. However, nurses' knowledge retention at 12-week and compliance rate at 24-week after the training programme declined. Conclusion: The evidence-based clinical practice guideline aims to promote comfort and prevent injury in infants receiving NIV, and outcomes of the infants depend on vigilant nursing care and compliance to this clinical practice guideline. Declining of nurse's knowledge level and practice compliance found in the study indicates the needs of continuous education and audit on the practice to sustain the service quality and patient's safety.
ABSTRACT
BACKGROUND: Adherence to guideline-concordant management of incidentally detected pulmonary nodules (PNs) is frequently poor. We designed and implemented a division-level intervention to improve Fleischner society guideline adherence at our institution. METHODS: Our intervention included: (1) radiology report templates for documentation of PNs, (2) generation of daily reports of incidentally identified PNs, (3) a population health coordinator who documented PN identification in the electronic health record (EHR) and managed patient outreach, and (4) EHR templates for clinician documentation of disclosure to patients and clinical care plan. Outcomes were rates of PN disclosure and completion of recommended surveillance chest computed tomography (CT) or sub specialist evaluation. Outcomes were assessed in patients with a PN identified before (01/02/ 2018-03/31/2019) and after (04/01/2019-09/30/2020) implementation of the intervention in 4 primary care practices. RESULTS: Pre-and post-implementation cohorts included 395 and 432 patients, respectively. Mean age was 65.1±10.8 vs 65.0±11.8 (p=0.881) and 59.5% vs 60.2% were female (p=0.895). Race was White in 52.4% vs 43.3%, Black in 39.5% vs 45.1%, and other 8.1%vs 11.6%(p=0.166). Recommended management was surveillance chest CT (72.4% vs 73.6%), subspecialist referral (21.0% vs 13.7%), or no further imaging (6.6% vs 12.7%;p=0.001). Disclosure of PNs increased from 78.5% to 94.9%, an improvement of 16.4% (95% CI 11.9-21.0%). Surveillance CT ordering increased from 66.4% [n=190/286] to 88.7% [n=282/318], an improvement of 22.3% (95% CI 15.8-28.7%) and CT completion increased from 67.1% [n=192/286] to 85.5% [n=272/318], an improvement of 18.4% (95% CI 11.7-25.1%). When CT was completed >30 days after the recommended time interval, median delay was reduced by 66.5 days (163.5 [n=72] vs 97.0 [n=97], p=0.004), despite post-intervention overlapping with the COVID-19 pandemic (Figure 1). The rate of completed sub specialist evaluation was similar (94.0% [n=78/83] vs 93.9% [n=46/49], p=1). CONCLUSIONS: A multicomponent division-level intervention improved rates of PN disclosure and surveillance CT ordering and completion. Our findings support expansion of system-level approaches that standardize and automate processes to improve guideline adherence.