Regular Ward Research Articles

Increase in consumption of alcohol-based hand rub in German acute care hospitals over a 12\u2009year period

BackgroundHand hygiene plays a crucial role in the transmission of pathogens and the prevention of healthcare-associated infections. In 2007, a voluntary national electronic surveillance tool for the documentation of consumption of alcohol-based hand rub (AHC) was introduced as a surrogate for hand hygiene compliance (HAND-KISS) and for the provision of benchmark data as feedback.The aim of the study was to determine the trend in alcohol-based hand rub consumption between 2007 and 2018.Materials and methodsIn this cohort study, AHC and patient days (PD) were documented on every ward in participating hospitals by trained local staff. Data was collected and validated in HAND-KISS. Intensive care units (ICU), intermediate care units (IMC), and regular wards (RW) that provided data during the study period between 2007 until 2018 were included into the study.ResultsIn 2018, 75.2% of acute care hospitals in Germany (n = 1.460) participated. On ICUs (n = 1998) mean AHC increased 1.74 fold (95%CI 1.71, 1.76; p < .0001) from 79.2 ml/PD to 137.4 ml/PD. On IMCs (n = 475) AHC increased 1.69 fold (95%CI 1.60, 1.79; p < .0001) from 41.4 ml/PD to 70.6 ml /PD..On RWs (n = 14,857) AHC was 19.0 ml/PD in 2007 and increased 1.71 fold (95%CI 1.70, 1.73; p < .0001) to 32.6 ml/PD in 2018.ConclusionsAHC in German hospitals increased on all types of wards during the past 12 years. Surveillance of AHC is widely established in German hospitals. Large differences among medical specialties exist and warrant further investigation.

Resumption of the treatment of non-COVID-19 gynecologic patients after lifting lockdown: Triage and infection prevention experiences from Wuhan.

AimTo share our experiences of resuming the treatments for gynecologic patients after lifting the lockdown in a hotspot area for the Coronavirus Disease 2019 (COVID‐19) pandemic.MethodsThe triage process used to resume medical activities for gynecologic patients at the Wuhan Union Hospital after a 76‐day lockdown of the city is described, and its effectiveness in preventing COVID‐19 nosocomial transmission is shown.ResultsNonemergency patients were pretriaged based on their contact history and body temperature at an outpatient clinic, and negative COVID‐19 screening test results were required for admission to the buffering rooms at the gynecologic department. The buffering lasted at least 3 days for symptom monitoring, and a second round of COVID‐19 testing was required before patients could be transferred to the regular gynecologic wards. For patients who needed emergency surgery, the first screening was completed at the isolation wards after surgery, followed by buffering at the gynecologic department. We received 19 298 outpatient visits, admitted 326 patients, and performed 223 operations in the first 2 months after the lockdown was lifted. No COVID‐19 cases occurred in the hospitalized patients, while the proportion of potentially high‐risk patients with cancer and severe anemia was increased in comparison to that observed during the same period in 2019 and the first 2 months of 2020 before the lockdown.ConclusionsWe provide an effective triage system with buffering at two levels to guarantee safe and timely treatment for non‐COVID‐19 gynecologic patients in the postlockdown phase.

Nursing and medical students’ experiences of interprofessional education during clinical training in psychiatry

ABSTRACT The aim of the study was to describe nursing and medical students’ experiences of participation in an interprofessional education (IPE) activity, “round school,” during their clinical rotations in psychiatric care. Data were collected in six focus groups with 32 students from nursing and medical programs, focusing on their experiences of the IPE activity and their reflections on interprofessional collaboration. The students considered the round school to be meaningful and true-to-life. Important conditions for learning were well-informed staff, sufficient time for preparation and feedback, clear routines, instructions, and an open climate. Non-explicit instructions and limited preunderstanding of psychiatric care left the students feeling uncertain. Students’ reflections regarding interprofessional competences encompassed both similarities and differences in roles, responsibilities, and collaboration. Evidence of hierarchical and stereotypical images of the nurse-physician relationship was identified. Round school is an example of how IPE can be integrated into the units’ regular ward rounds. However, if the clinical everyday work is not based on collaboration between different professions, it can be arduous to implement IPE. Well-planned preparations are necessary, both in the clinic and at the faculty.

