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The outcomes of tocilizumab (recombinant monoclonal antibody inhibiting IL-6) in SARS-CoV-2 infection have been variable, with REMAP-CAP and RECOVERY being the largest trials to show benefits. In this prospective, observational study we compared tocilizumab plus standard care (dexamethasone) vs standard care alone in patients with severe COVID-19 infection. Eligibility criteria included patients (age >18 years) with radiological evidence of COVID-19 Pneumonia, PO2/FiO2 (PF) ratio of <300 mmHg and an inflammatory phenotype defined by raised CRP, IL-6 and Ferritin. The primary outcome was a composite of mechanical ventilation and death. A total of 36 patients were included in this study, 27 in the treatment group and 9 in the standard care group. The treatment arm received tocilizumab 8mg/kg (maximum 800mg) as a single infusion within the first 24 hours of respiratory deterioration (identified as worsening RR and PF ratio). Results showed significantly lower mortality rate in the tocilizumab group compared to standard care group (3% vs 33% respectively, p=0.013). Patients who received tocilizumab were also less likely to progress to mechanical ventilation, with only 3.7% of the treatment group requiring mechanical ventilation vs 44% in the control group (p=0.002). Our findings support the use of tocilizumab in severe COVID-19 infection when given early in respiratory deterioration. The predominant variant at the time of this study was the Alpha variant, and so further investigation is required into its effectiveness in newer variants. Limitations include small sample size.
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BACKGROUND AND AIM: Physiological surveillance systems significantly reduced adult mortality in two large UK hospitals. In hospitalised children mortality is low, but there may be potential to reduce the morbidity associated with critical deterioration (CD). However, the risk models for adults are unsuitable for use in children because the signs associated with deterioration [heart rate, breathing rate, blood pressure], alter significantly across the age range. The aim is to evaluate whether this technology improves clinical outcomes for in-hospital deterioration, including sepsis in children. METHOD(S): ISRCTN61279068. https://bit.ly/36HtEGF Participants: Paediatric in-patients, aged less than 18 years at a tertiary hospital (240 beds). Intervention(s): Careflow Vitals and Connect app platform configured to incorporate the Alder Hey age-specific Paediatric Early Warning score (PEWS) and modified National Institute of Health and Clinical Excellence (NICE) Sepsis screening. The documentation of vital signs and clinical observations occur at the patient's bedside at intervals determined by the PEWS risk model. PEWS categorised CD risk as low, moderate, high and critical and provided targeted escalation advice and automated alerts to the Nurse in Charge of the shift and the responsible Clinical Teams. Primary Outcome:Emergency transfers to Critical Care (PICU/ HDU). RESULT(S): Prospective data collection baseline year March 2018 - February 2019 compared with 2 years postintervention March 2020-February 2022 (Extended due to COVID). Summary of results in Figure 1. CONCLUSION(S): The absolute number of CD and patients affected reduced by 29%. Associated review of the cases using the Predictability/Preventability framework showed reduction in the late recognition and CD with modifiable factors. (Figure Presented).
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The post-acute and long-term care (PALTC) sector has, in some respects, served as the epicenter in the U.S. during the COVID-19 pandemic. Many decisions were carried out by administrative and/or clinical leaders during this pandemic. The decisions were made based on their professional experiences, and recommendations by the Centers for Medicare & Medicaid Services (CMS). However, little research has reported on the perspective of those administrators who took the lead during this most difficult time. This study aims to understand how responses and decisions were formed during COVID-19 to ensure resources were available protect staff and residents. Accordingly, this study tried to answer two key questions: 1) What did the PALTC administrative and clinical leaderships learn? 2) What can we do better not if, but when COVID ever "…hits again?” We interviewed nursing home and/or assisted living administrators in two conveniently selected states: Pennsylvania and North Carolina. These interviews (each of which took about 30 minutes) were conducted over Zoom using structured and open-ended questions. The transcripts were entered and analyzed using NVivo – a qualitative data analysis software. The results revealed several themes including communications, relationship building, experience as an administrator, fears and resilience, as well as successful activities to support their staffs such as recognition, bonuses, and food bags prepared for their family. The findings highlight some important administrators' thoughts which recommend key future strategies. These include whether preparedness assets, knowledge, resources, and policies were adequate and where the future efforts should focus.
