Blood cancer care in a resource limited setting during the Covid-19 outbreak; a single center experience from Sri Lanka

Background The Covid-19 pandemic has caused significant morbidity and mortality among patients with cancer. Most countries employed measures to prevent spread of Covid-19 infection which include shielding, quarantine, lockdown, travel restrictions, physical distancing and the use of personal protective equipment. This study was carried out to assess the change in patient attendance and the efficacy of newly implemented strategies to mitigate the impact of Covid-19 on services at the Lanka Hospital Blood Cancer Centre (LHBCC) in Colombo, Sri Lanka. Methodology Telephone consultation, infection control, personal protective measures and emergency admission policy were implemented with the aim of having a Covid-19 free ward and to prevent cross-infections. This descriptive cross-sectional study was conducted with 1399 patient episodes (in-patient care or day-case review). We analysed patients treated as in-patient as well as day-case basis between 01st April 2020 and 31st December 2020. Results There were 977 day-case based episodes and 422 in-patient based episodes. There was a 14% drop in episode numbers compared to same period in 2019. There was no cross infection and no patients with Covid-19 related symptoms or positive test results entered the LHBCC during the study period. Conclusion Services in blood cancer care were maintained to prevent late stage presentation and adverse outcome. Measures implemented to prevent Covid-19 were effective to allow continuation of treatment. This study highlights the importance of implementing strict protocols, clinical screening, use of appropriate personal protective equipment in delivering blood cancer care during the Covid-19 pandemic. This is the only documented study relating to outcome and successful applicability of measures to prevent spread of Covid-19 infection and maintaining services among blood cancer patients in Sri Lanka.

Outcome of cancer patients considered for intensive care unit admission in two university hospitals in the Netherlands: the danger of delayed ICU admissions and off-hour triage decisions

Background Very few studies assessed the association between Intensive Care Unit (ICU) triage decisions and mortality. The aim of this study was to assess whether an association could be found between 30-day mortality, and ICU admission consultation conditions and triage decisions. Methods We conducted a retrospective cohort study in two large referral university hospitals in the Netherlands. We identified all adult cancer patients for whom ICU admission was requested from 2016 to 2019. Via a multivariable logistic regression analysis, we assessed the association between 30-day mortality, and ICU admission consultation conditions and triage decisions. Results Of the 780 cancer patients for whom ICU admission was requested, 332 patients (42.6%) were considered ‘too well to benefit’ from ICU admission, 382 (49%) patients were immediately admitted to the ICU and 66 patients (8.4%) were considered ‘too sick to benefit’ according to the consulting intensivist(s). The 30-day mortality in these subgroups was 30.1%, 36.9% and 81.8%, respectively. In the patient group considered ‘too well to benefit’, 258 patients were never admitted to the ICU and 74 patients (9.5% of the overall study population, 22.3% of the patients ‘too well to benefit’) were admitted to the ICU after a second ICU admission request (delayed ICU admission). Thirty-day mortality in these groups was 25.6% and 45.9%. After adjustment for confounders, ICU consultations during off-hours (OR 1.61, 95% CI 1.09–2.38, p-value 0.02) and delayed ICU admission (OR 1.83, 95% CI 1.00–3.33, p-value 0.048 compared to “ICU admission”) were independently associated with 30-day mortality. Conclusion The ICU denial rate in our study was high (51%). Sixty percent of the ICU triage decisions in cancer patients were made during off-hours, and 22.3% of the patients initially considered “too well to benefit” from ICU admission were subsequently admitted to the ICU. Both decisions during off-hours and a delayed ICU admission were associated with an increased risk of death at 30 days. Our study suggests that in cancer patients, ICU triage decisions should be discussed during on-hours, and ICU admission policy should be broadened, with a lower admission threshold for critically ill cancer patients.

