Sleep Promotion in a Busy Inner City High Dependency Unit

Introduction: Critical care patients commonly have disrupted sleep patterns, with reduction of REM sleep, duration of sleep, increased fragmentation and loss of circadian rhythm.1 Causes include the patients' pathophysiology, medications administered and the busy critical care environment. Data collection showed that our patients were sleeping, on average, for a single block of sleep of 3.5 hours. Delirium rates and its known deleterious effects are highly associated with poor sleep, as well as an impairment of psychomotor performance and neurocognitive dysfunction. Sleep deprivation in the healthy population impairs lymphocyte action, cytokine production and pro-inflammatory balance, as well as a reduction in respiratory function and prolongation of respiratory support.2 Objectives: To firstly measure the sleep quality and explore the reasons behind poor sleep from the patients themselves and to gauge the MDT knowledge and interest in sleep, as a fundamental component of patient management. Then using the results we aimed to improve the duration and quality of the patients sleep on high dependency unit. Method(s): The Adapted Richard Campbell Sleep Questionnaire was given to all patients in the HDU over a 4 week period. Results were analysed, then stored for post intervention comparison. The duration of sleep was documented for all patients and a staff questionnaire was done to assess knowledge and concern of staff. Interventions included a staff sleep awareness week with education and prompts attached to the charting tables promoting sleep. Face masks and ear plugs were freely available to be distributed at the evening ward round. The critical care pharmacist identified medications that could alter the patients ability to achieve REM sleep - e.g. evening administered PPIs, and melatonin was commenced early when sleep was troublesome. Estates fixed soft close doors and soft closed bins supplied for clinical areas. After interventions, there was a further 4 week study period where the above factors were repeated. The need for natural light was highlighted and thus this was optimized in the ward environment and those physiologically able were offered trips outdoors to facilitate normal day night wake cycle. With the COVID pandemic ongoing we also endeavored to limit movement overnight of venerable patients. Result(s): The original data collection was of 45 patients with multiple data points, and the second of 27 patients with multiple data points. Results from the Adapted Richard Campbell Sleep Questionnaire were compared using a one tailed students t test. There were significant increases in the subjective quality of sleep (p=0.046) and quantity of sleep (p=0.00018). Reasons given as to improvement of sleep were reduction in discomfort from monitoring and the bed (p=0.026), reduced ambient light (p=0.031) and reduced impact from the presence of other patients (p=0.002). Conclusion(s): There was marked improvement in the awareness of the importance of sleep within the critical care team after education promoting a change in attitude and culture towards sleep. We are planning a second iteration targeting sedation, noise from monitors and staff and overnight interventions. Although this has been done with level 2 patients, extension to level 3 areas would be beneficial.

A retrospective review of the functional status of patients post-severe COVID-19 disease

Introduction: The purpose of this study was to evaluate the functional status and ongoing respiratory symptoms of patients who have been discharged home, who were admitted to the intensive care unit (ICU) with severe COVID-19 disease. Long term complications post critical illness, such as post intensive care syndrome (PICS), are well-recognised [1], however, little data exists specific to COVID-19 ICU survivors. Method(s): Local ethics committee approval was secured. Participants were recruited using the electronic intensive care chart database. All patients, from March 2020 to November 2021, who survived Covid-19 were included. Researchers conducted phone interviews with participants and completed three questionnaires;Katz Index of Independent Living Questionnaire, Karnofsky Performance Status Scale and the American Thoracic Society (ATS) Respiratory Disease Questionnaire. Data was input and analysed using excel and stored on a password encrypted computer. Result(s): Database search revealed 61 patients available, 33 of 61 patients were included. 20 (61%) were male, 13 (39%) were female. Mean age was 58, with a range of 25-81. Mean length of ICU stay was 15 days, with a range of 1-74 days. 15 (45%) patients were intubated. Most common Katz score (range 1-6) was the highest score of 6 in 23 (70%) patients. Most common Karnofsky score (range 10-100) was 60 in 11 (33%) patients, with 31 (94%) scoring < 100. The most frequent ATS shortness of breath (SOB) grade (range 0-4) was 3 in 10 (9%) patients, with 23 (70%) patients scoring > 0. 14 (42%) patients had an ongoing cough, 11 (33%) patients had a wheeze and 0 (0%) patients were on home oxygen therapy. Conclusion(s): This study highlights in the majority of patients who survived severe Covid-19 disease to discharge home, there were serious ongoing limitations to their functional status and exercise tolerance, however, they remained independent of basic activities of daily living.

