A Virtual Ward Model of Care for Patients With COVID-19: Retrospective Single-Center Clinical Study.

BACKGROUND: COVID-19 has necessitated the implementation of innovative health care models in preparation for an influx of patients. A virtual ward model delivers clinical care remotely to patients in isolation. We report on an Australian cohort of patients with COVID-19 treated in a virtual ward. OBJECTIVE: The aim of this study was to describe and evaluate the safety and efficacy of a virtual ward model of care for an Australian cohort of patients with COVID-19. METHODS: Retrospective clinical assessment was performed for 223 patients with confirmed COVID-19 treated in a virtual ward in Brisbane, Australia, from March 25 to May 15, 2020. Statistical analysis was performed for variables associated with the length of stay and hospitalization. RESULTS: Of 223 patients, 205 (92%) recovered without the need for escalation to hospital care. The median length of stay in the virtual ward was 8 days (range 1-44 days). In total, 18 (8%) patients were referred to hospital, of which 6 (33.3%) were discharged after assessment at the emergency department. Furthermore, 12 (5.4%) patients were admitted to hospital, of which 4 (33.3%) required supplemental oxygen and 2 (16.7%) required mechanical ventilation. No deaths were recorded. Factors associated with escalation to hospital care were the following: hypertension (odds ratio [OR] 3.6, 95% CI 1.28-9.87; P=.01), sputum production (OR 5.2, 95% CI 1.74-15.49; P=.001), and arthralgia (OR 3.8, 95% CI 1.21-11.71; P=.02) at illness onset and a polymerase chain reaction cycle threshold of ≤20 on a diagnostic nasopharyngeal swab (OR 5.0, 95% CI 1.25-19.63; P=.02). CONCLUSIONS: Our results suggest that a virtual ward model of care to treat patients with COVID-19 is safe and efficacious, and only a small number of patients would potentially require escalation to hospital care. Further studies are required to validate this model of care.

Dextrose Prolotherapy Versus Control Injections in Painful Rotator Cuff Tendinopathy.

OBJECTIVE: To compare the effect of dextrose prolotherapy on pain levels and degenerative changes in painful rotator cuff tendinopathy against 2 potentially active control injection procedures. DESIGN: Randomized controlled trial, blinded to participants and evaluators. SETTING: Outpatient pain medicine practice. PARTICIPANTS: Persons (N=73) with chronic shoulder pain, examination findings of rotator cuff tendinopathy, and ultrasound-confirmed supraspinatus tendinosis/tear. INTERVENTIONS: Three monthly injections either (1) onto painful entheses with dextrose (Enthesis-Dextrose), (2) onto entheses with saline (Enthesis-Saline), or (3) above entheses with saline (Superficial-Saline). All solutions included 0.1% lidocaine. All participants received concurrent programmed physical therapy. MAIN OUTCOME MEASURES: Primary: participants achieving an improvement in maximal current shoulder pain ≥2.8 (twice the minimal clinically important difference for visual analog scale pain) or not. Secondary: improvement in the Ultrasound Shoulder Pathology Rating Scale (USPRS) and a 0-to-10 satisfaction score (10, completely satisfied). RESULTS: The 73 participants had moderate to severe shoulder pain (7.0±2.0) for 7.6±9.6 years. There were no baseline differences between groups. Blinding was effective. At 9-month follow-up, 59% of Enthesis-Dextrose participants maintained ≥2.8 improvement in pain compared with Enthesis-Saline (37%; P=.088) and Superficial-Saline (27%; P=.017). Enthesis-Dextrose participants' satisfaction was 6.7±3.2 compared with Enthesis-Saline (4.7±4.1; P=.079) and Superficial-Saline (3.9±3.1; P=.003). USPRS findings were not different between groups (P=.734). CONCLUSIONS: In participants with painful rotator cuff tendinopathy who receive physical therapy, injection of hypertonic dextrose on painful entheses resulted in superior long-term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline. These differences could not be attributed to a regenerative effect. Dextrose prolotherapy may improve on the standard care of painful rotator cuff tendinopathy for certain patients.

The use of cusum analysis in the early detection and management of hospital bed occupancy crises.

OBJECTIVE: To assess the value of cusum analysis in hospital bed management. DESIGN: Comparative analysis of medical patient flows, bed occupancy, and emergency department admission rates and access block over 2 years. SETTING: Internal Medicine Services and Emergency Department in a teaching hospital. INTERVENTIONS: Improvements in bed use and changes in the level of available beds. MAIN OUTCOME MEASURES: Average length of stay; percentage occupancy of available beds; number of patients waiting more than 8 hours for admission (access block); number of medical patients occupying beds in non-medical wards; and number of elective surgical admissions. RESULTS: Cusum analysis provided a simple means of revealing important trends in patient flows that were not obvious in conventional time-series data. This prompted improvements in bed use that resulted in a decrease of 9500 occupied bed-days over a year. Unfortunately and unexpectedly, after some initial improvement, the levels of access block, medical ward congestion and elective surgical admissions all then deteriorated significantly. This was probably caused by excessive bed closures in response to the initial improvement in bed use. CONCLUSION: Cusum analysis is a useful technique for the early detection of significant changes in patient flows and bed use, and in determining the appropriate number of beds required for a given rate of patient flow.

Achieving better in-hospital and after-hospital care of patients with acute cardiac disease.

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after-hospital care, patient self-care, and hospital-community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included: clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); educational interventions (seminars, academic detailing); regular performance feedback; patient self-management strategies; and hospital-community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before-after study design to assess program impact, significantly more program patients compared with historical controls received: ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and beta-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. CHF: Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, beta-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P = 0.06) and from 13.4% to 10.1% (P = 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P = 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.