# data[].attributes.attachment_link.description
It depends on the positive pressure device and circuit being used. If a single limb circuit without an active exhalation valve is being used (e.g. a home NIPPV machine), then a vented mask or vented circuit must be used (i.e. fixed orifice resistor outlet).

# data[].attributes.attachment_link.readable_text
Your central place to rapidly access latest news, translated guidance information, and expert interpretations from our former regulators related to COVID-19. Parexel's 1000+ consulting experts are closely following agency announcements and new guidances and can help provide deep expertise and experience in the race to bring this outbreak to a close. We're here to fight this with you.

# data[].attributes.attachment_link.description
Your central place to rapidly access latest news, translated guidance information, and expert interpretations from our former regulators related to COVID-19. Parexel's 1000+ consulting experts are closely following agency announcements and new guidances and can help provide deep expertise and experience in the race to bring this outbreak to a close.

# data[].attributes.headline
Innovation and Knowledge Sharing Can Transform COVID-19 Infection Prevention Response | Journal of Hospital Medicine

# data[].attributes.subject
Innovation and Knowledge Sharing Can Transform COVID-19 Infection Prevention Response | Journal of Hospital Medicine

# data[].attributes.attachment_link.readable_text
Emerging studies on coronavirus disease 2019 (COVID-19) confirm high rates of infection among healthcare workers (HCWs). ¹ As widespread community transmission increases, frontline HCWs, such as hospitalists, are at particularly high risk of exposure to people with undiagnosed COVID-19. Although there is no known effective treatment for COVID-19, early detection is vital to decreasing ongoing transmission through contact tracing and quarantine. However, lack of adequate testing capacity prevented basic public health interventions from curbing the pandemic at an earlier stage. As a result, given high rates of presumed community transmission of COVID-19 and evidence for asymptomatic transmission, there have been moves toward the use of universal personal protective equipment (PPE). This strategy is challenging to implement because of the acute PPE shortage, which has resulted in an urgent need to embrace innovation in infection prevention.

The current pandemic has resulted in an unprecedented volume of data being generated and disseminated, with the potential to impact real-time responses in geographically disparate regions. Here, we focus on the potential for innovation and knowledge sharing from an infection prevention perspective, which could enhance frontline HCW safety in the current COVID-19 pandemic.

Every outbreak begins and ends with a diagnostic test. Widespread population testing coupled with intensive contact tracing had the potential to curb national epidemics if it had been implemented in time. In the United States, which now has the highest number of COVID-19 cases worldwide, there were technical difficulties with the first diagnostic test developed by the Centers for Disease Control and Prevention (CDC) and subsequent delays in scaling up access to COVID-19 diagnostic testing. ² The strategy of initially reserving testing only for those who were critically ill meant that by the time patients with COVID-19 were being diagnosed, widespread community spread had occurred because of the lack of detection of individuals with less severe or asymptomatic infections.

In contrast, scaled-up testing in South Korea has helped limit the spread and consequences of COVID-19. The use of drive-through testing centers enabled safe and efficient testing, while minimizing the risk to HCWs and eliminating the possibility of cross infection among people being tested. ³ Although outdoor testing is not feasible in all settings, this approach avoids resources and time typically needed for ventilation (typically a negative pressure room with 12 air changes per hour would be used) and cleaning of specimen collection rooms.

The other major diagnostic gap is the ability to identify individuals who have recovered from COVID-19 and are immune. There is an urgent need to develop and scale up a rapid serological test that avoids cross-reactivity with other coronaviruses. Ideally, this test would permit testing of HCWs to determine who is likely immune and can therefore return safely to work.

There has been a massive and rapid increase in the need for PPE globally because of overwhelmed health systems having to care for large numbers of patients with suspected or confirmed COVID-19. This has been exacerbated by public fear, which has led to panic buying of medical face masks (primarily used to protect others from infections with a droplet mode of transmission) and filtering facepiece half-mask respirators, which include N95 respirators (used to protect the wearer from infections with an airborne mode of transmission).

COVID-19 is thought to be predominantly spread by transmission of respiratory droplets (>5 and <10 μm in diameter), which occurs when people are in close contact (within 1 meter) with others who typically (but not always) have respiratory symptoms such as cough or sneeze or with fomites that have come into contact with an infected person. This is in contrast to infectious diseases such as tuberculosis (TB) or measles, which are spread by airborne transmission of virus suspended in droplet nuclei (<5 μm in diameter), which can remain in the air for prolonged periods of time and can be transmitted over distances greater than 1 meter. ⁴

While World Health Organization (WHO) and CDC infection prevention guidance have cited droplet transmission as the primary mode of transmission for COVID-19, current CDC guidelines state that respirators are preferred for the care of patients with known or suspected COVID-19, given the potential for opportunistic airborne transmission. ⁵ However, in the setting of respirator shortages, it is recommended that these should be prioritized for HCWs caring for patients with COVID-19 in the context of aerosol-generating procedures or other patients with infections spread by airborne transmission such as TB or varicella until the supply chain is restored. Of note, optimal use of respirators requires fit testing, which is often lacking in nursing homes and outpatient facilities, as well as more widely in resource-limited countries.

Universal masking (use of surgical mask) for HCWs caring for any patient irrespective of symptoms or presenting complaint has also been implemented by many large hospital systems in recent days. Although universal masking adds to the burden of the PPE shortage, in settings with widespread community transmission and given increasing evidence ⁶ demonstrating transmission from people with asymptomatic and presymptomatic infection, universal masking may be useful to decrease transmission. However, particularly in the setting of PPE shortages, it is important to understand that surgical masks are designed to be single use and that dampness and frequent adjustment of the mask affects their effectiveness.

As urgent attempts to coordinate and increase PPE manufacture are being made by health systems, in conjunction with private partnerships, there has also been a burst of public campaigns to sew cloth masks to mitigate the real-time shortages. Although it is likely that cloth masks provide inadequate protection in comparison with surgical masks, ⁷ evidence does suggest that cloth masks provide some degree of protection from the spread of respiratory viruses, ⁸ particularly if these are replaced promptly when damp or damaged and if combined with other interventions such as hand hygiene. This has led to recommendations for the general public in various countries to wear cloth face coverings in public settings, particularly where social distancing may be harder to maintain, but these are not recommended for use by HCWs in healthcare settings.

Strategies to navigate the PPE shortage in the era of COVID-19 include importing, reclaiming, reusing, and repurposing PPE; generating and extending supply; eliminating nonessential services; reducing patient contact; and using nonhuman services such as drones to deliver equipment and undertake tasks such as decontamination. 9,10 Multidisciplinary teams are working on creative ways to use existing resources to make effective PPE, including alternatives to N95 respirators. An outbreak simulation study at Emory University in Atlanta, Georgia, and the University of Texas Health Science Center at Houston in Texas demonstrated that HCWs could be rapidly trained and fit tested to use elastomeric half-mask respirators, which are reusable. ¹¹ A multidisciplinary team at Boston Children's Hospital in Massachusetts has developed and completed a small pilot study of a reusable elastomeric respirator made using an anesthesia facemask, antimicrobial filter, and elastic straps. ¹²

Given evidence that suggests that COVID-19 involves a component of airborne transmission, ¹³ in addition to droplet spread and surface (fomite) contamination, ¹⁴ using known infection prevention techniques that work to decrease airborne transmission of other respiratory infectious diseases should also be considered. Germicidal ultraviolet (GUV) air disinfection rapidly disinfects upper room air, which is then continually exchanged with contaminated lower-room air. GUV air disinfection has been demonstrated to be a safe and cost-effective intervention, with an efficacy of approximately 80% for decreasing TB transmission. ¹⁵ GUV air disinfection is also effective against airborne influenza and measles and may play a role in surface decontamination by accelerating viral inactivation. Enabling GUV in high-risk areas such as the emergency department or intensive care unit could be a high-yield intervention to decrease transmission of COVID-19.

HCWs exposed to other respiratory infections such as influenza or TB may receive preventive therapy to reduce the risk of developing disease. High rates of COVID-19 in HCWs have prompted several initiatives to evaluate innovative approaches to decreasing this risk. Multiple studies are underway to determine whether hydroxychloroquine could be used for pre- or postexposure prophylaxis to prevent COVID-19. Another multisite trial will evaluate whether the BCG vaccine, primarily used to reduce the risk of TB, provides protection against COVID-19 in HCWs, driven by data suggesting a correlation between universal BCG vaccination policy and reduced morbidity and mortality for COVID-19. ¹⁶

Infection prevention efforts can benefit from the unprecedented amount of data on COVID-19 that is being generated and shared. Successful examples of the rapid intensification of infection prevention measures to decrease transmission in healthcare facilities should be emulated. The hospital authority of Hong Kong implemented a bundle of measures focused on early recognition, isolation, notification, and molecular diagnostics for people being evaluated for COVID-19. ¹⁷ They subsequently broadened the clinical and epidemiological criteria of surveillance as the outbreak evolved and intensified PPE recommendations to all HCWs (face masks for all and N95 respirators for those performing aerosol-generating procedures), which appears to have resulted in no cases of HCW infection or nosocomial transmission.

Data characterizing the extent of occupational infections in HCWs during acute and chronic epidemics is often lacking and subject to wide variability in reporting, which limits its impact. For example, HCWs in high TB incidence countries have at least twice the risk of developing TB, compared with the general population. Although there are still major gaps in national data collection regarding the incidence of occupational TB, recent attempts by WHO to systematically record this data have resulted in increasing prioritization of this group as an at-risk population who may benefit from TB preventive therapy. We strongly advocate that health systems systematically record and share longitudinal data on numbers of HCWs infected with COVID-19. This transparency will facilitate urgent action to replenish and sustain resources such as PPE and enable institutions to share and adapt successful infection prevention strategies. Examples such as the prevention of central line- associated bloodstream infections demonstrate the potential impact of national collaborative efforts to strengthen infection prevention, although further effort is needed to optimize knowledge sharing in the context of outbreaks.

The cost of not investing in public health pandemic preparedness including measures to protect HCWs is now widely apparent. HCWs have a right to safety in their workplaces as they fulfil their duty of care to patients. ¹⁸ Rapid scale-up of diagnostic testing capacity, and bundles of infection prevention interventions including universal masking and drive-through testing, can safeguard HCWs and the patients they serve in the current COVID-19 pandemic. Re-establishing immediate access to quality-assured PPE is imperative to reduce the individual and workforce consequences of HCWs developing COVID-19 or other infectious diseases like TB that are continuously a threat to the workforce. Meanwhile, innovative approaches such as repurposing resources to develop PPE and use of GUV air disinfection may help to mitigate PPE shortages, and use of preventive therapies may also decrease COVID-19 risk in HCWs. Reliable surveillance data on HCW infection rates can help identify and track gaps in infection prevention, as well as identify strategies that impact this outcome. Ultimately greater top-down political commitment is urgently needed to ensure that frontline HCWs have the necessary resources to address the current pandemic and to sustain these interventions to protect HCWs in the future.

Disclosures

The authors have no relevant disclosures.

Funding

There was no funding for this work. Dr Nathavitharana is supported by a National Institutes of Health Career Development Award (NIAID K23 AI132648-03) and an American Society of Tropical Medicine and Hygiene Burroughs Wellcome Fellowship.

# data[].attributes.attachment_link.title
Innovation and Knowledge Sharing Can Transform COVID-19 Infection Prevention Response

# data[].attributes.attachment_link.description
Emerging studies on coronavirus disease 2019 (COVID-19) confirm high rates of infection among healthcare workers (HCWs). 1 As widespread community transmission increases, frontline HCWs, such as hospitalists, are at particularly high risk of exposure to people with undiagnosed COVID-19. Although there is no known effective treatment for COVID-19, early detection is vital to decreasing ongoing transmission through contact tracing and quarantine.