Burnout among early-career medical oncologists: A single-institution experience

Background: Burnout is a psychological syndrome defined by the Maslach Burnout Inventory (MBI) as emotional exhaustion, depersonalization, and a low sense of personal accomplishment. Risk of job-related burnout for early-career medical oncologists can significantly impact career longevity and health outcomes for providers and patients alike. Because little is known about burnout specific to early-career academic oncologists, we sought to characterize the prevalence of burnout and associated factors among Assistant Professors at MD Anderson Cancer Center (MDACC). Methods: For this IRB-approved retrospective study, an electronic survey was developed for Assistant Professors in medical oncology at MDACC. Participants were all involved directly in patient care with at least some clinical effort. Our survey included nine questions validated in the MBI addressing equally the 3 aforementioned domains of burnout. An additional 31 questions were formulated to assess personal and professional factors that may contribute to burnout at our institution (clinical workload, research expectations, communication, COVID, and home-life). Each question was scored on a scale of 1 to 5, with higher scores correlating to higher levels of burnout. Descriptive statistics were used to describe the prevalence of burnout, and logistic regression analyses were performed to identify characteristics associated with burnout. Results: Among 70 (of 86 total) Assistant Professors who responded, mean duration on faculty was 3.1 years (standard deviation +/-1.8). Mean clinical effort was 67% (range, 19-95). Gender identifications were 44% female, 54% male, and 2% non-binary. 54% of respondents reported symptoms of burnout already, including 21% endorsing severe burnout. Severe burnout was more common for solid tumor providers than liquid tumor providers (55% vs 13%, p =.03). Using the MBI, severe emotional exhaustion (25%) was more prevalent (p <.0001) than depersonalization (6%) or lack of personal accomplishment (17%). Sentiments of being “emotionally drained” (20%), fatigue to face another day on the job” (37%), and “becoming more callous” (30%) were especially concerning among early-career faculty. Emotional exhaustion was associated with a feeling of less autonomy over personal decision making (p =.03) and female gender (p =.04). Conclusions: Burnout exists with high prevalence among early-career medical oncologists in this single-institution analysis. Emotional exhaustion was the specific manifestation of burnout in this population. Further validation of these data nationwide is anticipated. Interventions focusing on reducing emotional exhaustion are under development to reduce medical oncology-specific burnout in an academic setting for faculty retention and for deliverance of optimal care to patients with cancer.

Repeated transmission of SARS-CoV-2 in an overcrowded Irish emergency department elucidated by whole-genome sequencing.

AIM: To provide a detailed genomic-epidemiological description of a complex multi-ward SARS-CoV-2 outbreak, which originated in the crowded emergency department (ED) in our hospital during the third wave of the COVID-19 pandemic, and was elucidated promptly by local whole-genome sequencing (WGS). METHODS: SARS-CoV-2 was detected by reverse transcriptase real-time polymerase chain reaction on viral RNA extracted from nasopharyngeal swabs. WGS was performed using an Oxford MinION Mk1C instrument following the ARTIC v3 sequencing protocol. High-quality consensus genomes were assembled with the artic-ncov2019 bioinformatics pipeline and viral phylogenetic trees were built, inferred by maximum-likelihood. Clusters were defined using a threshold of 0-1 single nucleotide polymorphisms (SNPs) between epidemiologically linked sequences. RESULTS: In April 2021, outbreaks of COVID-19 were declared on two wards at University Hospital Limerick after 4 healthcare-associated SARS-CoV-2 infections were detected by post-admission surveillance testing. Contact tracing identified 12 further connected cases; all with direct or indirect links to the ED 'COVID Zone'. All sequences were assigned to the Pangolin B.1.1.7 lineage by WGS, and SNP-level analysis revealed two distinct but simultaneous clusters of infections. Repeated transmission in the ED was demonstrated, involving patients accommodated on trolleys in crowded areas, resulting in multiple generations of infections across three inpatient hospital wards and subsequently to the local community. These findings informed mitigation efforts to prevent cross-transmission in the ED. CONCLUSION: Cross-transmission of SARS-CoV-2 occurred repeatedly in an overcrowded emergency department. Viral WGS elucidated complex viral transmission networks in our hospital and informed infection, prevention and control practice.

The Effect of the COVID-19 Lockdown on Bilingual Singaporean Children’s Leisure Reading

Long-term school absences during pandemic lockdowns may result in learning gains and losses much like the summer reading loss, but little is known about the actual effects of such lockdowns. This mixed-methods study examined changes in reading enjoyment, amount and resources in three groups of bilingual children—English-Chinese, English-Malay, and English-Tamil speaking children—during the COVID-19 lockdown in Singapore. Results reveal a lockdown reading gap between children’s stronger language (English) and weaker language (Chinese/Malay/Tamil). Within each language, results show differential reading gains and losses for children who enjoyed and did not enjoy reading in print and digital formats. Children’s reading enjoyment before the lockdown, changes in reading enjoyment and print reading amount during the lockdown in English and Chinese/Malay were significantly correlated. Children preferred print reading over reading digitally both before and during the lockdown, and devices were underutilized for reading purposes. © The Author(s) 2021.