Judicious use of the Critical Care Outreach Team: A QIP to reduce the inappropriate use of Early Warning Scores through targeted communication

Introduction: Early Warning Scores (EWS) use physiological parameters to create an aggregate score alerting medical teams to patient deterioration. Although vital tools for triggering referrals to critical care services in appropriate patients, the score does not take account of patients with persistently altered physiology or patients who are not deemed suitable for escalation to critical care. In these instances, EWS can result in the over-monitoring of patients and inappropriate contact of already strained critical care outreach services.1-2 Guidelines state that in such circumstances routine recording of EWS may be stopped.1 The COVID-19 pandemic has placed unprecedented demands on already overstretched resources in the critical care services,3 in particular on the Critical Care Outreach Team (CCOT). This makes their judicious use, and this QIP, ever more pertinent. Objective(s): In our trust, it was found that despite documented decisions not to escalate patients to critical care, these patients were still being monitored according to EWS, resulting in the inappropriate call out of the CCOT. We introduced measures to improve the proportion of inpatients with treatment limitations in place that had these limitations documented on their EWS charts, with the overall aim of reducing the number of inappropriate call-out of the CCOT. Method(s): We performed two snapshot audits on acute medical (control) and general medical wards (intervention) in a large district general hospital between the years 2018-2019. We obtained the percentage of patients with treatment limitations in place who had this documented on their EWS charts before and after improvement measures. Firstly, a paper prompt on the EWS chart was used in both control and intervention wards. Secondly, targeted communication interventions to general medical wards only. Targeted communication was not repeated after the second audit. A third snapshot audit was completed a year after improvement measures (2020) to identify whether improvements were sustained. Result(s): There was no significant difference in EWS amendment in the acute medical ward, where only a paper prompt was used. However, where targeted communication was used (general medical ward), there was a statistically significant improvement in review and amendment of EWS scores between the first and second audit in the intervention ward (37.2% vs 59.1%, p=0.017). However, this improvement was not sustained when the audit was repeated a year later. Conclusion(s): The proportion of inpatients with treatment escalation limitation decisions in place that have EWS amended can be improved by targeted communication, but paper prompts alone are not sufficient. However, these improvements are not sustained without repeated communication. The importance of appropriate amendment of EWS has two key benefits. Firstly, it reduces inappropriate and futile monitoring of end-of-life patients, allowing them to have a more dignified death. Secondly, instead of performing repeated observations (nursing staff) or patient reviews (CCOT) that will not alter management, nursing staff can better utilise their time in providing palliative support where appropriate (particularly considering current visiting restrictions), and the ever- stretched CCOT can be used more judiciously.

Comparing Ankylosing Spondylitis Disease Activity during the Covid-19 Pandemic Using Patient-Reported Outcome Measures with Face-Toface Clinical Evaluation of Disease Scores Prepandemic

Background/Aims During the COVID-19 pandemic, asynchronous consultations were introduced for patients with ankylosing spondylitis (AS). To assess disease activity in the absence of face-to-face clinical review and blood testing, patients submitted patient-reported outcome measures (PROMs) via electronic survey forms which were subsequently triaged by clinicians. We compared pre-pandemic clinician-reported scores with intra-pandemic self-reported scores and assessed clinical outcomes including allocation of follow-up and further management/ treatment escalation. Methods Clinician-reported scores were obtained in-person pre-pandemic (defined as 01/01/2019-01/03/2020). Self-reported BASDAI scores were submitted by patients via electronic forms sent out duringpandemic (defined as 01/12/2020-31/03/22). The responses were stored and analysed in a secure database. These scores are analogous to disease activity scores completed by clinicians during outpatient appointments. Score comparison was performed using Wilcoxon Sign Rank testing. We used the need for a follow-up within 3 months as target for those with severe disease. Data analysis was performed in Microsoft Excel and R (version 4.2.1). Results We noted a significantly higher overall level of patient-reported disease activity during the pandemic. In the total cohort of AS patients, the median BASDAI Score collected during-pandemic increased from 5.30 (n=124, range 0-10) compared to 2.80 pre-pandemic (n=590, range 0-12) (p<0.001). The proportion of patients with severe/active disease (defined as BASDAI >4) increased from 36% pre- to 65% during pandemic. In a smaller cohort of 34 patients for whom we had both pre- and during-pandemic scores, all patient parameters worsened during the pandemic. Notably, median BASDAI increased from 2.65 to 5.62 (p<0.0001). Patients with severe AS increased from 10 (29.4%) to 21 (61.8%) intra-pandemic. Follow-up data was available for 12/21 patients with severe AS during-pandemic. 7/12 patients (58%) received a follow-up appointment within one month;11/12 (91%) were seen within three months. On subsequent clinician assessment, only 7 (58%) of patients with self-reported severe AS were felt to have active disease;treatment was escalated for 3 patients. Conclusion There was a significantly higher reported level of AS disease activity during the COVID-19 pandemic, with 62 % of patients qualifying for biologic therapy (BASDAI >4). In a focussed sample, 91% of patients with new severe disease during-pandemic were followed up within the target of 3 months. The BASDAI score is independent from clinical examination and inflammatory markers, and therefore self-reported score should reliably reflect a patient's perception of disease activity. Further work is required to determine the reason for the increased disease activity observed during pandemic, and for the disparity between clinician impression and score results.

