P-OGC30 High volume oesophagogastric resection in a small private hospital during COVID 19, April 2020- April 2021

Abstract Background Like other hospitals at the peak of the pandemic, our institution had limited elective critical care capacity. This study summarises the outcomes of patients undergoing oesophagogastric (OG) resection at our institution, treated as the result of the emergency national contract between the NHS and the independent sector hospitals. Methods Patients undergoing OG resection at our institution between April 2020 and April 2021 were included. Patients were managed through the multidisciplinary team and were treated according to standard ERAS pathways, involving critical care input. National OG Cancer Audit (NOGCA) metrics were collected and compared to pre-COVID data. Results 81 patients underwent oesophagogastric resection in the private sector (60 oesophagectomies). Median length of stay was 9 days (9 pre-COVID). This included 21 patients who were repatriated to our main centre for ongoing management. 30-day mortality was 3.7% (1.8% pre-COVID), 90-day mortality 6.7% (4.2% pre-COVID). This included one patient who contracted COVID following discharge. 9 patients suffered an anastomotic leak, equating to a leak rate of 11% (7% pre-COVID). 22 resections were performed at our main centre (110-140 OG resection pre-COVID) Conclusions It is likely the private institution in this study represented one of the busiest oesophagogastric centres in the UK during COVID-19. A large cohort of patients underwent potentially curative surgery as a result of the emergency contract, who would have otherwise been placed on prolonged or palliative chemotherapy. 30 and 90-day mortality and anastomotic leak rates were higher than pre-pandemic levels, reinforcing the value of centralised tertiary OG resection services.

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Assembly Line ICU: what the Long Shops taught us about managing surge capacity for COVID-19

BMJ Open Quality ◽

10.1136/bmjoq-2020-001117 ◽

2020 ◽

Vol 9 (4) ◽

pp. e001117

Author(s):

Callum Oakley ◽

Craig Pascoe ◽

Daivd Balthazor ◽

Davinia Bennett ◽

Nandan Gautam ◽

...

Keyword(s):

Critical Care ◽

Critical Care Unit ◽

Assembly Line ◽

Tertiary Hospital ◽

Multiple Organ ◽

Adaptive Responses ◽

Whole Process ◽

The Uk ◽

Care Capacity ◽

And Training

ObjectivesTo safely expand and adapt the normal workings of a large critical care unit in response to the COVID-19 pandemic.MethodsIn April 2020, UK health systems were challenged to expand critical care capacity rapidly during the first wave of the COVID-19 pandemic so that they could accommodate patients with respiratory and multiple organ failure. Here, we describe the preparation and adaptive responses of a large critical care unit to the oncoming burden of disease. Our changes were similar to the revolution in manufacturing brought about by ‘Long Shops’ of 1853 when Richard Garrett and Sons of Leiston started mass manufacture of traction engines. This innovation broke the whole process into smaller parts and increased productivity. When applied to COVID-19 preparations, an assembly line approach had the advantage that our ICU became easily scalable to manage an influx of additional staff as well as the increase in admissions. Healthcare professionals could be replaced in case of absence and training focused on a smaller number of tasks.ResultsCompared with the equivalent period in 2019, the ICU provided 30.9% more patient days (2599 to 3402), 1845 of which were ventilated days (compared with 694 in 2019, 165.8% increase) while time from first referral to ICU admission reduced from 193.8±123.8 min (±SD) to 110.7±76.75 min (±SD). Throughout, ICU maintained adequate capacity and also accepted patients from neighbouring hospitals. This was done by managing an additional 205 doctors (70% increase), 168 nurses who had previously worked in ICU and another 261 nurses deployed from other parts of the hospital (82% increase).Our large tertiary hospital ensured a dedicated non-COVID ICU was staffed and equipped to take regional emergency referrals so that those patients requiring specialist surgery and treatment were treated throughout the COVID-19 pandemic.ConclusionsWe report how the challenge of managing a huge influx of patients and redeployed staff was met by deconstructing ICU care into its constituent parts. Although reported from the largest colocated ICU in the UK, we believe that this offers solutions to ICUs of all sizes and may provide a generalisable model for critical care pandemic surge planning.

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Development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity: a discussion paper

Journal of Medical Ethics ◽

10.1136/medethics-2020-106771 ◽

2020 ◽

pp. medethics-2020-106771

Author(s):

Tim Cook ◽

Kim Gupta ◽

Chris Dyer ◽

Robin Fackrell ◽

Sarah Wexler ◽

...