# data[].attributes.attachment_link.readable_text
Welcome to Elsevier's Novel Coronavirus Information Center. Here you will find expert, curated information for the research and health community on SARS-CoV-2 (the novel coronavirus) and COVID-19 (the disease).

All resources are free to access and include guidelines for clinicians and patients.
See our directory of all Elsevier's COVID-19 resources
For researchers

Under the Research tab, you will find a selection of the latest early-stage and peer-reviewed research on COVID-19 from journals including The Lancet and Cell Press. We have also made related articles and book chapters free to access on ScienceDirect.
View free articles on ScienceDirect
These articles are also available to download over FTP with rights for full text and data mining, re-use and analyses for as long as needed.

Server address: coronacontent.np.elsst.com

Protocol: sftp (SSH File Transfer Protocol)

Username: public

Password: beat_corona

You will need to use FTP client software such as Cyberduck or WinSCP to access the FTP server.
Download full text for data mining

# data[].attributes.attachment_link.description
Welcome to Elsevier's Novel Coronavirus Information Center. Here you will find expert, curated information for the research and health community on SARS-CoV-2 (the novel coronavirus) and COVID-19 (the disease). All resources are free to access and include guidelines for clinicians and patients.

# data[].attributes.headline
Expanded Rooming and Discharge Protocols | Workflow and Process | AMA STEPS Forward | AMA Ed Hub

# data[].attributes.subject
Expanded Rooming and Discharge Protocols | Workflow and Process | AMA STEPS Forward | AMA Ed Hub

# data[].attributes.headline
Get The Facts - Social Media Toolkit | One by One: Target COVID-19

# data[].attributes.subject
Get The Facts - Social Media Toolkit | One by One: Target COVID-19

# data[].attributes.headline
COVID-19 – Considerations and Implications for Surgical Learners.pdf

# data[].attributes.subject
COVID-19 – Considerations and Implications for Surgical Learners.pdf

# data[].attributes.headline
Managing COVID in Surgical Systems v2.pdf

# data[].attributes.subject
Managing COVID in Surgical Systems v2.pdf

# data[].attributes.headline
Redesigning Hospital Spaces on the Fly to Protect Healthcare Workers_0.pdf

# data[].attributes.subject
Redesigning Hospital Spaces on the Fly to Protect Healthcare Workers_0.pdf

# data[].attributes.attachment_link.description
If the address matches an existing account you will receive an email with instructions to reset your password

# data[].attributes.headline
How Should Health Care Systems Prioritize Communication Amidst COVID-19? | Health Affairs

# data[].attributes.subject
How Should Health Care Systems Prioritize Communication Amidst COVID-19? | Health Affairs

# data[].attributes.attachment_link.description
If the address matches an existing account you will receive an email with instructions to reset your password

# data[].attributes.body
WHO app

# data[].attributes.attachment_link.readable_text
This is the official World Health Organization mobile learning app for health workers seeking COVID-19 information. Brought to you by the WHO Academy, it focuses on providing them with critical, evidence-based information and tools to improve their skills and capabilities related to the pandemic.

Health workers need accurate, extensive, reliable, and timely information on COVID-19 to save lives and stay safe.

This app delivers an efficient way to access WHO's COVID-19 knowledge resources all in one place. It offers up-to-the-minute guidance, training, and virtual workshops to support health workers in caring for patients infected by COVID-19 - as well as how they can protect themselves as they do their critical work.

With content in six languages - Arabic Chinese, English, French, Russian and Spanish - the app is a convenient tool for accessing WHO's rapidly expanding and evolving training materials and guidance, along with opportunities to participate in virtual classrooms and other live training.

Key features include learning guidance, learning materials, and tools organized into the following COVID-19 subject matter areas:
* Case Management: How to care for COVID-19 patients
* Infection Prevention Control / Staff Safety and Health: Protecting health worker and the community
* Epidemiology: Distribution, characteristics, and determinants of COVID-19
* Laboratory: Laboratory testing for COVID-19 in humans
* Maintaining Essential Health Services and Systems: Strategic planning and coordinated action
* International Health Regulations: Public health and international spread of disease
* Risk Communication and Community Engagement: Communicating effectively with the public
* Research & Development: Working towards a treatment and a vaccine.
* Operational Support and Logistics
* Regional Information

It also includes updated news and statistics on the COVID-19 pandemic.
This app is brought to you by the WHO Academy, a new internal division of WHO. The Academy will be officially launched in May 2021 as the WHO's state-of-the-art lifelong learning center, applying the latest technologies and adult learning science to meet the learning needs of millions of health workers, policymakers, and WHO staff around the world.

More about the WHO Academy: http://academy.who.int

# data[].attributes.attachment_link.description
This is the official World Health Organization mobile learning app for health workers seeking COVID-19 information. Brought to you by the WHO Academy, it focuses on providing them with critical, evidence-based information and tools to improve their skills and capabilities related to the pandemic.

# data[].attributes.body
World Federation of Anaesthesiologists

# data[].attributes.attachment_link.readable_text
On the 11 March 2020 WHO characterised the spread of coronavirus as a pandemic.

The spread of the virus can be monitored through various websites including the COVID-19 Global Cases by Johns Hopkins CSSE

This novel coronavirus route of transmission and clinical presentation is similar to SARS, with flu-like symptoms (typically involving fever, cough, shortness of breath) and acute respiratory failure (commonly bilateral pneumonia, acute respiratory distress). However, patients may present with atypical symptoms.

While COVID-19 has been suggested to have a lower case fatality rate (2.5%) than SARS (9.6%), MERS (34.4%), or H1N1 (17.4%), the extent of spread means that the death toll is significant. Frontline healthcare workers are at high risk of becoming infected, and are also at risk of spreading infection.

Anaesthesiologists and other perioperative care providers are particularly at risk when providing respiratory care and tracheal intubation of patients with COVID-19. WFSA would like to draw anesthesia team attention to the importance of appropriate precautions when providing respiratory care and intubation for these patients.

WFSA Statement on health care providers safety and wellbeing during the COVID-19 pandemic (pdf)

Guidance on anaesthesia and COVID-19

Guidance on Airway Management

Guidance on Obstetric Anaesthesia

Guidance for Low Resource Settings

Ressources en français

Recursos en español

Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR) - Portal de información sobre coronavirus

Ministerio de Salud Español - Documentos técnicos para profesionales

Asociación de anestesiólogos - Información esencial

CLASA - Guías para manejo de pacientes con COVID-19.

SCARE - Página de recursos de COVID-19

Sociedad Ecuatoriana de Anestesiología - Check list de seguridad para el manejo perioperatorio covid positivo

FUS & UIS - Aproximacion practica via aerea en pacientes pandemia COVID19

WFSA - Declaración de la WFSA sobre la seguridad y el bienestar de los proveedores de atención médica durante la pandemia de COVID-19

Recursos em Português

Coronavirus - General Information

# data[].attributes.attachment_link.title
World Federation Of Societies of Anaesthesiologists - Coronavirus

# data[].attributes.attachment_link.description
On the 11 March 2020 WHO characterised the spread of coronavirus as a pandemic. The spread of the virus can be monitored through various websites including the COVID-19 Global Cases by Johns Hopkins CSSE This novel coronavirus route of transmission and clinical presentation is similar to SARS, with flu-like symptoms (typically involving fever, cough, shortness of breath) and acute respiratory failure (commonly bilateral pneumonia, acute respiratory distress).

# data[].attributes.attachment_link.title
COVID-19 - A collection of useful infographics related to the Coronavirus Disease 2019 pandemic

# data[].attributes.attachment_link.description
COVID19+Summary - One page summary sheets for the intensivist, hospitalist, and more #COVID19+Diagnosis - Diagnostic Algorithms, Signs and Symptoms for Diagnosis #COVID19+Management - Medications and Treatment Protocols #COVID19+Checklist - Donning/Doffing, Intubation Checklists #COVID19+Intubation - Resources for Intubation #COVID19+PPE - Personal Protective Equipment Standards, Donning and Doffing #COVID19+Chest+CT - Computed Tomography Examples - Ground Glass, ARDS #COVID19+POCUS - Point of Care Ultrasound Examples #SocialDistancing - How we can mitigate the burden of this virus.

# data[].attributes.headline
Critical preparedness, readiness and response actions for COVID-19

# data[].attributes.subject
Critical preparedness, readiness and response actions for COVID-19

# data[].attributes.attachment_link.readable_text
Critical preparedness, readiness and response actions

WHO has defined four transmission scenarios for COVID-19:

1. Countries with no cases (No cases);

2. Countries with 1 or more cases, imported or locally detected (Sporadic cases);

3. Countries experiencing cases clusters in time, geographic location and/or common exposure (Clusters of cases);

4. Countries experiencing larger outbreaks of local transmission (Community transmission).

This document describes the preparedness, readiness and response actions for COVID-19 for each transmission scenario.

- Access the document (19 March 2020)

Responding to community spread of COVID-19
This document provides technical guidance for government authorities, health workers, and other key stakeholders to guide response to community spread. It will be updated as new information or technical guidance become available. For countries that are already preparing or responding, this document can also serve as a checklist to identify any remaining gaps.

- Access the document (7 March 2020)

Operational considerations for case management of COVID-19 in health facility and community
This document is intended to guide the care of COVID-19 patients as the response capacity of health systems is challenged; to ensure that COVID-19 patients can access life-saving treatment, without compromising public health objectives and safety of health workers.

It promotes two key messages:

1. Key public health interventions regardless of transmission scenario; and

2. Key action steps to be taken by transmission scenario to enable timely surge of clinical operations.

- Access the publication (19 March 20200

Prioritized Laboratory Testing Strategy According to 4Cs Transmission Scenarios
Diagnostic testing for COVID-19 is critical to tracking the virus, understanding epidemiology, informing case management, and to suppressing transmission. This document describes the strategic use of diagnostic testing in different transmission scenarios of the COVID-19 outbreak, from no cases to community transmission, including how testing might be rationalized when lack of reagents or testing capacity necessitates prioritization of certain populations or individuals for testing."

- Prioritized Laboratory Testing Strategy According to 4Cs Transmission Scenarios (published date : 22 March 2020)

Severe Acute Respiratory Infections Treatment Centre

Practical manual to set up and manage a SARI treatment centre and a SARI screening

- Access the publication (28 March 2020)

Considerations in adjusting public health and social measures in the context of COVID-19
This document is intended for national authorities and decision makers in countries that have introduced large scale public health and social measures. It offers guidance for adjusting public health and social measures, while managing the risk of a resurgence of cases.

- Access the publication (Uploaded 16 April 2020)

# data[].attributes.attachment_link.title
Critical preparedness, readiness and response actions for COVID-19

# data[].attributes.attachment_link.description
Critical preparedness, readiness and response actions WHO has defined four transmission scenarios for COVID-19: 1. Countries with no cases (No cases); 2. Countries with 1 or more cases, imported or locally detected (Sporadic cases); 3. Countries experiencing cases clusters in time, geographic location and/or common exposure (Clusters of cases); 4.

# data[].attributes.attachment_link.readable_text
The COVID-19 outbreak has now spread to 52 countries in Africa. Due to fragile health systems, Africa is at risk to be hit hardest by the outbreak. The poor and most vulnerable people on the continent are the least prepared to adopt preventive measures to limit the spread of the outbreak. Meanwhile, other patients are at risk: we are already observing that patients with other health conditions are afraid to visit hospitals due to the fear of getting infected. International, collective actions is critical to help reduce the spread of the virus, save lives and minimize social and economic impacts.