Admission to the Regular Ward is Safe Following Uncomplicated Craniosynostosis Surgery: A Retrospective Study

Background: At our craniofacial center patients are routinely admitted to a regular ward, or floor, rather an intensive care unit (ICU) after uncomplicated craniosynostosis surgery. In this study, we review the safety of our postoperative placement policy, examining the rate of transfer from floor to ICU. Methods: The charts of patients who underwent craniosynostosis surgery from 2009 through 2017 at a single children’s hospital were reviewed. Postoperative hospital courses were characterized as preoperatively-planned ICU admission, perioperatively-planned ICU admission, or primary floor admission. The primary outcome was transfer from floor to ICU. Secondary outcomes included duration of hospitalization. Results: Chart review yielded 420 patients. Three hundred sixty-eight (88%) were admitted directly to the floor and 52 (12.0%) directly to an ICU. Of patients admitted to the floor, 2 (0.5%) were transferred to an ICU. Twenty-four patients with syndromic and 20 patients with multisutural craniosynostosis were admitted to the floor. Only 1 patient from each group (the same patient; 4.2% and 5.0%, respectively), was transferred to an ICU. Thirty-two ICU admissions were preoperatively planned and 20 were perioperatively planned. Reasons for preoperatively planned ICU admission included significant comorbidities and type of surgery. Reasons for perioperatively planned ICU admissions included significant intraoperative adverse events, excessive blood loss, and failure of clearance from the post-anesthesia care unit (PACU). Patients admitted to the ICU had a statistically significant longer mean length of hospitalization (4.8 days vs 2.7 days) than did patients admitted to the floor. Conclusions: Most postoperative craniosynostosis surgery patients—including patients with syndromic and/or multisutural synostosis—are managed safely on the floor at our center. Some patients still need postoperative ICU admission, but are easily identified preoperatively, intraoperatively, or in the PACU. Our findings should be applicable to other large craniofacial centers.

Tactical blueprints for surgical weeks – An integrated approach for operating rooms and intensive care units

Decisions on the number of surgeries to perform during a typical week in an operating room (OR) generally affect downstream resources such as intensive care units (ICU), recovery rooms, or regular inpatient wards. Since capacity of e.g. ICUs is highly restricted, this bottleneck plays an important role in the management of an efficient flow of surgical patients through the system. This paper aims to provide hospital decision makers with easy-to-follow guidelines for the daily patient scheduling decisions and presents a novel chance-constraint optimisation model to develop efficient admission templates for elective surgeries on a tactical level. With a given patient mix, we decide on the number of surgeries that can realistically be treated during a typical week, with respect to limited resources of OR and ICU and considering stochastic demand. The benefit of such templates is exemplified using a dedicated simulation model in a realistic case study. The simulation model rebuilds daily operations in OR and ICU and allows to mimic typical decision making in OR and ICU. Computational studies show that continually applying such templates as admission guidelines leads to a well-utilised OR and efficiently used ICUs. The extensive simulation studies confirm that the template plans obtained from the chance-constraint optimisation model can provide guidance for an operating room planner.

Prevalence of COVID-19 in patients with autoimmune liver disease in Europe: A patient-oriented online survey.