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Since the onset of the COVID-19 pandemic many healthcare organizations have operated in a climate of uncertainty. Building resilience is one method used to survive and thrive during periods of uncertainty. Measuring an organization's resilience (ability to prepare for, respond and adapt during time of change) allows the organization to identify its vulnerabilities and set priorities to avert negative outcomes during an untoward event. Through collaboration with four long-term care professional associations, the Benchmark Resilience Tool (BRT-13) resilience survey was disseminated to North Carolina long-term care leaders in April 2021. The BRT-13 survey was also sent to North Carolina public health officials via email during the same timeframe. The BRT-13 contains 13 resilience (RES) items divided into two factors of adaptive capacity (AC) and planning (PL) on a five-point Likert scale of strongly disagree (1) to strongly agree (5). Organizational factors surveyed included type of facility, rural-urban classification area designation, ownership type, level of debt, level of profitability, and employee satisfaction. A total of 142 completed surveys were received, 101 (71%) from long-term care leaders and 41 (28.9%) from Public Health officials. Overall average resilience scores ranged from 3.96 for public health respondents to 4.46 for continuing care retirement communities (CCRC) respondents. Analysis of Variance (ANOVA) was employed to compare the three factors (AC, PL, and RES) to the organizational factors. Resilience was significantly associated with one factor, employee satisfaction. Our findings indicate that organizations can build resilience through processes that contribute to staff satisfaction.
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The coronavirus pandemic has led to an exceptional number of critical care hospitalizations followed by extended recovery periods that necessitate familial support. Using a qualitative descriptive approach, this study aimed to examine the strategies used by families to adjust to the caregiving role. Semi-structured interviews of patients who had been recently discharged from the Intensive Care Unit (ICU) (n=16) along with their family caregivers (n=16) were thematically analyzed. Three major themes were identified that highlight how family caregivers adapt to the caregiving role following an ICU COVID-19 related hospitalization including 1) engaging the support of family and friends, 2) shifting responsibilities to accommodate caregiving, and 3) managing one's emotions. Additional themes more specifically related to managing COVID-19 care included: 1) managing infection control, 2) care recipient's need for independence, and 3) managing support services. Flexibility and sufficient support allowed family caregivers to manage their new caregiving role and function optimally.
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Background: The global COVID-19 pandemic is having a major impact on experiences of dying and death. Family members perceptions about the quality of care for dying individuals and their preparedness for death may influence their psychological adjustment in grief. Aim: To explore relatives' experiences and needs when their family member was dying during the COVID-19 pandemic to help inform current/ future clinical practice and policy. Design: Participants, who had responded to a national on-line COVID- 19 survey, were invited to participate. Semi-structured interviews were conducted (via telephone or video-call) with relatives whose family member died during the pandemic. Data were analysed thematically. Results: 19 participants (12 female, 7 male) reflected experiences of deaths within hospital and care home settings, with and without COVIDrelated illness. Three themes were identified: (1) entering the final weeks and days of life during a pandemic, (2) navigating the final weeks of life during a pandemic, and (3) the importance of 'saying goodbye' in a pandemic. In the absence of direct physical contact, it was important for families to have a clear understanding of their family member's condition, declining health and detailed, holistic information about their wellbeing. Staying virtually connected with them in the final weeks/days of life and having the opportunity for a final contact before death were fundamentally important. Health and social care professionals were instrumental to providing these aspects of care but faced practical challenges in achieving these. Conclusions: Health and social care professionals have an important role in mitigating the absence of relatives' visits at end of life during a pandemic. Strategies include prioritising virtual connectedness, ensuring holistic, individualised care updates and creating alternative opportunities for relatives to 'say goodbye'.
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The COVID-19 pandemic provided a unique opportunity for quantifying the impact of Five Factor Model personality domains (i.e. neuroticism, extraversion, openness, agreeableness, and conscientiousness) and COVID -related lifestyle changes on psychological distress. To examine these relationships, we designed and preregistered the present study (https://osf.io/qfw9h). We assessed a large, heterogeneous sample including undergraduates, graduate students, faculty, and staff of a large, public, Midwestern university (n = 1055) to ascertain whether personality domains uniquely predicted distress in response to COVID-19 shelter-in-place orders. This was a three-panel study in which the same potential participant pools were invited to participate at each survey announcement. Data collection occurred between early March through late May 2020, from within days of local shelter-in-place order onset to within days of reaching 100,000 COVID-related deaths in the USA. Domain and distress scores were determined from self-reported ratings on the Big Five Inventory and the 21-Item Depression Anxiety and Stress Scales, respectively. Participants also reported personal experiences with six COVID-specific lifestyle impacts: insufficient outdoor or indoor living space, job insecurity, income insecurity, or taking care of or homeschooling school-aged children during working hours. Zero-order correlations revealed that all personality domains except openness had statistically significant correlations with distress, and all correlations were negative except for that of neuroticism. When entered simultaneously, neuroticism was the predominant risk factor of distress that held across all preregistered and exploratory analyses. Our expectation that extraversion would be negatively associated with distress was not supported broadly, while agreeableness was a unique potential risk factor (though this effect was mostly limited to exploratory analyses). The results especially highlight the link between employment and income uncertainty with psychological distress, while also identifying insufficient indoor and outdoor space as potential risk factors. We hope these findings inform future public health action and further emphasize the utility of personality trait models in general.