Clinical features and acute management in adults

COVID-19 is a multisystem disease that requires holistic management. Most patients will experience mild symptoms including cough, fever and mild dyspnoea. A small proportion of patients will have severe manifestations including respiratory failure, ARDS and multiorgan failure. Extrapulmonary features are common and include gastrointestinal, thromboembolic, neurological, cardiac, renal, endocrine and dermatological manifestations. The care of COVID-19 patients requires close attention to these features. This includes respiratory support (such as supplemental oxygen, NIV and awake proning);fluid, electrolyte and nutrition management;prevention, detection and treatment of thrombotic events;management of diabetic complications;review of medications;appropriate use of antibiotics;and evidence-based use of therapeutic agents such as corticosteroids, antivirals such as remdesivir and other emerging therapies such as immunomodulating agents. Early planning for treatment escalation and decision making around the appropriateness of cardiopulmonary resuscitation are crucial as deterioration can be rapid. Prolonged symptoms occur in a minority of patients and longitudinal follow-up is required.Copyright © ERS 2021.

Current Prescribing Practices in Psoriatic Arthritis - Comparison between the Uk and Europe

Background/Aims Psoriatic arthritis (PsA) is a multi-system disease with a range of management options. Treatment may vary by geographic location. We compared disease characteristics and prescribing practices in the UK and Europe in the post-Covid era. Methods The ASSIST study was a cross-sectional observational study of PsA patients aged 18 years and older selected from 24 centres across 5 countries (UK, France, Germany, Italy and Spain) between July 2021 and March 2022 (IRAS: 287039). Patients attending a face-to-face appointment with a diagnosis of PsA made by a rheumatologist were selected by systematic sampling at each centre and treated in routine clinical practice. Patient and disease characteristics, current treatment and treatment decisions (medications unchanged, switched, added or reduced) were recorded. The analysis was descriptive, with no imputation of missing data. Results 503 patients were included, with arthritis subtype, patient age, disease activity and duration shown (Table 1). Physician- and patient-reported disease severity was highest in the UK, where median patient age was lowest. Conventional synthetic (cs) DMARDS constituted a higher percentage of current PsA treatment in UK than continental Europe (66.4% vs 44.9%), whereas biologic use was more frequent in Europe (68.1% vs 36.4%). Adalimumab was the most commonly used biologic in the UK and Spain. Adalimumab and secukinumab were equally used in Germany, and ixekizumab and adalimumab were joint-first in Italy. Implementing change to the current PsA treatment was most common in the UK, predominantly being a treatment increase. This may reflect the higher level of disease activity or younger patient age in the UK than other countries, as treatment escalation is more likely earlier in the disease course. In the UK, treatment escalation was more commonly achieved by medication addition (26.2%) than medication switch (14%) or dose increase (7.5%). In Europe, medication addition and switch were of more similar frequency (10.9% vs 9.85%). Conclusion Disease characteristics and treatment strategies varied between countries, but particularly between UK and the rest of Europe. In contrast to mainland Europe, csDMARDs predominated in the UK, perhaps reflecting current NICE guidelines. Treatment escalation was most common in the UK, in keeping with higher disease activity. (Table Presented).

Impact of COVID-19 pandemics upon nationwide pulmonary hypertension cohort: 18-months analysis of BNP-PL national database

Introduction: Pulmonary hypertension (PH) patients may be vulnerable to SARS-CoV-2 infection, but large analytic studies on morbidity and mortality risks are limited. Aim(s): Assessment of the incidence and course of COVID-19 among patients (pts) diagnosed with PH, treated under the NFZ program, registered in the national BNP-PL database with the assessment of the impact of the SARS-CoV-2 pandemic on the care of patients with pulmonary hypertension in Poland. Method(s): We analyzed the records of the complete population of Polish pts treated under the National Drug Program of PH (PAH and CTEPH), registered in the national database of BNP-PL, and updated on an ongoing basis by all PH centers. The frequency of SARS-CoV-2 infections, clinical severity of COVID-19 course and mortality were reviewed. Clinical characteristics of infected and deceased patients were compared to the remaining patients registered in the BNP-PL database. The rate of increase of new diagnoses ended with inclusion in the Drug Program between 01 March 2020 and 31 August 2021, compared to the pre-pandemic year 2019, and the change in the treatment profile were reviewed. Result(s): The analysis included 1923 pts (PAH 1292, CTEPH 631). The incidence of SARS-CoV-2 infections was 7.4% (n=143) and similar to general population (7.6%), with a slight preponderance in PAH 8.1% (n=105) vs. CTEPH 6.0% (n=38) (p=0.099). 47 patients (33%) required hospitalization. Mortality rate was 24% (34/143) vs. 2.6% for general population - including 19/34 outside of hospital. Those who died due to COVID-19 were older (mean age 56+/-17.6 vs. 70.5+/-12.8 yrs;p<0.0001) and had more cardiovascular comorbidities (1.35 vs. 1.97;p=0.01). Systemic arterial hypertension was the strongest unique risk factor for mortality, present in 71% decedents vs. 45% of survivors, and the only independent risk factor in multivariate logistic regression analysis (OR 2.94, 95% CI 1.28-6.73). Moreover, there was a trend towards a higher incidence of diabetes and coronary artery disease in the group of non-survivors (Table 1). The number of new diagnoses of PH decreased during the pandemic compared to 2019 (new diagnoses rate in 2019 was 28.2/month vs. 19.2/month during COVID). A significant increase in total mortality was also observed in the PH group (11.1/month in 2019 vs. 13.7/month during COVID). Escalation of specific PH therapy also reduced (rate of specific therapy escalation in 2019 was 30.4/month vs. 20.5/month during COVID). Conclusion(s): The COVID-19 pandemic has deeply affected the care of patients with pulmonary hypertension by reducing the number of new diagnoses, escalation of therapy, and increasing overall mortality in this population, and this impact continues into second year of pandemics. Pulmonary hypertension is associated with a more severe course and higher mortality in COVID-19. (Figure Presented).