BackgroundDuring the current SARS‐CoV‐2 pandemic it is important to identify risk factors for COVID‐19. Registry studies are providing growing evidence on the elevated risk of mortality from COVID‐19 in patients with chronic liver disease, especially in advanced stages. Results may, however, have a selection bias towards severe cases. Limited data is available on COVID‐19 in patients with autoimmune liver disease (AILD).AimTo perform an online survey to capture the prevalence of COVID‐19 and the state of medical care of patients with AILD in Europe during the pandemic.MethodsData was collected via an anonymous patient‐oriented, online survey, which was available on the EUSurvey platform in nine European languages between 24th June 2020 and 14th October 2020. Of 1834 contributions, 51 were excluded because participants did not name an underlying AILD, and four were excluded because of duplicate data entry.ResultsOf 1,779 participants, 1,752 resided in 20 different countries of the European Union and the United Kingdom (UK). The five countries with the highest numbers of contributions were France (n = 450), Germany (n = 318), the Netherlands (n = 267), Spain (n = 225), and the UK (n = 183). 2.2% of participants (39/1779) had been diagnosed with COVID‐19. There were no differences regarding age, sex, AILD, the status of liver cirrhosis, or status post liver transplantation between COVID‐19 and non‐COVID‐19 cases. Of the 39 COVID‐19 cases, five patients were admitted to a regular ward, one patient was admitted to ICU and required ventilation.ConclusionIn our Europe‐wide, patient‐oriented survey on COVID‐19 in patients with AILD, we detected a low rate of COVID‐19, comparable to the period prevalence of the general population. These results suggest that patients with AILD are not at elevated risk of COVID‐19.

A CROSS-SECTIONAL STUDY ON MENTAL HEALTH AND CARDIOVASCULAR REACTIVITY AMONG FRESH RESIDENT DOCTORS DURING COVID19 PANDEMIC IN INDIA

Objective: The adverse psychological impact in doctors battling the Corona Virus Disease 2019 (COVID 19) epidemic arise from various social and administrative issues like excessive workload, inadequate interpersonal communications, biased work culture and lack of social support thus raising a warning of the mental health in doctors. The present study was done to assess the mental health and stress reactivity among the resident doctors who have been working for a prolonged duration during covid 19 pandemic in India.&#x0D; Methods: The subjects included 162 young resident doctors both males and females, of age group between 25-30 y, among which 92 were posted in covid wards on a rotation basis from 1st April 2020 to 31st December 2020 and 70 were doing duty in regular non-covid wards or not had done even a single duty in covid ward during the above period. All participants completed an online questionnaire that included the Beck Anxiety Inventory (BAI), the Beck Depression Inventory (BDI)–II, Connor-Davidson resilience scale (CDRISC) and Social Support Rating Scale (SSRS) followed by a cold pressor test to assess stress reactivity.&#x0D; Results: There were significant differences in the mental health and stress reactivity scores with lower resilience scores, lower social support rating scores, increased anxiety and depression in Covid ward doctors (p=0.001).&#x0D; Conclusion: The findings suggested high levels of training, resilience helpful social support and unbiased work culture were necessary to health care workers engaged in public health emergence.

Neurological outcome and quality of life 3 months after COVID‐19: A prospective observational cohort study

Background and purposeTo assess neurological manifestations and health‐related quality of life (QoL) 3 months after COVID‐19.MethodsIn this prospective, multicenter, observational cohort study we systematically evaluated neurological signs and diseases by detailed neurological examination and a predefined test battery assessing smelling disorders (16‐item Sniffin Sticks test), cognitive deficits (Montreal Cognitive Assessment), QoL (36‐item Short Form), and mental health (Hospital Anxiety and Depression Scale, Posttraumatic Stress Disorder Checklist–5) 3 months after disease onset.ResultsOf 135 consecutive COVID‐19 patients, 31 (23%) required intensive care unit (ICU) care (severe), 72 (53%) were admitted to the regular ward (moderate), and 32 (24%) underwent outpatient care (mild) during acute disease. At the 3‐month follow‐up, 20 patients (15%) presented with one or more neurological syndromes that were not evident before COVID‐19. These included polyneuro/myopathy (n = 17, 13%) with one patient presenting with Guillain‐Barré syndrome, mild encephalopathy (n = 2, 2%), parkinsonism (n = 1, 1%), orthostatic hypotension (n = 1, 1%), and ischemic stroke (n = 1, 1%). Objective testing revealed hyposmia/anosmia in 57/127 (45%) patients at the 3‐month follow‐up. Self‐reported hyposmia/anosmia was lower (17%) at 3 months, however, improved when compared to the acute disease phase (44%; p < 0.001). At follow‐up, cognitive deficits were apparent in 23%, and QoL was impaired in 31%. Assessment of mental health revealed symptoms of depression, anxiety, and posttraumatic stress disorders in 11%, 25%, and 11%, respectively.ConclusionsDespite recovery from the acute infection, neurological symptoms were prevalent at the 3‐month follow‐up. Above all, smelling disorders were persistent in a large proportion of patients.

