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1.
Chest ; 160(1): 175-186, 2021 07.
Article in English | MEDLINE | ID: covidwho-1525725

ABSTRACT

BACKGROUND: SARS-CoV-2 aerosolization during noninvasive positive-pressure ventilation may endanger health care professionals. Various circuit setups have been described to reduce virus aerosolization. However, these setups may alter ventilator performance. RESEARCH QUESTION: What are the consequences of the various suggested circuit setups on ventilator efficacy during CPAP and noninvasive ventilation (NIV)? STUDY DESIGN AND METHODS: Eight circuit setups were evaluated on a bench test model that consisted of a three-dimensional printed head and an artificial lung. Setups included a dual-limb circuit with an oronasal mask, a dual-limb circuit with a helmet interface, a single-limb circuit with a passive exhalation valve, three single-limb circuits with custom-made additional leaks, and two single-limb circuits with active exhalation valves. All setups were evaluated during NIV and CPAP. The following variables were recorded: the inspiratory flow preceding triggering of the ventilator, the inspiratory effort required to trigger the ventilator, the triggering delay, the maximal inspiratory pressure delivered by the ventilator, the tidal volume generated to the artificial lung, the total work of breathing, and the pressure-time product needed to trigger the ventilator. RESULTS: With NIV, the type of circuit setup had a significant impact on inspiratory flow preceding triggering of the ventilator (P < .0001), the inspiratory effort required to trigger the ventilator (P < .0001), the triggering delay (P < .0001), the maximal inspiratory pressure (P < .0001), the tidal volume (P = .0008), the work of breathing (P < .0001), and the pressure-time product needed to trigger the ventilator (P < .0001). Similar differences and consequences were seen with CPAP as well as with the addition of bacterial filters. Best performance was achieved with a dual-limb circuit with an oronasal mask. Worst performance was achieved with a dual-limb circuit with a helmet interface. INTERPRETATION: Ventilator performance is significantly impacted by the circuit setup. A dual-limb circuit with oronasal mask should be used preferentially.


Subject(s)
COVID-19 , Continuous Positive Airway Pressure , Disease Transmission, Infectious/prevention & control , Noninvasive Ventilation , Air Filters , Benchmarking/methods , COVID-19/therapy , COVID-19/transmission , Continuous Positive Airway Pressure/adverse effects , Continuous Positive Airway Pressure/instrumentation , Continuous Positive Airway Pressure/methods , Critical Pathways/standards , Critical Pathways/trends , Humans , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Noninvasive Ventilation/adverse effects , Noninvasive Ventilation/instrumentation , Noninvasive Ventilation/methods , Research Design , Respiratory Function Tests/methods , SARS-CoV-2 , Treatment Outcome , Ventilators, Mechanical
2.
Chest ; 160(1): 175-186, 2021 07.
Article in English | MEDLINE | ID: covidwho-1298651

ABSTRACT

BACKGROUND: SARS-CoV-2 aerosolization during noninvasive positive-pressure ventilation may endanger health care professionals. Various circuit setups have been described to reduce virus aerosolization. However, these setups may alter ventilator performance. RESEARCH QUESTION: What are the consequences of the various suggested circuit setups on ventilator efficacy during CPAP and noninvasive ventilation (NIV)? STUDY DESIGN AND METHODS: Eight circuit setups were evaluated on a bench test model that consisted of a three-dimensional printed head and an artificial lung. Setups included a dual-limb circuit with an oronasal mask, a dual-limb circuit with a helmet interface, a single-limb circuit with a passive exhalation valve, three single-limb circuits with custom-made additional leaks, and two single-limb circuits with active exhalation valves. All setups were evaluated during NIV and CPAP. The following variables were recorded: the inspiratory flow preceding triggering of the ventilator, the inspiratory effort required to trigger the ventilator, the triggering delay, the maximal inspiratory pressure delivered by the ventilator, the tidal volume generated to the artificial lung, the total work of breathing, and the pressure-time product needed to trigger the ventilator. RESULTS: With NIV, the type of circuit setup had a significant impact on inspiratory flow preceding triggering of the ventilator (P < .0001), the inspiratory effort required to trigger the ventilator (P < .0001), the triggering delay (P < .0001), the maximal inspiratory pressure (P < .0001), the tidal volume (P = .0008), the work of breathing (P < .0001), and the pressure-time product needed to trigger the ventilator (P < .0001). Similar differences and consequences were seen with CPAP as well as with the addition of bacterial filters. Best performance was achieved with a dual-limb circuit with an oronasal mask. Worst performance was achieved with a dual-limb circuit with a helmet interface. INTERPRETATION: Ventilator performance is significantly impacted by the circuit setup. A dual-limb circuit with oronasal mask should be used preferentially.


