Acute Respiratory Infection Hubs: A Service Model with Potential to Optimise Infection Management.

Patients with acute respiratory infections (ARI)-including those with upper and lower respiratory infections from both bacterial and viral pathogens-are one of the most common reasons for acute deterioration, with large numbers of potentially avoidable hospital admissions. The acute respiratory infection hubs model was developed to improve healthcare access and quality of care for these patients. This article outlines the implementation of this model and its potential impacts in a number of areas. Firstly, by improving healthcare access for patients with respiratory infections by increasing the capacity for assessment in community and non-emergency department settings and also by providing flexible response to surges in demand and reducing primary and secondary care demand. Secondly, by optimising infection management (including the use of point-of-care diagnostics and standardised best practise guidance to improve appropriate antimicrobial usage) and reducing nosocomial transmission by cohorting those with suspected ARI away from those with non-infective presentations. Thirdly, by addressing healthcare inequalities; in areas of greatest deprivation, acute respiratory infection is strongly linked with increased emergency department attendance. Fourthly, by reducing the National Health Service's (NHS) carbon footprint. Finally, by providing a wonderful opportunity to gather community infection management data to enable large-scale evaluation and research.

Establishing the acceptability and usability of an animated virtual patient simulation

Background An animated, video-based, virtual patient (VP) has been developed to allow pharmacists to learn how, and practice how, to advise patients taking non-vitamin K oral anticoagulants, a group of high-risk medicines. VPs are well-established resources but have historically only been accessed within specific online teaching sessions or at university sites;this new VP represents a mobile design that can be accessed from anywhere. Objective To investigate the usability and acceptability of the VP application with a focus on exploring perspectives on accessibility. Methods The study used an exploratory sequential mixed method design consisting of a satisfaction survey and interviews. Survey data were analysed descriptively to assess satisfaction with the application and to identify interview discussion areas. Interview data were analysed using the Framework Approach to thematic analysis. Participants were hospital or community pharmacists, or pre-registration pharmacists. Results A total of 94 survey responses were collected and 22 respondents went on to take part in an interview. Participants reported liking the concept and delivery of the VP, particularly the high-quality technology. They also reported finding it usable, and appeared to favour its mobility and accessibility, particularly as the VP can be used on any internet accessible device, including mobile phones, with no specific requirements. Amendments that were suggested included quickening the delivery of some animations and improving navigation within the application, possibly through a button to return to the previous step should a mistake be made. Conclusions The mobile VP appeared to be functional and usable, with the majority of users reporting satisfaction with use across a range of devices. Users reported positively about the VP's remote access, but navigation around the application requires development.

COVID-19 and delivery of difficult asthma services.

The COVID-19 pandemic necessitated an urgent reconfiguration of our difficult asthma (DA) service. We rapidly switched to virtual clinics and rolled out home spirometry based on clinical need. From March to August 2020, 110 patients with DA (68% virtually) were seen in clinic, compared with March-August 2019 when 88 patients were seen face-to-face. There was DA clinic cancellation/non-attendance (16% vs 43%; p<0.0003). In patients with home spirometers, acute hospital admissions (6 vs 26; p<0.01) from March to August 2020 were significantly lower compared with the same period in 2019. There was no difference in the number of courses of oral corticosteroids or antibiotics prescribed (47 vs 53; p=0.81). From April to August 2020, 50 patients with DA performed 253 home spirometry measurements, of which 39 demonstrated >20% decrease in forced expiratory volume in 1 s, resulting in new action plans in 87% of these episodes. In our DA cohort, we demonstrate better attendance rates at virtual multidisciplinary team consultations and reduced hospital admission rates when augmented with home spirometry monitoring.

Live streaming ward rounds using wearable technology to teach medical students: a pilot study.

Background: The COVID-19 pandemic resulted in a loss of clinical clerkship opportunities for medical students. To address this problem while maintaining patient safety, this pilot study explored the feasibility of using a wearable headset to live stream teaching ward rounds to remotely based medical students. Methods: Three live streamed teaching ward rounds were delivered to three groups of medical students (n=53) using the Microsoft HoloLens 2 device and Microsoft Teams software, and results pooled for analysis. Feedback was gathered from students and instructors using the evaluation of technology-enhanced learning materials (ETELM). Patient feedback was gathered using the Communication Assessment Tool to explore any impact on interpersonal communication. Results: The response rate for the ETELM-learner perceptions was 58% (31/53), 100% for the ETELM-instructor perceptions. Students strongly agreed that the overall quality of the teaching session and instructors was excellent. However, 32% experienced issues with audio or video quality and one remote student reported cyber sickness. The statement 'educational activities encouraged engagement with session materials/content' returned the most varied response. Instructors reported technological problems with delivery while using the HoloLens 2 device and environmental noise in the ward was a disruptive factor. Preparation and skilled facilitation were key to delivering a high-quality teaching session. Patients reacted generally favourably to the technology and no negative effects on interpersonal communication were identified. Conclusion: The experience of live streamed ward rounds was well received by patients, medical students and teaching faculty. However, there remain limitations to the routine use of HoloLens 2 technology in our setting including steep learning curves, hardware costs and environmental factors such as noise and WiFi connectivity. Live streamed ward rounds have potential postpandemic implications for the judicious use of resources, and the possibility for few educationally minded clinicians to teach at scale in a patient-friendly manner.