For African countries to avoid the devastation, early detection, effective surveillance, and quick response are critical. Strong data-driven health systems are the most effective way to respond to the outbreak. The rise of mobile technology and digital platforms in Africa offers the opportunity to deliver all stakeholders the much-needed insights in the spread of the epidemic and the impact of preventive measures. It also offers a great way to communicate directly with its citizens, as verified information at a time of fake news, is critical to the COVID response.

PharmAccess focuses on leveraging data and technology to strengthen African health systems to finance and deliver better healthcare. We are actively seeking partnerships to join forces in these uncertain times, as cooperation is key to fighting this pandemic.

# data[].attributes.attachment_link.title
Our COVID-19 response - PharmAccess Foundation

# data[].attributes.attachment_link.description
The COVID-19 outbreak has now spread to 52 countries in Africa. Due to fragile health systems, Africa is at risk to be hit hardest by the outbreak. The poor and most vulnerable people on the continent are the least prepared to adopt preventive measures to limit the spread of the outbreak.

# data[].attributes.headline
#VisualAbstract: Risk Factors Associated With ARDS and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China | 2 Minute Medicine

# data[].attributes.subject
#VisualAbstract: Risk Factors Associated With ARDS and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China | 2 Minute Medicine

# data[].attributes.attachment_link.readable_text
1. Study findings suggest that risk factors predisposing patients to progression to acute respiratory distress syndrome (ARDS) include older age, neutrophilia, and organ and coagulation dysfunction. 2. Some factors, including high fever, were associated with higher rates of ARDS development but lower rates of mortality. 3. In this observational study with small sample size and potential selection bias, methylprednisolone treatment may have been associated with lower mortality rates patients in COVID-19 patients with ARDS.
Evidence Rating: 3 (Average)

Development of hypoxemia and progression to acute respiratory distress syndrome (ARDS) is a mechanism is a cause of morbidity and mortality in COVID-19 patients. In this retrospective cohort study, the data of 201 patients aged 21 to 83 with confirmed COVID-19 pneumonia hospitalized in Wuhan China was analyzed to delineate risk factors associated with development of ARDS and progression from ARDS to death. Eighty-four patients (41.8%) developed ARDS and 44 of these patients (52.4%) died. Patients who developed ARDS were more likely to present with dyspnea (59.5% versus 25.6%) and pre-existing comorbidities such as hypertension (27.4% versus 13.7%), diabetes (19.0% versus 5.1%) versus patients that did not develop ARDS. Risk factors identified as being associated with development of ARDS and progression from ARDS to death include age over 65 years (hazard ratio [HR], 3.26, 6.17, respectively), neutrophilia (HR 1.14, 1.08, respectively), elevated end-organ related and coagulation indices, with LDH and D-dimer specifically being mentioned. High fever of over 39°C was associated with higher likelihood of ARDS development (HR, 1.77) but lower likelihood of death (HR, 0.41) and overall associated with better outcomes. Likewise, several other factors such as pre-existing comorbidities, lymphocyte counts, glucose, creatinine, and other markers, were associated with the development of ARDS but not progression from ARDS to death, indicating the possibility for different pathophysiological mechanisms underlying the outcomes. Finally, although this was not the primary focus for the investigation, it was found that patients with ARDS who received methylprednisolone treatment had lower rates of mortality that those who did not (46% versus 61.8%). This study findings provide important information regarding factors linked with ARDS in COVID-19 patients, and direction for further investigation into treatment regimens.
Click to read the study in JAMA Internal Medicine
©2020 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc.

# data[].attributes.attachment_link.keywords[]
acute respiratory distress syndrome (ards)

# data[].attributes.attachment_link.title
#VisualAbstract: Risk Factors Associated With ARDS and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China | 2 Minute Medicine

# data[].attributes.attachment_link.description
1. Study findings suggest that risk factors predisposing patients to progression to acute respiratory distress syndrome (ARDS) include older age, neutrophilia, and organ and coagulation dysfunction. 2. Some factors, including high fever, were associated with higher rates of ARDS development but lower rates of mortality. 3.

# data[].attributes.attachment_link.readable_text
Our apologies. An error occurred while setting your user cookie. Please set your browser to accept cookies to continue.

NEJM.org uses cookies to improve performance by remembering your session ID when you navigate from page to page. This cookie stores just a session ID; no other information is captured. Accepting the NEJM cookie is necessary to use the website.

1-800-843-6356 | [email protected]

# data[].attributes.attachment_link.description
Our apologies. An error occurred while setting your user cookie. Please set your browser to accept cookies to continue. NEJM.org uses cookies to improve performance by remembering your session ID when you navigate from page to page. This cookie stores just a session ID; no other information is captured.

# data[].attributes.headline
Management of COVID-19 Respiratory Distress | Critical Care Medicine | JAMA 

# data[].attributes.subject
Management of COVID-19 Respiratory Distress | Critical Care Medicine | JAMA 

# data[].attributes.headline
Doing things right vs. doing the right things | The Hospitalist

# data[].attributes.subject
Doing things right vs. doing the right things | The Hospitalist

# data[].attributes.attachment_link.title
Doing things right vs. doing the right things

# data[].attributes.attachment_link.description
The current coronavirus disease 2019 (COVID-19) pandemic shocked the world with its rapid spread despite stringent containment efforts, and it continues to wrea

# data[].attributes.headline
Infographic [image] | EurekAlert! Science News

# data[].attributes.subject
Infographic [image] | EurekAlert! Science News

# data[].attributes.attachment_link.readable_text
Caption

Converting a Small Surgical Team into a Pandemic Response Team for an Isolated Population.

Credit

American College of Surgeons

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.

# data[].attributes.attachment_link.description
Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.

# data[].attributes.headline
Recovery Rooms introduced at Salford, Oldham, Bury and Rochdale hospitals to support staff wellbeing during COVID-19 pandemic

# data[].attributes.subject
Recovery Rooms introduced at Salford, Oldham, Bury and Rochdale hospitals to support staff wellbeing during COVID-19 pandemic

# data[].attributes.attachment_link.readable_text
RECOVERY rooms, sometimes called 'wobble rooms,' have been launched by the Northern Care Alliance NHS Group (NCA), to support staff health and wellbeing during the COVID-19 pandemic.

The recovery rooms are one of a number of different health and wellbeing initiatives currently operating at the four hospitals and community services run by the NCA, which brings together the Salford Royal and Pennine Acute Trusts.

Nicky Clarke, Chief of People at the NCA said:

"Our safe haven recovery rooms are spaces for our staff to rest, regroup and recuperate for a short while away from the demands of front line pressures. We encourage our staff to help each other while in the recovery rooms, be that listening to one another or providing encouragement and support to one another.

"This might be the first time our staff have experienced such a demanding working situation and people cope in different ways. When one person might cry and want to chat, another might want to sit and contemplate, and either is fine, these are safe spaces, which our staff love."

Other initiatives introduced by the NCA to support mental health, health and wellbeing include a very well received NCA Family send a letter home scheme. Staff can download a letter from the organisation's Chief Executive thanking their kids for supporting their parents, our staff, through the COVID-19 pandemic.

The NCA Twitter account has been inundated with touching images of staff and children embracing with copies of their letters in hand.

Others include helplines for mental health, bereavement, general support and advice, as well as home workout programmes and self-help information.

There are also shower blocks that have been set up so that staff can shower before returning home, and free water bottles and free meals to keep our staff hydrated and energised throughout their time at work.

The recovery rooms are open to all staff, including those working in the community, not just those on the front line, and they offer a calm space where staff can come and sit in silence or talk to others and share their personal thoughts and feelings.

These safe spaces are rooms where staff can go to have a well-deserved and much needed break away from the frontline fighting COVID-19; to have a cup of coffee or a soft drink, a sit down to read a magazine.

They are also home to some of the kind donations of food/drinks/toiletries that the hospitals have received from generous members of the public and local businesses. These are placed in the rooms and staff are allowed to help themselves.

Staff are also bringing things in for each other, hand creams, baking cakes, knitting mascots and making stickers and keyrings, really nice little touches that are helping them through the difficult times.
The Haven Room at Fairfield General Hospital, Bury

# data[].attributes.attachment_link.title
Recovery Rooms introduced at Salford, Oldham, Bury and Rochdale hospitals to support staff wellbeing during COVID-19 pandemic

# data[].attributes.attachment_link.description
RECOVERY rooms, sometimes called 'wobble rooms,' have been launched by the Northern Care Alliance NHS Group (NCA), to support staff health and wellbeing during the COVID-19 pandemic. The recovery rooms are one of a number of different health and wellbeing initiatives currently operating at the four hospitals and community services run by the NCA, which brings together the Salford Royal and Pennine Acute Trusts.

# data[].attributes.attachment_link.description
These resources have been developed by SafeCare specifically for healthcare facilities in resource-restricted settings.

# data[].attributes.attachment_link.readable_text
#criticalCare #airway #procedures #checklists

I use checklists every day to do important stuff, like making sure I closed the garage or buckled my kids in. I use checklists in the ICU too. This is the checklist I refer to every time I intubate. It's intended to be printed 4 to a page and folded up (it fits in your scrub pockets this way). You can laminate if you're fancy or just print a new one when it wears out.

# data[].attributes.attachment_link.description
criticalCare #airway #procedures #checklists I use checklists every day to do important stuff, like making sure I closed the garage or buckled my kids in. I use checklists in the ICU too. This is the checklist I refer to every time I intubate.

# data[].attributes.attachment_link.readable_text
By using Brain Function Monitoring, healthcare professionals can optimise sedation therapy and thereby reduce the risk of over-sedation, drug-usage, myocardial depression, the need for inotropes and the number of ventilator days - all of which can help improve patient outcome during this crisis.

The experts:

Co-Presenter: Pr. Ari Ercole is a consultant in Neuro Intensive Care at Cambridge University Hospitals NHS Foundation Trust (CUHFT) and Honorary Senior Research Associate in the Division of Anaesthesia. His principle research focus involves the physiological measurement, support and resuscitation of critically ill patients, in particular patients that have sustained life-threatening severe trauma. His other interests include data-driven research and he chairs the ESICM Data Science Section.
Co-Presenter: Pr. Rafael Badenes is a specialist in Anaesthesiology and Intensive Care, working in the Department of Anaesthesiology and Surgical-Trauma Intensive Care at the Hospital Clinic Universitari de Valencia, Spain. He is Full Professor of the Department of Surgery at the University of Valencia and a scientist of the INCLIVA Research Health Institute. His primary research interests are neuroscience and organ donation and transplantation.

Co-Presenter: Pr. Frank Rasulo is Associate Professor of Anaesthesia and Intensive Care and Head of Neuro Critical Care in the Department of Anaesthesia, Critical Care and Emergency at Spedali Civili University Hospital, Brescia, Italy. He is Chair of the Neuroanaesthesia and Neuro Intensive Care Study Group for the Italian National Society of Anaesthesiology, Intensive Care and Pain (SIAARTI).

Moderator: Dr. Basil Matta is immediate past Divisional Director for Musculoskeletal, Digestive Diseases, Major Trauma and Perioperative Care Medicine at Cambridge University Hospitals NHS Foundation Trust, where he is the Clinical Lead for the International Business Unit and a Consultant in Anaesthesia and Critical Care. He is an Associate Lecturer at the University of Cambridge.