Subject(s)
COVID-19 , Continuous Positive Airway Pressure , Disease Transmission, Infectious/prevention & control , Noninvasive Ventilation , Air Filters , Benchmarking/methods , COVID-19/therapy , COVID-19/transmission , Continuous Positive Airway Pressure/adverse effects , Continuous Positive Airway Pressure/instrumentation , Continuous Positive Airway Pressure/methods , Critical Pathways/standards , Critical Pathways/trends , Humans , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Noninvasive Ventilation/adverse effects , Noninvasive Ventilation/instrumentation , Noninvasive Ventilation/methods , Research Design , Respiratory Function Tests/methods , SARS-CoV-2 , Treatment Outcome , Ventilators, Mechanical
4.
Mayo Clin Proc ; 96(5): 1250-1261, 2021 05.
Article in English | MEDLINE | ID: covidwho-1219872

ABSTRACT

The administration of spike monoclonal antibody treatment to patients with mild to moderate COVID-19 is very challenging. This article summarizes essential components and processes in establishing an effective spike monoclonal antibody infusion program. Rapid identification of a dedicated physical infrastructure was essential to circumvent the logistical challenges of caring for infectious patients while maintaining compliance with regulations and ensuring the safety of our personnel and other patients. Our partnerships and collaborations among multiple different specialties and disciplines enabled contributions from personnel with specific expertise in medicine, nursing, pharmacy, infection prevention and control, electronic health record (EHR) informatics, compliance, legal, medical ethics, engineering, administration, and other critical areas. Clear communication and a culture in which all roles are welcomed at the planning and operational tables are critical to the rapid development and refinement needed to adapt and thrive in providing this time-sensitive beneficial therapy. Our partnerships with leaders and providers outside our institutions, including those who care for underserved populations, have promoted equity in the access of monoclonal antibodies in our regions. Strong support from institutional leadership facilitated expedited action when needed, from a physical, personnel, and system infrastructure standpoint. Our ongoing real-time assessment and monitoring of our clinical program allowed us to improve and optimize our processes to ensure that the needs of our patients with COVID-19 in the outpatient setting are met.


Subject(s)
Antiviral Agents/administration & dosage , COVID-19 , Critical Pathways , Home Infusion Therapy , SARS-CoV-2 , Spike Glycoprotein, Coronavirus , Antibodies, Monoclonal/administration & dosage , COVID-19/epidemiology , COVID-19/therapy , Clinical Protocols , Critical Pathways/organization & administration , Critical Pathways/trends , Efficiency, Organizational , Home Infusion Therapy/methods , Home Infusion Therapy/standards , Humans , Intersectoral Collaboration , Organizational Culture , Program Development/methods , SARS-CoV-2/immunology , SARS-CoV-2/isolation & purification , Severity of Illness Index , Spike Glycoprotein, Coronavirus/antagonists & inhibitors , Spike Glycoprotein, Coronavirus/immunology , United States/epidemiology
5.
BMC Pregnancy Childbirth ; 21(1): 310, 2021 Apr 19.
Article in English | MEDLINE | ID: covidwho-1191317

