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BackgroundThe Covid-19 case fatality ratio varies between countries and over time but it is unclear whether variation is explained by the underlying risk in those infected. This study aims to describe the trends and risk factors for admission and mortality rates over time in England. MethodsIn this retrospective cohort study, we included all adults ([≥]18 years) in England with a positive Covid-19 test result between 1st October 2020 and 30th April 2021. Data were linked to primary and secondary care electronic health records and death registrations. Our outcomes were i) one or more emergency hospital admissions and ii) death from any cause, within 28 days of a positive test. Multivariable multilevel logistic regression was used to model each outcome with patient risk factors and time. Results2,311,282 people were included in the study, of whom 164,046 (7.1%) were admitted and 53,156 (2.3%) died within 28 days. There was significant variation in the case hospitalisation and mortality risk over time, peaking in December 2020-February 2021, which remained after adjustment for individual risk factors. Older age groups, males, those resident in more deprived areas, and those with obesity had higher odds of admission and mortality. Of risk factors examined, severe mental illness and learning disability had the highest odds of admission and mortality. ConclusionsIn one of the largest studies of nationally representative Covid-19 risk factors, case hospitalisation and mortality risk varied significantly over time in England during the second pandemic wave, independent of the underlying risk in those infected.
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ObjectivesTo identify the population level impact of a national pulse oximetry remote monitoring programme for covid-19 (COVID Oximetry @home; CO@h) in England on mortality and health service use. DesignRetrospective cohort study using a stepped wedge pre- and post-implementation design. SettingAll Clinical Commissioning Groups (CCGs) in England implementing a local CO@h programme. Participants217,650 people with a positive covid-19 polymerase chain reaction test result and symptomatic, from 1st October 2020 to 3rd May 2021, aged [≥]65 years or identified as clinically extremely vulnerable. Care home residents were excluded. InterventionsA pre-intervention period before implementation of the CO@h programme in each CCG was compared to a post-intervention period after implementation. Main outcome measuresFive outcome measures within 28 days of a positive covid-19 test: i) death from any cause; ii) any A&E attendance; iii) any emergency hospital admission; iv) critical care admission; and v) total length of hospital stay. ResultsImplementation of the programme was not associated with mortality or length of hospital stay. Implementation was associated with increased health service utilisation with a 12% increase in the odds of A&E attendance (95% CI: 6%-18%) and emergency hospital admission (95% CI: 5%-20%) and a 24% increase in the odds of critical care admission in those admitted (95% CI: 5%-47%). In a secondary analysis of CO@h sites with at least 10% or 20% of eligible people enrolled, there was no significant association with any outcome measure. However, uptake of the programme was low, with enrolment data received for only 5,527 (2.5%) of the eligible population. ConclusionsAt a population level, there was no association with mortality following implementation of the CO@h programme, and small increases in health service utilisation were observed. Low enrolment of eligible people may have diluted the effects of the programme at a population level.
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ObjectivesTo identify the impact of a national pulse oximetry remote monitoring programme for covid-19 (COVID Oximetry @home; CO@h) on health service use and mortality in patients attending Accident and Emergency (A&E) departments. DesignRetrospective matched cohort study of patients enrolled onto the CO@h pathway from A&E. SettingNational Health Service (NHS) A&E departments in England. ParticipantsAll patients with a positive covid-19 test from 1st October 2020 to 3rd May 2021 who attended A&E from three days before to ten days after the date of the test. All patients who were admitted or died on the same or following day to the first A&E attendance within the time window were excluded. InterventionsParticipants enrolled onto CO@h were matched using demographic and clinical criteria to participants who were not enrolled. Main outcome measuresFive outcome measures were examined within 28 days of first A&E attendance: i) death from any cause; ii) any subsequent A&E attendance; iii) any emergency hospital admission; iv) critical care admission; and v) length of stay. Results15,621 participants were included in the primary analysis, of whom 639 were enrolled onto CO@h and 14,982 were controls. Odds of death were 52% lower in those enrolled (95% CI: 7%-75% lower) compared to those not enrolled on CO@h. Odds of any A&E attendance or admission were 37% (95% CI: 16-63%) and 59% (95% CI: 16-63%) higher, respectively, in those enrolled. Of those admitted, those enrolled had 53% (95% CI: 7%-76%) lower odds of critical care admission. There was no significant impact on length of stay. ConclusionsThese findings indicate that for patients assessed in A&E, pulse oximetry remote monitoring may be a clinically effective and safe model for early detection of hypoxia and escalation, leading to increased subsequent A&E attendance and admissions, and reduced critical care requirement and mortality.