The tweets (with references...):

Todays #ESICMtv #COVID19 webinar is on protecting the brain https://t.co/sMr4BLLJ26

- Adrian Wong (@avkwong) April 30, 2020

First up @AriErcole on the importance of brain perfusion - more than just blood pressure management pic.twitter.com/vpruE71g6L

- Adrian Wong (@avkwong) April 30, 2020

Next up is Prof Badenes who will be talking about cerebral oxygenation and its implication#COVID19 #ESICMtv pic.twitter.com/lVvIwMHksI

- Adrian Wong (@avkwong) April 30, 2020

Protecting the brain in #COVID19 patientspptimizing sedation, maintaining perfusion, ensuring oxygenation: Basil Matta introducing @esicm webinar with @ICNARC data, live on #ESICMtv w @AriErcole @BadenesR @FrankRasulo #COVIDFOAM #FOAMcc
at the end check blog for slides/replay pic.twitter.com/N8WF034SFq

- foamecmo (@FOAMecmo) April 30, 2020

Brain high VO2 (20% of total) to support neuronal electrical activity/basic metabolism, receiving 15% of CO: potentially vulnerable to injury as protective autoregulatory processes coupling DO2/demands challenged by severe #COVID19/treatment @AriErcole @ESICM webinar #COVIDFOAM pic.twitter.com/EvHLTguINI

- foamecmo (@FOAMecmo) April 30, 2020

Cerebral dysfunction could occur in #COVID19 ie due
to perfusion/oxygenation anomalies; potential to #SARSCoV2 related cerebrovascular reactivity challenges: extremes of PaCO2/PaO2, disturbed autoregulation, haemodynamic impact of sedatives @AriErcole @ESICM webinar #COVIDFOAM pic.twitter.com/r6rlDul37W

- foamecmo (@FOAMecmo) April 30, 2020

Sedation needed in #ICU even if not cure disease; deep sedation/NMBAs frequently required in #ARDS to adapt to MV, but if too deep may be harmful; daily suspension + tapering to awake/comfortable state improve outcome keep it light! #ICUrehab @FrankRasulo #COVID19 @ESICM webinar pic.twitter.com/pZ60yzRBxb

- foamecmo (@FOAMecmo) April 30, 2020

The presentations:

# data[].attributes.attachment_link.description
By using Brain Function Monitoring, healthcare professionals can optimise sedation therapy and thereby reduce the risk of over-sedation, drug-usage, myocardial depression, the need for inotropes and the number of ventilator days - all of which can help improve patient outcome during this crisis. Co-Presenter: Pr.

# data[].attributes.headline
A Physician's Guide to COVID-19 | American Medical Association

# data[].attributes.subject
A Physician's Guide to COVID-19 | American Medical Association

# data[].attributes.attachment_link.readable_text
This quick-start COVID-19 physician guide, curated from comprehensive CDC, JAMA and WHO resources, will help prepare your practice, address patient concerns and answer your most pressing questions.

Updated as of March 23, 2020

Prepare your practice or health system for COVID-19

Resources for clinics and health care facilities: CDC resources

Prevent the spread of COVID-19 in your practice or health care facility: Guides from WHO (PDF)

How to protect yourself from infection

Diagnosing patients with suspected or confirmed COVID-19

What to do if you have been exposed to patients with COVID-19

How to assess risk, monitor for symptoms and understand work restriction decisions for health care professionals with potential exposure to COVID-19: Interim U.S. guidance

Return to work criteria for health care workers: Interim CDC guidance. Federal guidance may be adapted by state or local health departments to respond to rapidly changing local circumstances.

How to communicate with patients

Medicare and Medicaid coverage information

Guidance on elective procedures

CMS recommendations: Limit all non-essential planned surgeries and procedures, including dental, until further notice.

Telemedicine

# data[].attributes.attachment_link.description
This quick-start COVID-19 physician guide, curated from comprehensive CDC, JAMA and WHO resources, will help prepare your practice, address patient concerns and answer your most pressing questions.

# data[].attributes.body
Basic ICU for Covid

# data[].attributes.attachment_link.readable_text
In response to a global requirement to train additional doctors to care for critically ill ventilated patients we have created a blended learning version of BASIC which substitutes e-lectures for face to face lectures and reduces the number of skill stations, so that the skill stations we expect to be taught are assessment, airway management, mechanical ventilation I, II and III and metabolic disturbances. Candidates are expected to complete the ABG skill station that is on the course app.

Course manuals can be ordered from us, printed from the downloadable pdf or, as a last resort, candidates can read the course manual on the app. If you have not previously passed a BASIC instructor course please contact gomersall@cuhk.edu.hk to arrange instructor training by teleconference.

BASIC is a short course, usually held over 2 days, which covers essential and fundamental aspects of Intensive Care.

airway management

acute respiratory failure

mechanical ventilation

basics

common modes

settings

troubleshooting

specific conditions

haemodynamic monitoring

management of shock

severe sepsis

interpretation of arterial blood gases

transport of critically ill patients

severe trauma

neurological emergencies

oliguria & acute renal failure

cardiopulmonary resuscitation

arrhythmias

nutrition

sedation and analgesia

venous thromboembolic disease

stress ulceration

cardiovascular and respiratory physiology

metabolic & electrolyte disturbances

Since 2004 courses have been held in approximately 50 countries

# data[].attributes.attachment_link.description
In response to a global requirement to train additional doctors to care for critically ill ventilated patients we have created a blended learning version of BASIC which substitutes e-lectures for face to face lectures and reduces the number of skill stations, so that the skill stations we expect to be taught are assessment, airway management, mechanical ventilation I, II and III and metabolic disturbances.

# data[].attributes.attachment_link.description
A crowdsourced set of tech, tools and data relating to the Coronavirus Pandemic

# data[].attributes.attachment_link.readable_text
By Samantha Murphy Kelly, CNN Business

(CNN) -- As hospitals worldwide face severe shortages of health professionals, people are being called off the sidelines to help COVID-19 patients - even those with little to no experience in treating infectious diseases.

To train thousands of doctors and nurses with expertise in other areas such as knee surgery or neurology -- and retired practitioners reentering the medical field -- some hospitals are implementing an unlikely method: virtual reality simulations.

At Cedars-Sinai hospital in Los Angeles, more than 300 doctors have learned skills, such as how to assess a patient's symptoms or perform CPR while wearing protective gear, through VR.

"It feels like you are in the room with a patient," said Russell Metcalfe-Smith, the director of the Women's Guild Simulation Center for Advanced Clinical Skills at Cedars-Sinai Medical Center, which has been rapidly training staff for COVID-19. "Based on the decisions you make in the simulation, one direction will lead to another. We have [doctors] jump quickly into a virtual environment like this to get them to where they need to be."

Doctors and nurses at hospitals nationwide are undergoing a variety coronavirus-specific trainings right now, including how to correctly put on and take off protective equipment, how to utilize ventilators that are typically only used by critical care staff, learning new guidelines around concepts such as basic CPR and life support, and managing a diagnosis.

But because time and resources are limited, the door has opened for technologies like VR to fill in the gaps. Considering how the medical industry has long been an early adopter of VR, from using it as distraction therapy for medical procedures or even at the dentist, to a training method for surgeons, it's a natural place for hospitals to turn.

"We've found it very valuable to observe a [doctor's thinking] process -- and it's all been done with social distancing," Metcalfe-Smith said. "Because we can't get large groups together right now, we've had to rely on technology like this to give the same experience -- and we're grateful for that."

The hospital uses software from startup Virti, which provides detailed feedback and metrics on which procedures medical professionals may need more practice with. Cedars-Sinai started using the program in January but rolled it out to more health professionals in mid-March as the outbreak spread.

"We wanted the exercises to embody what is happening in the real-world right now," said Virti founder Dr. Alex Young. "One simulation puts the user alone in an isolation room, where they can see nurses and doctors come in and out, so they can get an idea of how scary it is for patients. It's easy to forget the basics of communicating through the masks, so scenarios like this help with bedside manner."

The company signed up 70,000 new users in the past three weeks across hospitals and universities in the US, UK and Israel.

Typically, trainees learn in environments watched by evaluators and their peers behind a glass wall. In such a scenario, a mannequin, controlled remotely, acts as the patient. But a virtual simulator lets medical professionals practice the skills they need through a VR headset or a tablet, at the hospital or at home.

Boston-based Oxford Medical Simulation is also focused on improving the decision-making process for practitioners in emergency situations. Its scenarios range from how to efficiently and safely put on protective gear to more intensive situations with sick patients.

In one of Oxford's simulations, a nurse, in the form of an avatar, hands the user a file with a brief history of the virtual patient. The doctor or nurse is then required to assess his or her symptoms, making decisions in real time based on how the patient reacts; they may need to check the stomach or the lungs or make fast judgment calls if someone vomits up blood, has a seizure or gasps for air. Oxford's scenarios aren't necessarily COVID-19-specific, but represent what any medical professional may encounter in an emergency.

"The concept is so doctors and nurses can make mistakes in virtual reality and learn from them," said founder and chief medical officer Dr. Jack Pottle, who launched the service in 2018. "Some physicians are coming directly from medical school and thrown into practice, or are retired doctors and nurses not necessarily trained in the areas needed for safely treating people with COVID-19. These simulations help get them up to speed and feel more confident about it, too."

Even before the pandemic, schools were using these tools to train the next generation of medical professionals. Some schools, including New York University, Middlesex University and University of New England, have adopted similar programs with nursing students to get them ready for graduation.

"Before we closed for the semester, we had labs open with eight Oculus Rift headset setups," said Dawne-Marie Dunbar, the director of the Interprofessional Simulation and Innovation Center at the University of New England. Students are still required to remotely complete Oxford's simulations through a mobile phone or tablet after they learn about certain conditions in virtual class.

"We prefer to have them in headsets because it's more immersive, but many are accessing the program on a mobile device right now," she said. "It's still a key way to teach skills they will have to perform often or give them exposure to high-risk conditions that need to be managed correctly."

Early clinical research on VR training has determined the tools could be effective in decreasing injury, speeding up processes and improving overall results. According to a 2018 study published in the Journal of Advances in Medical Education & Profession, people trained by VR had "lower performance errors and higher accuracy compared to those trained by conventional approaches."

However, it added that the technology should be used as a complementary tool to traditional methods and more research should be done on the topic.

"We've had an overwhelmingly positive response to the training," said Carol DerSarkissian, a clinical assistant professor of emergency medicine at New York University Langone Medical Center, which is currently using Oxford's platform to train students. "Part of becoming a good doctor is the experience of taking care of similar cases over and over and learning from each one. [The simulations] help with new skills and build their confidence before entering the frontlines -- and allow for that opportunity without putting anyone at risk."

The-CNN-Wire
™ & © 2020 Cable News Network, Inc., a WarnerMedia Company. All rights reserved.

# data[].attributes.attachment_link.title
Doctors and nurses are using VR to learn skills to treat coronavirus patients

# data[].attributes.attachment_link.description
By Samantha Murphy Kelly, CNN Business (CNN) -- As hospitals worldwide face severe shortages of health professionals, people are being called off the sidelines to help COVID-19 patients - even those with little to no experience in treating infectious diseases.

# data[].attributes.attachment_link.readable_text
Letter to the Editor

Open Access

Published:

Annals of Intensive Care 10, Article number: 33 (2020) Cite this article

10k Accesses

118 Altmetric

Metrics

A cluster of patients of novel coronavirus pneumonia (NCP) have been identified in Wuhan in December 2019 and soon this virus spread at a tremendous rate which swept through the whole China and more than 93 countries and regions around the world [ 1, 2]. This emerging, rapidly evolving situation has threatened the health of all mankind and WHO has raised COVID-19 risk to "very high" at global level.

