The experiences of NHS hospital acute medicine departments in England during the first wave of the COVID-19 pandemic

We conducted a survey exploring the experiences of NHS hospital acute medicine services in England during the 1st wave of the COVID-19 pandemic. Responses were collected from 26th May to 8th July 2020. The results of 91 sites are presented. The total number of patients referred to the medical take for assessment and admitted from the medical take decreased from pre-pandemic levels compared to peak COVID-19 activity. The total number of acute medical beds decreased, however critical care beds increased by 162%. We report the median timeline from first admission of COVID-19 to when baseline critical care capacity was reached. We found regional variation across the results. These findings can assist healthcare leaders prepare for future pandemics.

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Critical Care Demand and Intensive Care Supply for Patients in Japan with COVID-19 at the Time of the State of Emergency Declaration in April 2020: A Descriptive Analysis

Medicina ◽

10.3390/medicina56100530 ◽

2020 ◽

Vol 56 (10) ◽

pp. 530

Author(s):

Yosuke Fujii ◽

Kiichi Hirota

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Critical Care ◽

Intensive Care ◽

Extracorporeal Membrane Oxygenation ◽

Descriptive Analysis ◽

State Of Emergency ◽

Medical Institutions ◽

Number Of Patients ◽

Care Capacity

Background and objectives: The coronavirus disease 2019 (COVID-19) pandemic is overwhelming Japan’s intensive care capacity. This study aimed to determine the number of patients with COVID-19 who required intensive care and to compare the numbers with Japan’s intensive care capacity. Materials and Methods: Publicly available datasets were used to obtain the number of confirmed patients with COVID-19 undergoing mechanical ventilation and extracorporeal membrane oxygenation (ECMO) between 15 February and 19 July 2020 to determine and compare intensive care unit (ICU) and attending bed needs for patients with COVID-19, and to estimate peak ICU demands in Japan. Results: During the epidemic peak in late April, 11,443 patients (1.03/10,000 adults) had been infected, 373 patients (0.034/10,000 adults) were in ICU, 312 patients (0.028/10,000 adults) were receiving mechanical ventilation, and 62 patients (0.0056/10,000 adults) were under ECMO per day. At the peak of the epidemic, the number of infected patients was 651% of designated beds, and the number of patients requiring intensive care was 6.0% of ICU beds, 19.1% of board-certified intensivists, and 106% of designated medical institutions in Japan. Conclusions: The number of critically ill patients with COVID-19 continued to rise during the pandemic, exceeding the number of designated beds but not exceeding ICU capacity.

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Estimating critical care capacity needs and gaps in Africa during the COVID-19 pandemic

10.1101/2020.06.02.20120147 ◽

2020 ◽

Author(s):

Jessica Craig ◽

Erta Kalanxhi ◽

Gilbert Osena ◽

Isabel Frost

Keyword(s):

Critical Care ◽

Health Services ◽

Compartment Model ◽

African Countries ◽

Number Of Patients ◽

Hospital Beds ◽

Hospital Bed ◽

Severe Infections ◽

Bed Capacity ◽

Care Capacity

AbstractObjectiveThe purpose of this analysis was to describe national critical care capacity shortages for 52 African countries and to outline needs for each country to adequately respond to the COVID-19 pandemic.MethodsA modified SECIR compartment model was used to estimate the number of severe COVID-19 cases at the peak of the outbreak. Projections of the number of hospital beds, ICU beds, and ventilators needed at outbreak peak were generated for four scenarios – if 30, 50, 70, or 100% of patients with severe COVID-19 symptoms seek health services—assuming that all people with severe infections would require hospitalization, that 4.72% would require ICU admission, and that 2.3% would require mechanical ventilation.FindingsAcross the 52 countries included in this analysis, the average number of severe COVID-19 cases projected at outbreak peak was 138 per 100,000 (SD: 9.6). Comparing current national capacities to estimated needs at outbreak peak, we found that 31of 50 countries (62%) do not have a sufficient number of hospital beds per 100,000 people if 100% of patients with severe infections seek out health services and assuming that all hospital beds are empty and available for use by patients with COVID-19. If only 30% of patients seek out health services then 10 of 50 countries (20%) do not have sufficient hospital bed capacity. The average number of ICU beds needed at outbreak peak across the 52 included countries ranged from 2 per 100,000 people (SD: 0.1) when 30% of people with severe COVID-19 infections access health services to 6.5 per 100,000 (SD: 0.5) assuming 100% of people seek out health services. Even if only 30% of severely infected patients seek health services at outbreak peak, then 34 of 48 countries (71%) do not have a sufficient number of ICU beds per 100,000 people to handle projected need. Only four countries (Cabo Verde, Egypt, Gabon, and South Africa) have a sufficient number of ventilators to meet projected national needs if 100% of severely infected individuals seek health services assuming all ventilators are functioning and available for COVID-19 patients, while 35 other countries require two or more additional ventilators per 100,000 people.ConclusionThe majority of countries lack sufficient ICU bed and ventilator capacity to care for the projected number of patients with severe COVID-19 infections at outbreak peak even if only 30% of severely infected patients seek health services.This analysis reveals there is an urgent need to allocate resources and increase critical care capacity in these countries.

