A queuing model for ventilator capacity management during the COVID-19 pandemic.

We applied a queuing model to inform ventilator capacity planning during the first wave of the COVID-19 epidemic in the province of British Columbia (BC), Canada. The core of our framework is a multi-class Erlang loss model that represents ventilator use by both COVID-19 and non-COVID-19 patients. Input for the model includes COVID-19 case projections, and our analysis incorporates projections with different levels of transmission due to public health measures and social distancing. We incorporated data from the BC Intensive Care Unit Database to calibrate and validate the model. Using discrete event simulation, we projected ventilator access, including when capacity would be reached and how many patients would be unable to access a ventilator. Simulation results were compared with three numerical approximation methods, namely pointwise stationary approximation, modified offered load, and fixed point approximation. Using this comparison, we developed a hybrid optimization approach to efficiently identify required ventilator capacity to meet access targets. Model projections demonstrate that public health measures and social distancing potentially averted up to 50 deaths per day in BC, by ensuring that ventilator capacity was not reached during the first wave of COVID-19. Without these measures, an additional 173 ventilators would have been required to ensure that at least 95% of patients can access a ventilator immediately. Our model enables policy makers to estimate critical care utilization based on epidemic projections with different transmission levels, thereby providing a tool to quantify the interplay between public health measures, necessary critical care resources, and patient access indicators.

Novel design of inspiratory flow generation and gas mixing for critical care ventilators suitable for rapid production and mass casualty incidents.

Scarcity of medical resources inspired many teams worldwide to design ventilators utilizing different approaches during the recent COVID-19 pandemic. Although it can be relatively easy to design a simple ventilator in a laboratory, a large scale production of reliable emergency ventilators which meet international standards for critical care ventilators is challenging and time consuming. The aim of this study is to propose a novel and easily manufacturable principle of gas mixing and inspiratory flow generation for mechanical lung ventilators. Two fast ON/OFF valves, one for air and one for oxygen, are used to control the inspiratory flow generation using pulse width modulation. Short gas flow pulses are smoothed by low-pass acoustic filters and do not propagate further into the patient circuit. At the same time, the appropriate pulse width modulation of both ON/OFF valves controls the oxygen fraction in the generated gas mixture. Tests focused on the accuracy of the delivered oxygen fractions and tidal volumes have proved compliance with the international standards for critical care ventilators. The concept of a simple construction using two fast ON/OFF valves may be used for designing mechanical lung ventilators and thus suitable for their rapid production during pandemics.

Risk factors for developing ventilator-associated lower respiratory tract infection in patients with severe COVID-19: a multinational, multicentre study, prospective, observational study.

Around one-third of patients diagnosed with COVID-19 develop a severe illness that requires admission to the Intensive Care Unit (ICU). In clinical practice, clinicians have learned that patients admitted to the ICU due to severe COVID-19 frequently develop ventilator-associated lower respiratory tract infections (VA-LRTI). This study aims to describe the clinical characteristics, the factors associated with VA-LRTI, and its impact on clinical outcomes in patients with severe COVID-19. This was a multicentre, observational cohort study conducted in ten countries in Latin America and Europe. We included patients with confirmed rtPCR for SARS-CoV-2 requiring ICU admission and endotracheal intubation. Only patients with a microbiological and clinical diagnosis of VA-LRTI were included. Multivariate Logistic regression analyses and Random Forest were conducted to determine the risk factors for VA-LRTI and its clinical impact in patients with severe COVID-19. In our study cohort of 3287 patients, VA-LRTI was diagnosed in 28.8% [948/3287]. The cumulative incidence of ventilator-associated pneumonia (VAP) was 18.6% [610/3287], followed by ventilator-associated tracheobronchitis (VAT) 10.3% [338/3287]. A total of 1252 bacteria species were isolated. The most frequently isolated pathogens were Pseudomonas aeruginosa (21.2% [266/1252]), followed by Klebsiella pneumoniae (19.1% [239/1252]) and Staphylococcus aureus (15.5% [194/1,252]). The factors independently associated with the development of VA-LRTI were prolonged stay under invasive mechanical ventilation, AKI during ICU stay, and the number of comorbidities. Regarding the clinical impact of VA-LRTI, patients with VAP had an increased risk of hospital mortality (OR [95% CI] of 1.81 [1.40-2.34]), while VAT was not associated with increased hospital mortality (OR [95% CI] of 1.34 [0.98-1.83]). VA-LRTI, often with difficult-to-treat bacteria, is frequent in patients admitted to the ICU due to severe COVID-19 and is associated with worse clinical outcomes, including higher mortality. Identifying risk factors for VA-LRTI might allow the early patient diagnosis to improve clinical outcomes.Trial registration: This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable.