ABSTRACT

BACKGROUND: Induction of labour (IOL) is one of the most commonly performed interventions in maternity care, with outpatient cervical ripening increasingly offered as an option for women undergoing IOL. The COVID-19 pandemic has changed the context of practice and the option of returning home for cervical ripening may now assume greater significance. This work aimed to examine whether and how the COVID-19 pandemic has changed practice around IOL in the UK. METHOD: We used an online questionnaire to survey senior obstetricians and midwives at all 156 UK NHS Trusts and Boards that currently offer maternity services. Responses were analysed to produce descriptive statistics, with free text responses analysed using a conventional content analysis approach. FINDINGS: Responses were received from 92 of 156 UK Trusts and Boards, a 59% response rate. Many Trusts and Boards reported no change to their IOL practice, however 23% reported change in methods used for cervical ripening; 28% a change in criteria for home cervical ripening; 28% stated that more women were returning home during cervical ripening; and 24% noted changes to women's response to recommendations for IOL. Much of the change was reported as happening in response to attempts to minimise hospital attendance and restrictions on birth partners accompanying women. CONCLUSIONS: The pandemic has changed practice around induction of labour, although this varied significantly between NHS Trusts and Boards. There is a lack of formal evidence to support decision-making around outpatient cervical ripening: the basis on which changes were implemented and what evidence was used to inform decisions is not clear.


Subject(s)
Attitude of Health Personnel , COVID-19 , Cervical Ripening , Critical Pathways , Labor, Induced , Adult , Ambulatory Care/methods , COVID-19/epidemiology , COVID-19/prevention & control , Clinical Decision-Making , Critical Pathways/organization & administration , Critical Pathways/trends , Female , Humans , Infection Control/methods , Labor, Induced/methods , Labor, Induced/trends , Maternal Health Services/trends , Organizational Innovation , Policy Making , Pregnancy , Surveys and Questionnaires , United Kingdom
6.
Medicine (Baltimore) ; 100(15): e25495, 2021 Apr 16.
Article in English | MEDLINE | ID: covidwho-1180673

ABSTRACT

ABSTRACT: While the new Coronavirus Disease 2019 (COVID-19) pandemic rapidly spread across the world, South America was reached later in relation to Asia, Europe and the United States of America (USA). Brazil concentrates now the largest number of cases in the continent and, as the disease speedily progressed throughout the country, prompt and challenging operational strategies had to be taken by institutions caring for COVID-19 and non-COVID-19 patients in order to assure optimal workflows, triage, and management. Although hospitals in the USA, Europe and Asia have shared their experience on this subject, little has been discussed about such strategies in South America or by the perspective of outpatient centers, which are paramount in the radiology field. This article shares the guidelines adopted early in the pandemic by a nationwide outpatient healthcare center composed by a network of more than 200 patient service centers and nearly 2,000 radiologists in Brazil, discussing operational and patient management strategies, staff protection, changes adopted in the fellowship program, and the effectiveness of such measures.


Subject(s)
Ambulatory Care , COVID-19 , Change Management , Civil Defense , Critical Pathways , Strategic Planning , Technology, Radiologic , Ambulatory Care/methods , Ambulatory Care/organization & administration , Ambulatory Care/statistics & numerical data , Brazil/epidemiology , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/prevention & control , Civil Defense/organization & administration , Civil Defense/statistics & numerical data , Critical Pathways/organization & administration , Critical Pathways/trends , Humans , Organizational Innovation , Practice Guidelines as Topic , SARS-CoV-2 , Strategic Planning/standards , Strategic Planning/statistics & numerical data , Technology, Radiologic/methods , Technology, Radiologic/organization & administration , Technology, Radiologic/statistics & numerical data
12.
Adv Ther ; 38(3): 1397-1403, 2021 03.
Article in English | MEDLINE | ID: covidwho-1085619

ABSTRACT

The availability of pangenotypic direct-acting antivirals for treatment of hepatitis C (HCV) has provided an opportunity to simplify patient pathways. Recent clinical practice guidelines have recognised the need for simplification to ensure that elimination of HCV as a public health concern remains a priority. Despite the move towards simplified treatment algorithms, there remains some complexity in the recommendations for the management of genotype 3 patients with compensated cirrhosis. In an era where additional clinical trial data are not anticipated, clinical guidance should consider experience gained in real-world settings. Although more experience is required for some pangenotypic therapeutic options, on the basis of published real-world data, there is already sufficient evidence to consider a simplified approach for genotype 3 patients with compensated cirrhosis. The coronavirus disease 2019 (COVID-19) pandemic has highlighted the need to minimise the need for complex patient pathways and clinical practice guidelines need to continue to evolve in order to ensure that patient outcomes remain optimised.