Keyword(s):

Decision Making ◽

Critical Care ◽

Healthcare Delivery ◽

Rapid Expansion ◽

Fair Allocation ◽

Discussion Paper ◽

Hospital Policy ◽

Starting Point ◽

The Uk ◽

Care Capacity

Early in the COVID-19 pandemic there was widespread concern that healthcare systems would be overwhelmed, and specifically, that there would be insufficient critical care capacity in terms of beds, ventilators or staff to care for patients. In the UK, this was avoided by a threefold approach involving widespread, rapid expansion of critical care capacity, reduction of healthcare demand from non-COVID-19 sources by temporarily pausing much of normal healthcare delivery, and by governmental and societal responses that reduced demand through national lockdown. Despite high-level documents designed to help manage limited critical care capacity, none provided sufficient operational direction to enable use at the bedside in situations requiring triage. We present and describe the development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity. The document combines a wide variety of factors known to impact on outcome from critical illness, integrated with broad-based clinical judgement to enable structured, explicit, transparent decision-making founded on robust ethical principles. It aims to improve communication and allocate resources fairly, while avoiding triage decisions based on a single disease, comorbidity, patient age or degree of frailty. It is designed to support and document decision-making. The document has not been needed to date, nor adopted as hospital policy. However, as the pandemic evolves, the resumption of necessary non-COVID-19 healthcare and economic activity mean capacity issues and the potential need for triage may yet return. The document is presented as a starting point for stakeholder feedback and discussion.

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Reviewing the needs of forward deployed critical care: South Sudan and the future

BMJ Military Health ◽

10.1136/bmjmilitary-2021-001906 ◽

2021 ◽

Vol 167 (5) ◽

pp. 372-374

Author(s):

Victoria Bulleid ◽

T Hooper ◽

G Nordmann

Keyword(s):

Critical Care ◽

Damage Control ◽

South Sudan ◽

Damage Control Surgery ◽

Treatment Facility ◽

Medical Treatment Facility ◽

The Uk ◽

Care Capacity ◽

Battle Injuries ◽

Ballistic Trauma

The UK military medical treatment facility (MTF) that deployed to the United Nations Mission in South Sudan in 2017 was based on a facility that can provide damage control surgery and resuscitation for soldiers with ballistic trauma injuries. It had to be supplemented with additional medical equipment and drugs that could support a peacekeeping mission in Africa. The clinicians used this experience and opportunity to review the critical care capability of UK Army Medical Services forward MTFs and recommend changes to reflect the increasing contemporaneous need on recent deployments to support more casualties with medical, infectious diseases and other non-battle injuries and illnesses. A concurrent review of the facility’s critical care transfer equipment was also undertaken and allowed it to be adapted for use as either transfer equipment or as a critical care surge capability, to increase the facility’s critical care capacity.

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Evaluation of the safety of inter-hospital transfers of critically ill patients led by advanced critical care practitioners

British Journal of Nursing ◽

10.12968/bjon.2021.30.8.470 ◽

2021 ◽

Vol 30 (8) ◽

pp. 470-476

Author(s):

Gavin Denton ◽

Lindsay Green ◽

Marion Palmer ◽

Anita Jones ◽

Sarah Quinton ◽

...

Keyword(s):

Critical Care ◽

Quality Improvement ◽

Critically Ill ◽

Process Of Care ◽

Related Complication ◽

Improvement Project ◽

Hospital Transfer ◽

The Uk ◽

Critically Ill Adults ◽

Ill Adults

Introduction: Ten thousand inter-hospital transfers of critically ill adults take place annually in the UK. Studies highlight deficiencies in experience and training of staff, equipment, stabilisation before departure, and logistical difficulties. This article is a quality improvement review of an advanced critical care practitioner (ACCP)-led inter-hospital transfer service. Methods: The tool Standards for Quality Improvement Reporting Excellence was used as the format for the review, combined with clinical audit of advanced critical care practitioner-led transfers over a period of more than 3 years. Results: The transfer service has operated for 8 years; ACCPs conducted 934 critical care transfers of mechanically ventilated patients, including 286 inter-hospital transfers, between January 2017 and September 2020. The acuity of transfer patients was high, 82.2% required support of more than one organ, 49% required more than 50% oxygen. Uneventful transfer occurred in 81.4% of cases; the most common patient-related complication being hypotension, logistical issues were responsible for half of the complications. Conclusion: This quality improvement project provides an example of safe and effective advanced practice in an area that is traditionally a medically led domain. ACCPs can provide an alternative process of care for critically ill adults who require external transfer, and a benchmark for audit and quality improvement.