Persistent postconcussive symptoms in children and adolescents with mild traumatic brain injury receiving initial head computed tomography.

The aim of this paper was to evaluate the prevalence of postconcussive symptoms and their relation to health-related quality of life (HRQOL) in pediatric and adolescent patients with mild traumatic brain injury (mTBI) who received head CT imaging during initial assessment. Patients aged between 5 and 21 years with mTBI (Glasgow Coma Scale scores 13-15) and available Rivermead Post Concussion Questionnaire (RPQ) at 6 months of follow-up in the multicenter, prospectively collected CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) study were included. The prevalence of postconcussive symptoms was assessed, and the occurrence of postconcussive syndrome (PSC) based on the ICD-10 criteria, was analyzed. HRQOL was compared in patients with and without PCS using the Quality of Life after Brain Injury (QOLIBRI) questionnaire. A total of 196 adolescent or pediatric mTBI patients requiring head CT imaging were included. High-energy trauma was prevalent in more than half of cases (54%), abnormalities on head CT scans were detected in 41%, and admission to the regular ward or intensive care unit was necessary in 78%. Six months postinjury, 36% of included patients had experienced at least one moderate or severe symptom on the RPQ. PCS was present in 13% of adolescents and children when considering symptoms of at least moderate severity, and those patients had significantly lower QOLIBRI total scores, indicating lower HRQOL, compared with young patients without PCS (57 vs 83 points, p < 0.001). Adolescent and pediatric mTBI patients requiring head CT imaging show signs of increased trauma severity. Postconcussive symptoms are present in up to one-third of those patients, and PCS can be diagnosed in 13% 6 months after injury. Moreover, PCS is significantly associated with decreased HRQOL.

Thyroid Storm in Pregnancy

Abstract Endocrine emergencies can occur during pregnancy and are associated with the thyroid gland and diabetes. Thyrotoxicosis is a hypermetabolic condition associated with an increase in thyroid hormone in the blood. The manifestations of thyrotoxicosis can range from those without symptoms to a life-threatening condition such as thyroid storm. The diagnosis of thyroid storm can be made based on a history of previous thyroid gland disorders; current signs and symptoms; and laboratory tests of thyroid-stimulating hormone, free thyroxine, and triiodothyronine. The thyroid storm is a rare condition, but the mortality rate on these patients is high. Characteristics of thyroid storms are altered consciousness, hyperpyrexia, tachycardia, and gastrointestinal disturbances. Thyroid storm management focuses on the prevention of thyroid hormone synthesis and its conversion in the periphery, identification, and intervention of the thyroid storm causes and the management of systemic disorders that present during thyroid storm. We present a 24-year-old female who presented with a very high suspicion of thyroid storm based on her Burch and Wartofsky's score criteria had a total score with a very high suspicion of thyroid storm. While pregnancy itself can increase the risk of developing severe thyrotoxicosis, the main management is determined by the presence of emergency manifestations. Our concern was not only for the safety of the mother but also for the fetus. Some drugs need special attention because they cross the blood–placental barrier. Previous patient comorbidities should also receive attention in the management of thyroid storm. The patient was being treated in the intensive care unit and managed to move to a regular ward after 3 days.

Comparison of five SARS-CoV-2 rapid antigen detection tests in a hospital setting and performance of one antigen assay in routine practice: a useful tool to guide isolation precautions?