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Regional Anaesthesia, The Seed of Opportunity In COVID-19 Crisis: The Balance Has Shifted

Journal of Anaesthesia and Critical Care Reports ◽

10.13107/jaccr.2020.v06i03.154 ◽

2020 ◽

Vol 6 (3) ◽

Keyword(s):

Critical Care ◽

General Anaesthesia ◽

Regional Anaesthesia ◽

Albert Einstein ◽

Multimodal Analgesia ◽

Nerve Blocks ◽

Great Opportunity ◽

Aerosol Generation ◽

Number Of Patients ◽

Alternative Drugs

Albert Einstein once said, “in the midst of every crisis, lies great opportunity.” There’s no question that we’re in the midst of a global crisis. There’s no doubt that a crisis creates problems, lots of them, but it also creates opportunities. Something that every anaesthetist does day in day out safely, intubation of trachea, is now become a risk factor for spread of the disease. So where is the opportunity in this crisis? In the west, regional anaesthesia is often used as an adjunct rather than as sole anaesthetic technique, as part of multimodal analgesia in patients who are being operated under general anaesthesia. Unfortunately, general anaesthesia requires airway manipulation that is associated with aerosol generation and risks transmission of corona virus. This is a risk that can be averted with use of regional anaesthesia techniques for procedures that can be done with patient awake rather than asleep. At the beginning of the pandemic with surge of patients requiring endotracheal intubation and ventilation, increased intensive care admissions affected anaesthesia services in many ways. The increased number of patients needing critical care increased the demand for drugs used in both anaesthesia and critical care and this demand led to shortage of anaesthesia drugs and led the Association of Anaesthetists (AOA) and the Royal College of Anaesthetists (RCoA), working closely with the Chief Pharmaceutical Officer at NHS England to produce a guidance which summarised potential mitigations to be used in the management of such demand. Direct alternative drugs and techniques were offered (1). The options identified in the guidelines were not exhaustive but give a way of thinking about this situation we all have landed up in. We were unsure of how long this demand would continue and how we would manage the situation. This is where the opportunity to use regional anaesthesia for procedures that could be done purely under neuraxial or peripheral nerve blocks became

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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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Nursing Considerations for Patients Requiring Cardiopulmonary Support

AACN Advanced Critical Care ◽

10.4037/15597768-1991-3015 ◽

1991 ◽

Vol 2 (3) ◽

pp. 500-514 ◽

Cited By ~ 1

Author(s):

Terry K. Bavin

Keyword(s):

Critical Care ◽

Nursing Care ◽

Critical Care Nurses ◽

Care Plan ◽

Background Information ◽

Nursing Management ◽

Cardiopulmonary Support ◽

Complex Patients ◽

Number Of Patients

The number of patients receiving cardiopulmonary support (CPS) is increasing, requiring critical care nurses to be better prepared to care for these complex patients. Background information on CPS along with considerations for nursing management are presented. A case study of a patient requiring CPS and a suggested nursing care plan are included to assist in providing quality nursing care

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Research Utilization in Critical Care: An Exemplar

AACN Advanced Critical Care ◽

10.4037/15597768-1994-2004 ◽

1994 ◽

Vol 5 (2) ◽

pp. 124-132

Author(s):

Marita G. Titler ◽

Linda Moss ◽

Jane Greiner ◽

Michele Alpen ◽

Gerry Jones ◽

...