COVID-19: Extracorporeal Membrane Oxygenation as Last Resort for Regional Medical Centers

Background: Patients with COVID-19 are generally primarily treated in regional medical centers. Besides oxygen therapy, treatment usually involves mechanical ventilation and prone positioning should the patient develop acute respiratory distress syndrome (ARDS). In patients with refractory respiratory failure, initiation of veno-venous extracorporeal membrane oxygenation (vv-ECMO) may be the last therapeutic resort. Treatment with vv-ECMO requires highly experienced medical equipment and personnel. ECMO centers may be able to aid the regional medical centers, as this is not available for most hospitals. Implantation of the vv-ECMO system at the bedside and subsequently transporting the patient to a specialized center for further therapy could relieve both regional and specialized hospitals. Method(s): All patients in the participating centers of the DIVI between January 2020 and March 2021 with severe COVID-19induced ARDS were evaluated. Patients treated with vv-ECMO were included. Two groups were determined. The first group (group A) consisted of patients primarily treated in a regional medical center. These patients were cannulated at the bedside and transferred to the ECMO center. Group B consisted of patients directly referred to a specialized ECMO center. A comparison between mortality and ECMO-associated complications was made. Result(s): In total, 650 patients were treated with vv-ECMO in the timeframe. Group A consisted of 195 patients and group B of 455 patients. Patient characteristics such as sex, body mass index and pre-existing comorbidities were comparable. The time to admission to the intensive care unit was for both groups comparable. The delay from intubation to ECMO implantation was significantly shorter in group A 4.3 +/- 0.4 days versus 6.5 +/- 0.3 days (p < 0.001). Total time on mechanical ventilation, days spent in the intensive care unit and ECMO runtime were comparable in both groups. Furthermore, there was no significant difference in ECMO-associated complications and mortality. Conclusion(s): Respiratory failure due to severe COVID-19 pneumonia may primarily be treated in a regional medical center. There is no significant increase in ECMO-associated complications and mortality due to ECMO implantation and patient transfer to a specialized center, should therapy escalation be needed.

Was Icu Right for You? An Exploratory Qualitative Study of Patients >=65 Yrs and Next of Kin in Covid-19: The Escalate Study

Introduction The decision to admit an older patient to the intensive care unit (ICU) should reflect shared goals of care. Resource limitations during the Covid-19 pandemic highlighted challenges in selecting candidates for escalation. Patients and next of kin (NoK) who have experienced ICU are well-placed to reflect on whether the admission was right for them. Objective To explore older patients' (>65 years) and their loved ones' views on escalation decision making. Methods Qualitative study involving semi-structured interviews with patients, NoK of survivors and NoK of deceased who experienced UK ICU admission with Covid-19 respiratory failure between March 2020 and February 2021. A preliminary questionnaire was used to maximise sample diversity of age, sex, ethnicity, survival, decision regret and impact of event scores. Interview data were collected via video conferencing or telephone. Transcripts were analysed using framework analysis. Results 30 participants were interviewed. Results Five themes were identified: 'Inevitability' - a sense that the illness and its management are out of the control of the patient or their loved one;'Disconnect' - differences between hospital and lay person narratives;challenges to bridging that gap included effective communication aided by technology;'Acceptance' - of the consequences, good or bad, of an intensive care admission as unalterable;'Beyond comprehension' - participants had not contemplated ill health or ICU prior to admission and even with the benefit of hindsight struggled to describe which potential outcomes would be acceptable or unacceptable if they needed to be involved in similar decision-making around escalation in the future;'Covid-19' - unique impact of a pandemic. Conclusion This study, which includes bereaved NoK as well as patients and NoK of survivors, adds perspective to inform decision making regarding treatment escalation of older people.

Comparison of Monoclonal Antibody Cocktail (Casirivimab-Imdevimab) Treatment with Remdesivir and Favipiravir in Mild to Moderate COVID-19 Infection: A Retrospective Study

Introduction: Favipiravir and remdesivir are antiviral drugs being used in the present pandemic and were also used previously for other viral infections in the past. Monoclonal antibody (Mab) Casirivimab-Imdevimab is a Coronavirus Disease 2019 neutralising antibody approved in the last one year. Therefore, a clinical comparison with the existing treatment modalities is imperative. Aim: To compare Mab with remdesivir and favipiravir for mild to moderate COVID-19 disease. Materials and Methods: A retrospective, observational and single-centre study was conducted at a COVID-19 infection facility and private tertiary care hospital, Mumbai, Maharashtra, India. Data of patients admitted during the period of 1st June 2021 to 31st August 2021 was collected and analysed in the months of September 2021 and October 2021. Adults participants diagnosed to have COVID-19 infection, not requiring critical care or oxygen therapy were included in the study. Time to recovery from treatment onset and the need for treatment escalation were the primary outcome measures. Data was entered into Microsoft Excel spreadsheet version 16 and analysed. Statistical analysis was carried out using Chi-square test for the significance of association between tabulated values of data for qualitative and categorical data. Two-tailed unpaired t-test and Analysis of Variance (ANOVA) was used for quantitative tabulated data. Results: This study included 158 participants, grouped into remdesivir(n=63),favipiravir(n=30)andMab(n=65)treatmentgroups. Gender distribution was comparable in all groups (p-value=0.08). The three groups were compared for need of treatment escalation and time of recovery. The Mab treatment group (on comparing with other treatment arms) had earlier symptom recovery when given to patients with mild COVID-19 disease (p-value=0.006 for major symptoms) or when treatment was started within five days of symptom onset (p-value <0.001). Patients in Mab treatment group with mild illness required no treatment escalation compared to other groups (p-value=0.011). However, time to recovery patients in all treatment groups was comparable in case of patients with moderate COVID-19 illness (p-value=0.7381). In patients with moderate COVID-19 illness Mab treatment group required more frequent treatment escalation compared to remdesivir treatment group (p-value=0.044), when treatment was started within 5 days of symptom onset remdesivir and mab were comparable for treatment escalation (p=0.144). Vaccination status of the three groups differed significantly (p-value=0.033) hence a further subanalysis was done. On further analysis, non-vaccinated patients receiving Mab recovered from minor symptoms (p-value=0.0006) earlier than those receiving Remdesivir. Amongst the participants of the Mab treatment-group, vaccinated and non-vaccinated patients had comparable recovery time and need for treatment escalation (p-value=0.57 and p-value=0.76, respectively). Participants who received Mab-treatment within five days of symptom onset;recovered earlier compared to those who received Mab treatment after five days (p-value=0.019). Conclusion: Monoclonal antibody treatment group compared to the other treatment groups had earlier recovery in non vaccinated patients, mild COVID-19 disease, and when treatment was started before or on the 5th day of symptom onset.