Surface Contamination of Reusable Respirators and Face Shields During Care of Critically Ill COVID-19 Patients.

BACKGROUND: With the emergence of SARS-CoV-2, healthcare workers (HCW) have relied on reusable personal protective equipment (PPE), including respirators and face shields (FSs). The effectiveness of decontamination procedures outside experimental settings is unclear. We examined the prevalence of surface contamination on reusable PPE used by HCWs at a hospital incorporating daily centralized decontamination and post-use wiping by sampling for common pathogens. METHOD: Samples were collected from HCWs' CleanSpace Halo respirator face masks (FMs) and FSs at the start of shift, immediately after use, and after cleaning with disinfecting wipes. Samples were analyzed for pathogens using the Applied Biosystems™ TaqPath™ COVID-19 Combo Kit and ThermoFisher TaqMan Array Card. Patient charts were reviewed for clinical correlation. FINDINGS: Of the 89 samples, 51 from FMs and 38 from FSs, none tested positive for SARS-CoV-2, despite 58 being obtained from PPE used in the care of patients with COVID-19, many with recent aerosol-generating procedures. Four samples tested positive (4.5%) for Staphylococcus aureus, two each from FMs and FSs. FMs that tested positive were not worn concurrently with FSs that tested positive. The FM and FS samples testing positive were worn in the care of patients without diagnosed S. aureus infection. No FMs tested positive following wipe-based disinfection, but both positive FS samples were found after disinfection wiping. CONCLUSION/APPLICATION TO PRACTICE: Contamination of reusable PPE appears uncommon, especially with SARS-CoV-2, when regular decontamination programs are in place. The rare presence of S. aureus highlights the importance of doffing procedures and hand hygiene by HCW to prevent surface contamination.

Isolation, characterization, therapeutic potency, and genomic analysis of a novel bacteriophage vB_KshKPC-M against carbapenemase-producing Klebsiella pneumoniae strains (CRKP) isolated from Ventilator-associated pneumoniae (VAP) infection of COVID-19 patients.

