Analysis of European Air Medical Evacuation Flights of Coronavirus Disease 2019 Patients.

OBJECTIVE: As part of the humanitarian response to the coronavirus disease 2019 (COVID-19) pandemic, the German and French Armed Forces provided air transport for patients from overwhelmed regional hospitals in Italy and France. The objective of this study was to analyze the characteristics of the missions and the medical conditions of COVID-19 patients transported during an air medical evacuation on fixed wing aircraft in March and April 2020. METHOD: This was a retrospective analysis of transport records as well as other documents for 58 COVID-19 patients requiring artificial ventilation. RESULTS: The median age of the transported patients was 61.5 years, and 61% of them had preexisting medical conditions. They had been ventilated for a median of 5 days and experienced the first symptoms 18 days before transport. The patients flown out of France had less days of ventilation before flight, a lower end-tidal carbon dioxide level at the beginning of the flight, and a lower Charlson Comorbidity Index. There were also some differences between the ventilation and the flight level flown by the 2 air forces. CONCLUSION: The intensive care transport of ventilated COVID-19 patients requires highly qualified personnel and appropriate equipment and should be planned appropriately.

Initiation of an inter-hospital extracorporeal membrane oxygenation transfer programme for critically ill patients with coronavirus disease 2019: bringing extracorporeal membrane oxygenation support to peripheral hospitals.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) is a resource-intensive, highly specialized and expensive therapy that is often reserved for high-volume centres. In recent years, we established an inter-hospital ECMO transfer programme that enables ECMO implants in peripheral hospitals. During the pandemic, the programme was expanded to include ECMO support in selected critically ill patients with coronavirus disease 2019 (COVID-19). METHODS: This retrospective single-centre study reports the technical details and challenges encountered during our initial experience with ECMO implants in peripheral hospitals for patients with COVID-19. RESULTS: During March and April 2020, our team at the University Hospital of Zurich performed 3 out-of-centre ECMO implants at different peripheral hospitals. The implants were performed without any complications. The patients were transported by ambulance or helicopter. Good preparation and selection of the required supplies are the keys to success. The implant should be performed by a well-trained, seasoned ECMO team, because options are limited in most peripheral hospitals. CONCLUSIONS: Out-of-centre ECMO implants in well-selected patients with COVID-19 is feasible and safe if a well-established organization is available and if the implantation is done by an experienced and regularly trained team.

Caring for critically ill patients during interhospital transfers: A qualitative study.

BACKGROUND: The coronavirus pandemic has resulted in an increased number of interhospital transfers of patients with artificial airways. The transfer of these patients is associated with risks and has been experienced as highly challenging, which needs to be further explored. AIMS AND OBJECTIVES: To describe critical care nurses' experiences of caring for critically ill patients with artificial airways during interhospital transfers. DESIGN: A cross-sectional study using a qualitative approach was conducted during spring 2020. Participants were critical care nurses (n = 7) from different hospitals (n = 2). METHODS: The data were collected through semi-structured interviews based on an interview guide. A qualitative content analysis using an inductive approach was performed. RESULTS: The analysis resulted in one main theme, "Preserving the safety in an unknown environment," and three sub-themes, "Being adequately prepared is essential to feel secure," "Feeling abandoned and overwhelmingly responsible," and "Being challenged in an unfamiliar and risky environment." CONCLUSIONS: Critical care nurses experienced interhospital transfers of critically ill patients with artificial airways as complex and risky. It is essential to have an overall plan in order to prevent any unpredictable and acute events. Adequate communication and good teamwork are key to the safe transfer of a critically ill patient in that potential complications and dangers to the patient can be prevented. RELEVANCE TO CLINICAL PRACTICE: Standardized checklists need to be created to guide the transfers of critically ill patients with different conditions. This would prevent failures based on human or system factors, such as lack of experience and lack of good teamwork.

The impact of COVID-19 on pharmacy transitions of care services.

COVID-19 has necessitated alterations to the delivery of healthcare services. Modifications include those made to improve patient and healthcare worker safety such as the use of personal protective equipment. Pharmacy services, specifically pharmacy transitions of care services have not been immune to change which have brought along their own set of unique challenges to consider. This paper discusses how COVID-19 has impacted the delivery of pharmacy transitions of care services with real world examples from Sharp Grossmont Hospital and Hoag Memorial Hospital Presbyterian. Procedures implemented to minimize the spread and contraction of COVID-19 such as minimized patient contact and altered visitor policies have made it more challenging to obtain a best possible medication list the patient was taking prior to arrival to the hospital which has lead to an increased reliance on secondary sources to complete medication histories. Regarding discharge prescriptions, preference has shifted to the use of electronic vs. hard copy prescriptions, mail order, and utilization of med to bed programs and other hospital medication delivery services to limit patient contact in outpatient pharmacies. An improved effort to resolve medication acquisition issues prior to discharge utilizing patient assistance programs and other hospital programs to cover the cost of medications for COVID positive patients under certain circumstances has been seen. This paper highlights the important role pharmacists can play in providing effective communication, supporting continuity of care, and advocating for patient engagement and empowerment during transitions of care in the COVID-19 pandemic.

