An interdisciplinary approach to the management of critically ill patients during covid-19 pandemic; an experience of a university hospital in England.

COVID-19 pandemic presents significant challenges in delivering safe and efficient patient care, especially during the surges. In all health care systems, provision of available critical care facilities is a scarce resource, even in normal times. Problematic is not just the limitation of physical spaces in intensive care units, but also the availability of trained personnel. The critical care model, developed in Queen Elizabeth Hospital Birmingham to cope with the surge of COVID-19 patients, is based on early implementation of an interdisciplinary approach and extensive cooperation between the branches of practice, allowing to address both challenges. The main pillars are early upskilling of non-critical care staff, creation of safe, streamlined clinical pathways, adjustment of the physical layout of critical care units and comprehensive cross-town cooperation allowing to accommodate an increased number of patients, requiring intensive care. The model was well tested in clinical practice, enabling the hospital to increase the critical care footprint by more than 200% during the pandemic's surge between March and May 2020.

Understanding the Intensive Care Unit Experience of Patients and Relatives at the End-of-Life During the Coronavirus Disease 2019 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on patients and relatives' experiences of end-of-life care, as well as changing the provision of these services in intensive care units (ICUs) across the world. Established methods for assisting relatives through the grieving process have required modification due to the unique features and circumstances surrounding deaths from this disease. This mixed-methods study from the United Kingdom (UK) aims to review data from patients who died in a large ICU (the unit had a capacity for more than 100 ventilated patients), over the course of approximately 1 year. The inpatient noting of these patients was reviewed specifically for details of visiting practices, chaplaincy support, and patient positioning (prone vs supine) prior to death. Using this data, recommendations are made to improve end-of-life care services. To allow relatives the opportunity to attend the ICU, there is a need for early recognition of patients approaching the end of life. Clear explanations of the need for prone positioning and increased access to chaplaincy services were also identified.

Temperature management of adult burn patients in intensive care: findings from a retrospective cohort study in a tertiary centre in the United Kingdom.

INTRODUCTION: Patients with major burn injury are prone to hypothermia, potentially resulting in an increase in mortality and length of hospital stay. Our study comprehensively evaluates the practicalities of physiological thermoregulation and temperature control in the largest cohort of critically ill adult burn patients to date. MATERIAL AND METHODS: This retrospective study of routinely collected patient data from the Intensive Care Unit (ICU) of the West Midlands Burn Centre was conducted over a three-year period (2016-2019). Data were analysed to assess temperature control against local and International Society for Burn Injury (ISBI) standards. RESULTS: Thirty-one patients with significant burn injuries, requiring active critical care treatment for more than 48 hours were included (total body surface area [TBSA] mean = 42.7%, SD = 18.1%; revised Baux score [rBaux] = 99, SD = 25). The majority were male (77.29%) with an average age of 44 years (17-77 years). The patients were cared for in the ICU for a total of 15 119 hours. Hypothermia, defined as core temperature below 36.0°C, was recorded for 251 hours (2% of total stay). Only 27 patients (87%) had their temperature ≥ 36°C for more than 95% of their admission. Non-survivors were more prone to hypothermia during their stay in ICU. There was an association between rBaux score and post-opera-tive temperature, with a 0.12°C decrease per 10 points increase in rBaux score (P = 0.04). CONCLUSIONS: We have observed a high variability of temperature control between individual patients, especially in non-survivors, and have demonstrated an association between high rBaux score and poor temperature control, specifically during the postoperative period.

Differential benefits of steroid therapies in adults following major burn injury.

BACKGROUND: Major thermal injury induces a complex pathophysiological state characterized by burn shock and hypercatabolism. Steroids are used to modulate these post-injury responses. However, the effects of steroids on acute post-burn outcomes remain unclear. METHODS: In this study of 52 thermally injured adult patients (median total burn surface area 42%, 33 males and 19 females), the effects of corticosteroid and oxandrolone on mortality, multi-organ failure (MOF), and sepsis were assessed individually. Clinical data were collected at days 1, 3, 7, and 14 post-injury. RESULTS: Twenty-two (42%) and 34 (65%) burns patients received corticosteroids and oxandrolone within the same cohort, respectively. Following separate analysis for each steroid, corticosteroid use was associated with increased odds of in-hospital mortality (OR 3.25, 95% CI: 1.32-8•00), MOF (OR 2.36, 95% CI: 1.00-1.55), and sepsis (OR 5.95, 95% CI: 2.53-14.00). Days alive (HR 0.32, 95% CI: 0.18-0.60) and sepsis-free days (HR 0.54, 95% CI: 0.37-0.80) were lower among corticosteroid-treated patients. Oxandrolone use was associated with reduced odds of 28-day mortality (OR 0.11, 95% CI: 0.04-0.30), in-hospital mortality (OR 0.19, 95% CI: 0.08-0.43), and sepsis (OR 0.24, 95% CI: 0.08-0.69). Days alive, at 28 days (HR 6.42, 95% CI: 2.77-14.9) and in-hospital (HR 3.30, 95% CI: 1.93-5.63), were higher among the oxandrolone-treated group. However, oxandrolone was associated with increased MOF odds (OR 7.90, 95% CI: 2.89-21.60) and reduced MOF-free days (HR 0.23, 95% CI: 0.11-0.50). CONCLUSION: Steroid therapies following major thermal injury may significantly affect patient prognosis. Oxandrolone was associated with better outcomes except for MOF. Adverse effects of corticosteroids and oxandrolone should be considered when managing burn patients.