Analysis of combined non-invasive respiratory support in the first six waves of the COVID-19 pandemic. Outcome according to the first respiratory support

Introduction: COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients. Methods: Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain. Results: 424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713). Conclusions: Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome. © 2022 Elsevier Ltd

Paediatric Aps - Children Are Not Just Small Adults

Introduction/Background: Antiphospholipid syndrome (APS) is a rare autoimmune multisystem disease characterised by thrombosis and pregnancy morbidity in the presence of persistently elevated titres of: lupus anticoagulant, anticardiolipin and/or anti-glycoprotein 1. It may be primary (occurring alone) or secondary (in combination with another disease, most commonly systemic lupus erythematosus (SLE)). Recent publications highlighted clinical criteria limitations for children and raised awareness of the burden and prevalence of non-criteria manifestations in this population. This case report adds further weight to the need to raise multi-specialty awareness of non-criteria manifestations to aid recognition and treatment of this rare condition with potentially severe sequelae. Description/Method: 13-year-old female with SLE diagnosed aged 8 in India with bilateral optic neuritis occurring two months later. ANA positive at diagnosis with low complement and thrombocytopenia. Treated with prednisolone and hydroxychloroquine. Patient moved to the UK aged 9;initial abnormal bloods: mildly positive ANA (ENA negative), thrombocytopenia, strong lupus anticoagulant. As serology not strongly suggestive and optic neuritis rare in lupus diagnosis questioned. Ophthalmology review confirmed bilateral optic atrophy without evidence of previous vasculitis. There was debate whether the postretinal demyelination was due to antiphospholipid syndrome or a primary demyelinating condition. Hydroxychloroquine stopped and azathioprine started. Following normal neurology investigations (brain, spine MRI/MRV/MRA) concluded if patient developed new APSrelated symptoms or worsening visual evoked potentials anticoagulation would be discussed. Patient remained stable over four years with chronic thrombocytopenia and ESR persistently elevated. Azathioprine changed to Mycophenolate mofetil (MMF) due to side effects. Routine medication monitoring bloods in 2022 showed ESR 97, CRP 78, Platelets 61. Review identified vasculitic rash on soles of both feet with palpable nodules and normal pulses. Further investigation confirmed antiphospholipid antibody triple positivity. Aspirin commenced, hydroxychloroquine restarted, MMF dose increased and rituximab administered. Left foot rash settled but right progressed with toe discolouration and numbness. Skin biopsy considered but not performed due to skin integrity concerns. Foot pulses remained present and normal. Bilateral lower limb doppler reported as normal;increased symptoms resulted in CT angiogram which revealed bilateral non-occlusive popliteal thrombus and left pulmonary embolus. Subsequent echocardiogram was normal. Patient was anticoagulated with low molecular weight heparin followed by warfarin. Vascular surgical team advocated medical management and patient received seven infusions of Iloprost followed by Sildenafil. She achieved near total resolution of skin changes to toes with only minimal loss of skin over tip of right great toe. Patient will now require long-termanticoagulation. Discussion/Results: APS was considered in initial differential diagnosis but patient did not meet current clinical criteria as no past evidence of thrombosis. Lupus anticoagulant was consistently strongly positive and anticardiolipin repeatedly negative. As anti-B2 glycoprotein 1 antibody is not routinely tested and must be verbally requested, it was only checked once (negative) prior to discovery of triple positivity. ANA reported as strongly positive at time of SLE diagnosis but reviewing original notes from India titre was 1:100 and therefore not highly convincing. ENA negative and complement and white cell count normal on repeat testing since. Therefore, it is probable that this patient has primary APS as opposed to secondary APS in association with SLE. However, it is possible that this patient may develop more symptoms of SLE over time. When this patient presented with foot rash there were high numbers of children presenting with varying severity of painful, itchy toes coined 'covid toes' due to suspected lin to SARS-CoV-2 infection. Patient had exposure history, and COVID antibody serology was difficult to interpret due to recent vaccination. Dermatology found appearance to be consistent with 'covid toes' and advised supportive treatment. The triple APS antibody positivity result provided probable aetiology. Providing evidence of thrombus was problematic with false reassurance from apparently normal lower limb arterial doppler when actually popliteal arteries were not checked in view of the presence of normal flow proximally at the groin and distally in the feet. This case highlights the need to continue to search for thrombus in presence of high titres antiphospholipid antibodies and particularly in the case of triple positivity as although patient presented with colour change to toes, she was entirely asymptomatic from her PE and her left foot improved spontaneously despite a left popliteal thrombus also being present. Key learning points/Conclusion: Non-criteria manifestation of thrombocytopenia (occurs in 25% paediatric APS patients) was present throughout and patient had past history of haematuria (a recognised renal non-criteria manifestation). A paediatric specific APS criteria including these may have resulted in earlier detection of triple antiphospholipid antibody positivity and thus earlier treatment escalation and possible avoidance of thrombus. It has been reported that a high proportion of children with positive antiphospholipid antibodies don't develop a thrombus. However, it is interesting that our patient was entirely asymptomatic from her pulmonary embolus which was an incidental finding on her CT angiogram. This prompts a discussion about how much imaging should be performed in those with high levels of persistent positive antiphospholipid antibodies. Rituximab resulted in normalisation of platelet count and ESR for the first time since initial presentation. Anticardiolipin antibodies normalised, lupus anticoagulant decreased from strong to moderate and anti- B2 glycoprotein levels decreased but remained positive. Rituximab is a recognised treatment for catastrophic antiphospholipid syndrome (CAPS) but not routinely used in APS. The consistently raised ESR in an apparently clinically well patient is a reminder to continue to search for causes of inflammation. As the CRP was largely in normal range, this demonstrates the unique value of the ESR. In view of anti-B2 glycoprotein 1 antibody requiring to be verbally requested, discussions are ongoing with the laboratory department regarding the possibility of electronic request and a comment with recommendation to check other two antiphospholipid antibodies following one positive antibody result. As a result of this case, a plan will be put in place to ensure annual screening of antiphospholipid antibodies in all juvenile SLE patients in our care. It is hoped that this case report promotes discussion amongst the paediatric rheumatology community regarding further research required for development of paediatric specific APS criteria and management.