Subject(s)
COVID-19 , Communicable Disease Control , Critical Pathways , Disease Eradication , Hepatitis C , Antiviral Agents/pharmacology , COVID-19/epidemiology , COVID-19/prevention & control , Communicable Disease Control/methods , Communicable Disease Control/organization & administration , Critical Pathways/standards , Critical Pathways/trends , Disease Eradication/methods , Disease Eradication/organization & administration , Global Health/trends , Hepatitis C/epidemiology , Hepatitis C/therapy , Humans , Practice Guidelines as Topic , SARS-CoV-2
13.
Elife ; 102021 02 16.
Article in English | MEDLINE | ID: covidwho-1084995

ABSTRACT

Before the coronavirus 2019 (COVID-19) pandemic began, antimicrobial resistance (AMR) was among the top priorities for global public health. Already a complex challenge, AMR now needs to be addressed in a changing healthcare landscape. Here, we analyse how changes due to COVID-19 in terms of antimicrobial usage, infection prevention, and health systems affect the emergence, transmission, and burden of AMR. Increased hand hygiene, decreased international travel, and decreased elective hospital procedures may reduce AMR pathogen selection and spread in the short term. However, the opposite effects may be seen if antibiotics are more widely used as standard healthcare pathways break down. Over 6 months into the COVID-19 pandemic, the dynamics of AMR remain uncertain. We call for the AMR community to keep a global perspective while designing finely tuned surveillance and research to continue to improve our preparedness and response to these intersecting public health challenges.


Subject(s)
Anti-Bacterial Agents , COVID-19 , Critical Pathways , Drug Resistance, Bacterial/physiology , Global Health/trends , Anti-Bacterial Agents/supply & distribution , Anti-Bacterial Agents/therapeutic use , COVID-19/drug therapy , COVID-19/epidemiology , COVID-19/prevention & control , Communicable Disease Control/methods , Communicable Disease Control/organization & administration , Critical Pathways/organization & administration , Critical Pathways/trends , Humans , SARS-CoV-2
14.
Emerg Med J ; 37(9): 572-575, 2020 Sep.
Article in English | MEDLINE | ID: covidwho-1024251

ABSTRACT

The COVID-19 pandemic has led to a surge of information being presented to clinicians regarding this novel and deadly disease. There is a clear urgency to collate, review, appraise and act on this information if we are to do the best for clinicians and patients. However, the speed of the pandemic is a threat to traditional models of knowledge translation and practice change. In this concepts paper, we argue that clinicians need to be agile in their thinking and practice in order to find the right time to change. Adoption of new methods should be based on clinical judgement, the weight of evidence and the balance of probabilities that any new technique, test or treatment might work. The pandemic requires all of us to reach a new level of evidence-based medicine characterised by scepticism, thoughtfulness, responsiveness and clinically agility in practice.


Subject(s)
Coronavirus Infections , Critical Pathways , Evidence-Based Medicine , Pandemics , Pneumonia, Viral , Betacoronavirus , COVID-19 , Coronavirus Infections/epidemiology , Coronavirus Infections/prevention & control , Coronavirus Infections/therapy , Critical Pathways/organization & administration , Critical Pathways/trends , Evidence-Based Medicine/education , Evidence-Based Medicine/methods , Evidence-Based Medicine/organization & administration , Humans , Knowledge Management , Organizational Innovation , Pandemics/prevention & control , Pneumonia, Viral/epidemiology , Pneumonia, Viral/prevention & control , Pneumonia, Viral/therapy , Quality Improvement , SARS-CoV-2 , Surge Capacity , /trends
15.
Am J Kidney Dis ; 77(5): 777-785, 2021 05.
Article in English | MEDLINE | ID: covidwho-1003349