A comment on prognostic factors in burns.

We read the recent paper "Prognostic factors in patients with burns" [1] by Zielinski et al. with great interest. The article is very informative, in a concise and eloquent manner, allowing the reader to familiarise themselves with the plethora of prognostication models used worldwide in the assessment of burn patients. However, reading the paper we noticed that two aspects may require further consideration to provide the reader with a more comprehensive understanding of prognostication in burn patients.

A descriptive survey of operating theatre and intensive care unit temperature management of burn patients in the United Kingdom.

BACKGROUND: Patients with major burns lose the normal thermoregulatory function of their skin. They exhibit profound changes in metabolism which aim to compensate for the heat loss associated with water loss through burnt skin. Although these changes in physiology are well documented, the optimal methods for temperature management in both the Operating Theatre and Intensive Care Unit are less clear. METHODS: We distributed a survey consisting of 19 questions to all burn units and centres in the United Kingdom with the aim of ascertaining perception of both hypo and hyperthermia, as well as methods used to manage both of these scenarios. RESULTS: In the Operating Theatre, most respondents stated that they measured core temperature (82%); either alone (33%) or in conjunction with peripheral temperature (49%). In the Intensive Care Unit, most respondents measured both core and peripheral temperature (67%), with only a small minority not measuring core temperature (13%). Taking into consideration all professional groups, patients were considered hypothermic if their body temperature was less than 36.2°C (+/-0.7°C). On average, a patient was considered hyperthermic if their body temperature was above 38.8°C (+/-0.6°C). CONCLUSION: Differences in perception between the professional groups surveyed did not reach clinical or statistical significance. In both the Operating Theatre and Intensive Care Unit, hypothermia was most often managed by increasing the ambient room temperature whereas hyperthermia was most often managed by giving paracetamol. As far as we are aware, this is the first study of the management of altered thermoregulation in major burn patients in the United Kingdom.

Trainee doctors' experiences of learning and well-being while working in intensive care during the COVID-19 pandemic: a qualitative study using appreciative inquiry.

OBJECTIVES: Concern about trainee work-related well-being has been raised in recent years and is the subject of several reviews, reports and research studies. This study aimed to understand the experiences of trainees working in a large intensive care unit during the first surge of the COVID-19 pandemic from an educational and operational perspective in order to highlight what worked and what could be improved. DESIGN: A qualitative study using peer-to-peer semistructured interviews, developed using appreciative inquiry methodology, was conducted during July 2020. Responses were analysed using a thematic analysis technique. SETTING: A large, tertiary intensive care unit in the UK. PARTICIPANTS: All trainees in anaesthesia and intensive care working on the intensive care unit during the first surge were invited to participate. RESULTS: Forty interviews were conducted and four over-arching themes were identified. These were: feeling safe and supported; physical demands; the emotional burden of caring; and a sense of fulfilment, value and personal development. Positive aspects of the organisational response to the pandemic included communication, personal protective equipment supply, team working and well-being support. Suggestions for improvement focused on rest facilities, rota patterns and hierarchies, creating opportunities for reflection and ensuring continued educational and training opportunities despite operational demands. CONCLUSIONS: Trainees described opportunities for learning and fulfilment, as well as challenges, in working through a pandemic. Trainees described their needs and how well these were met during the pandemic. Ideas for improvement most frequently related to basic needs including safety and fatigue, but suggestions also related to supporting learning and development. The appreciative inquiry methodology of the project facilitated effective reflection on positive aspects of trainee experiences.

The utility of arterial blood gas parameters and chest radiography in predicting appropriate intubations in burn patients with suspected inhalation injury-A retrospective cohort study.

