Post-COVID syndrome symptoms, functional disability, and clinical severity phenotypes in hospitalized and nonhospitalized individuals: A cross-sectional evaluation from a community COVID rehabilitation service.

There is currently limited information on clinical severity phenotypes of symptoms and functional disability in post-coronavirus disease 2019 (COVID) Syndrome (PCS). A purposive sample of 370 PCS patients from a dedicated community COVID-19 rehabilitation service was assessed using the COVID-19 Yorkshire Rehabilitation Scale where each symptom or functional difficulty was scored on a 0-10 Likert scale and also compared with before infection. Phenotypes based on symptom severity were extracted to identify any noticeable patterns. The correlation between symptom severity, functional disability, and overall health was explored. The mean age was 47 years, with 237 (64%) females. The median duration of symptoms was 211 days (interquartile range 143-353). Symptoms and functional difficulties increased substantially when compared to before infection. Three distinct severity phenotypes of mild (n = 90), moderate (n = 186), and severe (n = 94) were identified where the severity of individual symptoms was of similar severity within each phenotype. Symptom scores were strongly positively correlated with functional difficulty scores (0.7, 0.6-0.7) and moderately negatively correlated with overall health (-0.4, -0.3, to -0.5). This is the first study reporting on severity phenotypes in a largely nonhospitalized PCS cohort. Severity phenotypes might help stratify patients for targeted interventions and planning of care pathways.

Adherence to the 'Atrial Fibrillation Better Care' Pathway in Patients with Atrial Fibrillation: Impact on Clinical Outcomes-A Systematic Review and Meta-Analysis of 285,000 Patients.

OBJECTIVE: The 'Atrial fibrillation Better Care' (ABC) pathway has been recently proposed as a holistic approach for the comprehensive management of patients with atrial fibrillation (AF). We performed a systematic review of current evidence for the use of the ABC pathway on clinical outcomes. METHODS AND RESULTS: We performed a systematic review and meta-analysis according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed and EMBASE were searched for studies reporting the prevalence of ABC-pathway-adherent management in AF patients, and its impact on clinical outcomes (all-cause death, cardiovascular death, stroke, and major bleeding). Meta-analysis of odds ratio (OR) was performed with random-effects models; subgroup analysis and meta-regression were performed to account for heterogeneity. Among the eight studies included, we found a pooled prevalence of ABC-adherent management of 21% (95% confidence interval, CI: 13-34%), with a high grade of heterogeneity, explained by the increasing adherence to each ABC criterion. Patients treated according to the ABC pathway showed a lower risk of all-cause death (OR: 0.42; 95% CI: 0.31-0.56), cardiovascular death (OR: 0.37; 95% CI: 0.23-0.58), stroke (OR: 0.55; 95% CI: 0.37-0.82) and major bleeding (OR: 0.69; 95% CI: 0.51-0.94), with moderate heterogeneity. Prevalence of comorbidities was moderators of heterogeneity for all-cause and cardiovascular death, while longer follow-up was associated with increased effectiveness for all outcomes. CONCLUSION: Adherence to the ABC pathway was suboptimal, being adopted in one in every five patients. Adherence to the ABC pathway was associated with a reduction in the risk of major adverse outcomes.

Strategies for sustaining high-quality pediatric asthma care in community hospitals.

OBJECTIVE: To identify strategies associated with sustained guideline adherence and high-quality pediatric asthma care in community hospitals. DATA SOURCES: Primary qualitative data from clinicians in hospitals across the United States (collected December 2019-February 2021). STUDY DESIGN: Pathways for Improving Pediatric Asthma Care (PIPA) was a national quality improvement (QI) intervention. In a prior quantitative study, data from 23 community hospitals in PIPA were analyzed to identify sites with the highest and lowest performance in sustaining improvements for 2 years. In this qualitative study, we conducted semi-structured interviews with multidisciplinary clinicians from these hospitals to identify strategies associated with sustainability. DATA COLLECTION/EXTRACTION METHODS: We purposefully sampled and interviewed participants involved in clinical care of children hospitalized with asthma at the identified hospitals (those with the highest/lowest sustainability performance). We transcribed and analyzed interview data using constant comparative methods. PRINCIPAL FINDINGS: Clinicians (n = 19) from five higher- and three lower-performing hospitals participated. In higher-performing hospitals, dedicated local champions more consistently provided reminders of evidence-based practices and delivered ongoing education. They also modified/developed electronic health record (EHR) tools (e.g., order sets with decision support). Higher-performing hospitals had a collaborative culture receptive to practice change and set firm expectations that evidence-based practices would be followed without exception. In lower-performing hospitals, participants described unique barriers, including delays in modifying the EHR and lack of automation of EHR tools (requiring clinicians to remember new EHR tasks without automated prompts). Barriers to sustainability for all hospitals included challenges with quality monitoring, decreasing focus of local champions over time, and ongoing difficulties developing consensus around evidence-based practices. CONCLUSIONS: To better ensure sustained high-quality care for children with asthma and greater returns on QI investments, QI leaders should prioritize: designating long-term local champions to continue reminders and educational efforts and developing electronic order sets to provide ongoing decision support.