Up to now, 80,859 cases were confirmed, among which 10-15% patients were critically ill and 3100 (3.83%) died in China. The large number of transmission population between Jiangsu and Hubei provinces led to the infinite burden in controlling the COVID-19 epidemic in Jiangsu Province [ 3, 4]. By 24:00 on March 7, a total of 631 confirmed cases of NCP were reported with a portion of critically ill patients whose ages ranged from 9 months to 96 years old. A total of 610 cases have been discharged from hospital, and the cure rate of confirmed cases in our province has reached 96.67%, which is far exceeding that of national data [ 5, 6, 7, 8]. Since the outcome of NCP patients in Jiangsu was much better than that in Hubei where the mortality of NCP patients was nearly 4.34%, we retrospectively summarized our therapeutic process and figured out that critical care-dominated treatment patterns might be the core in reducing mortality.

(1)
Early recognition of high-risk and critically ill patients

Since the severity of disease is closely related to the prognosis, the basic and essential strategies to improve outcomes that we should adhere to remain the early detection of high-risk and critically ill patients [ 9, 10]. During the clinical work in Jiangsu Province, critical care was shifted forward and early screening was measured. All NCP patients were screened twice every day and respiratory rate (RR), heart rate (HR), SpO2 (room air) were monitored regularly. Once SpO ₂  < 93%, RR > 30/min, HR > 120/min or any signs of organ failure were observed, patients would be transferred to intensive care unit (ICU) and ICU physicians and nurses would take over their treatment.

From our data of more than 600 NCP patients in Jiangsu Province, age, lymphocyte count, oxygen supplementation and aggressive pulmonary radiographic infiltrations are independent risk factors for NCP progressing to a critical condition. We established an early warning system combining these four factors to identify high-risk patients and then kept them under continuous close monitoring. The sensitivity of this warning system was 0.955 (95% CI [0.772-0.999]), the specificity was 0.899 (95% CI [0.863-0.928]) and the area under ROC curve was 0.962 (data unpublished). Our retrospective analysis of cases in Jiangsu Province proved a good consistency between early screening of SpO ₂, RR, HR and early warning model. Therefore, a flowchart integrating early warning model and early screening procedure is recommended for high-risk patients recognition and all patients' screening to make it possible for early intervention (Fig. 1).

Early warning system and screening procedures for NCP patients

1
Early intervention guided by intensivists

Since there have been no effective antiviral treatments for COVID-19 [ 7, 8], the vital way to reduce mortality is early and strong intervention to prevent the progression of disease. During the treatment of Jiangsu NCP patients, three points which showed valid evidence in reversing the disease and preventing tracheal intubation rate were summarized.

(1) For patients with ARDS or pulmonary extensive effusion in CT scan, high-flow nasal cannula oxygen therapy (HFNC) or non-invasive mechanical ventilation (NIV) was used to maintain positive end expiratory pressure (PEEP) to prevent alveolar collapse even if some of these patients did not have refractory hypoxemia. (2) Restrictive fluid resuscitation under the premise of adequate tissue perfusion is performed to relieve pulmonary edema. (3) Although previous study proved prone position's benefit in moderate-to-severe ARDS patients with invasive mechanical ventilation (IMV) [ 11], we attempted awake prone position in NCP patients which showed significant effects in improving oxygenation and pulmonary heterogeneity (Fig. 2). With all these measurements, although the rate of critically ill patients in Jiangsu had reached 10%, the IMV rate of Jiangsu was kept under 1%, which was significantly lower than our previous survey about ARDS patients [ 12].

Early intervention for patients with critical condition

1
Clinical experts-guided hierarchical management strategy

At the outset of epidemic situation, a clinical experts-guided, multidisciplinary, province-wide hierarchical management group was established to provide medical guidance for all NCP patients [ 13]. The members of this panel are mainly critical care specialists and respiratory specialists from tertiary hospitals. Jiangsu Province is divided into five regions according to geographical position and each leader takes responsibilities for a specific region so that problems can be solved layer-by-layer. This kind of regional responsibility, timely feedback communication management makes it possible for effective medical interventions (Fig. 3).

Organization chart of hierarchical management strategy

1
Rational allocation of materials and human resources

Health authorities attached great importance to epidemic and deployed disease prevention and control measures effectively [ 14, 15]. All kinds of resources, including frontline medical staff and medical protective materials, were mobilized and deployed uniformly to guarantee patients' medical care. 234 clinical staff invested in NCP patients' treatment and care, and 3500 clinical staff were reserved for unexpected needs. Adequate material and human resources are important cornerstones for controlling this epidemic.

Since the outbreak of COVID-19, Jiangsu takes effective measures to curb the spread of the virus and gives normative treatments for infected patients, which shows significant disease control and treatment effects. From our experience, early screening of critically ill patients and critical care-guided early intervention are prominent in reducing NCP patients' mortality. At this critical moment in the global outbreak of NCP, we hope our valid management and treatment bundles can help us achieve the victory in the battle against COVID-19.

Availability of data and materials

Funding

This work was supported, in part, by the research Grant 2020YFC0843700 from Ministry of Science and Technology of the People's Republic of China and Treatment procedures and Protocol establishing for critically ill patients (2020YFC0843700).

Author information

Affiliations

1. Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China

Qin Sun

, Haibo Qiu

& Yi Yang

2. Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China

Contributions

YY and MH, the corresponding authors, were responsible for the concept, revision and approval of this manuscript. QS participated in the design and drafted the manuscript. HBQ helped to revise the manuscript. All authors contributed to the data analysis and interpretation. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Mao Huang or Yi Yang.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

All authors have confirmed the manuscript and approved the publication of the manuscript. The corresponding author has completed the "Consent for publication".

Competing interests

The authors have no competing of interest nor any financial interest in any product mentioned in this paper.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

# data[].attributes.attachment_link.title
Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province

# data[].attributes.attachment_link.description
Letter to the Editor Open Access Published: Annals of Intensive Care 10, Article number: 33 (2020) Cite this article 10k Accesses 118 Altmetric Metrics A cluster of patients of novel coronavirus pneumonia (NCP) have been identified in Wuhan in December 2019 and soon this virus spread at a tremendous rate which swept through the whole China and more than 93 countries and regions around the world [ 1, 2].

# data[].attributes.attachment_link.provider_name
Life in the Fast Lane * LITFL * Medical Blog

# data[].attributes.attachment_link.readable_text
Podcasts

Dr Doug Lynch is a poorly differentiated doctor and pathological polymath. Emergency Medicine. Critical Care. Aeromedical Retrieval. Remote Area Medicine. Resource Poor Medicine. Disaster Medicine. Conflict Medicine. Ethics. Politics. Life. Death.

These podcasts are atypical interviews with persons of interest. Critical conversations with Critical Carers. Carers like you. The people that listen to this podcast are insiders, movers, shakers and, every listener potentially a future interviewee.

RAGE features panel discussions, interviews with experts, shout outs and insights from #FOAMcc and the wider critical care-iverse, not to mention various quirky segments on medical history, trivia and more.

The Resuscitationist's Awesome Guide to Everything...is an audio podcast created by a team of emergency physicians, intensivists and retrievalists that brings an irreverent and educational 'real world' perspective to current research, core topics and controversies in critical care.

The Mastering Intensive Care podcast was created to help and inspire intensive care clinicians to improve the care we give to our patients by providing interesting and thought-provoking conversations with highly respected and experienced clinicians. In each episode, Andrew Davies, an intensivist from Frankston Hospital in Melbourne, Australia, speaks with a guest for the purpose of hearing their perspectives on the habits and behaviours that they believe are the most important for improving the outcomes of our patients.

The folks at Medmastery are dedicated to teaching you the 20% of skills that will help you solve over 80% of your clinical problems. All their courses are CME accredited. They now provide LITFL readers with a series of award-winning FOAMed courses from across their website. MedMastery courses and workshops are fully CME accredited providing US (AMA PRA Category 1 Credits TM) and European (ECMECs) CME credits. Members can download their CME certificates upon successful completion of activities.

Dr. Tyler DeWitt is a research scientist, high school teacher, and digital content author. He is the creator of an online #FOAMed YouTube education channel on science topics, and STEM education. Tyler holds a Ph.D. in Microbiology from MIT, where he served as student coordinator for the new MIT+K12 video outreach project. Chemistry Basics collates a series of Dr Tyler DeWitt's Basic Science tutorials.

# data[].attributes.attachment_link.title
LITFL Podcasts * LITFL Medical Blog * Podcasts and Vodcasts

# data[].attributes.attachment_link.description
Dr Doug Lynch is a poorly differentiated doctor and pathological polymath. Emergency Medicine. Critical Care. Aeromedical Retrieval. Remote Area Medicine. Resource Poor Medicine. Disaster Medicine. Conflict Medicine. Ethics. Politics. Life. Death. These podcasts are atypical interviews with persons of interest. Critical conversations with Critical Carers. Carers like you.

# data[].attributes.attachment_link.readable_text
Training related to Coronavirus Disease 2019 (COVID-19) is available through the TRAIN Learning Network, a national learning network that aggregates training opportunities for public health, healthcare, and preparedness professionals from thousands of training providers. This includes training from the Centers for Disease Control and Prevention (CDC), World Health Organization, European Centre for Disease Prevention and Control, and other organizations.

Access training using the search tools below. The searches are live and will automatically update as new training is added to TRAIN.

* Disclaimer: There is an ongoing investigation to determine more about this outbreak. This is a rapidly evolving situation and information will be updated as it becomes available. Some trainings may be out of date based on the most current guidance. Please continue to check the CDC website for the most up-to-date information about COVID-19.

# data[].attributes.attachment_link.title
Coronavirus Disease 2019 (COVID-19) Training

# data[].attributes.attachment_link.description
Training related to Coronavirus Disease 2019 (COVID-19) is available through the TRAIN Learning Network, a national learning network that aggregates training opportunities for public health, healthcare, and preparedness professionals from thousands of training providers. This includes training from the Centers for Disease Control and Prevention (CDC), World Health Organization, European Centre for Disease Prevention and Control, and other organizations.

# data[].attributes.attachment_link.readable_text
Training related to Coronavirus Disease 2019 (COVID-19) is available through the TRAIN Learning Network, a national learning network that aggregates training opportunities for public health, healthcare, and preparedness professionals from thousands of training providers. This includes training from the Centers for Disease Control and Prevention (CDC), World Health Organization, European Centre for Disease Prevention and Control, and other organizations.

Access training using the search tools below. The searches are live and will automatically update as new training is added to TRAIN.

* Disclaimer: There is an ongoing investigation to determine more about this outbreak. This is a rapidly evolving situation and information will be updated as it becomes available. Some trainings may be out of date based on the most current guidance. Please continue to check the CDC website for the most up-to-date information about COVID-19.

# data[].attributes.attachment_link.title
Coronavirus Disease 2019 (COVID-19) Training

# data[].attributes.attachment_link.description
Training related to Coronavirus Disease 2019 (COVID-19) is available through the TRAIN Learning Network, a national learning network that aggregates training opportunities for public health, healthcare, and preparedness professionals from thousands of training providers. This includes training from the Centers for Disease Control and Prevention (CDC), World Health Organization, European Centre for Disease Prevention and Control, and other organizations.

# data[].attributes.attachment_link.readable_text
Mass General FLARE is a collaborative effort within the Pulmonary and Critical Care Division and the Department of Medicine. Its mission is to appraise the rapidly evolving literature on SARS-CoV-2 with a focus on critical care issues.

Core members include Laura Brenner, MD; Tiara Calhoun, MD; Raghu Chivukula, MD, PhD; David Dudzinski, MD; Jason Maley, MD; Camille Petri, MD; and Vlad Vinarsky, MD. The group is led by Corey Hardin, MD, PhD. Please send questions, comments or concerns about FLARE to charles.hardin@mgh.harvard.edu.

Sign up to receive Fast Literature Updates in your inbox here.