BACKGROUND: Carbapenem-resistant Klebsiella pneumoniae (CRKP) is a significant clinical problem, given the lack of therapeutic options. The CRKP strains have emerged as an essential worldwide healthcare issue during the last 10 years. Global expansion of the CRKP has made it a significant public health hazard. We must consider to novel therapeutic techniques. Bacteriophages are potent restorative cases against infections with multiple drug-resistant bacteria. The Phages offer promising prospects for the treatment of CRKP infections. OBJECTIVE: In this study, a novel K. pneumoniae phage vB_KshKPC-M was isolated, characterized, and sequenced, which was able to infect and lyse Carbapenem-resistant K. pneumoniae host specifically. METHODS: One hundred clinical isolates of K. pneumoniae were collected from patients with COVID-19 associated with ventilator-associated acute pneumonia hospitalized at Shahid Beheshti Hospital, Kashan, Iran, from 2020 to 2021. Initially, all samples were cultured, and bacterial isolates identified by conventional biochemical tests, and then the ureD gene was used by PCR to confirm the isolates. The Antibiotic susceptibility test in the disc diffusion method and Minimum inhibitory concentrations for Colistin was done and interpreted according to guidelines. Phenotypic and molecular methods determined the Carbapenem resistance of isolates. The blaKPC, blaNDM, and blaOXA-23 genes were amplified for this detection. Biofilm determination of CRKP isolates was performed using a quantitative microtiter plate (MTP) method. The phage was isolated from wastewater during the summer season at a specific position from Beheshti Hospital (Kashan, Iran). The sample was processed and purified against the bacterial host, a CRKP strain isolated from a patient suffering from COVID-19 pneumoniae and resistance to Colistin with high potency for biofilm production. This isolate is called Kp100. The separated phages were diluted and titration by the double overlay agar plaque assay. The separate Phage is concentrated with 10% PEG and stored at -80 °C until use. The phage host range was identified by the spot test method. The purified phage morphology was determined using a transmission electron microscope. The phage stability tests (pH and temperature) were analyzed. The effect of cationic ions on phage adsorption was evaluated. The optimal titer of bacteriophage was determined to reduce the concentration of the CRKP strain. One-step growth assays were performed to identify the purified phage burst's latent cycle and size. The SDS-PAGE was used for phage proteins analysis. Phage DNA was extracted by chloroform technique, and the whole genome of lytic phage was sequenced using Illumina HiSeq technology (Illumina, San Diego, CA). For quality assurance and preprocessing, such as trimming, Geneious Prime 2021.2.2 and Spades 3.9.0. The whole genome sequence of the lytic phage is linked to the GenBank database accession number. RASTtk-v1.073 was used to predict and annotate the ORFs. Prediction of ORF was performed using PHASTER software. ResFinder is used to assess the presence of antimicrobial resistance and virulence genes in the genome. The tRNAs can-SE v2.0.6 is used to determine the presence of tRNA in the genome. Linear genome comparisons of phages and visualization of coding regions were performed using Easyfig 2.2.3 and Mauve 2.4.0. Phage lifestyles were predicted using the program PHACTS. Phylogenetic analysis and amino acid sequences of phage core proteins, such as the major capsid protein. Phylogenies were reconstructed using the Neighbor-Joining method with 1000 bootstrap repeat. HHpred software was used to predict depolymerase. In this study, GraphPad Prism version 9.1 was used for the statistical analysis. Student's t-test was used to compare the sets and the control sets, and the significance level was set at P ≤ 0.05. RESULTS: Phage vB_KshKPC-M is assigned to the Siphoviridae, order Caudovirales. It was identified as a linear double-stranded DNA phage of 54,378 bp with 50.08% G + C content, had a relatively broad host range (97.7%), a short latency of 20 min, and a high burst size of 260 PFU/cell, and was maintained stable at different pH (3-11) and temperature (45-65 °C). The vB_KshKPC-M genome contains 91 open-reading frames. No tRNA, antibiotic resistance, toxin, virulence-related genes, or lysogen-forming gene clusters were detected in the phage genome. Comparative genomic analysis revealed that phage vB_KshKPC-M has sequence similarity to the Klebsiella phages, phage 13 (NC_049844.1), phage Sushi (NC_028774.1), phage vB_KpnD_PeteCarol (OL539448.1) and phage PWKp14 (MZ634345.1). CONCLUSION: The broad host range and antibacterial activity make it a promising candidate for future phage therapy applications. The isolated phage was able to lyse most of the antibiotic-resistant clinical isolates. Therefore, this phage can be used alone or as a phage mixture in future studies to control and inhibit respiratory infections caused by these bacteria, especially in treating respiratory infections caused by resistant strains in sick patients.

Mechanically Ventilated Patients With Coronavirus Disease 2019 Had a Higher Chance of In-Hospital Death If Treated With High-Flow Nasal Cannula Oxygen Before Intubation.

BACKGROUND: The impact of high-flow nasal cannula (HFNC) on outcomes of patients with respiratory failure from coronavirus disease 2019 (COVID-19) is unknown. We sought to assess whether exposure to HFNC before intubation was associated with successful extubation and in-hospital mortality compared to patients receiving intubation only. METHODS: This single-center retrospective study examined patients with COVID-19-related respiratory failure from March 2020 to March 2021 who required HFNC, intubation, or both. Data were abstracted from the electronic health record. Use and duration of HFNC and intubation were examined' as well as demographics and clinical characteristics. We assessed the association between HFNC before intubation (versus without) and chance of successful extubation and in-hospital death using Cox proportional hazards models adjusting for age, sex, race/ethnicity, obesity, hypertension, diabetes, prior chronic obstructive pulmonary disease or asthma, HCO 3 , CO 2 , oxygen-saturation-to-inspired-oxygen (S:F) ratio, pulse, respiratory rate, temperature, and length of stay before intervention. RESULTS: A total of n = 440 patients were identified, of whom 311 (70.7%) received HFNC before intubation, and 129 (29.3%) were intubated without prior use of HFNC. Patients who received HFNC before intubation had a higher chance of in-hospital death (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.06-4.05). No difference was found in the chance of successful extubation between the 2 groups (0.70, 0.41-1.20). CONCLUSIONS: Among patients with respiratory failure from COVID-19 requiring mechanical ventilation, patients receiving HFNC before intubation had a higher chance of in-hospital death. Decisions on initial respiratory support modality should weigh the risks of intubation with potential increased mortality associated with HFNC.

