Salt steps and sugar checks - Making arterial line use safer in our trust

Introduction: Arterial lines are used within our intensive care unit to allow invasive blood pressure monitoring and regular blood gas analysis. Inadvertent use of dextrose containing fluids in the flush have been associated with falsely high glucose readings. When these are acted on with insulin, it can cause devastating hypoglycaemic brain injury. There have been a number of deaths and other incidents relating to the wrong fluid being used in arterial line set up reported within the UK in recent years. In 2014 the AAGBI released a safety guideline on the use of arterial lines specifically to reduce to the risk of hypoglycaemic brain injury. Objective(s): Our objective was to ensure that 100% of arterial lines in use within Royal Victoria Hospital's intensive care unit were compliant with our trust policy on the management of arterial lines. Method(s): We audited our intensive care unit's compliance with our trust policy and found that we were 80% compliant. We formed a multi-disciplinary arterial line working group in order to tackle the problem. Our quality improvement project consisted of two main approaches: 1. To educate staff on how to manage arterial lines correctly. We divided the management of arterial lines into S.A.L.T steps (a 7 step bundle on "Setting up an Arterial Line Transducer") and SUGAR checks ( a series of red flag moments to prompt staff to review the patient prior to starting or increasing insulin administration).We developed educational posters for key areas in ICU and presented our findings at departmental meetings. 2. To change the system, in order to make it easier to do the right thing. We developed a Universal Adult Arterial Pack (UAAP) containing key components in the setup of an arterial line. This also included aide memoires for the S.A.L.T steps and SUGAR checks. In order to measure the effect of these changes, we: 1. Audited compliance on a regular basis. 2. Monitored serious bundle breaches ( for example no label, wrong fluid used) 3. Assessed usage of the UAAP. Result(s): 1. Bundle compliance improved during the first half of 2021, however then reduced in the second half with the number of serious bundle breaches increasing. This coincided with COVID surge 4 - associated with reduced nursing ratios and staff redeployment. 2. UAAP usage increased throughout the project, from an average of 6 to 9 per day. 86% of staff found the packs useful and 85% thought that they reduced the potential for error. Conclusion(s): The presence of a policy does not ensure that staff will know about it or adhere to it. Although we have not yet achieved our target of 100% compliance, we have seen evidence of how our project has the potential to do so in the near future. We aim to roll out our new e-learning module for staff education, manufacture our UAAP on a bigger scale, and disseminate the project to other departments within the trust.

Nurses' knowledge and implementation of antimicrobial stewardship and infection prevention strategies in acute paediatric settings.

BACKGROUND: Nurses are the first point of contact for patients and are responsible for monitoring and reporting signs of infection. The COVID-19 pandemic cemented nurses' leadership role in infection prevention. Despite this, nurses' contribution to antimicrobial stewardship initiatives remains under-recognized. AIM: To determine how paediatric nurses understood their role and contribution to antimicrobial stewardship and infection prevention and control practices in three different acute paediatric wards. METHODS: Forty-three nurses were recruited from an adolescent ward, an oncology ward, and a surgical ward in a metropolitan tertiary children's hospital for a qualitative exploratory descriptive study. FINDINGS: Thematic and content analysis derived three themes from the data: understanding of preventable infections; embracing evidence-based guidelines to protect the patient; and roles in preventing and controlling infections and antimicrobial stewardship. Associated subthemes were: desensitized to COVID-19; understanding infection prevention and control precautions; correct use of hospital policy and guidelines; restrictions associated with the use of electronic medical records; understanding of sepsis management and the importance of timely microbiological testing; ambivalence on antimicrobial stewardship roles; and high priority placed on consumer education. CONCLUSION: Nurses' understanding of their role focused on practices such as performing hand hygiene, standard precautions, and reporting the use of high-risk antimicrobials. A lack of understanding of paediatric COVID-19 transmission and presentations was also reported. Education on best practice in infection prevention and AMS was recognized as crucial for both nurses and parents.