EVALUATION of PATIENTS with RHEUMATOID ARTHRITIS in TELECONSULTATION during the FIRST WAVE of the COVID-19 PANDEMIC

Background: The sudden emergence of SARS-CoV-2 onto the world stage has accelerated a major change in the management of patients with chronic rheumatic diseases and has catalyzed the rapid emergence of telemedicine. Objectives: Our aim was to describe which parameters were used by rheumatol-ogists to monitor patients with rheumatoid arthritis (RA) in teleconsultation during the frst wave of the pandemic and identify the most relevant for decision making. Methods: Retrospective monocentric routine care cross-sectional study including RA patients seen in teleconsultation between March and September 2020. Available parameters assessing disease status were collected in teleconsultation files. Clinician intervention was defned by treatment escalation and/or the need for a rapid face-to-face consultation or day hospitalization. Results: 143 RA patients were included (117 females, mean age of 58±16 years, mean disease duration of 14±11 years). The presence or absence of patient self-reported RA fares was mentioned in all medical files, followed by the presence and/or the number of tender joints (76%), the duration of morning stiffness (66%), the number of pain-related nocturnal awakenings (66%) and the CRP value (54%). Patient self-reported RA fares concerned 43/143 patients (30%). The presence of self-reported RA fares was associated with a more detailed evaluation of patient in teleconsultation: The presence (or number) of tender joints and swollen joints were more signifcantly reported in patients who presented a fare (39/43, 91% vs. 70/100, 70%, p=0.008 and 25/43, 58% vs. 23/100, 23%, p<0.001, respectively). Teleconsultation led to a clinician intervention in 22/143 patients (14%), representing 51% of patients with self-reported fares (22/43 patients). Therapeutic escalation was necessary in 13 patients: introduction or dose increase of cor-ticosteroids in 8 patients, introduction or dose increase of methotrexate in 4 patients and introduction of hydroxychloroquine in 1 patient. Face-to-face consultation or day hospitalization were organized for 10 patients. Active disease was confrmed during this next face-to-face visit in 9 patients, with DAS28 ranging from 3.35 to 5.62, leading to therapeutic modifcation. The 133 other patients were seen in face-to-face consultation 6±2 months after the teleconsultation. No DMARD modifcation was recorded during this next face-to-face consultation. The following variables were associated with clinician intervention during the tel-econsultation in univariate analysis: patient self-reported RA fares since the last visit (p<0.001), CRP >10 mg/mL (p=0.012) and a morning stiffness > 30 minutes (p<0.001). Multivariate analysis confrmed RA fares (Odds Ratio, OR: 15.6 95% CI 3.37-68.28) and CRP values >10 mg/L (OR: 3.32, 95% CI % 1.12-13.27) as the variables independently associated with clinician intervention. Conclusion: Our study identifed patient reported RA fares and increased CRP values as 2 red fags in teleconsultation, independently associated with therapeutic modifcation and/or the need for a rapid face-to-face consultation. These indicators may help clinician's decision making in teleconsultation.