Which features of patients are morally relevant in ventilator triage? A survey of the UK public.

BACKGROUND: In the early stages of the COVID-19 pandemic, many health systems, including those in the UK, developed triage guidelines to manage severe shortages of ventilators. At present, there is an insufficient understanding of how the public views these guidelines, and little evidence on which features of a patient the public believe should and should not be considered in ventilator triage. METHODS: Two surveys were conducted with representative UK samples. In the first survey, 525 participants were asked in an open-ended format to provide features they thought should and should not be considered in allocating ventilators for COVID-19 patients when not enough ventilators are available. In the second survey, 505 participants were presented with 30 features identified from the first study, and were asked if these features should count in favour of a patient with the feature getting a ventilator, count against the patient, or neither. Statistical tests were conducted to determine if a feature was generally considered by participants as morally relevant and whether its mean was non-neutral. RESULTS: In Survey 1, the features of a patient most frequently cited as being morally relevant to determining who would receive access to ventilators were age, general health, prospect of recovery, having dependents, and the severity of COVID symptoms. The features most frequently cited as being morally irrelevant to determining who would receive access to ventilators are race, gender, economic status, religion, social status, age, sexual orientation, and career. In Survey 2, the top three features that participants thought should count in favour of receiving a ventilator were pregnancy, having a chance of dying soon, and having waited for a long time. The top three features that participants thought should count against a patient receiving a ventilator were having committed violent crimes in the past, having unnecessarily engaged in activities with a high risk of COVID-19 infection, and a low chance of survival. CONCLUSIONS: The public generally agreed with existing UK guidelines that allocate ventilators according to medical benefits and that aim to avoid discrimination based on demographic features such as race and gender. However, many participants expressed potentially non-utilitarian concerns, such as inclining to deprioritise ventilator allocation to those who had a criminal history or who contracted the virus by needlessly engaging in high-risk activities.

Fit testing and comfort evaluation of prophylactic dressing use for healthcare workers under N95/P2 respirators in one health service district in Australia.

BACKGROUND: This study evaluated the use of prophylactic dressings (silicone foam, silicone tape, hydrocolloid) under N95/P2 respirators to determine which dressings fit successfully. AIM: The aim was to develop a health service protocol for one state in Australia. METHODS: Data were collected during August and September 2021 as part of the Respiratory Protection Programme on 600 health workers using three types of prophylactic dressings. Five different types of respirators were used. Participant healthcare workers rated comfort on a four-point Likert scale. RESULTS: Successful fit was achieved by 63.6% of the respirator-dressing combinations. The best-performing respirator-dressing combination was the Trident® respirator with dressing Mepilex® Lite silicone foam (90.2% pass rate). High pass rates were found in the Trident® respirator with Mepilex® Border Lite with SofSicure silicone tape (79.1%); the 3M™ 1860 respirator with Mepilex® Border Lite with SofSicure silicone tape (74%); and the BSN orange duckbill respirator with Mepilex® Lite silicone foam (69.8%). The poorest-performing combination was the BYD™ respirator with Mepilex® Border Lite with SofSicure silicone tape (25.9% pass rate). Uncorrected chi-squared tests for association revealed significant associations between dressing type and outcome (P=0.004) and respirator type and outcome (P<0.001). Most respondents (82%) found the dressing combination markedly comfortable. CONCLUSIONS: When using prophylactic dressings under N95/P2 respirators, it is necessary to perform a fit test. In this study Trident® respirators had the highest probability of successful fit, while BYD™ respirators had the lowest. Combining Trident® respirators with Mepilex® Lite dressing was optimal. Most participants reported greater comfort with the dressings under the respirators.

Characterisation of superficial corneocytes in skin areas of the face exposed to prolonged usage of respirators by healthcare professionals during COVID-19 pandemic.