Towards optimal quarantine: A scoping review of quarantine planning in the pandemic preparedness plans and pandemic exercises of Australia and New Zealand

Introduction: Since 2020, the New Zealand and Australian federal, state and territory governments have used quarantine as a strategic infection control measure to contain the SRS-CoV-2 (COVID-19) virus. However, the quarantine programs of both countries were rapidly operationalised without a clear blueprint for infection prevention. This paper identifies gaps in forecasting the need, and planning, for widespread quarantine within New Zealand's and Australia's Pandemic Preparedness Plans and pandemic exercise reports. Method(s): This paper adhered to the Joanna Briggs Institute (JBI) methodology for scoping reviews. Parliamentary websites and databases (Parlinfo, Pandora) were searched for plans and exercise reports, that were publicly available from 2009 to May 2022. Documents were examined using directive content analysis and assessed on their alignment with the core elements of people, resources, governance, systems, and processes, as addressed in the Australian Disaster Preparedness Framework 2018. Result(s): The degree to which the core elements outlined in the Australian Disaster Preparedness Framework were covered in the documents varies significantly across both New Zealand, and the Australian federal, states and territories. Of the 15 identified plans and 8 exercise reports most did not foresee the need for mandatory, large-scale quarantine of people arriving from interstate or overseas and contemplated voluntary quarantine occurring within people's private residences. Conclusion(s): This paper confirms the need to focus on widespread quarantine as an infection control measure to enhance future pandemic operational preparedness. Further development of quarantine capabilities is required in locations aside from private residences, including at Australia's new purpose-built quarantine facilities.Copyright © 2022

A Feasibility Cluster Randomised Controlled Trial of Paramedic- Administered Breathlessness Management Intervention for Acute- On-Chronic Breathlessness (BREATHE): Study Findings

Background/aims: One-fifth of conveyances to the emergency department (ED) are due to acute-on-chronic breathlessness. Paramedic breathlessness management may ease distress quicker and/or reduce ED conveyances. We evaluated the feasibility of a full trial of a paramedic delivered intervention to reduce avoidable conveyances (recruitment, randomisation, consent, training and intervention acceptability, adherence, data quality, best primary outcome, sample size estimation). The intervention comprised evidence-based non-drug techniques and a self-management booklet. Methods: This mixed-methods feasibility cluster randomised controlled trial (ISRCTN80330546) with embedded qualitative study about trial processes, training and intervention delivery, randomised paramedics to usual care or to intervention + usual care. Retrospective patient consent to use call-out data and prospective patient/carer consent for follow-up was sought. Potential primary outcomes were breathlessness intensity (numerical rating scale) and ED conveyance. Follow-up included an interview for patients/carers and questionnaires at 14 days, 1 and 6 months and paramedic focus groups and survey. Results: Recruitment was during the COVID-19 pandemic, leading to high demands on paramedics and fewer call-outs by eligible patients. We enrolled 29 paramedics;9 withdrew. Randomisation and trial procedures were acceptable. Paramedics recruited 13 patients;8 were followed up. Data quality was good. The intervention did not extend call-out time, was delivered with fidelity and no contamination and was acceptable to patients, carers and paramedics. There were no repeat call-outs < 48 hours. Recruitment stop-go criteria were not met. We had insufficient data for sample size estimation. Conclusions: A full trial in the same circumstances is not feasible. However, valuable information was gained on recruitment, attrition, consent, training and intervention acceptability and adherence, and patient-reported data collection.

Preliminary analysis of the MM21 trial: Response adaptive salvage treatment with daratumumab-lenalidomide-dexamethasone (DRD) for newly diagnosed transplant eligible multiple myeloma patients failing front-line bortezomib-based induction therapy