BACKGROUND: This study evaluates the utility of arterial blood gas (ABG) parameters and chest radiography in predicting intubation need in patients with burn injuries with suspected inhalation injury. METHODS: Patients with suspected inhalation injury admitted to a single centre, Burn Intensive Care Unit, between April 4th 2016 and July 5th 2019, were included. Admission ABG parameters and chest radiograph opacification were compared with whether the patient received an appropriate intubation: defined as intubation for a duration of over 48 h. Area under the receiver operator characteristic curve was calculated (AUROC). RESULTS: Eighty-nine patients were included. The majority (84%; n = 75) were intubated, of which 81% (n = 61) received appropriate intubations. pH had an AUROC of 0.88 and a pH of <7.30 had an 80% sensitivity and specificity for detecting appropriate intubation. P/F ratio had an AUROC of 0.81 and a P/F ratio of <40 had a 70% sensitivity and specificity for appropriate intubation. Chest radiograph opacification had poor utility in this regard (AUROC = 0.69). Adding pH and P/F ratio to the ABA criteria improved their sensitivity in detecting appropriate intubations (sensitivity: ABA + pH + P/F = 0.97 vs ABA = 0.86; p = 0.013), without altering their specificity. CONCLUSIONS: In patients suspected inhalation injury, pH and P/F ratio were good predictors for appropriate intubations. Incorporating the parameters into the ABA criteria improved their clinical utility.

The Predictive Applicability of Liberal vs Restrictive Intubation Criteria in Adult Patients With Suspected Inhalation Injury-A Retrospective Cohort Study.

This study compares the ability of liberal vs restrictive intubation criteria to detect prolonged intubation and inhalation injury in burn patients with suspected inhalation injury. Emerging evidence suggests that using liberal criteria may lead to unnecessary intubation in some patients. A single-center retrospective cohort study was conducted in adult patients with suspected inhalation injury admitted to intensive care at Queen Elizabeth Hospital, Birmingham between April 2016 and July 2019. Liberal intubation criteria, as reflected in local guidelines, were compared to restrictive intubation criteria, as outlined in the American Burn Association guidelines. The number of patients displaying positive characteristics from either guideline was compared to the number of patients who had prolonged intubation (more than 48 hours) and inhalation injury. In detecting a need for prolonged intubation (n = 85), the liberal criteria had greater sensitivity (liberal = 0.98 [0.94-1.00] vs restrictive = 0.84 [0.75-0.93]; P = .013). However, the restrictive criteria had greater specificity (restrictive = 0.96 [0.89-1.00] vs liberal = 0.48 [0.29-0.67]; P < .001). In detecting inhalation injury (n = 72), the restrictive criteria were equally sensitive (restrictive = 0.94 [0.87-1.00] vs liberal = 0.98 [0.84-1.00]; P = .48) and had greater specificity (restrictive = 0.86 [0.72-1.00] vs liberal = 0.04 [0.00-0.13]; P < .001). In patients who met liberal but not restrictive criteria, 65% were extubated within 48 hours and 90% did not have inhalation injury. Liberal intubation criteria were more sensitive at detecting a need for prolonged intubation, while restrictive criteria were more specific. Most patients intubated based on liberal criteria alone were extubated within 48 hours. Restrictive criteria were highly sensitive and specific at detecting inhalation injury.

Prophylactic anti-coagulation after severe burn injury in critical care settings.

BACKGROUND: Severely burnt patients are at an increased risk of thromboembolic complications, hence sufficient prophylactic anticoagulation is of paramount importance. Local guidelines at the Burns Centre in the Queen Elizabeth Hospital, Birmingham therefore advise increasing the standard dose of low molecular weight heparin in these patients. An audit was carried out to assess the current practice in burns patients to ensure adequate anticoagulation and adherence to guidelines. MATERIALS AND METHODS: Retrospective data was collected on all burns patients in the Burns Centre over a two-year period. The main objectives were to assess:anticoagulation regimes prescribed to severe burns patientsmonitoring of Anti-Factor Xa levelsadjustment of dosing based on the resultsThe locally produced trust guidelines were used as the comparator. RESULTS: All burns patients were prescribed anticoagulation, but often the dose was not increased as suggested in the guidelines. Although most of the severely burnt patients were prescribed adjusted higher doses of anti-coagulation, only 60% of these patients were monitored with Anti-Factor Xa assays. Of these assays, 66% showed sub-prophylactic levels. The majority of results led to the adjustment of the dose of anticoagulant. However, often dose changes were made late. DISCUSSION AND CONCLUSIONS: The audit confirmed the need for increased doses of prophylactic anticoagulation in severe burns. The better adherence to the guidelines can be achieved by additional training and implementation of decision support via electronic prescribing system.