INTRODUCTION: During the COVID-19 pandemic healthcare workers (HCWs) have used respiratory protective equipment for prolonged periods, which has been associated with detrimental effects on the underlying skin. The present study aims to evaluate changes in the main cells (corneocytes) of the stratum corneum (SC) following prolonged and consecutive use of respirators. METHODS: 17 HCWs who wore respirators daily during routine hospital practice were recruited to a longitudinal cohort study. Corneocytes were collected via tape stripping from a negative control site (area outside the respirator) and from the cheek which was in contact with the device. Corneocytes were sampled on three occasions and analysed for the level of positive-involucrin cornified envelopes (CEs) and the amount of desmoglein-1 (Dsg1), as indirect measurements of immature CEs and corneodesmosomes (CDs), respectively. These were compared to biophysical measurements (Transepidermal water loss, TEWL, and SC hydration) at the same investigation sites. RESULTS: A large degree of inter-subject variability was observed, with maximum coefficients of variation of 43% and 30% for the level of immature CEs and Dsg1, respectively. Although it was observed that there was not an effect of prolonged respirator usage on the properties of corneocytes, the level of CDs was greater at the cheek than the negative control site (p < 0.05). Furthermore, low levels of immature CEs correlated with greater TEWL values after prolonged respirator application (p < 0.01). It was also noted that a smaller proportion of immature CEs and CDs was associated with a reduced incidence of self-reported skin adverse reactions (p < 0.001). CONCLUSIONS: This is the first study that investigated changes in corneocyte properties in the context of prolonged mechanical loading following respirator application. Although differences were not recorded over time, the levels of CDs and immature CEs were consistently higher in the loaded cheek compared to the negative control site and were positively correlated with a greater number of self-reported skin adverse reactions. Further studies are required to evaluate the role of corneocyte characteristics in the evaluation of both healthy and damaged skin sites.

Overview of tight fit and infection prevention benefits of respirators (filtering face pieces).

Regulations for measures to protect against SARS-CoV-2 transmission vary widely around the world, with very strict regulations in Germany where respirators (filtering face piece FFP2 or comparable) are often mandatory. The efficiency of respirators, however, depends essentially on the tight facial fit avoiding the bypass of contaminated air via gaps between mask and wearer's face. The facial fit can be verified in a fit test. The aim of this review was to describe the quantitative fit test results depending on the respirator designs. A literature search revealed 29 suitable studies. Of all respirators with circumferential head straps, three-panel folded dome-shaped respirators showed the best fit (80.8% of 4625 fit tests passed), followed by rigid-dome-shaped respirators (72.4% of 8234 fit tests passed), duckbill-shaped respirators (31.6% of 2120 fit tests passed), and coffee-filter-shaped respirators (30.9% of 3392 fit tests passed). Respirators with ear loops showed very poor tight fit (3.6% of 222 fit tests passed). In four randomized control trials, single-use respirators were not shown to be superior to surgical masks for the prevention of laboratory-confirmed viral respiratory infections, even when adjusted with a fit test. Therefore, we consider the mandatory use of respirators to be disproportionate and not supported by evidence. Further evidence should be generated, in which scenarios respirators might provide an effective benefit as part of occupational health and safety. For situations with confirmed benefits, only high-quality disposable respirators with head straps or respiratory protective equipment of higher protective levels should be used.

Protocol of a prospective comprehensive evaluation of an elastic band beard cover for filtering facepiece respirators in healthcare.

Individuals who are unable to be clean shaven for religious, medical or cultural reasons are unable to wear a filtering facepiece respirator (FFR), as the respirator cannot provide adequate protection against aerosol-transmissible diseases. There is currently a paucity of validated techniques to ensure the safe inclusion of bearded healthcare workers in the pandemic workforce. We propose to undertake a healthcare-based multi-modal evaluation study on the elastic band beard cover for FFR technique, examining the quantitative fit test (QNFT) results, usability and skill level of participants with repeated assessments over time. This is a prospective study conducted through the Respiratory Protection Program at the Royal Melbourne Hospital. Healthcare workers are invited to participate if they require respiratory protection and cannot shave for religious, cultural or medical reasons. An online education package on the use of respiratory protective equipment and the elastic band beard cover for FFR technique is provided. This is followed by a face-to-face session, where the participant will receive: one-on-one training; undergo a skill assessment on their donning, doffing and user seal check techniques; complete QNFTs and a usability survey. Participants will be invited to repeat the assessment within 3 months of the first session and at 12 months. This study involves multimodal and repeated assessments of an elastic band beard cover for FFRs. The findings of this study will provide information on: whether this simple technique can provide safe, consistent and effective respiratory protection; whether it will interfere with occupational activities; and whether it is comfortable and tolerable for the duration of wear. This is of significant importance to the health workforce around the world, who cannot shave but require access to respiratory protective equipment during the COVID-19 pandemic.

icumonitoring.ch: a platform for short-term forecasting of intensive care unit occupancy during the COVID-19 epidemic in Switzerland.