Latest Letters

Surfactant and COVID-19 (April 26, 2020)

1. Pulmonary surfactant is a complex mixture of lipids and proteins synthesized in alveolar epithelial cells that is essential to stability of the airspaces and simultaneously contributes to innate immune function. Alveoli are, in some superficial ways, similar to "tiny bubbles"-their stability depends on a balance between surface tension and transpulmonary "pressure". Alveolar instability and disruption of surfactant activity is a hallmark of lung diseases like ARDS

2. Some forms of acute lung injury, particularly in neonates, are effectively treated with surfactant administration and provide proof of concept for surfactant-based therapy of ARDS

3. To date, clinical trials have failed to identify a clear signal for mortality benefit of surfactant replacement in unselected ARDS patients

4. The biologic plausibility of surfactant therapy for ARDS is strong. Prior trials do demonstrate safety and have identified a suggestion of benefit in forms of ARDS driven by primary direct lung injury. COVID-19 associated respiratory failure (a primary lung process) provides a unique and valuable opportunity to revisit the utility of surfactant therapy in a large ARDS cohort with a single etiology

New Data From NYC (April 19, 2020)

1. As the global pandemic due to SARS-CoV-2 progresses, more and more data are becoming available about the clinical course and outcomes of patients with COVID-19

2. Tonight we review a recent case series from New York, New York

3. Clinical characteristics of patients described in this Open Letter to New York, are broadly similar to those described in earlier reports

4. Due to the short follow-up period, final outcome data are not yet available, but outcomes of ventilated patients thus far provide some reassurance

Fluid Management in ARDS (April 14, 2020)

1. The three best evidence-based interventions in ARDS are lung-protective ventilation (March 23 FLARE), prone positioning (March 29 FLARE), and conservative fluid management

2. Conservative fluid management is generally defined and guided by the results of the landmark 2006 FACTT (Fluid and Catheter Treatment Trial) study and includes avoidance of positive fluid balance and normalization of intravascular volume in patients post-resuscitation and without ongoing shock (ARDS Clinical Trials Network, 2006)

3. In addition to conservative management post-resuscitation, it is appropriate to guide fluid resuscitation by measures of volume responsiveness

4. Volume responsiveness should be assessed with dynamic rather than static measures

Viral Load in COVID-19 (April 11, 2020)

1. In most cases of SARS-CoV-2, viral load decreases as adaptive immunity develops

2. Severe COVID-19 is also characterized by significantly elevated inflammatory markers (e.g. CRP, IL-6, ferritin), which some speculate reflects an irrationally exuberant immune response

3. During the 2003 SARS epidemic, there were reports of poor outcomes with both prolonged and suppressed viral replication, suggesting some patients have poor outcomes due to failure to contain the virus, while some suffer from a maladaptive immune response

4. Tonight, we review data on the association of viral load with disease outcome

COVID-19 Risk Factor Round-Up (April 5, 2020)

1. To date, over a dozen studies have attempted to identify risk factors associated with severe COVID-19 or related death

2. A minority of patients with COVID-19 require ICU-level care. Early reports from China indicated that risk factors for severe disease included advanced age, cardiac disease and diabetes

3. More recent reports are largely consistent with early reports and emphasize that risk factors for severe COVID-19 are qualitatively similar to risk factors for mortality in general critical illness

iNO in COVID-19 (March 30, 2020)

1. Inhaled pulmonary vasodilators (iNO, epoprostenol) are periodically used to improve oxygenation in ARDS

2. Despite frequent use, inhaled pulmonary vasodilators have never been shown to improve outcomes

3. There may be a role for these interventions when there is an emergent need to improve oxygenation

4. There are postulated, but unproven, direct antiviral effects of iNO

5. iNO may be preferable to other pulmonary vasodilators due to both direct antiviral effects and mode of delivery

Prone Position in the Non-intubated Patient (March 29, 2020)

1. What is the effect of prone position in a non-intubated patient?

2. Should it be considered in patients with severe COVID-19?

Of ACEs, ARBs and COVID-19 (March 28, 2020)

1. The basic biology of the ACE2 pathway, explore the existing data regarding ACE2 and lung injury

2. Existing data regarding ACE2 and lung injury

3. Implications for patients receiving these medications in the setting of COVID-19

Use of Convalescent Plasma (March 27, 2020)

1. The rationale and evidence for utilizing convalescent plasma in COVID-19

2. Current trials and biotech developments

CT Scans & Early Tracheostomy (March 26, 2020)

1. What is the utility of chest CT in patients with suspected or confirmed COVID-19?

2. What is the role for early tracheostomy in patients with respiratory failure from COVID-19?

The Spectrum of Disordered Inflammation in Critical Illness (March 25, 2020)

1. Elevated inflammatory biomarkers are common in critical illness, including severe COVID-19

2. Hypothesis: a dysregulated immune response, or "cytokine storm", contributes to the progression of critical illness and/or SARS-CoV-2 infection

3. The pathophysiology of cytokine storm and the evidence for immune modulation in the treatment of critical illnesses

FAQs, GI Disease, Washington and Italy (March 24, 2020)

1. FAQs about the Mass General Critical Care Guidance

2. COVID-19 presenting as GI disease

3. Analysis and comparison of newly published clinical data from Washington State and Italy

PEEP, ARDS and COVID-19 Associated Respiratory Failure (March 23, 2020)

1. Discussion of ARDS, PEEP strategy and ARDS subphenotypes in COVID-19 by Dr. Corey Hardin

2. Summary of major PEEP strategy trials

ALVEOLI - High PEEP vs. Low PEEP

EXPRESS - High PEEP vs. Moderate PEEP

LOVS - Open lung approach vs. Low Vt

Additional Therapeutics for SARS-CoV-2 (March 22, 2020)

1. Chloroquine and its potential role in COVID-19

2. Data re-analysis and review of recent HCQ +/- Azithromycin trial

3. COVID-relative points about ARDS management

Stay in the Know

Find the latest news and information about Mass General's response to the Coronavirus (COVID-19) pandemic.

# data[].attributes.attachment_link.description
Mass General FLARE is a collaborative effort within the Pulmonary and Critical Care Division and the Department of Medicine. Its mission is to appraise the rapidly evolving literature on SARS-CoV-2 with a focus on critical care issues. Core members include Laura Brenner, MD; Tiara Calhoun, MD; Raghu Chivukula, MD, PhD; David Dudzinski, MD; Jason Maley, MD; Camille Petri, MD; and Vlad Vinarsky, MD.

# data[].attributes.body
Kenya MOH

# data[].attributes.attachment_link.description
This interim guidance is for staff at local and county health departments, infection prevention and control teams, and healthcare personnel who are coordinating the home care and isolation of people with confirmed or suspected COVID-19 infection presenting with mild symptoms and when managing contacts, including persons under investigation.

# data[].attributes.attachment_link.readable_text
The Basic Assessment & Support in Intensive Care (BASIC) collaboration is an informal grouping of Intensive Care and Emergency Medicine specialists with an interest in the development and dissemination of high quality, free course teaching material to teach clinicians intensive and acute care. It was founded in 2004 by members of the Department of Anaesthesia & Intensive Care at The Chinese University of Hong Kong and led by Prof. Charles Gomersall. This material is produced primarily in the form of short courses focusing on different topics or groups of students/professionals working with severely ill patients. All courses are generic and standardized (teaching material is produced in sufficient detail to be to be teachable, in-situ, by trained local instructors). To date all courses follow the same format: 1-3 day courses consisting of a course manual for pre-course reading, pre-course test, short lectures focusing on application of knowledge gained from pre-course reading, skill stations and a post-course test. All course material is provided free of charge (in an electronic format) and there are no license fees for running courses. The courses are disseminated using a train the trainer model. Educational material for all courses is updated on a regular basis, at least annually.

In excess of 350 courses are taught per year and our course have been taught in over 70 countries

Venues of BASIC Collaboration courses since 2004

Novices PICU doctors

Introduction to PICU with a focus on monitoring and organ support, especially mechanical ventilation

Very BASIC

Medical students and junior doctors

Care of critically ill patients outside ICU

Beyond BASIC Cardiothoracic Intensive Care

Intermediate-advanced Intensive Care trainees
(or refresher for specialists)

Management of immediate post operative and critically ill cardiothoracic patients

Doctors and nurses interested in running our courses should click here

1. Douglas A, Holley A, Udy A, Lipman J, Gomersall CD, Joynt GM, Freebairn RC, Boots R. Can learning to sustain life be BASIC? Teaching for the initial management of the critically ill in Australia and New Zealand. Anaesthesia and Intensive Care, 2010; 38:1043-51

2. P. C. Gruber, C. D. Gomersall, G. M. Joynt, F. M. Shields, M. C. Chu, J. L. Derrick, and for the Very BASIC development group. Teaching acute care: a course for undergraduates. Resuscitation 74:142-149, 2007.

3. C. D. Gomersall, P. Lam, and G. M. Joynt. Electronic interactive learning to supplement acute care teaching. Medical Education 44:526, 2010.
Joynt GM, Zimmerman J, Li TS, Gomersall CD. A systematic review of short courses for nonspecialist education in intensive care.Journal of Critical Care. 2011 Oct;26(5):533.e1-533.e10.

4. Wong WT, Ling L, Gomersall CD. Making critical care education BASIC: A collaborative approach to training. ICU Management & Practice. 2017;17(4):216-9. https://iii.hm/fay

# data[].attributes.attachment_link.title
Department of Anaesthesia and Intensive Care CUHK

# data[].attributes.attachment_link.description
The Basic Assessment & Support in Intensive Care (BASIC) collaboration is an informal grouping of Intensive Care and Emergency Medicine specialists with an interest in the development and dissemination of high quality, free course teaching material to teach clinicians intensive and acute care.

# data[].attributes.attachment_link.readable_text
The website is intended solely for general educational and information purposes, and is not intended to provide advice to healthcare professionals. EMORY MAKES NO WARRANTIES, EXPRESS OR IMPLIED AS TO THE MATERIAL DISCUSSED ON THIS WEBSITE WHATSOEVER, INCLUDING, WITHOUT LIMITATION, COMPLIANCE WITH QUALITY, REGULATORY, ACCREDITATION OR NATIONAL STANDARDS OF CARE. EMORY EXPRESSLY DISCLAIMS ANY WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE RELATED TO THE MATERIAL PRESENTED ON THIS WEBSITE.

# data[].attributes.attachment_link.description
The website is intended solely for general educational and information purposes, and is not intended to provide advice to healthcare professionals. EMORY MAKES NO WARRANTIES, EXPRESS OR IMPLIED AS TO THE MATERIAL DISCUSSED ON THIS WEBSITE WHATSOEVER, INCLUDING, WITHOUT LIMITATION, COMPLIANCE WITH QUALITY, REGULATORY, ACCREDITATION OR NATIONAL STANDARDS OF CARE.

# data[].attributes.attachment_link.provider_name
Life in the Fast Lane * LITFL * Medical Blog

# data[].attributes.attachment_link.readable_text
Difficult airway algorithms are useful for considering all the contingencies that may occur during intubation

All team members must be aware of all of the contingency plans

All intubation attempts should be considered potential difficult airways

Algorithms involve a step-wise approach using different techniques for difficult intubation and difficult ventilation

TECHNIQUES
Techniques for difficult intubation

Alternative laryngoscope blades

Awake intubation (either video laryngoscope or fiberoptic scope)

Blind intubation (oral or nasal)

Fiberoptic intubation

Intubating stylet or tube changer (e.g. Cook catheter or bougie)

Laryngeal mask airway as an intubating conduit

Light wand

Retrograde intubation

Invasive airway access

Techniques for Difficult Ventilation

Esophageal tracheal Combitube

Intratracheal jet stylet

Laryngeal mask airway

Oral and nasopharyngeal airways

Rigid ventilating bronchoscope

Invasive airway access

Transtracheal jet ventilation

Two-person mask ventilation

LEVITAN AIRWAY ALGORITHM Patient safety using RSI hinges on a redundancy of safety.
Can you intubate? If intubation fails, can you ventilate? Algorithm (above) focuses on the route of intubation and RSI decision.
The colored arrows are contraindications to RSI.

