The effect of SARS-COV-2 variant on non-respiratory features and mortality among vaccinated and non-fully vaccinated patients.

OBJECTIVE: To determine the effect of SARS-CoV-2 variants on non-respiratory features of COVID-19 in vaccinated and not fully vaccinated patients using a University of California database. METHODS: A longitudinal retrospective review of medical records (n = 63,454) from 1/1/2020-4/26/2022 using the UCCORDS database was performed to compare non-respiratory features, vaccination status, and mortality between variants. Chi-square tests were used to study the relationship between categorical variables using a contingency matrix. RESULTS: Fever was the most common feature across all variants. Fever was significantly higher in not fully vaccinated during the Delta and Omicron waves (p = 0.001; p = 0.001). Cardiac features were statistically higher in not fully vaccinated during Omicron; tachycardia was only a feature of not fully vaccinated during Delta and Omicron; diabetes and GI reflux were features of all variants regardless of vaccine status. Odds of death were significantly increased among those not fully vaccinated in the Delta and Omicron variants (Delta OR: 1.64, p = 0.052; Omicron OR: 1.96, p < 0.01). Vaccination was associated with a decrease in the frequency of non-respiratory features. CONCLUSIONS: Risk of non-respiratory features of COVID-19 is statistically higher in those not fully vaccinated across all variants. Risk of death and correlation with vaccination status varied.

Secondary infections in critically ill patients with COVID-19 receiving steroid therapy.

Secondary infections can occur during or after the treatment of an initial infection. Glucocorticoids may decrease mortality in patients with severe COVID-19; however, risk of secondary infection is not well described. Our primary objective was to investigate the risk of secondary infection among critically ill patients with COVID-19 treated with glucocorticoids. We examined patients with COVID-19 being treated in the intensive care unit at two academic medical centers from 1 to 7/2020. One hundred-seven patients were included. Of these, 31 received steroids and 76 patients did not. Analysis of the larger cohort was performed followed by a matched pairs analysis of 22 steroid and 22 non-steroid patients. Secondary infection was seen in 14 patients (45.2%) receiving steroids compared to 35(46.1%) not receiving steroids (p = 0.968). Secondary infections were most frequently encountered in the respiratory tract. Escherichia coli and Staphylococcus aureus were the most frequently identified organisms. Mortality was 16.1% in the steroid-treated group compared to 23.7% in the control group (p = 0.388). After performing matched pairs analysis and multivariable logistic regression there was no significant difference between secondary infection or mortality and steroid receipt. Secondary infections were common among critically ill patients with COVID-19, but the incidence of secondary infection was not significantly impacted by steroid treatment.

Development and Validation of an ICU Delirium Playbook for Provider Education.

Although delirium detection and prevention practices are recommended in critical care guidelines, there remains a persistent lack of effective delirium education for ICU providers. To address this knowledge-practice gap, we developed an "ICU Delirium Playbook" to educate providers on delirium detection (using the Confusion Assessment Method for the ICU) and prevention. DESIGN: Building on our previous ICU Delirium Video Series, our interdisciplinary team developed a corresponding quiz to form a digital "ICU Delirium Playbook." Playbook content validity was evaluated by delirium experts, and face validity by an ICU nurse focus group. Additionally, focus group participants completed the quiz before and after video viewing. Remaining focus group concerns were evaluated in semi-structured follow-up interviews. SETTING: Online validation survey, virtual focus group, and virtual interviews. SUBJECTS: The validation group included six delirium experts in the fields of critical care, geriatrics, nursing, and ICU education. The face validation group included nine ICU nurses, three of whom participated in the semi-structured feedback interviews. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The 44-question quiz had excellent content validity (average scale-level content validity index [S-CVI] of individual items = 0.99, universal agreement S-CVI = 0.93, agreement κ ≥ 0.75, and clarity p ≥ 0.8). The focus group participants completed the Playbook in an average (sd) time of 53 (14) minutes, demonstrating significant improvements in pre-post quiz scores (74% vs 86%; p = 0.0009). Verbal feedback highlighted the conciseness, utility, and relevance of the Playbook, with all participants agreeing to deploy the digital education module in their ICUs. CONCLUSIONS: The ICU Delirium Playbook is a novel, first-of-its-kind asynchronous digital education tool aimed to standardize delirium detection and prevention practices. After a rigorous content and face validation process, the Playbook is now available for widespread use.

The effect of SARS-CoV-2 variant on respiratory features and mortality.