Zoning-Based System of New Students Admission Policy

The zoning system in accepting new students is the government's effort to build quality, fair and equitable education. The purpose of the study was to obtain in-depth information about the implementation of the zoning system in the acceptance of new students in Jakarta. This study used a descriptive qualitative tentative approach. Data were collected through interviews, observation and documentation. Data analysis techniques consist of data reduction, data presentation, and conclusion drawing/verification. The study results concluded that the implementation of the zoning system in the acceptance of new students was quite good and provided equal opportunities for all prospective students according to the right selection path. While the problems complained about are related to the internet network and also fraud committed by some people. However, the results of this study have an impact on improving the more equitable zoning system.

CHALLENGES WITH THE IMPLEMENTATION OF THE ADMISSION POLICY FOR GRADES R AND 1 IN THE MOTHEO DISTRICT IN THE FREE STATE PROVINCE OF SOUTH AFRICA

At the beginning of every year thousands of learners report for Grade R and Grade 1 across schools in South Africa. Unfortunately, many learners are refused admission to these grades when parents apply. The national policy that guides and governs admission of learners to public schools is the South African Schools Act (SASA) 84 of 1996. This policy stipulates that the admission age of a learner to a public or independent school for Grade R is age four, turning five by 30 June in the year of admission. For a learner to be admitted to Grade 1, the learner has to be five, turning six by 30 June in the year of admission (SASA 1996 Section 5a-6; Ramadiro and Vally 2005:1). But SASA (1996: Section 3(1) also states that attendance is compulsory in the year in which a learner turns seven. According to the National Education Policy Act (NEPA) 27 of 1996 and SASA (1996: Section 5) the Admission Policy of a public school is determined by the School Governing Body (SGB). However, according to the findings of the research there is no uniformity and consistency in schools as far as admission to Grades R and 1 is concerned. In addition, the study reveals that many parents are unaware of the age requirements for Grades R and 1. Although SASA does stipulate the admission age to Grade R and Grade 1, it also states that schools, in the form of the SGB, can determine their own Admission Policy. Hence some schools admit learners according to SASA, while others ignore the requirements stipulated in SASA and determine their own Admission Policies. The study aims to determine what the challenges are with the implementation of the policy. A qualitative research method in the form of interviews was conducted to collect data from teachers, parents, SGBs, school principals and departmental officials. Based on the findings recommendations were made, one of which is that there should be uniformity amongst schools as far as policy implementation is concerned. The theoretical framework that guides this study is document phenomenology.

Provision of critical care for the elderly in Europe: a retrospective comparison of national healthcare frameworks in intensive care units

ObjectivesIn Europe, there is a distinction between two different healthcare organisation systems, the tax-based healthcare system (THS) and the social health insurance system (SHI). Our aim was to investigate whether the characteristics, treatment and mortality of older, critically ill patients in the intensive care unit (ICU) differed between THS and SHI.SettingICUs in 16 European countries.ParticipantsIn total, 7817 critically ill older (≥80 years) patients were included in this study, 4941 in THS and 2876 in the SHI systems.Primary and secondary outcomes measuresWe chose generalised estimation equations with robust standard errors to produce population average adjusted OR (aOR). We adjusted for patient-specific variables, health economic data, including gross domestic product (GDP) and human development index (HDI), and treatment strategies.ResultsIn SHI systems, there were higher rates of frail patients (Clinical Frailty Scale>4; 46% vs 41%; p<0.001), longer length of ICU stays (90±162 vs 72±134 hours; p<0.001) and increased levels of organ support. The ICU mortality (aOR 1.50, 95% CI 1.09 to 2.06; p=0.01) was consistently higher in the SHI; however, the 30-day mortality (aOR 0.89, 95% CI 0.66 to 1.21; p=0.47) was similar between THS and SHI. In a sensitivity analysis stratifying for the health economic data, the 30-day mortality was higher in SHI, in low GDP per capita (aOR 2.17, 95% CI 1.42 to 3.58) and low HDI (aOR 1.22, 95% CI 1.64 to 2.20) settings.ConclusionsThe 30-day mortality was similar in both systems. Patients in SHI were older, sicker and frailer at baseline, which could be interpreted as a sign for a more liberal admission policy in SHI. We believe that the observed trend towards ICU excess mortality in SHI results mainly from a more liberal admission policy and an increase in treatment limitations.Trial registration numbersNCT03134807 and NCT03370692.