In cardiac arrest (blue box - patient apneic) muscle relaxants are not needed. When there is obvious oral pathology, or intrinsic laryngo-tracheal pathology (green boxes - patient breathing spontaneously), the redundancy of safety does not exist - avoid RSI.

When the mouth is blocked (step 2), intubate through the nose or through the neck (cricothyroidotomy). RSI is specifically done to optimize laryngoscopy conditions and permit oral intubation. If it is apparent that the oral route has obvious anatomic problems (not merely potential difficulty), RSI should never be considered.

When the oral route is impossible, intubation will need to take place through the nose or neck, and this should be done with the patient awake.

Examples include massive angioedema, advanced Lundwig's angina, wired jaw, or readily apparent combinations of airway distortion, disproportion, and dysmobility (cervical spine and mandible), that preclude oral intubation. With intrinsic laryngeal pathology (step 3), safest approach is with the patient breathing spontaneously, using fiberoptic intubation, or a surgical airway (tracheotomy) below the level of the lesion.

At step 4, the decision to use RSI is a matter of judgment, not a strict contraindication.

The four Ds (distortion, disproportion, dysmobility, dentition) may make direct laryngoscopy with standard equipment impossible.

Is an "awake" approach feasible? Will you be able to rescue ventilate? How fast are intubation and patient control needed? What are the risks of delay vs. the potential risks of RSI?

After crossing the RSI line, patient safety often depends on first pass success at laryngoscopy, since many patients requiring emergent intubation have very short safe apneic periods.
Pre-oxygenation is only marginally effective in critically ill patients.
STRAYER AIRWAY ALGORITHM

RSI vs. Awake - latter preferred if:

Less urgent intubation

More difficult airway features

Low risk of vomiting

Prepare for failure of intubation and failure of ventilation

Discuss plan A, B, C, D with team

Equipment for plan A, B, C, D at bedside

Airway attempt successful -> post-intubation management

Airway attempt unsuccessful, able to ventilate -> Plan B/C/D

change patient position

change blade

change modality (e.g. direct vs video laryngoscopy)

change proceduralist

Airway attempt unsuccessful, unable to ventilate -> supraglottic airway -> surgical airway if unsuccessful -> post-intubation management

WALLS AIRWAY ALGORITHMS
Ron Wall's algorithms from his Airway Course and Manual of Emergency Airway Management:
AUSTIN HOSPITAL AIRWAY ALGORITHMS
Algorithms from the Austin Hospital ED, Melbourne, courtesy of George Douros. Here's the RSI pre-intubation checklist

Here's the difficult airway action plan
THE VORTEX APPROACH
Nicholas Chrimes and Peter Fritz have developed an algorithmic approach to airway management based on a cognitive aid called 'The Vortex'

DIFFICULT AIRWAY SOCIETY ALGORITHM

The Difficult Airway Society in the UK has comprehensive guidelines for airway management, including multiple algorithms.

The integrated algorithm can be downloaded here (pdf).

the Austin Hospital's algoirthm by George Douros above, is a modified version of the DAS integrated algorithm - note that the option of waking the patient up has been removed for 'out-of-theatre' use!

References and Links
Journal articles

Apfelbaum JL, et al; American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013 Feb;118(2):251-70. PMID: 23364566. [Free Full Text]

Henderson JJ, Popat MT, Latto IP, Pearce AC; Difficult Airway Society. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia. 2004 Jul;59(7):675-94. PMID: 15200543.

FOAM and web resources
On Twitter, he is @precordialthump.

# data[].attributes.attachment_link.title
Difficult Airway Algorithms * LITFL Medical Blog * CCC Airway

# data[].attributes.attachment_link.description
Difficult airway algorithms are useful for considering all the contingencies that may occur during intubation All team members must be aware of all of the contingency plans All intubation attempts should be considered potential difficult airways Algorithms involve a step-wise approach using different techniques for difficult intubation and difficult ventilation TECHNIQUES Techniques for difficult intubation Alternative laryngoscope blades Awake intubation (either video laryngoscope or fiberoptic scope) Blind intubation (oral or nasal) Fiberoptic intubation Intubating stylet or tube changer (e.g.

# data[].attributes.attachment_link.description
Calculators to aid with clinical decision-making during the COVID-19 crisis.

# data[].attributes.attachment_link.readable_text
Each of these scores were designed to predict mortality and used to determine who can safely be sent home. A low risk CURB-65 score (0 or 1), confers a 0.6-2.7% risk of mortality. ⁷ A low risk PSI/PORT score (<90) confers a 0.1-2.8% risk of mortality. ⁸ Comparing the utility of the two, CURB-65 may not identify patients requiring ICU admission as well as the PSI. In addition, CURB-65 does not consider patients' comorbidities (e.g. COPD), which may have a major impact on outcomes in COVID-19 patients. While CURB-65 is considerably faster to compute, with less inputs, this advantage matters less in the age of electronic records and resources. The PSI/PORT places a larger emphasis on age than CURB-65, assigning points by absolute age (i.e., a 70-year-old gets 70 points), which seems more consistent with what we know about COVID-19's high mortality in the elderly.

In both of these cohorts, community acquired pneumonia was generally defined as a combination of clinical (e.g. fever, cough, dyspnea, rales) and radiographic (e.g. infiltrate on CXR) findings in the absence of risk factors for healthcare. Neither the CURB-65 or PSI/PORT studies differentiated between viral and bacterial pathogens as a cause for the pneumonia, although the incidence of viral-associated CAP may be up to 29%, with rhinoviruses and influenza being the most common. ⁹⁻¹⁰

Recently, a clinical prediction tool was developed to risk-stratify patients specifically diagnosed with viral pneumonia - the MuLBSTA score. ¹⁰ The aim of this was to predict clinical characteristics that affect mortality in patients with viral pneumonia. Interestingly, there are predictors of adverse outcomes that correlate with the clinical characteristics that are reported in COVID-19 patients. The presence of a multilobar infiltrate, low lymphocyte count, smoking history, and advanced age all were independent risk factors for mortality in this population - all relatively consistent with risk factors from our COVID cohort. But... before we get too excited, we must take note that this single-center, retrospective, not-externally-validated design may lead to bias and unknown applicability and generalizability.

Due to stronger emphasis on age and comorbidities, PSI/PORT may be a more accurate tool in disposition decision-making for COVID-19 patients, as age and underlying disease seem to be the major contributors to adverse patient-oriented outcomes.

The MuLBSTA score examines a patient population with similar characteristics to those with COVID-19 PNA. However, this single-center, retrospective study limits its applicability and reliability. We recommend its use as adjunct to clinical suspicion, but not in isolation.

All of these scores likely underestimate the importance of advanced age and of low lymphocytes.

# data[].attributes.attachment_link.title
MDCalc Review: Calcs in Resource-Limited Situations

# data[].attributes.attachment_link.description
Each of these scores were designed to predict mortality and used to determine who can safely be sent home. A low risk CURB-65 score (0 or 1), confers a 0.6-2.7% risk of mortality. 7 A low risk PSI/PORT score (<90) confers a 0.1-2.8% risk of mortality.

# data[].attributes.body
Brindle, Mary MD, MPH*; Gawande, Atul MD, MPH†Author InformationJournal of Craniofacial Surgery: March 23, 2020 - Volume Publish Ahead of Print - Issue -doi: 10.1097/SLA.0000000000003923

# data[].attributes.attachment_link.description
This site uses cookies. By continuing to browse the site you are agreeing to our use of cookies. Find out more.

# data[].attributes.body
Daily checklist Covid

# data[].attributes.attachment_link.readable_text
Anne Marie Martland, MS, ACNP-BC; Meredith Huffines, MS, BA, RN; and Kiersten Henry, DNP, ACNP-BC

Background

Effective management of critically ill patients infected with the COVID-19 virus is dependent upon the efficient provision of evidence-based care. Ensuring the safety and resilience of nursing staff during pandemic-related surge capacity is an essential component of disaster preparedness. The suggestions in this article are focused on nursing leadership and administrative considerations, strategies for optimizing staffing resources, and maintaining staff safety and resilience. The suggestions in this article are important for hospital administrators, nursing leaders, and bedside nursing personnel.

Summary of suggestions
Identifying alternate staffing resources
We suggest that hospitals consider alternate sources of staffing to supplement existing critical care nursing staff. These may be internal or external resources.

Internal Resources

1. Identify alternate staffing resources within the facility who may have prior critical care experience. These include advanced practice nurses (Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Nurse Practitioners), as well as nurses in procedural areas (such as the post- anesthesia care unit, cardiac catheterization lab, electrophysiology lab, and operating room).

2. Identify nurses in progressive care units (intermediate care, telemetry, or stepdown units) who could contribute to team-based care with the guidance and expertise of a critical care nurse.

3. Identify staff who could provide support to both associates and patients, such as psychiatric counselors and social workers.

External Resources

1. Identify critical care nurses who have transitioned to ambulatory settings but have only been out of critical care environment for less than 3 years.

2. Consider partnering with prehospital resources to support the ICU care team.1,2

Local emergency medical services (EMS) to utilize paramedics or emergency medical technicians for appropriate patient care skills as part of the critical care team approach

Neighboring medical practices (RNs and medical assistants) and urgent care facilities³

3. Consider utilizing telemedicine, particularly in community facilities with limited specialist support. E-ICU monitoring (remote monitoring of patients by critical care nurses and providers at an offsite facility) is also a potential means of force expansion to provide support to on-site staff.4,5

4. Utilize additional established resources through the US Department of Health and Human Services Assistant Secretary of Preparedness Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) at https://asprtracie.hhs.gov/.

Develop a team-based approach for critical care patient management
A team-based approach with critical care registered nurses (RNs) supported by additional staff members would increase the capacity for care of critically ill patients. Utilizing the unique skill set of each team member in a collaborative approach would provide force multiplication. This team-based approach has been demonstrated to work effectively in both aeromedical transportation and disaster medicine settings. Role definition is an essential component of this approach to patient care. 1,4

1. To establish group norms, we recommend utilizing the principles of highly reliable organizations (HRO) and the American Association of Critical-Care Nurses' Healthy Work Environment Standards.⁶

HRO principles include preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise. Determining the skill set and expertise of each team member will support staff comfort with deference to expertise.⁷

The Healthy Work Environment Standards include skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.

2. Utilize team huddles at the start of each shift and at regular intervals (such as every 4 hours) to discuss team assignments, patient care goals, and red flags that should be reported immediately to the critical care RN. This will enhance communication, optimize patient care activities, and allow each team member to discuss their clinical strengths and address any concerns. Huddles at regular intervals throughout the shift will inform all team members of changes in plan of care and provide the opportunity to address any concerns.⁸

3. Determine appropriate tasks for team members without critical care training, designating the critical care RN as team lead for each patient care team. Examples include paramedics performing intubation, IV starts, and nebulizer treatments. RNs without critical care experience could be utilized to document vital signs, perform appropriate nursing interventions, such as routine medication administration, vital sign monitoring, and assisting with patient care activities.

Administrative Considerations for Nurse Staffing
Critical care surge capacity secondary to infectious disease presents unique nursing administrative concerns. These include patient placement, addressing visitor policies, providing adequate amounts of advised personal protective equipment, and determining staff who should not be involved in direct care of COVID-19 infected patients. Formally addressing topics such as the potential need for staff isolation and compensation at the onset of surge will assist in mitigating staff concerns.