JUNIOR DOCTORS' EXPERIENCES OF RESPECT CONVERSATIONS DURING COVID-19: RESULTS OF A SERVICE EVALUATION PROJECT

Background During the COVID-19 pandemic, with limited intensive care resources and an unprecedented number of acutely unwell patients in hospital, conversations about resuscitation and treatment escalation plans became more important than ever. Locally, these decisions are documented using a ReSPECT form. We aimed to explore junior doctors' experiences of having these conversations with patients and their relatives during the COVID-19 pandemic, in order to identify areas for further training. Methods An anonymous mixed-methods questionnaire was distributed to junior doctors across a teaching hospital in the East Midlands. The free-text responses were manually coded and underwent thematic analysis. As this was an internally approved service evaluation project, no ethics committee approval was required. Results 14 junior doctors' responses were included in the final analysis. 93% of respondents had discussed resuscitation or treatment escalation with a patient or relative during the COVID-19 pandemic. Compared to prior to the pandemic, 62% of these respondents felt more confident in their ability to discuss resuscitation, and 77% felt more able to identify a patient who should have a ReSPECT form in place. However, 62% would like more training on how to discuss resuscitation or treatment escalation, and only 52% felt adequately supervised when having these conversations. Thematic analysis revealed the following major themes: challenges of virtual conversations, emotional burden on junior doctors, and unmet training needs. Conclusion The findings reveal that junior doctors' confidence in their own ability to have conversations about resuscitation and treatment escalation has improved since the start of the COVID-19 pandemic. However, there are still significant unmet training needs in this area. The results of this work are informing the development of local educational interventions to address these requirements.

USING FRAILTY REVIEWS TO MANAGE THE COVID-19 PANDEMIC IN AN EVIDENCE-BASED AND PERSONCENTRED MANNER ACROSS BUCKINGHAMSHIRE CARE HOMES

Aim NICE COVID-19 guidelines NG191 recognise that frailer patients, including those with a higher Rockwood Clinical Frailty Scale1 (CFS), are seldom improved by hospital admission. The project used a collaborative approach to undertake frailty reviews, aiming to reduce inappropriate hospital admissions. The reviews included discussing residents' preferred place of care and options in the event of deterioration, a Treatment Escalation Plan (TEP). Method A collaborative was formed between care home managers, pharmacists and geriatricians to review frailty factors in residents over 65 years, excluding those with Learning Disabilities. Care homes with high risk of COVID-19 were prioritised. A Standard Operational Procedure was approved within one month. Using existing resources only, the project was delivered over 3 months. Communication was sent to GP practices, care homes and residents/families and consent was obtained. Templates were developed and education delivered. Results Review outcomes were recorded electronically onto the GP clinical system. Care homes kept a copy and informed residents/ families of the outcome. 595 residents were reviewed in 21 care homes. Preliminary analysis for 71 residents reviewed May 2020 to April 2021 show: • 42 survivors, 33 with severe frailty (CFS 7-9), 9 not severely frail (CFS<7). Out of total 28 residents with TEP indicating avoidance of hospital admission, 23 were not admitted and 5 had single hospital admission. 14 residents TEP included hospital management of whom 7 were admitted. • 26 of the 29 deceased residents were severely frail. 96% died in their preferred place of death. Conclusion Clinical leadership demonstrated courage and capacity to challenge the status quo, improve organisational processes and innovate practice. This helped staff morale at a difficult time of immense pressure and positively enhanced care homes' profile and residents' experience.

EARLY INTESTINAL ULTRASOUND PREDICTS ENDOSCOPIC RESPONSE ON ANTI-INFLAMMATORY TREATMENT AND SHOWS DRUG-SPECIFIC RESPONSE TO BIOLOGICALS AND TOFACITINIB IN ULCERATIVE COLITIS

Introduction Objective evaluation of treatment response is the gold standard in ulcerative colitis (UC). In this setting, intestinal ultrasound (IUS) is a non-invasive alternative to endoscopy. Recent studies showed change in IUS parameters after treatment initiation but studies with an endoscopic reference standard are scarce. The aim of this study was to evaluate early change of IUS parameters and determine cut-off values for endoscopic endpoints in UC patients starting anti-inflammatory treatment. Methods In this longitudinal prospective study consecutive patients with moderate-severe UC (baseline endoscopic Mayo score (EMS)≥2) starting an anti-inflammatory treatment were included. Clinical scores, biochemical parameters and IUS parameters were collected at baseline, after 2 (T1), 6 (T2) and 8-26 weeks (T3) around time of the second sigmoidoscopy/colonoscopy. Bowel wall thickness (BWT), Colour Doppler signal (CDS), haustrations, inflammatory fat and wall layer stratification were measured as previously established1. Endoscopic remission (ER) and mucosal healing (MH) were evaluated in the sigmoid and defined as EMS=0 and EMS≤1, respectively. The ultrasonographist and endoscopist were blinded for the outcomes of endoscopy and IUS, respectively. Results 51 consecutive patients were included (Table 1) of whom 31 underwent a second endoscopy. Two additional patients underwent colectomy and were considered non-responders. 18 patients did not undergo second endoscopy due to the COVID-19 pandemic (n=2), refusal (n=5), loss to follow-up (n=1) or treatment escalation because of clinical deterioration confirmed by IUS and biomarkers before second endoscopy was performed (n=10). BWT was significantly lower from T2 onwards in patients reaching MH (p=0.026) and ER (p=0.002) at T3 (Fig 1). A significant decrease in BWT was already visible at T1 in patients receiving infliximab (median DBWT T0-T1: -26% [-43% - -6%], p=0.001) or tofacitinib (median ∆BWT T0-T1: -33% [-46% - -5%], p=0.001) but not in patients treated with vedolizumab (median ∆BWT T0-T1: -14% [-43% - 5%], p=0.11). Most accurate BWT cut-off values at T3 to determine MH and ER were 3.52 mm (AUROC: 0.95, 95% CI: 0.86-1.00, p<0.0001, sens:91%, spec:91%) and 2.98 mm (AUROC: 0.94, 95% CI: 0.85-1.00, p=0.001, sens:87%, spec:100%), respectively. At T2, BWT per 1 mm increase and CDS were inversely associated with MH (BWT: OR: 0.48 (0.24-0.96, p=0.038);CDS: OR 0.16 (0.03-0.83), p=0.028) and ER (BWT: OR: 0.30 (0.11-0.76), p=0.01). Conclusion BWT and CDS 6 weeks after start of treatment could predict MH and ER. In addition, treatment response at IUS is drug-specific. Furthermore, we have provided accurate BWT cut-off values for endoscopic outcomes. In a point-of-care setting, (early) treatment evaluation with IUS could guide treatment decision in UC in order to optimize treatment response. 1. Bots et al. JCC 2021