In Switzerland, the COVID-19 epidemic is progressively slowing down owing to “social distancing” measures introduced by the Federal Council on 16 March 2020. However, the gradual ease of these measures may initiate a second epidemic wave, the length and intensity of which are difficult to anticipate. In this context, hospitals must prepare for a potential increase in intensive care unit (ICU) admissions of patients with acute respiratory distress syndrome. Here, we introduce icumonitoring.ch, a platform providing hospital-level projections for ICU occupancy. We combined current data on the number of beds and ventilators with canton-level projections of COVID-19 cases from two S-E-I-R models. We disaggregated epidemic projection in each hospital in Switzerland for the number of COVID-19 cases, hospitalisations, hospitalisations in ICU, and ventilators in use. The platform is updated every 3-4 days and can incorporate projections from other modelling teams to inform decision makers with a range of epidemic scenarios for future hospital occupancy.

Automatic air volume control system for ventilation of two patients using a single ventilator: a large animal model study.

The COVID-19 pandemic outbreak led to a global ventilator shortage. Hence, various strategies for using a single ventilator to support multiple patients have been considered. A device called Ventil previously validated for independent lung ventilation was used in this study to evaluate its usability for shared ventilation. We performed experiments with a total number of 16 animals. Eight pairs of pigs were ventilated by a ventilator or anesthetic machine and by Ventil for up to 27 h. In one experiment, 200 ml of saline was introduced to one subject's lungs to reduce their compliance. The experiments were analyzed in terms of arterial blood gases and respiratory parameters. In addition to the animal study, we performed a series of laboratory experiments with artificial lungs (ALs). The resistance and compliance of one AL (affected) were altered, while the tidal volume (TV) and peak pressure (Ppeak) in the second (unaffected) AL were analyzed. In addition, to assess the risk of transmission of pathogens between AL respiratory tracts, laboratory tests were performed using phantoms of virus particles. The physiological level of analyzed parameters in ventilated animals was maintained, except for CO2 tension, for which a permissive hypercapnia was indicated. Experiments did not lead to injuries in the animal's lungs except for one subject, as indicated by CT scan analysis. In laboratory experiments, changes in TV and Ppeak in the unaffected AL were less than 11%, except for 2 cases where the TV change was 20%. No cross-contamination was found in simulations of pathogen transmission. We conclude that ventilation using Ventil can be considered safe in patients undergoing deep sedation without spontaneous breathing efforts.

Model-based patient matching for in-parallel pressure-controlled ventilation.

BACKGROUND: Surges of COVID-19 infections have led to insufficient supply of mechanical ventilators (MV), resulting in rationing of MV care. In-parallel, co-mechanical ventilation (Co-MV) of multiple patients is a potential solution. However, due to lack of testing, there is currently no means to match ventilation requirements or patients, with no guidelines to date. In this research, we have developed a model-based method for patient matching for pressure control mode MV. METHODS: The model-based method uses a single-compartment lung model (SCM) to simulate the resultant tidal volume of patient pairs at a set ventilation setting. If both patients meet specified safe ventilation criteria under similar ventilation settings, the actual mechanical ventilator settings for Co-MV are determined via simulation using a double-compartment lung model (DCM). This method allows clinicians to analyse Co-MV in silico, before clinical implementation. RESULTS: The proposed method demonstrates successful patient matching and MV setting in a model-based simulation as well as good discrimination to avoid mismatched patient pairs. The pairing process is based on model-based, patient-specific respiratory mechanics identified from measured data to provide useful information for guiding care. Specifically, the matching is performed via estimation of MV delivered tidal volume (mL/kg) based on patient-specific respiratory mechanics. This information can provide insights for the clinicians to evaluate the subsequent effects of Co-MV. In addition, it was also found that Co-MV patients with highly restrictive respiratory mechanics and obese patients must be performed with extra care. CONCLUSION: This approach allows clinicians to analyse patient matching in a virtual environment without patient risk. The approach is tested in simulation, but the results justify the necessary clinical validation in human trials.

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update.

