Orientation of medical trainees to a new clinical environment (the ready-steady-go model): a constructivist grounded theory study

Background High-quality orientation of trainees entering a new clinical workplace is essential to support education and patient safety. However, few consultants receive extensive formal training to support new trainees and must create their own ways of integrating newcomers into their clinical team and work environment. We aim to conceptualise the strategies consultants use in the early stages of working with new trainees that will be useful for future faculty development in this area. Methods We used constructivist grounded theory (CGT) methodology by interviewing fifteen consultants in three medical specialties, to explore how trainees are integrated into a new clinical environment. We used CGT principles and procedures (iteration, constant comparison, and theoretical sampling) to analyse and construct a conceptual interpretation of the empirical data. Results Consultants’ central concern when introduced to a new cohort of trainees was that they had the required knowledge and skills (ready), were adapted and integrated into the new workplace and clinical team (steady), and safely participating in practice (go). Consultants used two broad strategies: formal orientation and informal orientation. Both these approaches had the common goal of intensifying interaction between consultants and trainees to get trainees to a position where they were ready, adapted, integrated, and participating safely and efficiently in practice. Several disruptors were identified by participants that delayed and sometimes completely inhibited the orientation process. Conclusions The model of orientation constructed through this research could be a valuable tool to support faculty development initiatives, the reflective learning practice of clinical supervisors, and curriculum design. The disruptors were identified as valid priorities for improving trainee orientation in postgraduate medical education. Future research should involve a longitudinal approach to explore trainee engagement with orientation upon entering a new clinical workplace.

Comparison of Anterior Nares Viral Loads in Asymptomatic and Symptomatic Individuals Diagnosed with SARS-CoV-2 in a University Screening Program

RT-qPCR has been used as the gold standard method for detecting SARS-CoV-2 since early in the pandemic. At our university based high throughput screening program, we test all members of our community weekly. RT-qPCR cycle threshold (CT) values are inversely proportional to the amount of viral RNA in a sample, and thus are a proxy for viral load. We hypothesized that CT values would be higher, and thus the viral loads at the time of diagnosis would be lower in individuals who were infected with the virus but remained asymptomatic throughout the course of the infection. We collected the N1 and N2 CT values from 1633 SARS-CoV-2 positive RT-qPCR tests of individuals sampled between August 7, 2020, and March 18, 2021, at the BU Clinical Testing Laboratory. We matched this data with symptom reporting data from our clinical team. We found that asymptomatic patients had CT values significantly higher than symptomatic individuals on the day of diagnosis. Symptoms were followed by the clinical team for 10 days post the first positive test. Within the entire population, 78.1% experienced at least one symptom during surveillance by the clinical team (n=1276/1633). Of those experiencing symptoms, the most common symptoms were nasal congestion (73%, n=932, 1276), cough (60.0%, n=761/1276), fatigue (59.0%, n=753/1276), and sore throat (53.1%, n=678/1276). The least common symptoms were diarrhea (12.5%, n=160/1276), dyspnea on exertion (DOE) (6.9%, n=88/1276), foot or skin changes (including rash) (4.2%, n=53/1276), and vomiting (2.1%, n= 27/1276). Presymptomatic individuals, those who were not symptomatic on the day of diagnosis but became symptomatic over the following 10 days, had CT values higher for both N1 (median= 27.1, IQR 20.2- 32.9) and N2 (median=26.6, IQR 20.1-32.8) than the symptomatic group N1 (median= 21.8, IQR 17.2- 29.4) and N2 (median= 21.4, IQR 17.3- 28.9) but lower than the asymptomatic group N1 (median=29.9, IQR 23.6-35.5) and N2 (median= 30.0, IQR 23.1- 35.7). This study supports the hypothesis that viral load in the anterior nares on the day of diagnosis is a measure of disease intensity at that time.

Vitamin D levels in hospice in-patients

ObjectiveSerum 25-hydroxyvitamin D was obtained alongside routine blood tests in all suitable patients admitted to the St Cuthbert’s Hospice Inpatient Unit for a period of 12 months. Supplementation was offered to exclude vitamin D insufficiency or deficiency as a contributor to the complex pain and symptom profile of our patients.MethodsDuring admission, and alongside routine blood tests, a serum 25-hydroxyvitamin D test was requested for suitable patients. Supplementation was offered to patients with serum 25-hydroxyvitamin D less than 50 nmol/L.ResultsThis audit identified that 79.73% of patients assessed had a 25-hydroxyvitamin D level less than 50 nmol/L and were therefore insufficient or deficient in vitamin D. The results of the audit were discussed within the clinical team at the hospice and guidance changed to obtain serum 25-hydroxyvitamin D levels in all suitable patients. A reaudit highlighted that some patients were missed from testing and therefore reminders were sent to the clinical team.ConclusionsMost patients admitted to St Cuthbert’s Hospice had either insufficient or deficient levels of vitamin D. It seems reasonable for all suitable palliative care patients to have their vitamin D level checked and to be started on a suitable dose of vitamin D replacement therapy.