INTRODUCING TREATMENT ESCALATION PLANS (TEP) FOR OLDER PERSONS: RESPONSE TO THE COVID-19 PANDEMIC

Introduction: TEP detail appropriate ceilings of care and guide treatment of patients based on shared decision making. TEP documentation was not standard within our trust up to 2018.We aimed to design and introduce a standardised TEP proforma and evaluate its use in older persons aged ≥80. Methods: Data was obtained from patient notes and questionnaires within the Medicine for Older Persons department (MOP) from four PDSA cycles between 2018-2020. Cycle 1 was a service evaluation. Based on this data, a TEP form was created and approved for use in all adult patients. Cycles 2, 3 and 4 evaluated TEP after Introduction: of the proforma. Results: There was a 239% increase in TEP after Introduction: of the proforma, compared to baseline (cycle 1: n = 14/47 [29.8%], cycle 2: n = 17/112 [15.2%], cycle 3: n = 30/97 [30.9%], cycle 4: n = 42/59 [71.2%]).Theincrease in TEP between cycles 3 and 4 coincided with the COVID-19 epidemic. Clinicians were more confident in actioning TEP based on the proforma, compared to those written in the notes (cycle 2: 83% confidence vs 54%, cycle 3: 100% vs 35%, Cycle 4: 98% vs none written in the notes). An improvement in understanding the purpose, comprehensiveness and location of TEP forms was observed. Feedback suggested TEP provided clear guidance for 1. ceilings of care;especially useful out of hours 2. discussions with critical care and 3. patient handover between staff and successive shifts. Conclusion: TEP forms offer clear guidance on ceilings of care. Introduction: of the TEP proforma has led tomore frequent and proactive discussions with patients on ceilings of care and have facilitated a culture change in the management of older persons. Use of the forms increased during the COVID-19 pandemic but are now viewed as an essential component of patient safety and have been successfully implemented trustwide.

Covid-19 vaccine does not increase the likelihood of disease exacerbation in ibd: Results from a population-based study

Background: While short-term safety data of COVID-19 vaccination has been reassuring, it is theoretically possible that the vaccineassociated immune activation could trigger immune dysregulation and thus exacerbation of IBD. We used the epi-Israeli IBD Research Nucleus (IIRN) database to perform a population-based study exploring the effect of COVID-19 vaccination on disease course in IBD patients. Methods: We included all IBD patients insured in two of the four Israeli HMOs, covering 35% of the population, by validated algorithms, and selected those who received two doses of Pfizer BNT162b2 vaccine. These were matched to unvaccinated IBD patients by demographics, parameters of disease severity at baseline generated by hierarchical clustering of laboratory data, and length of time from previous exacerbation to baseline. The primary outcome was rate of IBD exacerbation as defined by proxies of hospitalizations, treatment escalation, and commencement of corticosteroid or enema. The study period was December, 2020 to June, 2021 Results: 707 pairs of vaccinated and unvaccinated IBD patients were compared. The pairs matched exactly for gender, district, IBD type and disease severity, and ±1 year for age at IBD diagnosis and at vaccination. Mean age was 38.5±13.5 years and median follow-up was 98 days (IQR 16-143). No difference in the outcome was found between the groups from the 2nd vaccination to the end of follow-up, with risk of exacerbation in vaccinated patients of 29% and risk in unvaccinated patients 26% (p=0.3). Conclusion: COVID-19 vaccinated IBD patients demonstrated a rate of IBD exacerbation following vaccination that was no different from that of unvaccinated patients. The multifaceted immune activation induced by the vaccine did not result in worsening IBD disease course. These results provide further reassurance for IBD patients receiving the vaccine.

Early intestinal ultrasound predicts endoscopic response to anti-inflammatory treatment and shows drug-specific response to biologicals and tofacitinib in Ulcerative Colitis

