ABSTRACT
The global health crisis of coronavirus disease 2019 (COVID-19) continues to challenge the standard of care in both the inpatient and outpatient setting. One area that has been heavily impacted is effective management of anticoagulation. COVID-19 has led to new and innovative ways to manage vitamin K-antagonist therapy in the ambulatory care clinics, with increased utilization of drive-through testing sites, home international normalized ratio monitoring, and conversions to direct oral anticoagulants. The COVID-19 infection has been found to have an increased risk in venous thromboembolism events due to its complex inflammatory response. Since 2019, multiple strategies have been trialed in the inpatient setting, including therapeutic, intermediate, and prophylaxis anticoagulation using heparin or low-molecular-weight heparin. Vaccines and therapeutics for COVID-19 have added complexity to the clinical situation, including an FDA warning for a vaccine-induced immune thrombocytopenia with the adenoviral vector vaccine (Ad26.COV2.S) and the potential for drug interactions between COVID-19 therapeutics and anticoagulation therapy. Copyright © 2022, Jobson Publishing Corporation. All rights reserved.
ABSTRACT
Background: The COVID-19 pandemic presented unique challenges to pediatric emergency medicine (PEM) departments nationwide. The purpose of this study was to identify these challenges and ascertain how centers overcame barriers in creating solutions to continue to provide high-quality care while keeping their workforce safe. Methods: This is a qualitative study based on semi-structured interviews with PEM physicians in leadership positions within their institution's COVID-19 response or emergency/disaster management departments. Participants were identified through convenient purposive sampling. Demographic data was captured in a pre-interview survey. Interviews were recorded and transcribed electronically. Themes and codes were extracted from the transcripts by two independent coders. Constant comparison analysis was performed until thematic saturation was achieved. Member checking was completed to ensure trustworthiness of the results. Results: Fourteen PEM-trained physicians participated in this study. Eleven of the participants received specialized disaster management training, and ten are directors of their institutions' emergency/disaster management departments. Communication, leadership and planning, clinical practice, and personal adaptations were the principal themes identified. Within these themes, participants discussed challenges and offered examples as to how they overcame them within their department and their larger institution. To improve communication and disseminate new information, departments might consider shift huddles, town hall meetings, limiting the number of daily emails, and highlighting the newest changes. During traumas and resuscitations, “gatekeepers” oversee who goes into the trauma bay, and technology should be utilized to communicate with the team outside. For leadership and planning, the emergency department should appoint leaders to summarize updates and attend incident command meetings. Institutions should consider developing containment units and having multiple vendors for key supplies as part of their pandemic plans. Business continuity plans should be updated regularly as part of pandemic preparedness. Hospitals should be prepared to utilize telehealth and accept adult patients if pediatric volumes drop. Recommendations regarding adjusting clinical practice include having clear guidelines for what constitutes an aerosol-generating procedure, drive-through testing sites to alleviate pressure on emergency centers, and performing triage in the patient's room if possible. Personal protective equipment (PPE) should be safely re-purposed if supplies are insufficient. Staff must be trained on the proper donning and doffing of PPE with regular reminders during prolonged pandemics. Transparency with the workforce regarding supplies, testing, and safety protocols help alleviate fear and anxiety. Medical caregivers can limit their exposure by utilizing cardiac monitors visible from outside patient rooms and providing updates via telephone in patient rooms. For a full list of challenges and recommendations, see Table 1. Conclusion: By sharing COVID-19 experiences and offering solutions to commonly encountered problems nationwide, pediatric emergency centers and their institutions may better prepare both themselves and one another for future pandemics.