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic required transplant nephrologists, surgeons, and care teams to make decisions about the full spectrum of transplant program operations and clinical practices in the absence of experience or data. Initially, across the country, there was a reduction in kidney transplant procedures and a striking pause in the conduct of living donation and living-donor transplant surgeries. Aspects of candidate evaluation and follow-up rapidly converted to telehealth. Months into the pandemic, much has been learned from experiences worldwide, yet many questions remain. In this Perspective, we reflect on some of the practice decisions made by the transplant community in the initial response to the pandemic and consider lessons learned, including those related to the risks, benefits, and logistical considerations of proceeding with versus delaying deceased-donor transplantation, living donation, and living-donor transplantation during the pandemic. We review the evolution of therapeutic strategies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their use in transplant recipients, current consensus related to immunosuppression management in infected transplant recipients, and emerging information on vaccination against SARS-CoV-2. We share our thoughts on research priorities, discuss the areas in which we are still practicing with uncertainty, and look ahead to the next phase of the pandemic response.


Subject(s)
COVID-19 , Critical Pathways , Kidney Failure, Chronic , Kidney Transplantation/methods , COVID-19/epidemiology , COVID-19/prevention & control , Clinical Decision-Making , Critical Pathways/organization & administration , Critical Pathways/trends , Humans , Infection Control/methods , Kidney Failure, Chronic/epidemiology , Kidney Failure, Chronic/surgery , SARS-CoV-2 , Telemedicine/methods , Time-to-Treatment , Tissue Donors/statistics & numerical data , Transplant Recipients
16.
J Intensive Care Med ; 36(5): 612-616, 2021 May.
Article in English | MEDLINE | ID: covidwho-978875

ABSTRACT

BACKGROUND: Covid-19 pandemic has resulted in the development of severe and persistent respiratory failure requiring long term ventilatory support. This necessitates the need for a reliable and easy to implement tracheostomy protocol given the concern for viral transmission risk to the involved healthcare personnel due to the aerosol generating nature of the procedure. We describe a protocol with unique and novel modifications to the Ciaglia dilatational percutaneous tracheostomy, effectively implemented during the Covid-19 pandemic at our institution. METHODS: We describe the baseline characteristics of our initial 11 patients who underwent the procedure. Outlined are the healthcare personnel involved and the steps which are organized into 4 phases: planning, pre-procedure, intra-procedure and post-procedure. We have tracked procedural duration, provider safety as well as the development of new complications. RESULTS: We describe use of this protocol for 11 bedside percutaneous tracheostomies performed on patients with COVID-19. The average total procedural duration as well as incision to tracheostomy tube placement times was 32.6 minutes and 5.8 minutes respectively. All 3 providers performing the tracheostomies remained asymptomatic with negative COVID-19 RT-PCR testing at 3 weeks. CONCLUSIONS: We report an efficacious and adaptable protocol for elective bedside percutaneous tracheostomies for patients with persistent ventilatory requirements due to COVID-19 with an intent to provide standardized and safe care for the patient and the involved healthcare personnel.


Subject(s)
COVID-19 , Critical Pathways , Occupational Exposure/prevention & control , Personal Protective Equipment/standards , Respiratory Insufficiency , Tracheostomy , COVID-19/complications , COVID-19/physiopathology , COVID-19/prevention & control , Critical Pathways/organization & administration , Critical Pathways/trends , Female , Health Personnel , Humans , Infection Control/methods , Male , Middle Aged , Patient Care Team/organization & administration , Proof of Concept Study , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy , SARS-CoV-2/isolation & purification , Safety Management , Tracheostomy/methods , Tracheostomy/trends , United States
17.
Nephrology (Carlton) ; 25(11): 822-828, 2020 Nov.
Article in English | MEDLINE | ID: covidwho-913640

ABSTRACT

AIM: The COVID-19 pandemic poses unprecedented operational challenges to nephrology divisions in every country as they cope with COVID-19-related kidney disease in addition to regular patient care. Although general approaches have been proposed, there is a lack of practical guidance for nephrology division response in a hospital facing a surge of cases. Here, we describe the specific measures that our division has taken in the hope that our experience in Singapore may be helpful to others. METHODS: Descriptive narrative. RESULTS: A compilation of operational responses to the COVID-19 pandemic taken by a nephrology division at a Singapore university hospital. CONCLUSION: Nephrology operational readiness for COVID-19 requires a clinical mindset shift from usual standard of care to a crisis exigency model that targets best outcomes for available resources. Rapid multi-disciplinary efforts that evolve flexibly with the local dynamics of the outbreak are required.