BACKGROUND Bortezomib-based induction (V-IND) approaches are used in >90% of Australian newly diagnosed transplant eligible multiple myeloma (NDTE MM) patients (pts) with a maximum of 4 cycles of V-IND therapy available via the pharmaceutical benefits scheme (PBS) prior to a planned autologous stem cell transplantation (ASCT). However, NDTE MM patients failing V-IND (defined as best response < partial response [PR]) demonstrate shortened survival and continue to represent a sub-group of MM where a clear unmet medical need persists. The ALLG MM21 was designed to evaluate the efficacy of an early response adapted approach with a switch to an intensive Daratumumab-lenalidomide-dexamethasone (DRd)-based salvage-ASCT- consolidation strategy in patients failing V-IND. METHOD We present the results of a planned interim analysis of the multi-centre single arm study MM21 (ACTRN12618001490268). Eligible pts were NDTE MM who had received V-IND pre-ASCT and demonstrated either a sub-optimal response (SOR - defined as <minimal response [MR] after 2 cycles or <PR after 4 cycles of V-IND) or primary refractoriness (1REF - defined as disease progression while on or within 60 days of completing V-IND). Pre-ASCT DRd was DARA 16mg/kg IV days 1, 8, 15 and 22 for cycles 1 (C1) and 2, and on days 1 and 15 of C3 and C4;Lenalidomide 25mg OD D1-21;and, dexamethasone 40mg PO on D 1, 8, 15 and 22 of each 28-day cycle for C1 to C4. Anti-thrombotic and anti-viral prophylaxis was as per individual institutional practice. Between C3 and C4, patients underwent a G-CSF mobilised PBSC collection with a melphalan 200mg/m2 conditioned ACST after C4. Patients underwent D100 post-ASCT disease response assessment including EuroFlow minimal residual disease (MRD) testing. In the absence of disease progression, patients then received 12, 28-day cycles of consolidation comprising DARA IV 16mg/kg on D1, 15 of C1 and C2 and on D1 of C3 to C12, lenalidomide 25mg PO on D1-21 of C1 and C2 and 10mg OD on days 1-28 of C3 to C12;dexamethasone 40mg was weekly from C1 to C12. RESULTS Fifty patients were recruited from 7 Australian sites between March 2019 and July 2020. Median age was 61 years with 66% males. Disease status at study entry was SOR in 72% (<MR n = 9, <PR n = 27) and 1REF in 28%. Data cut-off date was June 30 2021. 45 patients (90%) received 4 complete cycles of salvage DRd. 11/50 (22%) patients did not undergo ASCT and 4 patients failed stem cell collection. Two pts were withdrawn due to treatment related gastrointestinal toxicity - persistent oesophagitis (n =1) and recurrent colitis (n=1). There were two deaths, due to COVID-19 pneumonia (n =1) and septic shock (n =1). Pre-ASCT response was evaluable in 43 patients, overall response rate (ORR) was 70% - complete response (CR) 6%, very good partial response (VGPR) 18%, partial response (PR) 46%, clinical benefit rate (CBR) 83% - MR 11% and stable disease (SD) 2% on Intention to Treat (ITT n = 50) analysis. 33 patients were assessed for MRD - MRD negative 6% on ITT (3/33 9%). Pre-consolidation disease assessment was evaluable in 37 pts, both ORR and CBR were 72% - stringent complete response (sCR) 4%, CR 14%, VGPR 24%, PR 30% ITT analysis. 31 pts were evaluated for MRD - MRD negative 28% ITT (14/31 45%). In 6 patients, MRD was omitted or could not be performed due to pre-analytical issues. Post-C2 consolidation assessment was evaluable in 37 pts, ORR 72% - sCR 2%, CR 24%, VGPR 26%, PR 20%, CBR 74% - SD 2% ITT analysis. To date, 22 patients have been evaluated for MRD with 4 patients awaiting results, MRD negative rate of 38% ITT (10/22 45%). MRD sample collection at this time-point was omitted in 7 patients, potentially skewing MRD negativity on ITT analysis. CONCLUSION Preliminary analysis of the MM21 trial demonstrates early response-adaptive escalation to DRd facilitated ASCT in the majority patients with robust ORR post-autologous stem cell transplant and substantial improvement in disease control, as reflected in improved rates of MRD and disease response to treatment. At both post-ASCT time-p ints there was significant drop off in MRD testing due to testing omission, potential skewing results of MRD analysis. MRD and duration of response analysis following C12 consolidation is planned and will be of interest. Current data suggests this drug combination shows potential for substantial benefit in the study population. (Figure Presented).

Hearing the voice of the child through the storm of the pandemic: The impact of covid-19 measures on the detection of and response to child protection concerns

Covid-19 and the resulting “lockdown” and social distancing measures significantly disrupted the mechanisms by which child maltreatment may be identified or disclosed and children’s voices in relation to their protection are heard. This paper reports on the first stage of a multi-disciplinary study in which 67 interviews were undertaken with strategic and operational leads in all professions with child protection responsibilities from24LondonboroughsinJunetoearlySeptember2020.Findingshighlightdisruptions to communication pathways caused by redeployment and the closure of universal and early help services, and concerns about the effectiveness and safety of distanced interactions. Innovations in practice to overcome these challenges are reported, including risk reevaluation exercises, keeping in touch strategies and online innovations. Lundy’s model of participation rights is employed to identify lessons for addressing the invisibility of some groups of children, enhancing access to and quality of communication, and embedding responsibility for listening to children. © Jenny Driscoll et al., 2021.