Clinical characteristics and outcomes of 952 hospitalized COVID-19 patients in The Netherlands: A retrospective cohort study

Objective To describe clinical characteristics, disease course and outcomes in a large and well-documented cohort of hospitalized COVID-19 patients in the Netherlands. Methods We conducted a multicentre retrospective cohort study in The Netherlands including 952 of 1183 consecutively hospitalized patients that were admitted to participating hospitals between March 2nd, 2020, and May 22nd, 2020. Clinical characteristics and laboratory parameters upon admission and during hospitalization were collected until July 1st. Results The median age was 69 years (IQR 58–77 years) and 605 (63.6%) were male. Cardiovascular disease was present in 558 (58.6%) patients. The median time of onset of symptoms prior to hospitalization was 7 days (IQR 5–10). A non ICU admission policy was applicable in 312 (32.8%) patients and in 165 (56.3%) of the severely ill patients admitted to the ward. At admission and during hospitalization, severely ill patients had higher values of CRP, LDH, ferritin and D-dimer with higher neutrophil counts and lower lymphocyte counts. Overall in-hospital mortality was 25.1% and 183 (19.1%) patients were admitted to ICU, of whom 56 (30.6%) died. Patients aged ≥70 years had high mortality, both at the ward (52.4%) and ICU (47.4%). The median length of ICU stay was 8 days longer in patients aged ≥70 years compared to patients aged ≤60 years. Conclusion Hospitalized COVID-19 patients aged ≥70 years had high mortality and longer ICU stay compared to patients aged ≤60 years. These findings in combination with the patient burden of an ICU admission and possible long term complications after discharge should encourage us to further investigate the benefit of ICU admission in elderly and fragile COVID-19-patients.

Length of Stay in ICU of Covid-19 Patients in England, March - May 2020

IntroductionLength of Stay (LoS) in Intensive Care Units (ICUs) is an important measure for planning beds capacity during the Covid-19 pandemic. However, as the pandemic progresses and we learn more about the disease, treatment and subsequent LoS in ICU may change. ObjectivesTo investigate the LoS in ICUs in England associated with Covid-19, correcting for censoring, and to evaluate the effect of known predictors of Covid-19 outcomes on ICU LoS. Data sourcesWe used retrospective data on Covid-19 patients, admitted to ICU between 6 March and 24 May, from the “Covid-19 Hospitalisation in England Surveillance System” (CHESS) database, collected daily from England’s National Health Service, and collated by Public Health England. MethodsWe used Accelerated Failure Time survival models with Weibull and log-normal distributional assumptions to investigate the effect of predictors, which are known to be associated with poor Covid-19 outcomes, on the LoS in ICU. ResultsPatients admitted before 25 March had significantly longer LoS in ICU (mean = 18.4 days, median = 12), controlling for age, sex, whether the patient received Extracorporeal Membrane Oxygenation, and a co-morbid risk factors score, compared with the period after 7 April (mean = 15.4, median = 10). The periods of admission reflected the changes in the ICU admission policy in England. Patients aged 50-65 had the longest LoS, while higher co-morbid risk factors score led to shorter LoS. Sex and ethnicity were not associated with ICU LoS. ConclusionsThe skew of the predicted LoS suggests that a mean LoS, as compared with median, might be better suited as a measure used to assess and plan ICU beds capacity. This is important for the ongoing second and any future waves of Covid-19 cases and potential pressure on the ICU resources. Also, changes in the ICU admission policy are likely to be confounded with improvements in clinical knowledge of Covid-19.