Assessing the need for transfer to the intensive care unit for Coronavirus-19 disease: Epidemiology and risk factors.

BACKGROUND: Although many patients with coronavirus disease 2019 (Covid-19) require direct admission to the intensive care unit (ICU), some are sent after admission. Clinicians require an understanding of this phenomenon and various risk stratification approaches for recognizing these subjects. METHODS: We examined all Covid-19 patients sent initially to a ward who subsequently required care in the ICU. We examined the timing transfer and attempted to develop a risk score based on baseline variables to predict progressive disease. We evaluated the utility of the CURB-65 score at identifying the need for ICU transfer. RESULTS: The cohort included 245 subjects (mean age 59.0 ± 14.2 years, 61.2% male) and 20% were eventually sent to the ICU. The median time to transfer was 2.5 days. Approximately 1/3rd of patients were not moved until day 4 or later and the main reason for transfer (79.2%) was worsening respiratory failure. A baseline absolute lymphocyte count (ALC) of ≤0.8 103/ml and a serum ferritin ≥1000 ng/ml were independently associated with ICU transfer. Co-morbid illnesses did not correlate with eventual ICU care. Neither a risk score based on a low ALC and/or high ferritin nor the CURB-65 score performed well at predicting need for transfer. CONCLUSION: Covid-19 patients admitted to general wards face a significant risk for deterioration necessitating ICU admission and respiratory failure can occur late in this disease. Neither baseline clinical factors nor the CURB-65 score perform well as screening tests to categorize these subjects as likely to progress to ICU care.

Hospital-in-the-Home experience of first 23 COVID-19 patients at a regional NSW hospital.

Ambulatory care is an important service for patients with the COVID-19 infection especially in a regional area where most of the patients underwent home isolation. Escalation of treatment and timely transition to inpatient care are critical when COVID-19 patients deteriorate. Equally important is ensuring transfer into facility is carried out in a well-planned, safe manner to prevent exposure to health care professionals as well as other inpatients. This study is a summary of our COVID Hospital-in-the-Home (HITH) service and clinical presentation of COVID-19 patients.

Three-Tiered COVID-19 Cohorting Strategy and Implications for Memory-Care.

An outbreak of SARS-CoV-2 in a skilled nursing facility (SNF) can be devastating for residents and staff. Difficulty identifying asymptomatic and presymptomatic cases and lack of vaccination or treatment options make management challenging. We created, implemented, and now present a guide to rapidly deploy point-prevalence testing and 3-tiered cohorting in an SNF to mitigate an outbreak. We outline key challenges to SNF cohorting.

Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria.

OBJECTIVES: To identify and appraise articles describing criteria used to prioritize or withhold a critical care admission. DATA SOURCES: PubMed, Embase, Medline, EBM Reviews, and CINAHL Complete databases. Gray literature searches and a manual review of references were also performed. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. STUDY SELECTION: We sought all articles and abstracts of original research as well as local, provincial, or national policies on the topic of ICU resource allocation. We excluded studies whose population of interest was neonatal, pediatric, trauma, or noncritically ill. Screening of 6,633 citations was conducted. DATA EXTRACTION: Triage and/or transport criteria were extracted, based on type of article, methodology, publication year, and country. An appraisal scale was developed to assess the quality of identified articles. We also developed a robustness score to further appraise the robustness of the evidence supporting each criterion. Finally, all criteria were extracted, evaluated, and grouped by theme. DATA SYNTHESIS: One-hundred twenty-nine articles were included. These were mainly original research (34%), guidelines (26%), and reviews (21%). Among them, we identified 200 unique triage and transport criteria. Most articles highlighted an exclusion (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). Criteria were classified in one of four emerging themes: patient, condition, physician, and context. The majority of criteria used were nonspecific. No study prospectively evaluated the implementation of its cited criteria. CONCLUSIONS: This systematic review identified 200 criteria classified within four themes that may be included when devising triage programs including the coronavirus disease 2019 pandemic. We identified significant knowledge gaps where research would assist in improving existing triage criteria and guidelines, aiming to decrease arbitrary decisions and variability.

Managing Care Transitions to the Community During a Pandemic.

This column discusses the establishment of a multidisciplinary model for care transition of COVID-19-positive patients from hospital to community. The pandemic has presented challenging issues for discharge transition. A tiered patient identification and clinical messaging referral system was developed. The use of the COVID-19 transition model provided support to patients and physicians during the 30-day discharge period and can serve as a model for emerging public health issues in the future.

Large-Scale Air Medical Operations in the Age of Coronavirus Disease 2019: Early Leadership Lessons From the Front Lines of British Columbia.

In late 2019, a novel coronavirus was identified as the cause of a cluster of atypical pneumonia cases in Wuhan, China. It subsequently spread throughout China and around the world, quickly becoming a public health emergency. In March 2020, the World Health Organization declared coronavirus disease 2019 a pandemic. This article explores the preparation and early experiences of a large Canadian critical care transport program during the coronavirus disease 2019 pandemic focused on 6 broad strategic objectives centered around staff welfare, regular and transparent communication, networking, evidenced-based approach to personal protective equipment, agile mission planning, and an expedited approach to clinical practice and policy updates and future state modeling.