Immunosuppression and Covid-19: Risk factor or treatment?

Introduction: During the Covid-19 pandemic, 540,895 people were identified as immunosuppressed and believed to be at increased risk of severe disease.1 As the pandemic evolved, biologic immunosuppression became a treatment of severe Covid-19.2 The true impact of immunosuppression on disease severity remains unclear. Objective(s): 1. Identify the incidence of immunosuppressed patients admitted to the ICU. 2. Analyse the mortality of those who are immunocompetent and immunosuppressed. 3. Examine the differences in mortality and level of care required between sub groups of patients on immunosuppression;those on biologics, non-biologics, and a combination of both. Method(s): A retrospective search of all Covid-19 positive admissions from March 2020 to November 2021 across two adult ICUs at Chelsea & Westminster NHS Trust was performed, using the EPR system. We identified those on immunosuppressive drugs, the level of care they required, and 28 day mortality. We categorised different types of immunosuppression, vaccination status, if applicable and co-morbidities. The exclusion criteria were primarily those with false positive swabs or incomplete data. Result(s): Baseline characteristics were median age (56 vs 56), and APCHE II score (20.08 in the immunosuppressed group vs 14.0 in immunocompetent). Thirteen immunosuppressed patients were identified. Reasons for drug immunosuppression in this group included solid organ transplant (6/13), and autoimmune conditions (7/13). Two patients were on biologic drugs alone, 8 were on non-biologics, and 3 were on a combination. Four of this group had received at least 2 doses of a Covid-19 vaccine. Mortality was 61.54% (8/13) in the immunosuppressed group vs 36.65% (199/543) in the immunocompetent group. Conclusion(s): Despite similar demographics, patients on immunosuppression had a significantly higher mortality than the immunocompetent group. Interestingly, those on targeted biological immunosuppression had the lowest incidence of requiring level 3 care, and no deaths. It is a possibility that biologics dampen the hyper-inflammation seen in severe Covid-19 pneumonitis, raising the question of a possible protective benefit from severe disease. This reflects the findings of the REMAP-CAP investigators,3 who showed that the IL-6 inhibiting biologics Tocilizumab and Sarilumab are efficacious against the most severe disease following admission to ICU with Covid-19 pneumonitis. The single centre and retrospective observational design, combined with small numbers on immunosuppression, despite a large inclusion criterion, mean it is not possible to make statistical conclusions. Confounding factors include the effects of vaccination, shielding and the change in SARS-CoV-2 variant prevalent during different times during the pandemic.

Taking Stock: Mobile Covid-19 airway trolleys, whose responsibility is it?

Introduction: During the COVID-19 pandemic, mobile airway trollies formed an integral part of the emergency airway management. The AAGBI and ICS produced consensus guidelines recommending a COVID-19 airway trolley or pack;however, the maintenance guidance of these trollies is unclear.1 The pandemic placed severe pressure on all critical care staff, especially nursing staff. The airway trolley checks were transitioned to the junior doctors after wave one at Chelsea and Westminster Hospital. Unfortunately, trollies were not adequately checked and stocked. This created potential delays with emergency tracheal intubations, jeopardizing patient safety. Using a Plan Do Study Act (PDSA) approach we attempted to understand the factors affecting our compliance and ultimately improve patient safety. Objectives: 1. Identify which group of ICU professionals should check the airway trollies 2. Identify the barriers to safety checks? 3. Assess which targeted interventions improve compliance with checks? Methods: Single centre, prospective data collection (surveys n= 23 and trollies checklist compliance) over a 7 month period. Data on the frequency and accuracy of the checks was collected monthly. Surveys were used to identify appropriate and targeted interventions. Interventions were made at each cycle to address shortfalls in checks. Results: 1. 87% of staff believed that doctors (SHOs or SpRs) should check the airway trollies. 2. Barriers identified were 1. Lack of time or too busy 68% 2. Lack of organisation (finding stock or understanding equipment) 41% 3. Difficulty in finding the checklists 27% 3. Compliance improved from 34% to 77%, through various interventions (see graph below) At baseline (November) trolley check compliance was 34%. Changes were made to improve accessibility of checklists and equipment, and daily reminders were added to the morning operational handover. However, this only improved the check frequency to 38%. A staff survey highlighted recommendations for improvement: daily allocation of checks to a specific doctor and airway education. The trolley check allocation was built into the doctors' rota and airway trolley education was added to the departmental induction. There was minimal initial change in the following month but further applied education in the form of consultant-led airway skills sessions to engage the doctors in the process saw rates drastically improved to 75% and 77% over the following two months. Unpredictable challenges which negatively influenced the results were identified. These included surge rotas, including redeployed non-ICU doctors in checks and increased trolley numbers with increased ICU capacity. Conclusions: This quality improvement project, performed during the height of a pandemic, demonstrates the importance of adaptation and persistence to identify interventions that take into account the evolving clinical environment and human factors. It highlighted the difficulty in building new habits within the daily routine of junior doctors and the necessity of senior lead teaching to build the doctors' confidence, understanding and engagement with safety processes. Following the rigorous cycles, it is expected that the routine for the trolley checks is sufficient to withstand the rotations of junior doctors and expansion of the department in potential future waves of the pandemic.