Effect of the Implementation of a Local Care Pathway on the Transient Ischemic Attack Management in Emergency Departments.

BACKGROUND: Recent studies have demonstrated that urgent care decreases the risk of subsequent stroke after transient ischemic attack (TIA). In response to heterogeneous TIA management observed in our area, we developed a structured pathway, in accordance with current guidelines and adapted to local resources. We aim to assess the effect of local implementation of this care pathway on TIA management in emergency departments (EDs) in the Rhône area (France). PATIENTS AND METHODS: EDs of 5 centers that had a minimum of 30 TIA/year in Lyon and Bourgoin-Jallieu participated. The first 30 consecutive patients who had a TIA as main diagnosis admitted to one of these EDs from January 1 to December 31, 2013 and from January 1 to December 31, 2016, that is, before-and-after care pathway implementation, respectively, were retrospectively included in the study. The primary outcome was the adequate management of TIA defined as having had appropriate workup and antithrombotic treatment within 24 hours. RESULTS: A total of 141 patients were included in 2013 and 150 in 2016. There was a significant increase of complete (intracrania and extracranial) vessel imaging from 2013 to 2016 (n=42, 29.8% in 2013 vs. n=118, 78.7% in 2016; P<0.001). Computed tomography angiography was more often performed to assess intracranial and/or extracranial vessel imaging in 2016 compared with 2013 (n=54, 34.8% in 2013 vs. n=116, 77.3% in 2016; P<0.001). Overall, the rate of patients receiving adequate management significantly increased from 2013 to 2016 (n=36, 25.5% in 2013 vs. n=101, 67.3% in 2016; P<0.001). CONCLUSIONS: Implementation of a local care pathway, in accordance with current guidelines and adapted to local resources, improved TIA management in EDs, mostly by increasing the rate of vessel imaging by computed tomography angiography.

Pathways to diagnosis of pediatric TB patients: A mixed methods study from India.

BACKGROUND: A significant proportion of pediatric tuberculosis (TB) patients go unnotified due to the challenges in diagnosis of TB among children. The experiences of this vulnerable group while going through the TB care cascade remain largely undocumented. The aim of this study was to explore the experiences of pediatric TB patients and families along the pathway to TB diagnosis and appropriate treatment in four cities of India. METHODS: The study used a mixed methods, single phased, embedded design. The primary qualitative and secondary quantitative data were collected simultaneously by interviewing families of 100 randomly selected Xpert MTB/RIF positive pediatric TB patients, under the pediatric TB project, in 4 Indian cities using a semi-structured questionnaire. The qualitative component was analyzed to deduce patterns and themes on the patient and family experiences. Descriptive statistics were used to quantify various events along the TB care pathway including various delays (patient, diagnosis and total) and number of providers visited by patients during the diagnostic process. RESULTS: The median patient, diagnostic and total delays were 3 (IQR: 2,5), 39 (IQR: 23, 91) and 43 days (IQR: 28.5, 98.5), respectively. Patients visited a median of 3 (IQR: 2,4) providers before accessing Xpert MTB/RIF testing. On an average, 68.4% of physicians ordered any test most of them being irrelevant for TB diagnosis. Qualitative data showed considerable suffering for children and their families before and after TB diagnosis including serious concerns of stigma, disruption in education and social life and recurrence of the disease. CONCLUSION: Our study highlights the significant physical and social distress that the children with TB and their families undergo along the TB care pathway. It also shows diagnostic delay in excess of a month during which multiple providers were met and the patients underwent several diagnostic tests, most of them being inappropriate. Efforts to make Xpert MTB/RIF testing more accessible and part of physicians' toolkit will be of considerable value to ease the complexity of TB diagnosis in children. In addition, communication strategy needs to be developed and implemented to generate awareness among general population around pediatric TB and its management.

Assessing preparation for care transition among adolescents with rheumatologic disease: a single-center assessment with patient survey.