Background: Objective evaluation of treatment response is the gold standard in ulcerative colitis (UC). In this setting, intestinal ultrasound (IUS) is a non-invasive alternative to endoscopy. Recent studies showed change in IUS parameters after treatment initiation but studies with an endoscopic reference standard are scarce. The aim of this study was to evaluate early change of IUS parameters and determine cut-off values for endoscopic endpoints in UC patients starting anti-inflammatory treatment. Methods: In this longitudinal prospective study consecutive patients with moderate-severe UC (baseline endoscopic Mayo score (EMS)≥2) starting an anti-inflammatory treatment were included. Clinical scores, biochemical parameters and IUS parameters were collected at baseline, after 2 (T1), 6 (T2) and 8-26 weeks (T3) around time of the second sigmoidoscopy/colonoscopy. IUS parameters were measured as previously established1. Endoscopic remission (ER) and mucosal healing (MH) were evaluated in the sigmoid and defined as EMS=0 and EMS≤1, respectively. The ultrasonographist and endoscopist were blinded for the outcomes of endoscopy and IUS, respectively. Results: 51 consecutive patients were included (Table 1) of whom 31 underwent a second endoscopy (MH: n=15 (45%), ER: n=9 (27%)). Two additional patients underwent colectomy and were considered non-responders. 18 patients did not undergo second endoscopy due to the COVID-19 pandemic (n=2), refusal (n=5), loss to follow-up (n=1) or treatment escalation because of clinical deterioration confirmed by IUS and biomarkers before second endoscopy was performed (n=10). Bowel wall thickness (BWT) was significantly lower from T2 onwards in patients reaching MH (p=0.026) and ER (p=0.002) at T3 (Fig 1). A significant decrease in BWT was already visible at T1 in patients receiving infliximab (p=0.001) or tofacitinib (p=0.007), but not in patients treated with vedolizumab (p=0.11) (Fig 2). Most accurate BWT cut-off values at T3 to determine MH and ER were 3.52 mm (AUROC: 0.95, 95% CI: 0.86-1.00, p<0.0001, sens: 91%, spec: 91%) and 2.98 mm (AUROC: 0.94, 95% CI: 0.85-1.00, p=0.001, sens: 87%, spec: 100%), respectively. Other IUS parameters at T3 did not improve association with MH or ER. IUS parameters at T2 that predict MH and ER are demonstrated in Table 2. Conclusion: BWT and Colour Doppler Signal 6 weeks after start of treatment are associated with and could predict MH and ER. In addition, treatment response patterns at IUS are drug-specific. Furthermore, we have provided accurate BWT cut-off values for endoscopic outcomes. In a point-of-care setting, (early) treatment evaluation with IUS could guide treatment decision in UC in order to optimize treatment response.

Using quality improvement methodology to visualise change interventions to improve managing the unwell care home resident

Background: The COVID19 pandemic highlighted deficiencies in the recognition, monitoring, escalation and de-escalation of the acutely unwell care home resident. RESTORE2 is endorsed by the British Geriatric Society as the preferred tool for use in a care home setting. It incorporates: recognition of soft-signs;NEWS2 (National Early Warning Score 2);and SBAR-D (Situation Background Assessment Recommendation-Decision). Implementing RESTORE2 required a series of change interventions in a mesosystem environment in intermediate care bed-based rehabilitation setting in an independent care home. Methods: The Flow Coaching Academy '5Vs' Framework was used. A vision of 'CHAIN of CARE' was developed (Care Home Assessment of Intervention Need and Communicate Act Review Evaluate). Stake-holder mapping was undertaken. A Sinek Circle distilled intentions. A global aim led to specific aims and informed driver diagrams. Problems and risks were mapped out with an Ishikawa diagram. A high-level process map of future state was and cross-functional swim-lane chart for RESTORE2 use were devised. A clinical value compass map was used to consider outcomes. PDSA cycles were used. Results: The FCA Framework methodology, albeit without the ability to undertake 'Big Room' meetings due to the COVID19 pandemic restrictions, enabled the development of a care-home tailored Treatment Escalation Plan;an electronic template Nursing Handover;Multidisciplinary Safety Brief;training of all nursing team in RESTORE2;and use of NEWS2 for all residents in the intermediate care setting. Additional prompt for how to use RESTORE2 was developed. Conclusion: Bringing about complex change in a complex mesosystem benefits from different techniques thanmicrosystem change methodology. The 5Vs: Visualisation, Vision, Value, eVidence and inVolvement in the FCA Framework are an effective approach. The residents' voice was largely absent in the pressures of the COVID19 pandemic. 'The Chain of Care' proved helpful in visualising the global aims for the clinical team.

A collaborative quality improvement project between an NHS trust and independent provider to develop a care-home specific treatment escalation plan

Background: The COVID19 pandemic highlighted deficiencies in information exchange around treatment escalation plans (TEP) in an intermediate care unit, based in a 30 bed independent care home, into which the hospital organisation assigns medical, pharmacy, physiotherapy, occupational therapy and social work teams to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and>75% return home. Weekly bed turnover is approximately 15%. TEP documentation is a component of RESTORE2 use, as recommended in the British Geriatric Society Good Practice Guide for Managing COVID19 in Care Homes. Methods: Semi-structured interviews with nursing leaders and a weighted questionnaire for the whole nursing team were used to determine baseline levels of confidence around aspects of TEP. An Ishikawa diagram analysed factors contributing to poor documentation and communication. The 'Chain Of Care' vision for care home environments incorporated the need for a TEP. Three iterations occurred. A post-implementation weighted questionnaire collated qualitative information on confidence change. Results: Areas of greatest 'swing' towards INCREASED or SLIGHTLY INCREASED confidence around.: 90%, Cardiopulmonary Resuscitation (CPR) status clarity;90%, treatment 'ceiling of care' e.g. 'conveyance to the Emergency Department in any situation that the clinical team deem necessary';40%, conversations with out-of-hours services/external clinicians around appropriate actions;30%, conversations with nominated persons around appropriate actions. Conclusion: TheTEP incorporates more than just CPR status and contributed to increased nursing team confidence in responding to the acutely deteriorating adult appropriately in a care home environment. Clear documentation of: capacity assessment;patient prioritisation (using ReSPECT principles);and agreed treatment escalation and limitation, enabled information exchange. Standardisation of language, and cross-fertilisation with Nursing Handover, facilitated conversations with external clinicians and nominated persons. Tailoring the TEP to the care-home environment and rendering it generalisable to nonintermediate care, non-geriatrician supported care home microsystems was considered in the iterations.