BackgroundIn a hospital setting, there is a need for rapid detection of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) to guide isolation measures and targeted admission.AimTo evaluate the diagnostic performance of five SARS-CoV-2 rapid nucleocapsid protein antigen detection (RAD) assays (Biosynex, Biotical, Orient Gene, Panbio and SD Biosensor), and describe the performance and impact of implementation of the SD Biosensor assay in an emergency department.MethodsSensitivity and specificity of the five RAD assays were analysed on 100 respiratory samples: 60 real-time reverse transcriptase polymerase chain reaction (rRT-PCR)-confirmed SARS-CoV-2-positive samples, 24 SARS-CoV-2 RNA-negative samples and 16 samples positive for other respiratory pathogens. The manufacturer's protocol was adapted to validate the antigen tests on transport media used for rRT-PCR in the authors' routine practice. The SD Biosensor RAD assay was implemented as a screening method for rapid diagnosis and targeted admission.FindingsSensitivity of the five RAD assays ranged from 88.9% to 100% for samples with cycle threshold values <26, and specificity ranged from 46.2% to 100%. During the implementation period, 4195 RAD tests were performed. Due to the rapid RAD result, 157 patients were transferred directly to the coronavirus disease 2019 (COVID-19) cohort ward instead of the regular ward (N=47) or the temporary COVID-19 ward (N=110).ConclusionThe SD Biosensor, Biotical and Panbio SARS-CoV-2 antigen tests showed acceptable overall performance, and identified the majority of contagious patients. In the context of high prevalence of SARS-CoV-2, RAD tests can be used as a rapid screening tool to guide infection prevention measures and aid targeted admission.

Theorising rehabilitation: Actors and parameters shaping normality, liminality and depersonalisation in a UK hospital.

Sociological concern for rehabilitation remains limited. This paper aims to contribute to rehabilitation theory. It examines two units of a specialist rehabilitation hospital in the UK (amputee and neurological services) by focusing on the key actors involved - families, patients, staff - and the parameters shaping their relationships. The findings extend previous theoretical understandings of rehabilitation in three themes: normality, liminality and depersonalisation. We argue, first: normality is constantly negotiated amongst the different actors. This complicates existing works' critique of rehabilitation as reproducing the ideology of normality. Second, discourses produced during acute care shape the inpatient rehabilitation experience. This calls attention to the pre-rehabilitation phase and complicates existing works' emphasis on the transition from inpatient stay to the time of discharge. Finally, inpatient rehabilitation is notable in rendering the adverse effects of depersonalisation apparent. It combines the bureaucracy of a regular hospital ward, with institutionalising aspects of long-term care. These findings have a potential to enhance practice as well as knowledge. We call for a deeper sociological attention,combiningtheory-building with empirical data for a better understanding of inpatient rehabilitation.

The risk of postoperative deterioration of non-cardiac surgery patients with ICU referral status who are admitted to the regular ward: a retrospective observational cohort study

BackgroundHigher-risk surgical patients may not be admitted to the intensive care unit due to stable immediate post-operative status on review. The outcomes of this cohort are not well described. Our aim was to examine the subsequent inpatient course of intensive care unit -referred but not admitted surgical patients.MethodsAll patients aged ≥18 years who were referred but not admitted for post-operative management in a tertiary metropolitan intensive care unit following non-cardiac surgery between 1/7/2017 and 30/6/2018 were eligible for inclusion in this retrospective observational cohort study. Primary outcome was Medical Emergency Team activation. Secondary outcomes included unplanned intensive care unit admission; length of stay; and 30-day mortality. Risk of serious complications and predicted length of stay were calculated using the National Surgical Quality Improvement Program scoring tool.ResultsFifteen of 60 patients (25%) had a MET-call following surgery, eight (13%) patients required unplanned intensive care unit admission, with median (IQR) time to Medical Emergency Team call 9 (6–13) hours. No patients died within 30-days. There was no significant difference between mean National Surgical Quality Improvement Program predicted and actual length of stay; after adjustment, National Surgical Quality Improvement Program predicted risk of serious complications was associated with unplanned intensive care unit admission (OR [95% CI] = 1.08 [1.00–1.16], p = 0.04), although not Medical Emergency Team calls.ConclusionsPost-operative deterioration occurs frequently, and early, in a cohort of high-risk surgical patients initially assessed as being safe for ward care. Changes to current triage models for post-operative intensive care unit admission may reduce the impact of complications in this high-risk group.