We, who haven't been diagnosed, are sort of out of the pictureâ?' breathless without a diagnosis: The UK covid-19 lockdown experience

Aim To describe experiences during the COVID-19 pandemic of people living with chronic breathlessness without a diagnosis. Methods As part of a wider mixed methods study (Breathlessness-DiagnosE Early in Primary care: Breathe-DEEP), semistructured interviews were undertaken with people referred for investigation of chronic breathlessness across ten GP practices. The interview guide included questions around experiences of breathlessness, healthcare interactions and the impact of COVID-19 pandemic. Telephone interviews were audiorecorded, transcribed, coded and reviewed by the study team using thematic analysis. Results Over six weeks during the UK lockdown for the COVID-19 pandemic, 20 participants were interviewed (12 female, mean age 65 yrs). Five participants lived alone, two were working and three recently received a confirmed diagnosis for their breathlessness. None of the participants experienced COVID-19. Three key themes were identified. 1. Unintentional de-prioritisation of diagnosis by patients. The COVID-19 pandemic has led to a reduction in seeking healthcare for this group. Some described their breathlessness as a 'non-urgent' problem, and others felt worried about burdening their GP and the National Health Service (NHS) at this time. 2. Following UK 'lockdown' guidance for the general population, is this enough? This group are not identified as vulnerable but have a clear perception that they are at increased risk if they were to contract COVID-19. 3. Impact of lockdown on coping strategies for managing breathlessness. People have expressed modified behaviour to help them cope with lockdown. Some people are obliged by the nature of lockdown to use disengaged coping strategies which has a negative impact on managing their breathlessness and mental health. Conclusion The existing unpredictable pathway to diagnosis for people living with chronic breathlessness has been further interrupted during the COVID-19 pandemic. People expressed concern about only following general population advice, rather than shielding, due to not having a diagnosis. Patients and clinicians need to re-engage with the pathway to diagnosis and management of chronic breathlessness.

S115 ‘We, who haven’t been diagnosed, are sort of out of the picture…’ breathless without a diagnosis: the UK COVID-19 lockdown experience

S115 Figure 1Results Table: Themes and quotes for interviews during UK lockdown for COVID-19Theme 1. Unintentional de-prioritisation of diagnosis by patients. ‘I mean obviously you don’t want to be phoning the doctors, because they’re there only for emergency now’ (Participant 5)‘I ain’t getting any healthcare at the moment. You know, I won’t bother the doctors with this at the moment... And I wouldn’t want to go doctors to be seen because I wouldn’t, there’s a risk of catching anything.’ (Participant 19)‘…it’s inhibited me from going to see my GP to try and get kind of follow-up on what’s going on.’ (Participant 18)‘Yeah they just said they’ll contact me when it’s possible to start doing things again, you know, because it’s not an urgent thing.’ (Participant 7) Theme 2. Following the guidance for the general population – is this enough? ‘General guidance, yes, that helps, but mostly for my health. I’m maybe a little bit frightened in case, I think if I got it I wouldn’t get over it because of my breathing. And yes when you can’t get your breath it is frightening, so I think that’s, obviously I don’t want to go just yet so.’ (Participant 19)‘It feels like you’re being a bit of a bother for nothing, because I’ve not been actually diagnosed you see… So we don’t even know what we’re meant to be doing... So we’re stuck.’ (Participant 5)‘Because I have said to my husband, if I get this, it’s going to be serious because I have problems breathing anyway.’ (Participant 28) Theme 3. Impact of lockdown on coping strategies for managing breathlessness. Engaged coping ‘I mean like I said I’m doing exercises nearly every day and practising yoga…’(Participant 27)‘Yeah I’ve got a lady who comes on the tablet and she does yoga with me, tells me what to do. I do that twic a week.’ (Participant 22)Disengaged coping ‘It is very depressing not being able to go out anywhere. Even though I can’t walk that far without getting out of breath, I could still visit people, you know… but now I can’t at the moment, it’s just being indoors all the time.’’ (Participant 14)‘It affects you mentally when you can’t see anybody, because obviously my strategies for my mental health are going out and things.’ (Participant 5)