Palliative care in critically ill COVID-19 patients: the early New York City experience.

OBJECTIVES: The COVID-19 pandemic in the USA has been accompanied by high rates of mortality and an unprecedented need for palliative care delivery. Little is known about the use of palliative care services in intensive care unit (ICU) settings during the COVID-19 pandemic. METHODS: This is a retrospective cohort study of critically ill COVID-19 patients requiring ICU admission, between 7 March and 14 April 2020 to two academic teaching hospitals in New York City. Palliative care consultation included a one-time telemedicine consultation or continued telemedicine consultation and follow-up with multidisciplinary team involvement. Patient information was collected from the electronic health record and analyses were conducted with Stata V.15.1 (StataCorp) statistical software. RESULTS: A total of 151 critically ill patients with COVID-19 pneumonia requiring ICU admission were identified, of whom 59 (39.07%) received an inpatient palliative care consultation. More than half of patients died (n=85/151, 56.29%), with 57.65% (n=49/85) of these patients receiving palliative care services during their hospitalisation. Patients who received palliative care consultation were more likely to be older, sicker and receive mechanical ventilation than their counterparts. Patients who died and did not receive palliative care were younger and required non-invasive ventilation support. CONCLUSION: There is a lack of utilisation of palliative care in COVID-19 patients admitted to the ICU. Further research into predictors of poor outcomes in critically ill COVID-19 patients may help identify patients that would benefit from early palliative care involvement going forward.

Impact of corticosteroids in hospitalised COVID-19 patients.

BACKGROUND: Corticosteroids are a potential therapeutic agent for patients with COVID-19 pneumonia. The RECOVERY (Randomised Trials in COVID-19 Therapy) trial provided data on the mortality benefits of corticosteroids. The study aimed to determine the association between corticosteroid use on mortality and infection rates and to define subgroups who may benefit from corticosteroids in a real-world setting. METHODS: Clinical data were extracted that included demographic, laboratory data and details of the therapy, including the administration of corticosteroids, azithromycin, hydroxychloroquine, tocilizumab and anticoagulation. The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) admission and invasive mechanical ventilation. Outcomes were compared in patients who did and did not receive corticosteroids using the multivariate Cox regression model. RESULTS: 4313 patients were hospitalised with COVID-19 during the study period, of whom 1270 died (29.4%). When administered within the first 7 days after admission, corticosteroids were associated with reduced mortality (OR 0.73, 95% CI 0.55 to 0.97, p=0.03) and decreased transfers to the ICU (OR 0.72, 95% CI 0.47 to 1.11, p=0.02). This mortality benefit was particularly impressive in younger patients (<65 years of age), females and those with elevated inflammatory markers, defined as C reactive protein ≥150 mg/L (p≤0.05), interleukin-6 ≥20 pg/mL (p≤0.05) or D-dimer ≥2.0 µg/L (p≤0.05). Therapy was safe with similar rates of bacteraemia and fungaemia in corticosteroid-treated and non-corticosteroid-treated patients. CONCLUSION: In patients hospitalised with COVID-19 pneumonia, corticosteroid use within the first 7 days of admission decreased mortality and ICU admissions with no associated increase in bacteraemia or fungaemia.

Relocating IV Pumps for Critically Ill Isolated Coronavirus Disease 2019 Patients From Bedside to Outside the Patient Room.

Discuss advantages and disadvantages of relocating IV pumps for coronavirus disease 2019 patients from bedside to outside the patient room and characterize reproducible details of an external infusion pump model. DESIGN: Brief report. SETTING: ICUs at a single-center teaching hospital. PATIENTS: Critically ill coronavirus disease 2019 patients under contact and special droplet precautions. INTERVENTIONS: Relocation of IV pumps for coronavirus disease 2019 patients from bedside to outside the patient room using extension tubing. MEASUREMENTS AND MAIN RESULTS: Infusion pumps secured to a rolling IV pole are moved immediately outside the patient room with extension tubing, reaching the patient through a closed door. It is anticipated that this practice may reduce unnecessary coronavirus disease 2019 exposure for healthcare professionals, reduce the consumption of personal protective equipment, and promote patient safety by limiting delays of donning personal protective equipment to initiate or adjust medications. CONCLUSIONS: Risks of situating IV pumps outside the patient room must be carefully weighed against the benefits. Relocation of IV pumps outside the patient room may be considered given shortages of personal protective equipment and high risk of healthcare professional exposure. Institutional review-approved studies investigating the measured impact on decreased exposure, personal protective equipment usage, and patient safety are required.

The Feasibility and Impact of Prospective Medication Review in the Emergency Department.

OBJECTIVE: We evaluated the feasibility and impact of prospective medication review (PMR) in the emergency department (ED). METHODS: This was a retrospective cohort study of all nonadmitted ED patients who were prescribed medication orders by ED clinicians from September 2014 to September 2015 to determine the time intervals utilized during each step of the medication use process and quantify the number of interventions conducted by the pharmacist and cost avoidance accrued from the interventions. RESULTS: A total of 834 medication orders were included for evaluation. The median time for order verification, order verification to dispense, and dispense to administration were 3 minutes (interquartile range [IQR] = 1-7 minutes), 20 minutes (IQR = 7-45 minutes), and 10 minutes (IQR = 6-16 minutes). The median time interval for order verification was longer during the overnight pharmacy shift (median = 5 minutes, IQR = 2-9 minutes) compared to the day and evening shifts (median = 3 minutes, IQR = 1-6 minutes). A total of 563 interventions were recommended by the pharmacists and accepted by ED clinicians. These interventions equated to US$47 585 worth of cost avoidance. CONCLUSION: The PMR is a feasible process that resulted in safe and effective use of medications without causing delays to patient care.