Latent class cluster analysis identified hidden headache phenotypes in COVID-19: impact of pulmonary infiltration and IL-6.

Background and objectiveClinical studies on COVID-19 headache are limited. This prospective study aimed to define headache characteristics, associated clinical and laboratory factors, and treatment response in COVID-19.MethodsCross-sectional study enrolled 287 patients diagnosed with COVID-19 and hospitalized on a regular ward during the pandemic. All patients were examined face to face and followed by a neurologist during their stay in the hospital. The characteristics, concomitant symptoms, treatment responses, and laboratory findings of COVID-19-associated headaches were recorded.ResultsEighty-three COVID-19 patients reported headache (28.9%), in which 85.5% had no prior headaches. Mean age was 48.40 ± 15.90 and 58% was men. Compared to COVID-19 patients without headache (n = 204), patients with headache showed significantly higher frequency of pulmonary involvement (76%) and increased D-dimer levels. Fifty-nine percent of headaches responded iv paracetamol 1000 mg, and 85% of the paracetamol unresponsive headaches were relieved by greater occipital nerve (GON) blocks. Latent class cluster analysis identified 2 distinct class of bilateral, frontal, throbbing headaches: severe (VAS > 84), longer (> 14 h), frequent (> 7 headache days), paracetamol unresponsive-GON responsive headaches (85%), with pulmonary involvement (100%), and higher IL-6 levels (> 90 pg/mL) were classified in cluster 1. Cluster 2 included moderately affected patients (VAS > 54, > 6 h, > 4 days, 60% pulmonary involvement, > 20 pg/mL IL-6) and paracetamol responsive headaches (96%). VAS scores showed positive linear correlation with IL-6 levels (p < 0.001; r = 0.567).ConclusionThe intensity, duration, frequency, bilateral frontal location, and treatment response of COVID-19 headache was related to pulmonary involvement and IL-6 levels, which indicated a role of inflammation in determining the headache manifestations in moderately affected hospitalized patients. ROC curve cutoff values pointed that VAS > 70 severity, > 9 h duration, > 5 headache days, and IL-6 > 43 pg/mL levels can be diagnostic for COVID-19 headache. GON blocks can effectively abort headache when patients are unresponsive to paracetamol, and other NSAIDs are avoided during the SARS-CoV-2 infection.

Simplified Postoperative Care After Spring-assisted Strip Craniotomy for Sagittal Synostosis: A Prospective Before-and-After Study.

Since the development of spring-assisted techniques for corrective craniofacial surgery, routine postoperative admission to intensive care units (ICUs) has been questioned. However, close monitoring is necessary if the continuous infusion of morphine is used as recommended for better pain relief. In this study, the authors evaluated a simplified postoperative protocol without continuous morphine infusion and no indwelling urinary catheter following spring-assisted surgery (SAS) for sagittal synostosis. Ten children were cared for according to a standard protocol with postoperative intravenous (i.v.) infusion of morphine and an indwelling urinary catheter, and 11 consecutive children were treated according to a simplified protocol with pain relief based on intermittent injections of morphine and clonidine [according to Face, Legs, Activity, Cry, Consolability (FLACC) scores >4] without the indwelling catheter. A Mann-Whitney U test was used for comparison of distributions between the two groups. The results revealed no differences between groups regarding the proportion of FLACC scores >4, total amount of administered i.v. morphine and clonidine, total volume of buffered glucose infused, time to first feeding on breast milk or substitute, or the length of stay. Despite the inherent limitations of our small observational study, the authors concluded that at our institution, it was possible to exclude a standard continuous i.v. infusion of morphine and an indwelling urinary catheter from our postoperative care protocol without decreasing the quality of pain relief in children submitted to SAS for sagittal synostosis. This finding supports downgrading the level of care from the ICU to a regular ward after limited immediate postoperative observation.