544. Using Active Surveillance to Identify Monoclonal Antibody Candidates Among COVID-19 Positive Veterans, Atlanta VA Healthcare System

Background Monoclonal antibody (Mab) infusions have reduced hospitalization and mortality among higher risk patients with mild to moderate COVID-19 symptoms. Using an interdisciplinary team approach, we created a clinical team to proactively screen and outreach patients with COVID-19 to equitably offer Mab. Methods From December 28, 2020 - May 3, 2021, a clinical team consisting of an Infectious disease pharmacist and physician, reviewed each outpatient with a positive SARS-CoV-2 PCR test at the Atlanta VA Healthcare System (AVAHCS) daily. The clinical team used the published Emergency Use Authorization criteria to determine eligibility. Eligible patients were prioritized using the Veterans Health Administration (VACO) Index for COVID-19 Mortality, which estimates the risk of 30-day mortality after COVID-19 infection using pre-COVID-19 health status (Figure 1). Eligible patients were contacted via telephone to confirm eligibility and obtain verbal consent. We performed SARS-CoV-2 IgG antibody tests when possible prior to Mab infusion, but results did not preclude Mab receipt. Telehealth follow-up occurred at 1- and 7-days post infusion. Figure 1. Veterans Health Administration COVID-19 (VACO) Index for COVID-19 Mortality Overview of the elements of the VACO index, part 1 of 2. Figure 1 continued. Veterans Health Administration COVID-19 (VACO) Index for COVID-19 Mortality Overview of the elements of the VACO index, part 2 of 2. Results In total, 1,346 COVID-19 patients were identified; 86 (6%) patients were eligible, and 48/86 (55%) received Mab infusions (Figure 2). The median time from symptom-onset to positive COVID-19 PCR test result was 6 days (0-9) and the median time from positive COVID-19 PCR test result to Mab infusion was 2 days (0-8). SARS-CoV-2 IgG antibodies were detected in 4 of 24 (17%) patients tested. The most common comorbidities were hypertension (73%) and diabetes, (42%) (Table). Five (10%) patients required hospitalization for worsening COVID-19 symptoms post infusion. No deaths occurred. Figure 2. Overview of COVID-19 Monoclonal Antibody (Mab) infusion Process Summary of Mab Infusion Screening Process Table. Patient Characteristics of Monoclonal (Mab) Infusion Recipients (N = 48) Descriptive Statistics and Findings of Study Data, part 1 of 2 Table continued. Patient Characteristics of Monoclonal (Mab) Infusion Recipients (N = 48) Descriptive Statistics and Findings of Study Data, part 2 of 2 Conclusion This approach of combining laboratory surveillance and active screening minimized delay in symptoms onset to Mab infusion, thereby optimizing outpatient treatment of COVID-19 disease. Our approach successfully treated a more diverse patient population compared to clinical trials. Mab infusions overall was well tolerated with few hospitalizations and no deaths in this cohort. Disclosures All Authors: No reported disclosures

Using lean management approach in improving clinical team leader handover process: nursing services

This report describes the result of the study using lean management approach in improving clinical team leader handover process in nursing services at Sultan Bin Abdulaziz Humanitarian City, the largest rehabilitation facility in the Middle East with 511-bed capacity and more than 20 nursing inpatient units. Clinical handover refers to the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another pehealthcare system is a crson or professional group on a temporary or permanent basis. It is in fact a valuable and essential part of the care processes in the hospitals. However, clinical team leaders face a challenging role during handover due to prolonged process, causing extra nursing working hour beyond their 12-hour scheduled shift, resulting in additional burden and exhaustion. The aim of this project was to test the effectivity of the lean management approach in improving the duration of clinical handover by reducing the handover time frame to 50% through eliminating unnecessary steps towards a more efficient, sustainable and effective communication between clinical nursing team leaders. The project results demonstrated the effectiveness and efficiency of the team leader clinical handover process by decreasing the duration by 50%. One hundred per cent of nursing units that were involved in the project were able to start and end their team leader handover process by the average of the selection target of 20–30 min of handover duration.

Making the invisible visible: New perspectives on the intersection of human–environment interactions of clinical teams in intensive care

Understanding human behaviour is essential to the successful adoption of new technologies, and for the promotion of safer care. This requires capturing the detail of clinical workflows to inform the design of new human–technology interactions. We are interested particularly in the possibilities for touchless technologies that can decipher human speech, gesture and motion and allow for interactions that are free of contact. Here, we employ a new approach by installing a single 360° camera into a clinical environment to analyse touch patterns and human–environment interactions across a clinical team to recommend design considerations for new technologies with the potential to reduce avoidable touch.