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BackgroundWith the onset of COVID-19, primary care has swiftly transitioned from face-to-face to virtual care, yet it remains largely unknown how this has impacted on the quality and safety of care. AimTo evaluate patient use of virtual primary care models during COVID-19 in terms of change in uptake, perceived impact on the quality and safety of care, and willingness of future use. Design and settingAn online cross-sectional survey was administered to the public across the United Kingdom, Sweden, Italy and Germany. MethodsMcNemar tests were conducted to test pre- and post pandemic differences in uptake for each technology. One-way analysis of variance was conducted to examine patient experience ratings and perceived impacts on healthcare quality and safety across demographic characteristics. ResultsRespondents (N=6,326) reported an increased use of telephone consultations (+6.3%, P<.001), patient-initiated services (+1.5%, n=98, p<0.001), video consultations (+1.4%, P<.001), remote triage (+1.3, p<0.001), and secure messaging systems (+0.9%, P=.019). Experience rates using virtual care technologies were higher for men (2.39{+/-}0.96 vs 2.29{+/-}0.92, P<.001), those with higher literacy (2.75{+/-}1.02 vs 2.29{+/-}0.92, P<.001), and participants from Germany (2.54{+/-}0.91, P<.001). Healthcare timeliness and efficiency were the quality dimensions most often reported as being positively impacted by virtual technologies (60.2%, n=2,793 and 55.7%, n=2,401, respectively), followed by effectiveness (46.5%, n=1,802), safety (45.5%, n=1,822), patient-centredness (45.2%, n=45.2) and equity (42.9%, n=1,726). Interest in future use was highest for telephone consultations (55.9%), followed by patient-initiated digital services (56.1%), secure messaging systems (43.4%), online triage (35.1%), video consultations (37.0%), and chat consultations (30.1%), although significant variation was observed between countries and patient characteristics. ConclusionFuture work must examine the drivers and determinants of positive experiences using remote care to co-create a supportive environment that ensures equitable adoption and use across different patient groups. Comparative analysis between countries and health systems offers the opportunity for policymakers to learn from best practices internationally.
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ObjectivesTo determine the safety and effectiveness of home oximetry monitoring pathways safe for Covid-19 patients in the English NHS DesignThis was a retrospective, multi-site, observational study of home oximetry monitoring for patients with suspected or proven Covid-19 SettingThis study analysed patient data from four Covid-19 home oximetry pilot sites in North West London, Slough, South Tees and Watford across primary and secondary care settings. Participants1338 participants were enrolled in a home oximetry programme at one of the four pilot sites. Participants were excluded if primary care data and oxygen saturations are rest at enrolment were not available. 908 participants were included in the analysis. InterventionsHome oximetry monitoring was provided to participants with a known or suspected diagnosis of Covid-19. Participants were enrolled following attendance to accident and emergency departments, hospital admission or referral through primary care services. ResultsOf 908 patients enrolled into four different Covid-19 home oximetry programmes in England, 771 (84.9%) had oxygen saturations at rest of 95% or more, and 320 (35.2%) were under 65 years of age and without comorbidities. 52 (5.7%) presented to hospital and 28 (3.1%) died following enrolment, of which 14 (50%) had Covid-19 as a named cause of death. All-cause mortality was significantly higher in patients enrolled after admission to hospital (OR 8.70, 95% CI: 2.5 - 29.9), compared to those enrolled in primary care, Patients enrolled after hospital discharge (OR 0.31, 95% CI: 0.15 - 0.68) or emergency department presentation (OR 0.42, 95% CI: 0.20 - 0.89) were significantly less likely to present to hospital after enrolment than those enrolled in primary care. ConclusionsThis study find that home oximetry monitoring can be a safe pathway for Covid-19 patients; and indicates increases in risk to vulnerable groups and patients with oxygen saturations < 95% at enrolment, and in those enrolled on discharge from hospital. Findings from this evaluation have contributed to the national implementation of home oximetry across England, and further work will be undertaken to evaluate clinical effectiveness of the new pathway. Section 1: What is already known on this topicO_LIThe Covid-19 pandemic has created a new and significant burden on health systems globally. C_LIO_LIOxygen saturations have been found to be an important factor to stratify patient risk and guide treatment of Covid-19. C_LIO_LIHome oximetry programmes emerged during the early stages of the pandemic as an innovative means of monitoring patients with Covid-19 without admission to hospital. C_LI Section 2: What this study addsO_LIHome oximetry monitoring is associated with low rates of hospitalisation (5.7%) and all-cause mortality (3.1%). Many low-risk patients were enrolled in home oximetry pilots, and were associated with low rates of mortality. C_LIO_LIHome oximetry monitoring may represent a safe and programme for the delivery of community care to Covid-19 patients with pre-existing risk factors including increased age, high BMI and clinical comorbidities but who do not meet clinical thresholds for hospital admission. C_LI