Imgs 'the glue of paediatric rotas', but who are they?

Background International Medical Graduates (IMG) form a significant part of the paediatric workforce in the UK. IMGs come from diverse cultural and ethnic backgrounds, and some have many years of postgraduate training in their country of origin (COO). The composition of this workforce includes: Speciality Trainees (ST1-ST8), Trust grade (Clinical Fellows), SAS (Speciality and Associate Specialty), and Locums. Due to the heterogeneity of this group, it is hard to find data to characterise this vital part of the workforce. We hope to fill a gap by starting to understand this group and the particular challenges they face, related to adopting to the new environment in their personal, social and work life. During Covid many of these doctors have faced additional challenges of isolation, being separated for long periods from family overseas, and not having the usual opportunities to make connections outside work. Our project, 'Soft Landing' aims to understand and help address these challenges. Objectives To explore the challenges faced by an IMGs in personal, social and working lives and how they progress through their careers in UK. Methods The survey was distributed via email to Training Programme Directors, as well as via social media. It was open to all paediatric IMGs in UK. Results 108 IMGs participated in the survey. 44% of them had worked in the UK for <12 months. Almost half planned to apply for training posts. The doctor's roles: Trainees: 15%, Non-Trainees (Level 1 and 2): 65%, Locum SHO: 20%. For most (80%), induction at start of post was not IMG tailored. 75% of participants had more than 5 years postgraduate experience. Despite most having many years of clinical experience, only 14% of IMGs felt confident during their first on call. Communication was a challenge for 50% of the cohort, and safeguarding was another concern with only 9% reporting feeling confident. Career-wise, 33% of participants mentioned their educational supervisor was aware of their career goals. 90% of the cohort reported opportunity to participate in audits and QIPs. However, only 30% of participants had an opportunity to present at national/international conference. Of concern, and reflecting WRES (Workforce Race Equality Standard) data on the experience of the medical BAME workforce, 60% of the cohort, mentioned that they had to take time off from work due to stress. The stress was related to 'work load', 'racism', 'non-supportive supervisors', 'difficult colleagues' and 'challenging patients'. 56% of the cohort mentioned that they were bullied and harassed in the work place. 40% of the cohort had received negative feed back at work. A large number, 46%, of the cohort had considered leaving UK. Conclusions Our survey highlights areas of challenge, data which reflects our own experiences as IMGs. This allows us to identify key areas for improvement. With a better understanding of the issues, and gaps identified we have established the Soft Landing project. We hope to work with key stakeholders to address these identified areas for improved support in order to continue to recruit and retain this valuable part of the workforce.

Non-pulmonary manifestations of coronavirus disease 2019 (COVID-19): Case report

Doctors from various specialties across the world are faced with the management of coronavirus disease 2019 (COVID-19). The typical presentation is one of viral pneumonia, with a large spectrum of disease severity. Increasingly, extra-pulmonary manifestations are being reported, often in those with significant pulmonary pathology. Here we discuss a novel presentation of COVID-19, with no pulmonary involvement and the challenges faced by clinicians in achieving the correct diagnosis. A previously fit and well 30-year-old female presented with gastroenteritis, pyrexias, myalgia, rashes, conjunctivitis, and myocarditis. There were no respiratory features, either from her history or clinical examination. Initial and subsequent reverse transcription polymerase chain reaction (RT-PCR) swabs were negative for severe acute respiratory failure coronavirus 2 (SARS-CoV-2), alongside normal appearances of her lungs on computed tomography scans. Her third and final COVID-19 RT-PCR swab was positive, just prior to transfer for her ongoing myocarditis management, at a specialist cardiac critical care. She went on to make a full recovery. Novel presentations of COVID-19 signify a new challenge to clinicians. Correct diagnosis is important for the patient, as well as staff safety. Atypical presentations often have non-specific clinical features, and so a strong index of suspicion, appropriate exclusion of differentials and a multi-disciplinary approach are needed. © Journal of Emergency and Critical Care Medicine. All rights reserved.