Clinical course of COVID-19 patients needing supplemental oxygen outside the intensive care unit

Patients suffering from CVOID-19 mostly experience a benign course of the disease. Approximately 14% of SARS-CoV2 infected patients are admitted to a hospital. Cohorts exhibiting severe lung failure in the form of acute respiratory distress syndrome (ARDS) have been well characterized. Patients without ARDS but in need of supplementary oxygen have received much less attention. This study describes the diagnosis, symptoms, treatment and outcomes of hospitalized patients with COVID-19 needing oxygen support during their stay on regular ward. All 133 patients admitted to the RWTH Aachen university hospital with the diagnosis of COVID-19 were included in an observational registry. Clinical data sets were extracted from the hospital information system. This analysis includes all 57 patients requiring supplemental oxygen not admitted to the ICU. 57 patients needing supplemental oxygen and being treated outside the ICU were analyzed. Patients exhibited the typical set of symptoms for COVID-19. Of note, hypoxic patients mostly did not suffer from clinically relevant dyspnea despite oxygen saturations below 92%. Patients had fever for 7 [2–11] days and needed supplemental oxygen for 8 [5–13] days resulting in an overall hospitalization time of 12 [7–20] days. In addition, patients had persisting systemic inflammation with CRP levels remaining elevated until discharge or death. This description of COVID-19 patients requiring oxygen therapy should be taken into account when planning treatment capacity. Patients on oxygen need long-term inpatient care.

Trends in mortality of hospitalised COVID-19 patients: A single centre observational cohort study from Spain.

BackgroundWe aimed to describe changes in characteristics and treatment strategies of hospitalised patients with COVID-19 and detail the mortality trend over time.MethodsObservational cohort study of all consecutive patients admitted ≥ 48 h to Hospital Clinic of Barcelona for COVID-19 (1 March–30 September 2020).FindingsA total of 1645 consecutive patients with COVID-19 were assessed over a 7-month period. Overall mortality (≤30 days) was 9.7% (159 patients), 7.7% in patients hospitalised in regular wards and 16.7 % in patients requiring ICU admission. Overall mortality decreased from 11.6% in the first month to 1.4% in the last month, reflecting a progressive, significant downward trend (p for trend <0.001). Patients’ age changed over time, peaking in June. Most changes in the use of antivirals and anti-inflammatory treatments were documented. Age (OR 1.1, CI 1.1–1.12), chronic heart disease, (OR 1.7, CI 1.1–2.9), D-dimer>700 ng/mL (OR 2.3, CI 1.3–4.1), ferritin>489 ng/mL (OR 1.9; CI 1.5–3.2), C-RP>7 mg/dL (OR 2.6; CI 1.5–4.6), and shorter duration from symptom onset to hospital admission (OR 1.11; CI 1.04–1.17) were factors associated with 30-day mortality at hospital admission. Conversely, hospital admission in the last months (OR 0.80; CI 0.65–0.98) was significantly associated with lower mortality.InterpretationIn-hospital mortality has decreased in patients with COVID-19 over the last, few months, even though main patient characteristics remain similar. Several changes made when managing patients may explain this decreasing trend. Our study provides current data on mortality of patients hospitalised with COVID-19 that might be useful in establishing quality of standard of care.FundingEIT Health, European Union´s Horizon 2020 Research and Innovation Programme), EDRD. PPA [CM18/00132], NGP [FI19/00133], and CGV [FIS PI18/01061], have received grants from Ministerio de Sanidad y Consumo, ISCIII.

Prospective Longitudinal Serosurvey of Healthcare Workers in the First Wave of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic in a Quaternary Care Hospital in Munich, Germany.