Interventional Planning for Endovascular Revision of a Lateral Tunnel Fontan: A Patient-Specific Computational Analysis

IntroductionA 2-year-old female with hypoplastic left heart syndrome (HLHS)-variant, a complex congenital heart defect (CHD) characterized by the underdevelopment of the left ventricle, presented with complications following single ventricle palliation. Diagnostic work-up revealed elevated Fontan pathway pressures, as well as significant dilation of the inferior Fontan pathway with inefficient swirling flow and hepatic venous reflux. Due to the frail condition of the patient, the clinical team considered an endovascular revision of the Fontan pathway. In this work, we performed a computational fluid dynamics (CFD) analysis informed by data on anatomy, flow, and pressure to investigate the hemodynamic effect of the endovascular Fontan revision.MethodsA patient-specific anatomical model of the Fontan pathway was constructed from magnetic resonance imaging (MRI) data using the cardiovascular modeling software CardiovasculaR Integrated Modeling and SimulatiON (CRIMSON). We first created and calibrated a pre-intervention 3D-0D multi-scale model of the patient’s circulation using fluid-structure interaction (FSI) analyses and custom lumped parameter models (LPMs), including the Fontan pathway, the single ventricle, arterial and venous systemic, and pulmonary circulations. Model parameters were iteratively tuned until simulation results matched clinical data on flow and pressure. Following calibration of the pre-intervention model, a custom bifurcated endograft was introduced into the anatomical model to virtually assess post-intervention hemodynamics.ResultsThe pre-intervention model successfully reproduced the clinical hemodynamic data on regional flow splits, pressures, and hepatic venous reflux. The proposed endovascular repair model revealed increases of mean and pulse pressure at the inferior vena cava (IVC) of 6 and 29%, respectively. Inflows at the superior vena cava (SVC) and IVC were each reduced by 5%, whereas outflows at the left pulmonary artery (LPA) and right pulmonary artery (RPA) increased by 4%. Hepatic venous reflux increased by 6%.ConclusionOur computational analysis indicated that the proposed endovascular revision would lead to unfavorable hemodynamic conditions. For these reasons, the clinical team decided to forgo the proposed endovascular repair and to reassess the management of this patient. This study confirms the relevance of CFD modeling as a beneficial tool in surgical planning for single ventricle CHD patients.

Safety of healthcare workers undertaking transport and retrieval of patients on extracorporeal membrane oxygenation during the peak of COVID-19 pandemic in the State of Qatar

Background: Transport and retrieval of patients on extracorporeal membrane oxygenation (ECMO) support can be hazardous to patients and healthcare workers (HCWs). COVID-19 is highly contagious and can be transmitted by contact, droplet, or airborne route. Transport of COVID-19 patients exposes HCWs and the public to infection risks, hence strict measures must be in place to ensure everyone's safety. ECMO cannulation and transportation is considered an aerosol generating procedure and can pose significant risks to HCWs. In addition, close contact with the patient in the confined space of the ambulance may put HCWs at increased risk of exposure and infection. Methods: Between March 1st and September 30th 2020, a total of 32 episodes of COVID-19 ECMO transport were undertaken by the Medical Intensive Care Unit (MICU) and Ambulance Service. We reviewed the incidence of COVID-19 infection among HCWs involved in these missions. The transport clinical team is composed of ECMO consultant, two ECMO nurses, a perfusionist and a Critical Care Paramedic (CCP). Due to staff shortage and clinical needs, a respiratory therapist did not attend to the majority of cases. A crew of two paramedics supports the clinical team with their intensive care ambulance. Results: The number of clinical staff involved in the COVID-19 ECMO transport during that period is shown in . The duration of clinical staff’s exposure to the infected patient in the back of the ambulance is demonstrated in. MICU staff underwent COVID-19 serology tests every 2 weeks as per local policy. None of the clinical staff involved in these transfers and retrievals of COVID-19 positive patients tested positive after 2 weeks of transport. Conclusion: Strict infection prevention and personal protective measures are mandatory to avoid cross-infection and were carefully adhered to during all the missions. They translated into the well-being of the clinical staff involved in the transfer and retrievals of COVID-19 positive patients.

Challenges of paediatric palliative care in the intensive care unit during the COVID-19 pandemic

Background: The integration of paediatric palliative care into the Iranian health system is essential. Aims: The aim of this study was to identify the challenges of palliative care in the paediatric intensive care unit during COVID-19 through the experiences of healthcare providers. Methods: A qualitative study with content analysis approach was conducted. Fifteen physicians and nurses were selected by purposeful sampling. The semi-structured, in-depth interviews were applied in the data collection. Findings: Ten main categories were extracted from data analysis, including ‘caring in COVID-19’, ‘communication and family centre care’, ‘breaking bad news’, palliative care training’, ‘pain and symptom management’, ‘support of the child, family and clinical team’, ‘physical environment’, ‘guidelines’, ‘specialised staff’ and ‘home based palliative care’. Conclusion: Palliative care in the PICU faces several challenges, especially during COVID-19, but the clinical team are making every attempt to improve the comprehensive care of children and their families. Telehealth is important in COVID-19, and education is also a key component to improve palliative care in the PICU in Iran.