Could the Emergency Department Facilitate the Start of a Holistic Follow-Up Pathway for Patients Recovering from COVID-19?

Background: For many patients suffering from COVID-19, Emergency Departments (ED) facilitate the first contact with clinicians. There is a high rate of psychiatric symptoms in COVID-19 survivors, including anxiety, depression, fatigue and sleep disturbance, which persist months after the acute phase. Aims: To investigate if COVID-19 patients discharged from ED have a higher prevalence of mental health symptoms than those admitted.In addition, this study will investigate if discharged ED patients who now require COVID-19 follow-up with the respiratory team had a higher prevalence of mental health symptoms than admitted patients requiring follow-up. Methods: This was a retrospective cohort study (n = 472) with the PHQ2 and GAD-2 scoring systems to quantify current anxiety and depression symptoms via a telephone consultation. Results: The PHQ-2 and GAD-2 scores were significantly higher for discharged ED patients than the admitted patients. There was a higher proportion of females with a positive PHQ2 or GAD-2 score. Of the patients requiring respiratory follow-up, discharged ED patients were more likely to have a positive PHQ-2 or GAD-2 score than those admitted. Conclusions: Clinicians should maintain a low threshold for referring patients with psychiatric complaints post-COVID alongside respiratory symptoms irrespective of admission. It is imperative that available psychological services, crisis lines and other avenues of support post-COVID-19 are signposted to patients before discharge to facilitate earlier intervention.

Clinical characteristics and outcomes of 85 intensive care patients with Covid-19 in South London: A single centre observational study.

Background: In March 2020, Covid-19 secondary to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was declared a global pandemic. Methods: This retrospective observational study included patients with Covid-19, managed in a single intensive care unit (ICU). We collected data on patient characteristics, laboratory and radiological findings and ICU management. Data are reported as median (interquartile range). Binary logistic regression modelling was used to identify variables at ICU admission associated with mortality. Results: 85 patients (age 57.3 years [49.4-64.2], 75.3% male) were followed up for 34 days (26-40). The commonest comorbidities were hypertension (51.8%), obesity (48.7%), and type 2 diabetes (31.8%). Covid-19 presented with shortness of breath (89.4%), fever (82.4%), and cough (81.2%), first noted 8 days (6-10) prior to ICU admission. PaO2/FiO2-ratios at ICU admission were 8.28 kPa (7.04-11.7). Bilateral infiltrates on chest X-ray, lymphopenia, and raised C-reactive protein and ferritin were typical. 81.2% received invasive mechanical ventilation (IMV). Acute kidney injury occurred in 62.4% with renal replacement therapy required in 20.0%. By the end of the follow-up period, 44.7% had died, 30.6% had been discharged from hospital, 14.1% had been discharged from ICU but remained in hospital and 10.6% remained in ICU. ICU length of stay was 14 days (9-23). Age was the only variable at admission which was associated with mortality. PaO2/FiO2-ratio, driving pressure and peak ferritin and neutrophil count over the first 72-hours of IMV all correlated with mortality. Conclusions: We report the clinical characteristics, ICU practices and outcomes of a South London cohort with Covid-19, and have identified factors which correlate with mortality. By sharing our insight, we hope to further understanding of this novel disease.

The effects of COVID-19 on sickness of medical staff across departments: A single centre experience.

INTRODUCTION: COVID-19 presents a risk to healthcare workers, incurring harm to staff physical and mental wellbeing and difficulties in provision of care and service planning. METHODOLOGY: Doctors' anonymised demographic and staff sickness data were collected between 16 March and 26 April 2020, corresponding with the single centre's greatest COVID-19 caseload. FINDINGS: 128 (39%) of doctors experienced at least one sickness episode. Episodes totalled 1,240 days, equating to a sickness absence rate of 9.1%. Rates varied between departments and grades. High levels of sickness were seen in medicine and both adult and paediatric emergency departments with the lowest levels seen in intensive care. DISCUSSION: COVID-19 caused a burden of sickness on the medical workforce which must be accounted for in future workforce planning. The disparity in sickness rates across departments is likely to be multi-factorial. Further study is needed to investigate these factors to protect healthcare staff and their patients.

Subcutaneous Emphysema, Pneumomediastinum, and Pneumothorax in Critically Ill Patients With Coronavirus Disease 2019: A Retrospective Cohort Study.

IMPORTANCE: Management of severe coronavirus disease 2019 relies on advanced respiratory support modalities including invasive mechanical ventilation, continuous positive airway pressure, and noninvasive ventilation, all of which are associated with the development of subcutaneous emphysema, pneumomediastinum, and pneumothorax (herein collectively termed barotrauma). OBJECTIVES: To assess the occurrence rate of barotrauma in severe coronavirus disease 2019 and to explore possible associated factors. DESIGN SETTING AND PARTICIPANTS: A retrospective, single-center cohort study with nested case series, conducted at University Hospital Lewisham: a 450-bed general hospital in London, United Kingdom. All patients with confirmed coronavirus disease 2019 admitted to the critical care department from March 12, to April 12, 2020, were included. MAIN OUTCOMES AND MEASURES: Patients were retrospectively screened for radiological evidence of barotrauma. Admission characteristics, modalities of respiratory support, and outcomes were compared between barotrauma and nonbarotrauma groups. Respiratory parameters in the period preceding barotrauma identification were recorded. RESULTS: Of 83 admissions with coronavirus disease 2019, eight suffered barotrauma (occurrence rate 9.6%; 95% CI 4.3%-18.1%). Barotrauma cases had longer illness duration prior to critical care admission (10 vs 7 d; interquartile range, 8-14 and 6-10, respectively; p = 0.073) and were more often treated with continuous positive airway pressure or noninvasive ventilation as the initial modality of advanced respiratory support (87.5% vs 36.0%; p = 0.007). Patients managed with continuous positive airway pressure or noninvasive ventilation prior to the development of barotrauma had median minute ventilation of 16.2-19.9 and 21.3-22.7 L/min, respectively. Compared with the nonbarotrauma group, a higher proportion of patients with barotrauma had died (62.5% vs 43.2%), and a lower proportion of patients had been discharged (25.0% vs 53.3%) at 3-month follow-up. CONCLUSIONS AND RELEVANCE: Barotrauma appears to be a common complication of severe coronavirus disease 2019. Determining whether high minute ventilation while using continuous positive airway pressure or noninvasive ventilation predisposes patients to barotrauma requires further investigation.