Keyword(s):

Critical Care ◽

Pain Management ◽

Research Utilization ◽

Care Center ◽

Tertiary Care ◽

Practice Change ◽

Research Committee ◽

Staff Members ◽

Number Of Patients ◽

Management Protocol

The authors describe the process and outcome of implementing a research-based pain management protocol in four adult critical care units at a large, Midwestern tertiary care center. The project was initiated and directed by members of the divisional research committee. Strategies used to change practice included determining if pain management was a problem via quality assessment monitors, surveying nurses regarding their knowledge and attitude toward pain management, educating staff members about the research base for the practice change, using change champions in each unit, and developing a core group of nurses in each unit to facilitate the change. Outcomes of this research utilization project include a 41% decline in the number of patients in pain, a 44% decline in pain intensity, and improvement in nurses knowledge about pain

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A Donor Utilization Index to Assess the Utilization and Discard of Deceased Donor Kidneys Perceived as High Risk

Clinical Journal of the American Society of Nephrology ◽

10.2215/cjn.02770319 ◽

2019 ◽

Vol 14 (11) ◽

pp. 1634-1641 ◽

Cited By ~ 9

Author(s):

Corey Brennan ◽

Syed Ali Husain ◽

Kristen L. King ◽

Demetra Tsapepas ◽

Lloyd E. Ratner ◽

...

Keyword(s):

High Risk ◽

Regional Variation ◽

Organ Procurement ◽

Deceased Donor ◽

Level Variation ◽

Donor Kidney ◽

Perceptions Of Risk ◽

Deceased Donor Kidney ◽

Number Of Patients ◽

Donor Characteristics

Background and objectivesAn increasing number of patients on the waitlist for a kidney transplant indicates a need to effectively utilize as many deceased donor kidneys as possible while ensuring acceptable outcomes. Assessing regional and center-level organ utilization with regards to discard can reveal regional variation in suboptimal deceased donor kidney acceptance patterns stemming from perceptions of risk.Design, setting, participants, & measurementsWe created a weighted donor utilization index from a logistic regression model using high-risk donor characteristics and discard rates from 113,640 deceased donor kidneys procured for transplant from 2010 to 2016, and used it to examine deceased donor kidney utilization in 182 adult transplant centers with >15 annual deceased donor kidney transplants. Linear regression and correlation were used to analyze differences in donor utilization indexes.ResultsThe donor utilization index was found to significantly vary by Organ Procurement and Transplantation Network region (P<0.001), revealing geographic trends in kidney utilization. When investigating reasons for this disparity, there was no significant correlation between center volume and donor utilization index, but the percentage of deceased donor kidneys imported from other regions was significantly associated with donor utilization for all centers (rho=0.39; P<0.001). This correlation was found to be particularly strong for region 4 (rho=0.83; P=0.001) and region 9 (rho=0.82; P=0.001). Additionally, 25th percentile time to transplant was weakly associated with the donor utilization index (R2=0.15; P=0.03).ConclusionsThere is marked center-level variation in the use of deceased donor kidneys with less desirable characteristics both within and between regions. Broader utilization was significantly associated with shorter time to transplantation.

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The Impact of Changes to an Electronic Admission Order Set on Prescribing and Clinical Outcomes in the Intensive Care Unit

Applied Clinical Informatics ◽

10.1055/s-0040-1702215 ◽

2020 ◽

Vol 11 (01) ◽

pp. 182-189

Author(s):