Subject(s)
Civil Defense , Coronavirus Infections , Critical Pathways/trends , Group Practice , Kidney Diseases , Pandemics , Pneumonia, Viral , Renal Insufficiency, Chronic , Betacoronavirus , COVID-19 , Civil Defense/standards , Civil Defense/statistics & numerical data , Coronavirus Infections/epidemiology , Coronavirus Infections/physiopathology , Coronavirus Infections/therapy , Group Practice/organization & administration , Group Practice/trends , Hospitals, University , Humans , Interdisciplinary Communication , Kidney Diseases/diagnosis , Kidney Diseases/epidemiology , Kidney Diseases/virology , Nephrology/trends , Organizational Innovation , Patient Care Management/methods , Patient Care Management/organization & administration , Pneumonia, Viral/epidemiology , Pneumonia, Viral/physiopathology , Pneumonia, Viral/therapy , Renal Insufficiency, Chronic/epidemiology , Renal Insufficiency, Chronic/therapy , SARS-CoV-2 , Singapore/epidemiology
18.
J Plast Reconstr Aesthet Surg ; 74(3): 644-710, 2021 03.
Article in English | MEDLINE | ID: covidwho-912071

ABSTRACT

The SARS-CoV-2 cornovirus disease (COVID-19) pandemic has significantly affected referrals of new suspected cancers from primary care to specialist services in the National Health Service (NHS) across the UK.  Amongst the many factors causing delay, such as fear and uncertainty about COVID-19 transmission, reluctance to seek medical attention for cancer sypmtoms and avoiding additional pressure on NHS services, we anticipate a surge in urgent skin cancer referrals to our plastic surgery service as we enter a post-COVID recovery phase.  On the basis of previous referral data and statistical forecasting, we share our predicted numbers against our actual number of urgent skin cancer referrals for the COVID-19 period and, based on this analysis, encourage all cancer services to prepare and allocate resources appropriately for the busy months to follow.


Subject(s)
COVID-19 , Referral and Consultation , Skin Neoplasms , Surgery, Plastic , Time-to-Treatment/statistics & numerical data , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19/psychology , Critical Pathways/trends , Early Detection of Cancer/methods , Early Detection of Cancer/standards , Health Services Misuse/prevention & control , Health Services Misuse/statistics & numerical data , Humans , Infection Control/methods , Infection Control/organization & administration , Needs Assessment , Referral and Consultation/organization & administration , Referral and Consultation/trends , SARS-CoV-2 , Skin Neoplasms/diagnosis , Skin Neoplasms/epidemiology , Skin Neoplasms/surgery , Surgery, Plastic/methods , Surgery, Plastic/organization & administration , Surgery, Plastic/trends , United Kingdom/epidemiology
19.
J Plast Reconstr Aesthet Surg ; 74(3): 644-710, 2021 03.
Article in English | MEDLINE | ID: covidwho-912068

ABSTRACT

During the recovery restitution phase of the coronavirus pandemic, breast reconstruction teams have faced particular challenges to restarting this essential service. This is due to the length and complexity of the surgery, along with the demands on healthcare staff. The Royal College of Surgeons have classified immediate breast reconstruction as priority 2 and the National Institute for Health and Care Excellence have provided a pre-operative pathway for resumption of elective procedures. We therefore describe our experience in restarting our service for providing a breast reconstruction service from the 29th June 2020.


Subject(s)
Breast Neoplasms , COVID-19 , Critical Pathways , Elective Surgical Procedures , Mammaplasty , Breast Neoplasms/epidemiology , Breast Neoplasms/surgery , COVID-19/epidemiology , COVID-19/prevention & control , Critical Pathways/organization & administration , Critical Pathways/trends , Elective Surgical Procedures/methods , Elective Surgical Procedures/statistics & numerical data , Female , Humans , Infection Control/methods , Infection Control/organization & administration , Mammaplasty/methods , Mammaplasty/statistics & numerical data , Organizational Innovation , Outcome and Process Assessment, Health Care , SARS-CoV-2 , State Medicine/organization & administration , State Medicine/trends , United Kingdom/epidemiology
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