Consent for orthopaedic trauma surgery during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has brought a series of new challenges to the management of surgical patients. The consent process relies on a foundation of open and non-coerced discussion between clinician and patient, which includes all the potential risks of surgery. This must be updated to incorporate the additional risks of surgery during the pandemic including infection with the SARS-CoV-2 and increased risks of complications with the potential requirement for intensive care support. AIM: The aim of this multi-cycle quality improvement project was to ensure all patients were fully informed of the risks of developing COVID-19 and the possible need for intensive care unit (ICU) support. METHODS: We investigated the quality of the consent process for patients undergoing surgery for trauma at our major trauma centre. Our baseline data collection included a review of all orthopaedic trauma consent forms over a 4-week period in March 2020. We subsequently undertook three further Plan-Do-Study-Act (PDSA) cycles over separate 4-week periods. First, in June 2020, after education measures and presentation of baseline data, second in July 2020 after further education and regular digital reminders were sent to staff, and third in September 2021 after the implementation of an electronic consent form. RESULTS: At baseline, only 2.6% of consent forms mentioned the risk of COVID-19 and none mentioned the risk of requiring ITU support. Through three PDSA cycles this increased to 97% of cases where consent forms displayed the additional risks of COVID-19 and the potential need for ITU admission. CONCLUSION: Our quality improvement project improved the informed consent procedure at our trust. By incorporating these additional risks into the template of an electronic consent form, we hope to achieve sustained improvement in practice.

Immune responses against SARS-CoV-2 variants after two and three doses of vaccine in B-cell malignancies: UK PROSECO study.

Patients with hematological malignancies are at increased risk of severe COVID-19 outcomes due to compromised immune responses, but the insights of these studies have been compromised due to intrinsic limitations in study design. Here we present the PROSECO prospective observational study ( NCT04858568 ) on 457 patients with lymphoma that received two or three COVID-19 vaccine doses. We show undetectable humoral responses following two vaccine doses in 52% of patients undergoing active anticancer treatment. Moreover, 60% of patients on anti-CD20 therapy had undetectable antibodies following full vaccination within 12 months of receiving their anticancer therapy. However, 70% of individuals with indolent B-cell lymphoma displayed improved antibody responses following booster vaccination. Notably, 63% of all patients displayed antigen-specific T-cell responses, which increased after a third dose irrespective of their cancer treatment status. Our results emphasize the urgency of careful monitoring of COVID-19-specific immune responses to guide vaccination schemes in these vulnerable populations.

The epidemiology of hospital inpatient exposure to SARS-CoV-2: A cohort study.

BACKGROUND: Exposure to SARS-CoV-2 was widespread in hospitals during 2020. The risk of infection after in-hospital exposure has not yet been quantified and effective strategies to prevent it remain unclear. METHODS: All incidences of patient-to-patient exposure to SARS-CoV-2 on non-COVID wards between October and December 2020 at a UK hospital trust were identified. Patient contacts were traced, and data collected on SARS-CoV-2 testing, symptoms, and outcomes. Factors associated with acquiring infection and mortality were investigated. RESULTS: Of 575 patients exposed, 118 (19.5%) tested positive within 14 days of their exposure, with secondary attack rates (SAR) ranging from 0 to 72%. 68.6% (81/118) of secondary cases had not been in the same bay as the index case.For exposed patients, sharing a bay with the index case and having spent longer on the ward with them were associated with acquiring infection (ORs of 3.8, 95% CI: 1.89, 7.74, and 1.08, 95% CI: 1.01, 1.15 respectively). 71% of secondary cases tested positive while asymptomatic and 94.6% had tested negative earlier in their admission. CONCLUSIONS: This is the first study to describe the outcomes of a cohort of patients exposed to COVID-19 in hospital. Exposure to COVID-19 in hospital commonly leads to transmission that is not confined to the index case's bay. This study confirms that asymptomatic testing is important and suggests that an increased frequency of testing may be beneficial. Moreover, we provide factors that can be used to identify the contacts at the greatest risk of acquiring infection.

Multimorbidity among People Experiencing Homelessness-Insights from Primary Care Data.

BACKGROUND: Although the poor health of people experiencing homelessness is increasingly recognised in health discourse, there is a dearth of research that has quantified the nature and magnitude of chronic health issues and morbidity among people experiencing homelessness, particularly in the Australian context. METHODS: Analysis of the medical records of 2068 "active" patients registered with a specialist homeless health service in Perth, Western Australia as of 31 December 2019. RESULTS: Overall, 67.8% of patients had at least one chronic physical health condition, 67.5% had at least one mental health condition, and 61.6% had at least one alcohol or other drug (AOD) use disorder. Nearly half (47.8%) had a dual diagnosis of mental health and AOD use issues, and over a third (38.1%) were tri-morbid (mental health, AOD and physical health condition). Three-quarters (74.9%) were multimorbid or had at least two long-term conditions (LTCs), and on average, each patient had 3.3 LTCs. CONCLUSIONS: The study findings have substantial implications from both a health risk and healthcare treatment perspective for people experiencing homeless. The pervasiveness of preventable health conditions among people experiencing homelessness also highlights the imperative to improve the accessibility of public health programs and screening to reduce their morbidity and premature mortality.

Continuity of Cancer Care: The Surgical Experience of Two Large Cancer Hubs in London and Milan.