Ellen T. Muniga ◽

Todd A. Walroth ◽

Natalie C. Washburn

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Clinical Outcomes ◽

Prescribing Patterns ◽

Number Of Patients ◽

Order Sets ◽

Critical Care Admission ◽

The Impact ◽

Order Set

Abstract Background Implementation of disease-specific order sets has improved compliance with standards of care for a variety of diseases. Evidence of the impact admission order sets can have on care is limited. Objective The main purpose of this article is to evaluate the impact of changes made to an electronic critical care admission order set on provider prescribing patterns and clinical outcomes. Methods A retrospective, observational before-and-after exploratory study was performed on adult patients admitted to the medical intensive care unit using the Inpatient Critical Care Admission Order Set. The primary outcome measure was the percentage change in the number of orders for scheduled acetaminophen, a histamine-2 receptor antagonist (H2RA), and lactated ringers at admission before implementation of the revised order set compared with after implementation. Secondary outcomes assessed clinical impact of changes made to the order set. Results The addition of a different dosing strategy for a medication already available on the order set (scheduled acetaminophen vs. as needed acetaminophen) had no impact on physician prescribing (0 vs. 0%, p = 1.000). The addition of a new medication class (an H2RA) to the order set significantly increased the number of patients prescribed an H2RA for stress ulcer prophylaxis (0 vs. 20%, p < 0.001). Rearranging the list of maintenance intravenous fluids to make lactated ringers the first fluid option in place of normal saline significantly decreased the number of orders for lactated ringers (17 vs. 4%, p = 0.005). The order set changes had no significant impact on clinical outcomes such as incidence of transaminitis, gastrointestinal bleed, and acute kidney injury. Conclusion Making changes to an admission order set can impact provider prescribing patterns. The type of change made to the order set, in addition to the specific medication changed, may have an effect on how influential the changes are on prescribing patterns.

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Impact of center case volume on cardiotoxicity during adjuvant trastuzumab in breast cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.6625 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 6625-6625 ◽

Cited By ~ 1

Author(s):

Nicolas J. Chin-Yee ◽

Andrew Yan ◽

George A. Tomlinson ◽

Craig Earle ◽

Maureen E. Trudeau ◽

...

Keyword(s):

Breast Cancer ◽

Cardiac Imaging ◽

Systemic Therapy ◽

Regional Variation ◽

Cardiac Monitoring ◽

Administrative Databases ◽

Case Volume ◽

Funding Program ◽

Number Of Patients ◽

The Impact

6625 Background: A recent study suggested that cardiotoxicity from trastuzumab (T) was associated with regional variation and insufficient cardiac monitoring (Ng et al.SABCS 2012). Few studies have examined the impact of centre or physician (MD) case volume (vol) on outcomes in systemic therapy. Methods: All breast cancer patients who were diagnosed in 2003-2009 in Ontario and treated with adjuvant T were identified through a provincial drug funding program, and linked to administrative databases to ascertain patient demographics, hospitalizations, cardiac risk factors, cardiac imaging, comorbidities, and treating centre and MD. For each year, we calculated case vol as the number of patients treated with adjuvant T by each MD and by each centre. Cardiotoxicity was defined as receiving less than 16 out of 18 doses of T because of heart failure (HF) admission, HF diagnosis by physician claims, or discontinuation after cardiac imaging. Insufficient cardiac monitoring was defined as per recent guideline and per Ng et al. Logistic regression and mixed models were constructed to examine factors associated with cardiotoxicity. Results: Our cohort consisted of 3,777 patients, 214 MDs and 68 centres. For patients, 16.5% were over age 65; 30.3%, 9.4%, and 1.2% had previous diagnoses of hypertension, diabetes, and HF, respectively; 16.9% had cardiotoxicity. Univariate analyses found that high centre vol, but not MD vol, was associated with lower cardiotoxicity. Cardiotoxicity rates by centre vol quintiles (Q) were 23.4% (Q1-3), 18.2% (Q4), and 15.2% (Q5). Multivariable analyses found that lower cardiotoxicity was associated with higher centre vol (OR=0.85 per Q, p=0.02) and diagnosis in recent years (2008-2009 vs. before 2008; OR=0.50, p<0.001), after adjusting for age, previous HF, comorbidities, regional variation, and cardiac monitoring. Accounting for clustering within centres, there remained a strong trend of lower cardiotoxicity with higher centre vol (OR=0.77 per Q, p=0.06) and recent diagnosis (OR=0.50, p<0.001). Conclusions: Our findings suggest a reduction in cardiotoxicity with experience and over time, and support the notion of centralization of systemic therapy in high vol centres to optimize outcomes.

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