BACKGROUND: Despite the risk for poor outcomes and gaps in care in the transfer from pediatric to adult care, most pediatric rheumatology centers lack formal transition pathways. As a first step in designing a pathway, we evaluated preparation for transition in a single-center cohort of adolescents and young adults (AYA) with rheumatologic conditions using the ADolescent Assessment of Preparation for Transition (ADAPT) survey. FINDINGS: AYA most frequently endorsed receiving counseling on taking charge of their health and remembering to take medications. Less than half reported receiving specific counseling about transferring to an adult provider. AYA with lower education attainment compared with those who had attended some college or higher had lower scores in self-management (1.51 vs 2.52, p = 0.0002), prescription medication counseling (1.96 vs 2.41, p = 0.029), and transfer planning (0.27 vs 1.62, p < 0.001). AYA with a diagnosis of MCTD, Sjögren's or SLE had higher self-management scores than those with other diagnoses (2.6 vs 1.9; p = 0.048). Non-white youth indicated receiving more thorough medication counseling than white youth (2.71 vs 2.07, p = 0.027). When adjusting for age, educational attainment remained an independent predictor of transfer planning (p = 0.037). AYA with longer duration of seeing their physician had higher transition preparation scores (p = 0.021). CONCLUSION: Few AYA endorsed receiving comprehensive transition counseling, including discussion of transfer planning. Those who were younger and with lower levels of education had lower preparation scores. A long-term relationship with providers was associated with higher scores. Further research, including longitudinal assessment of transition preparation, is needed to evaluate effective processes to assist vulnerable populations.

Consequences of the emergency response to COVID-19: a whole health care system review in a single city in the United Kingdom.

BACKGROUND: The response to the COVID-19 pandemic in the United Kingdom included large scale changes to healthcare delivery, without fully understanding the potential for unexpected effects caused by these changes. The aim was "to ascertain the characteristics of patients, uncertainty over diagnosis, or features of the emergency response to the pandemic that could be modified to mitigate against future excess deaths". METHODS: Review of the entire pathway of care of patients whose death was registered in Salford during the 8 week period of the first wave (primary care, secondary care, 111 and 999 calls) in order to create a single record of healthcare prior to death. An expert panel judged avoidability of death against the National Mortality Case Record Review Programme scale. The panel identified themes using a structured judgement review format. RESULTS: There were 522 deaths including 197 in hospital, and 190 in care homes. 51% of patients were female, 81% Caucasian, age 79 ± 9 years. Dementia was present in 35%, COVID-19 was cause of death in 44%. Healthcare contact prior to death was most frequently with primary care (81% of patients). Forty-six patients (9%) had healthcare appointments cancelled (median 1 cancellation, range 1-9). Fewer than half of NHS 111 calls were answered during this period. 18% of deaths contained themes consistent with some degree of avoidability. In people aged ≥75 years who lived at home this was 53%, in care home residents 29% and in patients with learning disability 44% (n = 9). Common themes were; delays in patients presenting to care providers (10%), delays in testing (17%), avoidable exposure to COVID-19 (26%), delays in provider response (5%), and sub-optimal care (11%). For avoidability scores of 2 or 3 (indicating more than 50% chance of avoidability), 44% of cases had > 2 themes. CONCLUSIONS: The initial emergency response had unforeseen consequences resulting in late presentation, sub-optimal assessments, and delays in receiving care. Death in more vulnerable groups was more likely to display avoidability themes.

A Framework for Outpatient Infusion of Antispike Monoclonal Antibodies to High-Risk Patients with Mild-to-Moderate Coronavirus Disease-19: The Mayo Clinic Model.

The administration of spike monoclonal antibody treatment to patients with mild to moderate COVID-19 is very challenging. This article summarizes essential components and processes in establishing an effective spike monoclonal antibody infusion program. Rapid identification of a dedicated physical infrastructure was essential to circumvent the logistical challenges of caring for infectious patients while maintaining compliance with regulations and ensuring the safety of our personnel and other patients. Our partnerships and collaborations among multiple different specialties and disciplines enabled contributions from personnel with specific expertise in medicine, nursing, pharmacy, infection prevention and control, electronic health record (EHR) informatics, compliance, legal, medical ethics, engineering, administration, and other critical areas. Clear communication and a culture in which all roles are welcomed at the planning and operational tables are critical to the rapid development and refinement needed to adapt and thrive in providing this time-sensitive beneficial therapy. Our partnerships with leaders and providers outside our institutions, including those who care for underserved populations, have promoted equity in the access of monoclonal antibodies in our regions. Strong support from institutional leadership facilitated expedited action when needed, from a physical, personnel, and system infrastructure standpoint. Our ongoing real-time assessment and monitoring of our clinical program allowed us to improve and optimize our processes to ensure that the needs of our patients with COVID-19 in the outpatient setting are met.