SARS-CoV-2 (COVID-19) has caused over 80 million infections 973,000 deaths in the United States, and mutations are linked to increased transmissibility. This study aimed to determine the effect of SARS-CoV-2 variants on respiratory features, mortality, and to determine the effect of vaccination status. A retrospective review of medical records (n = 55,406 unique patients) using the University of California Health COvid Research Data Set (UC CORDS) was performed to identify respiratory features, vaccination status, and mortality from 01/01/2020 to 04/26/2022. Variants were identified using the CDC data tracker. Increased odds of death were observed amongst unvaccinated individuals and fully vaccinated, partially vaccinated, or individuals who received any vaccination during multiple waves of the pandemic. Vaccination status was associated with survival and a decreased frequency of many respiratory features. More recent SARS-CoV-2 variants show a reduction in lower respiratory tract features with an increase in upper respiratory tract features. Being fully vaccinated results in fewer respiratory features and higher odds of survival, supporting vaccination in preventing morbidity and mortality from COVID-19.

Reflexive thematic analysis of job-related problems associated with pharmacist suicide, 2003-2019.

BACKGROUND: Few qualitative studies have focused on suicide and specific job-related problems associated with suicide in pharmacists. Greater knowledge of specific work-related stressors amongst pharmacists could inform suicide prevention strategies. OBJECTIVE: To identify job-related stressors associated with pharmacist suicides and compare stressors to those previously reported in physicians and nurses. METHODS: Free-text law enforcement and medical examiner data for pharmacist suicides were extracted from the National Violent Death Registry (NVDRS) for 2003-2019. Reflexive thematic analysis was deployed via a deductive approach utilizing codes and themes found in previous research on nurse and physician suicides. New codes were also identified through inductive coding. RESULTS: A total of 291,872 suicides occurred between 2003 and 2019, of which 392 were pharmacist deaths. Of these, 62 pharmacist suicides were coded with job-related problems. Almost all deductive themes/codes extracted from nurses and physicians were present in pharmacists. Common codes found in the pharmacist dataset that were also found previously in physicians and nurses were: history of mental health, substance use disorder, hopelessness impending or proceeding job loss, and access to lethal weapons and/or drugs. Novel codes were added through inductive content analysis. Codes novel to pharmacists were: verbalized suicidal ideation (SI) or intent, diversion for the purpose of suicide, and the fear of job loss. Disciplinary action at the institutional level was associated with the fear of job loss and cited as the event triggering suicide completion. CONCLUSION: Pharmacists have similar job-related stressors associated with suicide as physicians and nurses. Evaluating the process of disciplinary action is warranted. Future research is indicated to evaluate causal relationship between work-related stressors and mental health outcomes leading to suicide in pharmacists.

Proning in COVID-19 Acute Respiratory Distress Syndrome: Role of Paralytics.

Although proning is beneficial to acute respiratory distress syndrome, impressions vary about its efficacy. Some providers believe that paralysis is required to facilitate proning. We studied impact of paralysis on prone-induced gas exchange improvements and provider attitudes regarding paralytics. DESIGN: Observational. SETTING: University of California San Diego. PATIENTS: Intubated COVID acute respiratory distress syndrome patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 1) Changes in Pao2:Fio2 and Spo2:Fio2 ratios before and after proning with and without paralytics, 2) adverse events during proning with and without paralytics, and 3) nurse and physician attitudes about efficacy/safety of proning with and without paralytics. Gas-exchange improvement with proning was similar with and without paralytics (with no serious adverse events). Survey results showed similar attitudes between nurses and physicians about proning efficacy but differing attitudes about the need for paralytics with proning. CONCLUSIONS: Findings support use of proning and may help in design of randomized trials to assess paralytics in acute respiratory distress syndrome management.

Development and Evaluation of an Intensive Care Unit Video Series to Educate Staff on Delirium Detection.

Background: Delirium affects up to 80% of patients who are mechanically ventilated in the intensive care unit (ICU) but often goes undetected because of incomplete and/or inaccurate clinician evaluation and documentation. A lack of effective, feasible, and sustainable educational methods represents a key barrier to efforts to optimize, scale, and sustain delirium detection competencies. Progress with such barriers may be addressed with asynchronous video-based education. Objective: To evaluate a novel ICU Delirium Video Series for bedside providers via a knowledge assessment quiz and a feedback questionnaire. Methods: An interdisciplinary team scripted and filmed an educational ICU Delirium Video Series, providing detailed instruction on delirium detection using the validated CAM-ICU (Confusion Assessment Method for the ICU). A cohort of bedside nurses subsequently viewed and evaluated the ICU Delirium Video Series using a feedback questionnaire and a previously developed knowledge assessment quiz pre- and post-video viewing. Results: Twenty nurses from four ICUs viewed the ICU Delirium Video Series and completed the pre-post quiz and questionnaire. Ten (50%) respondents had 10 or more years of ICU experience, and seven (35%) reported receiving no CAM-ICU education locally. After video viewing, overall pre-post scores improved significantly (66% vs. 79%; P < 0.0001). In addition, after video viewing, more nurses reported comfort in their ability to evaluate and manage patients with delirium. Conclusion: Viewing the ICU Delirium Video Series resulted in significant improvements in knowledge and yielded valuable feedback. Asynchronous video-based delirium education can improve knowledge surrounding a key bedside competency.