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BackgroundThe Covid-19 pandemic has placed unprecedented pressure on healthcare systems and workers around the world. Such pressures may impact on working conditions, psychological wellbeing and perception of safety. In spite of this, no study has assessed the relationship between safety attitudes and psychological outcomes. Moreover, only limited studies have examined the relationship between personal characteristics and psychological outcomes during Covid-19. MethodsFrom 22nd March 2020 to 18th June 2020, healthcare workers from the United Kingdom, Poland, and Singapore were invited to participate using a self-administered questionnaire comprising the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory (OLBI) and Hospital Anxiety and Depression Scale (HADS) to evaluate safety culture, burnout and anxiety/depression. Multivariate logistic regression was used to determine predictors of burnout, anxiety and depression. ResultsOf 3,537 healthcare workers who participated in the study, 2,364 (67%) screened positive for burnout, 701 (20%) for anxiety, and 389 (11%) for depression. Significant predictors of burnout included patient-facing roles: doctor (OR 2.10; 95% CI 1.49-2.95), nurse (OR 1.38; 95% CI 1.04-1.84), and other clinical (OR 2.02; 95% CI 1.45-2.82); being redeployed (OR 1.27; 95% CI 1.02-1.58), bottom quartile SAQ score (OR 2.43; 95% CI 1.98-2.99), anxiety (OR 4.87; 95% CI 3.92-6.06) and depression (OR 4.06; 95% CI 3.04-5.42). Factors significantly protective for burnout included being tested for SARS-CoV-2 (OR 0.64; 95% CI 0.51-0.82) and top quartile SAQ score (OR 0.30; 95% CI 0.22-0.40). Significant factors associated with anxiety and depression, included burnout, gender, safety attitudes and job role. ConclusionOur findings demonstrate a significant burden of burnout, anxiety, and depression amongst healthcare workers. A strong association was seen between SARS-CoV-2 testing, safety attitudes, gender, job role, redeployment and psychological state. These findings highlight the importance of targeted support services for at risk groups and proactive SARS-CoV-2 testing of healthcare workers.
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IntroductionCovid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and in turn patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture. MethodsThe Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture at a large UK teaching hospital during Covid-19. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined. ResultsSignificant increased were seen in SAQ scores of doctors and other clinical staff, there was no change in the nursing group. During Covid-19, on univariate regression analysis, female gender, age 40-49 years, non-white ethnicity, and nursing job role were all associated with lower SAQ scores. Training and support for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (-0.13), non-disclosed ethnicity (-0.11), nursing role (-0.15), and support (0.29) persisted to significance. A significant decrease (p<0.003) was seen in error reporting after the onset of the Covid-19 pandemic. DiscussionThis is the first study to report SAQ during Covid-19 and compare with baseline. Differences in SAQ scores were observed during Covid-19 between professional groups and compared to baseline. Reductions in incident reporting were also seen. These changes may reflect perception of risk, changes in volume or nature of work. High-quality support for redeployed staff may be associated with improved safety perception during future pandemics. WHAT IS ALREADY KNOWN ON THE SUBJECTO_LISafety culture is associated with patient safety and outcomes C_LIO_LIThis is the first study to investigate safety culture during the Covid-19 pandemic C_LIO_LIThis study uses the Safety Attitudes Questionnaire (SAQ) and Datix incident reporting data to investigate determinants of safety climate during the Covid-19 pandemic. C_LIO_LISafety climate is context specific, this study is strengthened by the availability of benchmarking data from before the onset of the Covid-19 pandemic. C_LIO_LISignificant differences in SAQ scores between professional groups were observed during Covid-19. C_LIO_LIGender, ethnicity and job role were significant determinants of safety attitudes. C_LIO_LISupport during redeployment was associated with improved safety attitudes. C_LIO_LIThe number of incidents that were reported reduced significantly during Covid-19, although the number of events leading to harm remained constant. C_LI