[Place of coordination of complex pathways in oncology by coordinating private nurses]. / Place d'une coordination de parcours complexes en cancérologie par des infirmiers libéraux coordinateurs.

BACKGROUND: The complexity of the hospital-city care pathway is a real challenge because of the lack of coordination and communication between many stakeholders. As part of a call for projects from the General Directorate of Healthcare Provision, an experiment involving private oncology coordinating nurses was developed to address this issue. To our knowledge, there is no evaluation so far of such a protocol . METHODS: This single-center retrospective study focused on data from the ONC'IDEC program between 2015 and 2018, where 28 private nurses provided a 24/7 hotline. The objective was to qualitatively assess the coordination of this system. The nature and number of calls, patient satisfaction and medico-economic parameters were assessed. RESULTS: More than a hundred patients (n=114) were included in this device (mean age: 72 ± 12 years). The most frequent reasons for calls concerned the patient's general condition (35 %) and home treatment follow-ups (13 %) but also referrals to the primary doctor (4 %), which helped avoiding hospitalizations. The patients were satisfied with the experiment (overall score of 8.4/10). DISCUSSION: Thanks to the ONC'IDEC program, patients were able to benefit from more appropriate care through a privileged interlocutor by making their care pathway more fluid and avoiding hospitalizations. It would be interesting to confirm these results by means of a study with a higher level of evidence, by comparing this protocol to conventional hospital coordination.

Critical preparedness and operational response actions directed for the acute and post-acute COVID-19 pandemic in Brazil: the experience of a nationwide outpatient healthcare group.

ABSTRACT: While the new Coronavirus Disease 2019 (COVID-19) pandemic rapidly spread across the world, South America was reached later in relation to Asia, Europe and the United States of America (USA). Brazil concentrates now the largest number of cases in the continent and, as the disease speedily progressed throughout the country, prompt and challenging operational strategies had to be taken by institutions caring for COVID-19 and non-COVID-19 patients in order to assure optimal workflows, triage, and management. Although hospitals in the USA, Europe and Asia have shared their experience on this subject, little has been discussed about such strategies in South America or by the perspective of outpatient centers, which are paramount in the radiology field. This article shares the guidelines adopted early in the pandemic by a nationwide outpatient healthcare center composed by a network of more than 200 patient service centers and nearly 2,000 radiologists in Brazil, discussing operational and patient management strategies, staff protection, changes adopted in the fellowship program, and the effectiveness of such measures.

Speech and language therapy assessment of patients on the 2-week wait head and neck cancer referral pathway: evidence and opinion following a pilot study.

PURPOSE OF REVIEW: Spiralling numbers of patients are being referred on the two-week wait (2WW) head and neck cancer referral pathway. Only a small proportion are found to have cancer. There is a call for change in the management of these referrals, particularly following coronavirus. Allied health professionals (AHPs) are being encouraged by the NHS to extend their clinical practice to address increased demand. Speech and Language Therapists (SLTs) may offer a solution to some of the 2WW pathway's challenges. RECENT FINDINGS: Recent evidence highlights problems with the pathway and reasons for change. Hoarse voice is consistently found to be the most common presenting symptom. Emerging evidence suggests SLTs can extend their scope of practice to manage new hoarse voice referrals. A pilot project is described. Outcomes from this and other ongoing studies explore efficacy and investment required to make this proposal an achievable prospect for the future. SUMMARY: The management of 2WW referrals on the head and neck cancer pathway needs to change. Preliminary findings suggest SLTs working within the context of the multidisciplinary team can safely extended their role to improve management of these patients. Professional role outline, recognition, guidance, and training framework are needed.

Induction of labour during the COVID-19 pandemic: a national survey of impact on practice in the UK.