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Self-Leadership in a Critical Care Outreach Service for Quality Patient Care

Africa Journal of Nursing and Midwifery ◽

10.25159/2520-5293/7542 ◽

2020 ◽

Vol 22 (2) ◽

Author(s):

Carine Prinsloo

Keyword(s):

Critical Care ◽

Nursing Care ◽

Private Hospital ◽

Professional Staff ◽

Research Approach ◽

Serious Adverse Events ◽

Outreach Service ◽

Outreach Services ◽

General Wards ◽

Critical Care Outreach

The deterioration of patients in general wards could go unnoticed owing to the intermittent monitoring of vital data. The delayed or missed recognition of deteriorating patients results in serious adverse events in general wards. These challenges have resulted in the development of a critical care outreach service. Australia was the first country to establish critical care outreach services in 1990. In South Africa, critical care outreach services were implemented in 2005 at a private hospital in Pretoria. The researcher has noticed certain phenomena supported by literature such as the hesitancy of nurses working in general wards to escalate a patient to a critical care outreach service, and incorrect interpretation of modified early warning scores which could cause delays in patients being referred to outreach nurse experts. In this study, nurses’ (professional, staff and auxiliary nurses) experiences in respect of their self-leadership in critical care outreach services were explored. To this end, a qualitative phenomenological research approach was followed. Focus groups were held with the nurses (all nurse categories) working in a South African private hospital which provides critical care outreach services. It is recommended that nurses be granted access to training sessions, workshops and information to provide appropriate nursing care. Nurses should be encouraged to focus on the positive outcomes of providing nursing care and to “applaud themselves mentally” when they have successfully assisted or cared for their patients. Nurses also need to identify and correct negative assumptions about their competence.

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Complication rates of thyroidectomy by an experienced, high-volume thyroid surgeon in a private hospital in Abu Dhabi, United Arab Emirates

Hamdan Medical Journal ◽

10.7707/hmj.735 ◽

2018 ◽

Vol 11 (1) ◽

pp. 17

Author(s):

Zahoor Ahmad ◽

Ammar Kutaiman ◽

Youssef Hassan ◽

Peshraw Amin ◽

MohammadAmjad Khan

Keyword(s):

United Arab Emirates ◽

Private Hospital ◽

High Volume ◽

Abu Dhabi ◽

Complication Rates

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COVID‐19 and critical care capacity: Can we mitigate demand?

Respirology ◽

10.1111/resp.14193 ◽

2021 ◽

Author(s):

Matthew Byrne ◽

Timothy E. Scott ◽

Jonathan Sinclair ◽

Nachiappan Chockalingam

Keyword(s):

Critical Care ◽

Care Capacity

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An unusual presentation of Legionella pneumonia in a returning traveller

BMJ Case Reports ◽

10.1136/bcr-2019-230130 ◽

2019 ◽

Vol 12 (8) ◽

pp. e230130

Author(s):

Robert John Shorten ◽

Jane Norman ◽

Louise C Sweeney

Keyword(s):

Bone Marrow ◽

Critical Care ◽

Legionella Pneumophila ◽

Bone Marrow Aspiration ◽

Severe Pneumonia ◽

Cell Leukaemia ◽

Hairy Cell ◽

Acute Presentation ◽

Legionella Pneumonia ◽

The Uk

A male patient in his mid-60s presented with a severe pneumonia following return to the UK after travel to Crete. He was diagnosed with Legionnaire’s disease (caused by an uncommon serogroup of Legionella pneumophila). He was pancytopenic on admission, and during a long stay on critical care he was diagnosed with a disseminated Aspergillus infection. Bone marrow aspiration revealed an underlying hairy cell leukaemia that undoubtedly contributed to his acute presentation and subsequent invasive fungal infection.

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Critical care as part of respiratory training in the UK

Thorax ◽

10.1136/thx.2006.074765 ◽

2007 ◽

Vol 62 (9) ◽

pp. 834-835

Author(s):

B C Creagh-Brown ◽

A M. Johnston ◽

D Pandit ◽

R J Parker ◽

A C Davidson

Keyword(s):

Critical Care ◽

Respiratory Training ◽

The Uk

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Hypertensive disease

Obstetric Anaesthesia ◽

10.1093/med/9780199688524.003.0019 ◽

2020 ◽

pp. 493-520

Author(s):

Eleanor Lewis ◽

Stuart Davies

Keyword(s):

Critical Care ◽

Wide Spectrum ◽

Mode Of Delivery ◽

Disease Process ◽

Hypertensive Disease ◽

System Disease ◽

Critical Care Management ◽

Labour Ward ◽

The Uk ◽

In Pregnancy

Hypertension affects ~1 in 10 pregnant women in the UK, whilst pre-eclampsia (PET) complicates 2–8% of pregnancies. Hypertensive disease is the 4th leading cause of direct deaths, with recent triennium deaths due to intracerebral causes. This chapter explores the pathophysiology of hypertensive disease and its current management in pregnancy, including the treatment of eclampsia on labour ward. PET is a multi-system disease, which may present across a wide spectrum of organs. Therefore, the anaesthetic plan of management is greatly influenced by the extent of the disease process and which systems may be involved. This chapter provides detailed recommendations for the anaesthetic plan of care, whichever mode of delivery is indicated, and the peripartum critical care management required.

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