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

COVID-19 Lessons Learned: Response to the Anticipated Ventilator Shortage.

Early in the COVID-19 pandemic predictions of a worldwide ventilator shortage prompted a worldwide search for solutions. The impetus for the scramble for ventilators was spurred on by inaccurate and often unrealistic predictions of ventilator requirements. Initial efforts looked simply at acquiring as many ventilators as possible from national and international sources. Ventilators from the Strategic National Stockpile were distributed to early hotspots in the Northeast and Northwest United States. In a triumph of emotion over logic, well-intended experts from other industries turned their time, talent, and treasure toward making a ventilator for the first time. Interest in shared ventilation (more than one patient per ventilator) was ignited by an ill-advised video on social media that ignored the principles of gas delivery in deference to social media notoriety. With shared ventilation, a number of groups mistook a physiologic problem for a plumbing problem. The United States government invoked the Defense Production Act to push automotive manufacturers to partner with existing ventilator manufacturers to speed production. The FDA granted emergency use authorization for "splitters" to allow shared ventilation as well as for ventilators and ancillary equipment. Rationing of ventilators was discussed in the lay press and medical literature but was never necessary in the US. Finally, planners realized that staff with expertise in providing mechanical ventilation were the most important shortage. Over 200,000 ventilators were purchased by the United States government, states, cities, health systems, and individuals. Most had little value in caring for patients with COVID-19 ARDS. This paper attempts to look at where miscalculations were made, with an eye toward what we can do better in the future.

Race and resource allocation: an online survey of US and UK adults' attitudes toward COVID-19 ventilator and vaccine distribution.

OBJECTIVE: This study aimed to assess US/UK adults' attitudes towards COVID-19 ventilator and vaccine allocation. DESIGN: Online survey including US and UK adults, sampled to be representative for sex, age, race, household income and employment. A total of 2580 participated (women=1289, age range=18 to 85 years, Black American=114, BAME=138). INTERVENTIONS: Participants were asked to allocate ventilators or vaccines in scenarios involving individuals or groups with different medical risk and additional risk factors. RESULTS: Participant race did not impact vaccine or ventilator allocation decisions in the USA, but did impact ventilator allocation attitudes in the UK (F(4,602)=6.95, p<0.001). When a racial minority or white patient had identical chances of survival, 14.8% allocated a ventilator to the minority patient (UK BAME participants: 24.4%) and 68.9% chose to toss a coin. When the racial minority patient had a 10% lower chance of survival, 12.4% participants allocated them the ventilator (UK BAME participants: 22.1%). For patients with identical risk of severe COVID-19, 43.6% allocated a vaccine to a minority patient, 7.2% chose a white patient and 49.2% chose a coin toss. When the racial minority patient had a 10% lower risk of severe COVID-19, 23.7% participants allocated the vaccine to the minority patient. Similar results were seen for obesity or male sex as additional risk factors. In both countries, responses on the Modern Racism Scale were strongly associated with attitudes toward race-based ventilator and vaccine allocations (p<0.0001). CONCLUSIONS: Although living in countries with high racial inequality during a pandemic, most US and UK adults in our survey allocated ventilators and vaccines preferentially to those with the highest chance of survival or highest chance of severe illness. Race of recipient led to vaccine prioritisation in cases where risk of illness was similar.

The effect of the COVID-19 pandemic on deceased and living organ donors in the United States of America.

A life-saving treatment, solid organ transplantation (SOT) has transformed the survival and quality of life of patients with end-organ dysfunction. The coronavirus disease (COVID-19) pandemic has impacted the practice of deceased and living donations worldwide by various resource shifting, including healthcare personnel and equipment such as ventilators and bed space. Our work explores the COVID-19 pandemic and global transplant data to create a statistical model for deducing the impact of COVID-19 on living donor and deceased donor transplants in the United States of America (USA). In severely impacted regions, transplant centers need to carefully balance the risks and benefits of performing a transplant during the COVID-19 pandemic. In our statistical model, the COVID cases are used as an explanatory variable (input) to living or deceased donor transplants (output). The model is shown to be statistically accurate for both estimation of the correlation structure, and prediction of future donors. The provided predictions are to be taken as probabilistic assertions, so that for each instant where the prediction is calculated, a statistical measure of accuracy (confidence interval) is provided. The method is tested on both low and high frequency data, that notoriously exhibit a different behavior.