BACKGROUND: Induction of labour (IOL) is one of the most commonly performed interventions in maternity care, with outpatient cervical ripening increasingly offered as an option for women undergoing IOL. The COVID-19 pandemic has changed the context of practice and the option of returning home for cervical ripening may now assume greater significance. This work aimed to examine whether and how the COVID-19 pandemic has changed practice around IOL in the UK. METHOD: We used an online questionnaire to survey senior obstetricians and midwives at all 156 UK NHS Trusts and Boards that currently offer maternity services. Responses were analysed to produce descriptive statistics, with free text responses analysed using a conventional content analysis approach. FINDINGS: Responses were received from 92 of 156 UK Trusts and Boards, a 59% response rate. Many Trusts and Boards reported no change to their IOL practice, however 23% reported change in methods used for cervical ripening; 28% a change in criteria for home cervical ripening; 28% stated that more women were returning home during cervical ripening; and 24% noted changes to women's response to recommendations for IOL. Much of the change was reported as happening in response to attempts to minimise hospital attendance and restrictions on birth partners accompanying women. CONCLUSIONS: The pandemic has changed practice around induction of labour, although this varied significantly between NHS Trusts and Boards. There is a lack of formal evidence to support decision-making around outpatient cervical ripening: the basis on which changes were implemented and what evidence was used to inform decisions is not clear.

Effect of the CRADLE vital signs alert device intervention on referrals for obstetric haemorrhage in low-middle income countries: a secondary analysis of a stepped- wedge cluster-randomised control trial.

BACKGROUND: Obstetric haemorrhage is the leading cause of maternal death worldwide, 99% of which occur in low and middle income countries. The majority of deaths and adverse events are associated with delays in identifying compromise and escalating care. Management of severely compromised pregnant women may require transfer to tertiary centres for specialised treatment, therefore early recognition is vital for efficient management. The CRADLE vital signs alert device accurately measures blood pressure and heart rate, calculates the shock index (heart rate divided by systolic blood pressure) and alerts the user to compromise through a traffic light system reflecting previously validated shock index thresholds. METHODS: This is a planned secondary analysis of data from the CRADLE-3 trial from ten clusters across Africa, India and Haiti where the device and training package were randomly introduced. Referral data were prospectively collected for a 4-week period before, and a 4-week period 3 months after implementation. Referrals from primary or secondary care facilities to higher level care for any cause were recorded. The denominator was the number of women seen for maternity care in these facilities. RESULTS: Between April 1 2016 and Nov 30th, 2017 536,223 women attended maternity care facilities. Overall, 3.7% (n = 2784/74,828) of women seen in peripheral maternity facilities were referred to higher level care in the control period compared to 4.4% (n = 3212/73,371) in the intervention period (OR 0.89; 0.39-2.05) (data for nine sites that were able to collect denominator). Of these 0.29% (n = 212) pre-intervention and 0.16% (n = 120) post-intervention were referred to higher-level facilities for maternal haemorrhage. Although overall referrals did not significantly reduce there was a significant reduction in referrals for obstetric haemorrhage (OR 0.56 (0.39-0.65) following introduction of the device with homogeneity (i-squared 26.1) between sites. There was no increase in any bleeding-related morbidity (maternal death or emergency hysterectomy). CONCLUSIONS: Referrals for obstetric haemorrhage reduced following implementation of the CRADLE Vital Signs Alert Device, occurring without an increase in maternal death or emergency hysterectomy. This demonstrates the potential benefit of shock index in management pathways for obstetric haemorrhage and targeting limited resources in low- middle- income settings. TRIAL REGISTRATION: This study is registered with the ISRCTN registry, number ISRCTN41244132 (02/02/2016).

IAP Guideline on Practicing Safely During COVID-19 Era: Clinics and Small Establishments.

JUSTIFICATION: The unprecedented COVID-19 pandemic has had a formidable impact on Indian health care. With no sight of its end as yet, various establishments including the smaller clinics and nursing homes are restarting full operations. Hence, there is the need for recommendations to allow safe practice ensuring the safety of both the heath care worker (HCW) and patients. PROCESS: Indian Academy of Pediatrics organized an online meeting of subject experts on 27 July, 2020. A committee was formed comprising of pediatricians, pediatric and neonatal intensivists, and hospital administrators. The committee held deliberations (online and via emails) and a final consensus was reached by November, 2020. OBJECTIVES: To develop recommendations to provide a safe and practical healthcare facility at clinics and small establishments during COVID times. RECOMMENDATIONS: The key recommendation to practise safely in this setting are enumerated. Firstly, organizing the out-patient department (OPD). Secondly, appropriate personal protective equipment (PPE) to provide protection to the individual. Thirdly, decontamination/disinfection of various common surfaces and equipment to prevent transmission of infection from fomites. Next, maintaining the heating ventilation and air conditioning (HVAC) to provide a stress-free, comfortable, and safe environment for patients and HCWs. Finally, steps to effectively manage COVID-19 exposures in a non-COVID-19 facility. All these measures will ensure safe practice during these unprecedent times in clinics and smaller establishments.