BackgroundHigh infection rates among health care personnel in an uncontained pandemic can paralyze health systems due to staff shortages. Risk constellations and rates of seroconversion for health care workers during the first wave of the SARS-CoV-2 pandemic are still largely unclear.MethodsHealth care personnel (n=300) on different organizational units in the LMU Munich University Hospital were included and followed in this prospective longitudinal study in the period of March 24 until July 7, 2020. Participants were monitored in intervals of two to six weeks using different antibody assays for serological testing and questionnaires to evaluate risk contacts. In a subgroup of infected participants, we obtained nasopharyngeal swabs to perform whole genome sequencing for outbreak characterization.ResultsHealth care workers involved in patient care on dedicated COVID-19 wards or on regular non-COVID-19 wards showed a higher rate of SARS-CoV-2 seroconversion compared to staff in the emergency department and non-frontline personnel. The landscape of risk contacts in these units was dynamic, with a decrease of unprotected risk contacts in the emergency department and an increase on non-COVID-19 wards. Both, the intensity and number of risk contacts, were associated with higher rates of seroconversion. On regular wards, staff infections tended to occur in clusters, while infections on COVID-19 wards were less frequent and apparently independent of each other.ConclusionThe risk of SARS-CoV-2 infection for front-line health care workers was increased during the first pandemic wave in Southern Germany. Stringent measures for infection control are essential to protect all patient-facing staff during the ongoing pandemic.

Aiming for zero fluid accumulation: First, do no harm.

Critically ill patients are often presumed to be in astate of "constant dehydration" or in need of fluid, thereby justifying acontinuous infusion with some form of intravenous (IV) fluid, despite their clinical data suggesting otherwise. Overzealous fluid administration and subsequent fluid accumulation and overload are associated with poorer outcomes. Fluids are drugs, and their use should be tailored to meet the patient's individualized needs; fluids should never be given as routine maintenance unless indicated. Before prescribing any fluids, the physician should consider the patient's characteristics and the nature of the illness, and assess the risks and benefits of fluid therapy. Decisions regarding fluid therapy present adaily challenge in many hospital departments: emergency rooms, regular wards, operating rooms, and intensive care units. Traditional fluid prescription is full of paradigms and unnecessary routines as well as malpractice in the form of choosing the wrong solutions for maintenance or not meeting daily requirements. Prescribing maintenance fluids for patients on oral intake will lead to fluid creep and fluid overload. Fluid overload, defined as a10% increase in cumulative fluid balance from baseline weight, is an independent predictor for morbidity and mortality, and thus hospital cost. In the last decade, increasing evidence has emerged supporting arestrictive fluid approach. In this manuscript, we aim to provide apragmatic description of novel concepts related to the use of IV fluids in critically ill patients, with emphasis on the different indications and common clinical scenarios. We also discuss active deresuscitation, or the timely cessation of fluid administration, with the intention of achieving azero cumulative fluid balance.

Sitagliptin for the prevention and treatment of perioperative hyperglycaemia in patients with type 2 diabetes undergoing cardiac surgery: A randomized controlled trial.

To assess whether treatment with sitagliptin, starting before surgery and continued during the hospital stay, can prevent and reduce the severity of perioperative hyperglycaemia in patients with type 2 diabetes undergoing coronary artery bypass graft (CABG) surgery. We conducted a double-blinded, placebo-controlled trial in adults with type 2 diabetes randomly assigned to receive sitagliptin or matching placebo starting 1 day prior to surgery and continued during the hospital stay. The primary outcome was difference in the proportion of patients with postoperative hyperglycaemia (blood glucose [BG] > 10 mmol/L [>180 mg/dL]) in the intensive care unit (ICU). Secondary endpoints included differences in mean daily BG in the ICU and after transition to regular wards, hypoglycaemia, hospital complications, length of stay and need of insulin therapy. We included 182 participants randomized to receive sitagliptin or placebo (91 per group, age 64 ± 9 years, HbA1c 7.6% ± 1.5% and diabetes duration 10 ± 9 years). There were no differences in the number of patients with postoperative BG greater than 10 mmol/L, mean daily BG in the ICU or after transition to regular wards, hypoglycaemia, hospital complications or length of stay. There were no differences in insulin requirements in the ICU; however, sitagliptin therapy was associated with lower mean daily insulin requirements (21.1 ± 18.4 vs. 32.5 ± 26.3 units, P = .007) after transition to a regular ward compared with placebo. The administration of sitagliptin prior to surgery and during the hospital stay did not prevent perioperative hyperglycaemia or complications after CABG. Sitagliptin therapy was associated with lower mean daily insulin requirements after transition to regular wards.