The SARS-CoV-2 (COVID-19) pandemic is having a large effect on the management of cancer patients. This study reports on the approach and outcomes of cancer patients receiving radical surgery with curative intent between March and September 2020 (in comparison to 2019) in the European Institute of Oncology, IRCCS (IEO) in Milan and the South East London Cancer Alliance (SELCA). Both institutions implemented a COVID-19 minimal pathway where patients were required to self-isolate prior to admission and were swabbed for COVID-19 within 72 h of surgery. Positive patients had surgery deferred until a negative swab. At IEO, radical surgeries declined by 6% as compared to the same period in 2019 (n = 1477 vs. 1560, respectively). Readmissions were required for 3% (n = 41), and <1% (n = 9) developed COVID-19, of which only one had severe disease and died. At SELCA, radical surgeries declined by 34% (n = 1553 vs. 2336). Readmissions were required for 11% (n = 36), <1% (n = 7) developed COVID-19, and none died from it. Whilst a decline in number of surgeries was observed in both centres, the implemented COVID-19 minimal pathways have shown to be safe for cancer patients requiring radical treatment, with limited complications and almost no COVID-19 infections.

O9 Intensive interprofessional ED team simulation for COVID-19 preparedness

O9 Figure 1Questionnaire feedback[Figure omitted. See PDF]ISS has been shown to be a valuable tool for education and improving patient safety when used in an intensive programme to deal with novel, rapidly evolving situations such as the COVID-19 pandemic.

Changing clinical patterns of Rhegmatogeneous Retinal Detachments during the COVID19 pandemic lockdown in the North West of the UK.

INTRODUCTION: The UK Government imposed a COVID19 lockdown (LD) restricting all but essential activities from 24th March 2020. Subsequently, there has been a significant reduction in casualty attendances nationwide including for ophthalmic emergencies. We aim to study the presentation of rhegmatogenous retinal detachments (RRD) and significant vitreous haemorrhage caused by posterior vitreous detachment (PVD-VH) in three tertiary centres covering most of the North West of England in the 6 weeks before and during the lockdown. METHODS: A retrospective multicenter non-randomised consecutive case series study was designed to collect information on all cases of RRD and PVD-VH requiring surgery presenting to the vitreoretinal departments of Manchester Royal Eye Hospital, East Lancashire NHS Foundation Trust and the Lancashire NHS Foundation Trust from 11th February to 4th May 2020. RESULTS: A total of 137 eyes of 137 patients were identified between the three centres of which 132 eyes were operated for RRD. Of these, 86 (64.7%) were operated pre-LD compared with 46 eyes (34.8%) during LD. Forty-five out of 86 eyes (52.3%) were macula-off pre-LD compared with 31 out of 46 eyes (67.3%) during LD (p = 0.06). There was lower proportion of non-PVD related RRD during LD (11 pre-LD to 1 during LD, p = 0.05). PVR was present in four cases during LD compared to 2 before (p = 0.19). CONCLUSION: There was a clinically significant reduction in the overall incidence of RRD in our centres with an increase in the proportion of macula-off and proliferative vitreoretinopathy during the LD period compared to a similar period before.

An audit of end-of-life symptom control in patients with corona virus disease 2019 (COVID-19) dying in a hospital in the United Kingdom.

BACKGROUND: The literature contains limited information on the problems faced by dying patients with COVID-19 and the effectiveness of interventions to manage these. AIM: The aim of this audit was to assess the utility of our end-of-life care plan, and specifically the effectiveness of our standardised end-of-life care treatment algorithms, in dying patients with COVID-19. DESIGN: The audit primarily involved data extraction from the end-of-life care plan, which includes four hourly nursing (ward nurses) assessments of specific problems: patients with problems were managed according to standardised treatment algorithms, and the intervention was deemed to be effective if the problem was not present at subsequent assessments. SETTING/PARTICIPANTS: This audit was undertaken at a general hospital in England, covered the 8 weeks from 16 March to 11 May 2020 and included all inpatients with COVID-19 who had an end-of-life care plan (and died). RESULTS: Sixty-one patients met the audit criteria: the commonest problem was shortness of breath (57.5%), which was generally controlled with conservative doses of morphine (10-20 mg/24 h via a syringe pump). Cough and audible respiratory secretions were relatively uncommon. The second most common problem was agitation/delirium (55.5%), which was generally controlled with standard pharmacological interventions. The cumulative number of patients with shortness of breath, agitation and audible respiratory secretions increased over the last 72 h of life, but most patients were symptom controlled at the point of death. CONCLUSION: Patients dying of COVID-19 experience similar end-of-life problems to other groups of patients. Moreover, they generally respond to standard interventions for these end-of-life problems.

COVID-19, Virtual Church Services and a New Temporary Geography of Home.

The COVID-19 pandemic and subsequent lockdown measures implemented by the United Kingdom government from 23 March 2020 led to unprecedented adaptations from individuals and communities including places of worship, their clergy and congregations. This paper through a multi-disciplinary dialogue between human geography and theology explores the interrelations between place, space and the spiritual. It identifies the bricolage mechanisms that were developed rapidly by churches to shift towards providing virtual church services. This was an uncommon practice by Christian denominations in the UK. COVID-19 changed the rules requiring new practices to emerge resulting in a new form of infrasecular space to emerge. Such rapid transformations through the provision of online services and virtual embeddedness blurred the lines between sacred and secular spaces. During virtual services, the minister's home is temporally linked to the homes of congregants forming an intersacred space. Homes and spaces within homes are transformed into temporary sacred spaces.

Palliative care in the context of a pandemic: similar but different.

Palliative care is an important component of the medical response to pandemics and other health emergencies. The principles of palliative care do not change, but the practice of palliative care has to change as a result of factors such as greater demand and infection control measures. This article makes suggestions for palliative care provision during a pandemic (in developed countries), based on a limited review of the literature and personal experience of the ongoing pandemic (COVID-19 infection).