Exclusion of bacterial co-infection in COVID-19 using baseline inflammatory markers and their response to antibiotics.

BACKGROUND: COVID-19 is infrequently complicated by bacterial co-infection, but antibiotic prescriptions are common. We used community-acquired pneumonia (CAP) as a benchmark to define the processes that occur in bacterial pulmonary infections, testing the hypothesis that baseline inflammatory markers and their response to antibiotic therapy could distinguish bacterial co-infection from COVID-19. METHODS: Retrospective cohort study of CAP (lobar consolidation on chest radiograph) and COVID-19 (PCR detection of SARS-CoV-2) patients admitted to Royal Free Hospital (RFH) and Barnet Hospital (BH), serving as independent discovery and validation cohorts. All CAP and >90% COVID-19 patients received antibiotics on hospital admission. RESULTS: We identified 106 CAP and 619 COVID-19 patients at RFH. Compared with COVID-19, CAP was characterized by elevated baseline white cell count (WCC) [median 12.48 (IQR 8.2-15.3) versus 6.78 (IQR 5.2-9.5) ×106 cells/mL, P < 0.0001], C-reactive protein (CRP) [median 133.5 (IQR 65-221) versus 86.0 (IQR 42-160) mg/L, P < 0.0001], and greater reduction in CRP 48-72 h into admission [median ΔCRP -33 (IQR -112 to +3.5) versus +14 (IQR -15.5 to +70.5) mg/L, P < 0.0001]. These observations were recapitulated in the independent validation cohort at BH (169 CAP and 181 COVID-19 patients). A multivariate logistic regression model incorporating WCC and ΔCRP discriminated CAP from COVID-19 with AUC 0.88 (95% CI 0.83-0.94). Baseline WCC >8.2 × 106 cells/mL or falling CRP identified 94% of CAP cases, and excluded bacterial co-infection in 46% of COVID-19 patients. CONCLUSIONS: We propose that in COVID-19, absence of both elevated baseline WCC and antibiotic-related decrease in CRP can exclude bacterial co-infection and facilitate antibiotic stewardship efforts.

Keep calm and carry on learning: using Microsoft Teams to deliver a medical education programme during the COVID-19 pandemic.

The outbreak of COVID-19 in the UK in March 2020 required a radical remodelling of the medical workforce at Royal Free London NHS Foundation Trust to prepare for the anticipated surge of hospital admissions. The provision of relevant teaching and training was immediately identified as a priority, particularly for staff due to work outside their regular medical specialty. Rather than deliver face-to-face teaching, doctors at the Trust utilised Microsoft Teams, an online communications and collaboration platform, to deliver a multi-disciplinary Trust-wide education programme responsive to the needs of surveyed medical staff. To date members of 18 departments across the Trust have delivered 51 virtual teaching sessions which have been viewed 3,814 times. During this pandemic the virtual education programme has facilitated rapid dissemination of new information and provided a platform for discussion and unity amongst colleagues with overwhelmingly positive feedback from both learners and teachers.

Antiviral treatment for COVID-19: the evidence supporting remdesivir.

The emergence of the novel beta coronavirus SARS-CoV-2 and the ensuing COVID-19 pandemic has generated a rapidly evolving research landscape in the search for new therapeutic agents. The intravenous antiviral drug remdesivir has in vitro activity against SARS-CoV-2 and now studies have reported its clinical efficacy, demonstrating shorter time to recovery in hospitalised patients with severe COVID-19. Adverse event rates were low and remdesivir has now received conditional marketing authorisation from the European Medicines Agency. An interim clinical commissioning policy is in place in the UK. These studies make remdesivir the first antiviral drug able to alter the natural history of severe COVID-19, and a benchmark for the comparison of new therapies in the future. Ongoing studies are investigating its use in early mild/moderate COVID-19, alternative formulations, and the combination of remdesivir with immunomodulatory agents.