An innovative Indigenous-led model for integrated COVID-19 case management in Auckland, New Zealand: lessons from implementation.

In Aotearoa/New Zealand (NZ), the Indigenous Maori population have been more severely impacted than non-Maori throughout the COVID-19 pandemic, and less well served by NZ's COVID-19 response. This case-study describes an innovative Indigenous-led service delivery model, which was designed and implemented to improve the case and contact management of Maori with COVID-19 in Auckland. We outline the context in which the conventional public health case and contact management was failing Maori and the factors which enabled Indigenous innovation and leadership. We describe the details of the model and how the approach fundamentally differed to the conventional approach to care. Qualitative and quantitative data on impact of the model are shared, along with the key barriers and enablers in the implementation of the model. The Maori Regional Coordination Hub (MRCH) model offers a valuable alternative to the conventional public health case and contact management approach, and this case study highlights lessons which may be applicable to improving the design and delivery of public health services to other Indigenous and marginalized groups.

Guidelines on the management of acute respiratory distress syndrome.

The Faculty of Intensive Care Medicine and Intensive Care Society Guideline Development Group have used GRADE methodology to make the following recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS). The British Thoracic Society supports the recommendations in this guideline. Where mechanical ventilation is required, the use of low tidal volumes (<6 ml/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) was recommended. For patients with moderate/severe ARDS (PF ratio<20 kPa), prone positioning was recommended for at least 12 hours per day. By contrast, high frequency oscillation was not recommended and it was suggested that inhaled nitric oxide is not used. The use of a conservative fluid management strategy was suggested for all patients, whereas mechanical ventilation with high positive end-expiratory pressure and the use of the neuromuscular blocking agent cisatracurium for 48 hours was suggested for patients with ARDS with ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF) ratios less than or equal to 27 and 20 kPa, respectively. Extracorporeal membrane oxygenation was suggested as an adjunct to protective mechanical ventilation for patients with very severe ARDS. In the absence of adequate evidence, research recommendations were made for the use of corticosteroids and extracorporeal carbon dioxide removal.

The role of occupational and physiotherapy in multi-modal approach to tackling delirium in the intensive care.

The presence of delirium within critical care remains a long-standing challenge for patients and clinicians alike. A myriad of pre-disposing and precipitating factors lead to this patient cohort being high risk for developing delirium during their critical care stay. Until now, non-pharmacological management of these patients usually encompasses a 'bundle' of principles to reduce delirium days. These bundles have limited focus on the entire multi-disciplinary team (including occupational therapists and physiotherapists) who could assist with the reduction of delirium. The purpose of this analysis is to review the current literature and develop a mnemonic, which may help facilitate collaborative working for patients with delirium. Electronic databases were searched for non-pharmacological managements of delirium within intensive care settings, after 2006. Critical appraisal using Critical Appraisal Skills Programme methodology was completed by the author. Multi-intervention approaches and bundles are successful at reducing delirium days, and in some cases, reducing hospital length of stay. The key components of these bundles include spontaneous breathing trials, daily sedation holds, addressing pain relief, early mobilisation and to a small extent normalisation of a daily routine. There is limited research into the role of therapy within this patient group, but there is a role for cognitive therapy, functional tasks, and a greater rehab emphasis within other patient populations such as stroke and elderly care. The critical care population have similar rehabilitation needs to these groups, and therefore would benefit from similar treatment plans. Critical care patients with delirium may benefit from a range of additional therapeutic activities to reduce the duration of delirium. The D.E.L.I.R.I.U.M mnemonic has been developed to encompass all the key elements of current delirium research in a simplistic memorable fashion. Further work is needed to trial the usefulness of the mnemonic in clinical practice to enable the entire multi-disciplinary team work collaboratively to reduce delirium with the intensive care.

Perceptions of diagnosis and management of patients with acute respiratory distress syndrome: a survey of United Kingdom intensive care physicians.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is a potentially devastating refractory hypoxemic illness with multi-organ involvement. Although several randomised controlled trials into ventilator and fluid management strategies have provided level 1 evidence to guide supportive therapy, there are few, established guidelines on how to manage patients with ARDS. In addition, and despite their continued use, pharmacotherapies for ARDS disease modulation have no proven benefit in improving mortality. Little is known however about the variability in diagnostic and treatment practices across the United Kingdom (UK). The aim of this survey, therefore, was to assess the use of diagnostic criteria and treatment strategies for ARDS in critical care units across the UK. METHODS: The survey questionnaire was developed and internally piloted at University Hospital Southampton NHS Foundation Trust. Following ethical approval from University of Southampton Ethics and Research Committee, a link to an online survey engine (Survey Monkey) was then placed on the Intensive Care Society (UK) website. Fellows of The Intensive Care Society were subsequently personally approached via e-mail to encourage participation. The survey was conducted over a period of 3 months. RESULTS: The survey received 191 responses from 125 critical care units, accounting for 11% of all registered intensive care physicians at The Intensive Care Society. The majority of the responses were from physicians managing general intensive care units (82%) and 34% of respondents preferred the American European Consensus Criteria for ARDS. There was a perceived decline in both incidence and mortality in ARDS. Primary ventilation strategies were based on ARDSnet protocols, though frequent deviations from ARDSnet positive end expiratory pressure (PEEP) recommendations (51%) were described. The majority of respondents set permissive blood gas targets (hypoxia (92%), hypercapnia (58%) and pH (90%)). The routine use of pharmacological agents is rare. Neuromuscular blockers and corticosteroids are considered occasionally and on a case-by-case basis. Routine (58%) or late (64%) tracheostomy was preferred to early tracheostomy insertion. Few centres offered routine follow-up or dedicated rehabilitation programmes following hospital discharge. CONCLUSIONS: There is substantial variation in the diagnostic and management strategies employed for patients with ARDS across the UK. National and/or international guidelines may help to improve standardisation in the management of ARDS.

What errors can be identified by Pharmacy-led medicines reconciliation? A prospective study.

AIM: To establish the nature and frequency of discrepancies identified by pharmacy staff during medicines reconciliation.(MR) METHODS: Pharmacy staff collected data prospectively from 161 patients over a 1 week period, including information on any prescription errors identified. RESULTS: In total, 62 patients (48%) taking one or more medications prior to admission to hospital had one or more discrepancies found by pharmacy staff during MR. The most common discrepancy was omission of one or more drugs. CONCLUSIONS: Pharmacy staff identified several unintentional discrepancies in prescribing of medications at admission to hospital. Doctors should ensure that intentional changes to patient prescriptions are clearly documented.