1. Visitation policies should be adapted based on exposure risk and patient population. We recommend that administrators clearly communicate changes to visitation policies, and ensure this information is available to patients and their families. Consider options for video communication so that patients do not feel isolated from their family members during this time and families are provided reassurance and regular updates.

2. We recommend that leadership provide just-in-time training to reinforce knowledge of COVID-19 symptoms, transmission, and other important clinical information. This training should include a review of donning and doffing of appropriate personal protective equipment (PPE). A brief but standardized orientation for outside health-care providers assisting in surge management should also be developed to ensure compliance with pertinent policies.⁹

3. The Centers for Disease Control and Prevention indicate that there is limited information on COVID-19 in pregnancy. High fever can increase the risk of birth defects in the first trimester of pregnancy. There are also documented cases of pregnancy loss with other related coronaviruses (SARS-CoV and MERS-CoV). We recommend that administrators consider limiting exposure of pregnant nurses from care of patients with COVID-19, particularly during high risk procedures that increase exposure.

4. Administrators should also evaluate other high-risk staff (those who are immunocompromised or have respiratory illness) to determine their risk of exposure and ability to wear the required personal protective equipment for the required duration.

5. Staff members with potential exposure to COVID-19 may be placed on isolation. Those staff may have concerns regarding lodging, as well as compensation. We recommend that facilities develop a plan for housing and compensating staff who need to isolate away from family members and are unable to return to work during their isolation period.

Nursing Leadership Concerns
Nursing literature on the SARS epidemic identified challenges faced by nursing leadership during a period of patient surge related to infectious disease.10 Five stages experienced by nurse leaders were identified as facing shock and chaos, sourcing for reliable sources to clarify myths, developing and adjusting nursing care, supporting nurses and their clients, and rewarding nurses.

1. We recommend that nurse leaders collaborate with hospital administrators to develop consistent and regularly scheduled methods of updating staff on operating conditions, safety concerns, and other issues related to surge capacity.

2. Nurse leaders should be prepared to assist staff in managing internal conflict between personal and professional responsibilities.

3. We recommend that nurse leaders identify resources for assistance in mitigating internal conflicts among staff working under surge conditions, such as social workers and mental health personnel.

4. We recommend that even in times of surge, nurse leaders provide meaningful recognition to staff engaged in patient care efforts. This recognition promotes a healthy work environment and reinforces staff resilience.

Nurse Safety and Resilience

We suggest that facilities implement proactive strategies to prevent staff attrition due to fatigue or illness. These include the provision of mental health support, ensuring safe utilization of personal protective equipment to prevent staff infection, and maintaining a healthy work environment. Perceived organizational support had an impact on predicting burnout in Canadian nursing staff during the SARS crisis. ¹¹

1. We recommend implementation of a safety officer role to monitor PPE and staff exposure risk as part of a total staff safety model. This individual could be an Emergency Medical Technician or Nursing Technician familiar with PPE, or another identified individual who is trained in PPE utilization. The safety officer could provide just-in-time training for those not comfortable with donning and doffing of PPE, and, intermittently, audit PPE utilization.

2. We recommend that each care team designate a team safety officer to ensure team members are taking routinely scheduled breaks for hydration, rest, toileting, and refreshments. Staff should also be assessed for skin breakdown related to extended time periods in PPE.¹³

3. Provide staff with resources to plan with their family in advance of reporting to their first shift.

4. Promote a team culture, particularly if staff are staying on-site during their off time. This may include team meals, team exercise sessions, or other bonding activities.¹⁴

5. Provide access to mental health support for staff feeling overwhelmed or concerned. SARS team nurses in Taiwan demonstrated worry about infecting family and colleagues. Utilization of video communication with family members reduced nurse worry.⁸

6. We recommend that hospital administration maintain visibility with impacted patient care areas to provide support. Mechanisms should be in place for addressing staff concerns about psychosocial issues and working conditions. Meaningful recognition of staff providing support during the surge effort should be provided at regular intervals.11,15

References

1. Centers for Disease Control and Prevention. Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health. Atlanta, GA: U.S. Department of Health and Human Services; 2018.

2. Brannman S, Nieratko J, Patnosh J, et al. Engaging healthcare partners in the disaster healthcare delivery system. Washington, DC: U.S. Health and Human Services Office of the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). https://files.asprtracie.hhs.gov/documents/aspr-tracie-engaging-healthcare- partners-in-the-disaster-healthcare-delivery-system-508.pdf . Accessed March 14, 2020.

3. Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). Medical Surge and the Role of Urgent Care Centers. Washington, DC: ASPR TRACIE; 2018.

4. Arizman I. Field organization and disaster medical assistance teams. Turk J Emerg Med. 2015;15(Supp 1):11-19.

5. Greenwald PW, Hsu H, Sharma R. Planning for future disasters: telemedicine as a resource. Ann Emerg Med. 2018:71(3):435-436.

6. The American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2nd ed. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2016.

7. Provost SM, Lanham HJ, Leykum LK, McDaniel RR, Pugh J. Health care huddles: managing complexity to achieve high reliability. Health Care Manage Rev. 2015;40(1):2-12.

8. Lee SH, Juang YY, Su YJ, Lin YH, Chao CC. Facing SARS: psychological impacts on SARS team nurses and psychiatric nurses in a Taiwan general hospital. Gen Hosp Psychiatry. 2005;27(5):352-358.

9. Joshi N. Just in time training. 2013. Available from: www.aliem.com/just-in-time-training/. Accessed March 14, 2020.

10. Shih FJ, Turale S, Lin YS, et al. Surviving a life-threatening crisis: Taiwan's nurse leaders' reflections and difficulties fighting the SARS epidemic. J Clin Nurs. 2009;18(24):3391-3400.

11. Marjanovic Z, Greenglass ER, Coffey S. The relevance of psychosocial variables and working conditions in predicting nurses' coping strategies during the SARS crisis: an online questionnaire survey. Int J Nurs Stud. 2007;44(6):991-998.

12. Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). Tips for Retaining and Caring for Staff After a Disaster. Washington, DC: ASPR TRACIE; 2018.

13. U.S. Fire Administration. Emergency Incident Rehabilitation. Washington, DC: International Association of Firefighters; 2008.

14. Substance Abuse and Mental Health Services Administration. Tips for Disaster Responders: Preventing and Managing Stress. Washington, DC: U.S. Department of Health and Human Services; 2014.

15. Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). Disaster behavioral health. The Exchange. 2017;2(1).

Please enable JavaScript to view the comments powered by Disqus.

# data[].attributes.attachment_link.title
Surge Priority Planning COVID-19: Critical Care Staffing and Nursing Considerations

# data[].attributes.attachment_link.description
Anne Marie Martland, MS, ACNP-BC; Meredith Huffines, MS, BA, RN; and Kiersten Henry, DNP, ACNP-BC Effective management of critically ill patients infected with the COVID-19 virus is dependent upon the efficient provision of evidence-based care. Ensuring the safety and resilience of nursing staff during pandemic-related surge capacity is an essential component of disaster preparedness.

# data[].attributes.attachment_link.title
Figure 1 | COVID-19: Updates from the frontlines

# data[].attributes.attachment_link.description
Share your clinical experience on Figure 1 and tag it with #COVID-19 to help your colleagues around the globe. Here is what your peers are sharing about coronavirus on Figure 1.

# data[].attributes.attachment_link.readable_text
Dr Mia Van Manen - COVID Resource Pack Editor
Welcome!! I hope this page will form a single resource, as up to date as possible, on everything to do with the topic that has hit us all so hard...Coronavirus!

There is a lot out there and you can spend hours getting lost on the web, reading news stories and hearing one thing, then another contradicting the first! So, take some time to have a flick through what I have put together. More to come and updated regularly.

There are guidelines, infographics, papers and downloads. I will also try to collate the information coming through from some of our brilliant regional groups. Many thanks to David Lyness, Jenny Briggs, Paul Groves, Martin Smith, Grace Hoey and many others.

Stay safe, look after your patients AND yourselves.

All the best

JW

So much on here...click the section you want to jump to it!

1. NGH info pack for staff only (Password Protected)

2. Useful COVID Calculator

3. Training Video on COVID and what its is, myths, realities etc!

4. Our COVID resource pack, loads of brilliant guides, SOP,s etc

5. Latest evidence / papers on everything COVID

6. Lung Ultrasound and POCUS

7. COVID Twitter Feed

8. Official guidance

9. Personal experiences of COVID

10. Infographics

11. Statistics

12. Patient Information

13. The Situation unfolding around the world

14. Downloadable powerpoint compilations on various aspects of COVID

15. ECMO referral pathway

16. Radiology information

17. Blogs on COVID

18. Videos on COVID

19. Tweetorials on COVID

20. Top Resources

Click below to access and use your code mailed to you!

Thanks to MDCalc!

Here is my full talk. Myth-busting, the virus, how we can cope together and well-being. Access it, use it and teach with it. I hope it helps you all?

Please download it here. We have sourced resources for you all to take and use, learn from, teach with etc and it will grow daily! Please take advantage of it. Much of it is written by us as we discover more about new evidence, what works, what doesn't etc. Watch this space and keep a check on new stuff coming in.

Matt Bigwood has been manning the research scanning...he is keeping the list, you can find here, as up to date as possible! Please click in!

Check out Crit Care Reviews Database

Also, check out the Lancet's free resource!

Could this be the key???

Justin Kirk Bailey et al discuss what could be a key measure in prophylaxis?? See what you think.

We are building a page all about it for you all here. Edited by myself and Cian McDermott. Click the pic to get you to the page!

Yale's COVID Diary!

As below, my good friend Yale Tung Chen contracted COVID and made it through the other side....with a full ultrasound diary. With his kind permission, I made the lot into a graphic. Thank you Yale and we are so glad you got through it and are, "back in the trenches", as he said.

Multiple College Guidance

UK Intensive Care society

UK Government and Department of Health

NICE

NICE ICU

https://www.criticalcarenice.org.uk

Here is just a subset of many of the images freely available on the internet. Not all are 100% accurate, but considering much of this is cloaked in hysteria worldwide, it isn't surprising there is so much out there!

Check out Grepmed's Graphics

A brilliant video set below

Click below to see what is developing and where!

Click for clinical management graphics!

Click here for graphics on the virus itself!

Click here for Lessons Learned graphics!

The Brompton has an excellent site for ECMO referral. The 'how-to refer' section is what I am pointing to here. Please see this as a guide and DO NOT REFER ALL PATIENTS HERE IN THE UK. There are other local centres, find yours.

Work out your patient's RESP Score before ECMO referral

Italian Society of Radiology

Check out the Italian Society of Radiology COVID database.

Propofology

Please go to our sister site and see what Dave Lyness has been up to with COVID-19. We share info, resources and infographics and Dave is 'on it', with the lot!

Anaesthesia Blog

RESUSMed

Pharm So Hard Blog

JW's Coronavirus playlist

Click the arrow submenu to see the list of video resources. Click on the play symbol top right to scroll through the playlist.

We talk all about COVID with Butterfly!

A panel of great friends and great discussion...see for yourself!

Dr Yale Tung Chen talks about his unique COVID 19 experience!!

He is a great friend and fellow Butterfly user. We cannot thank him enough for what he has done, both from the angle of selflessness and for the fact he has put himself on the line to get information out to us, free of nonsense. Yale contracted COVID 19 and tells us first hand what he has been going through, with lung ultrasound in a daily diary too! His twitter feed can be found here .

David Lyness talks about the virus!

Listen to David Lyness and his excellent analysis and presentation of the situation so far, all about the virus and what the future may hold...

Donning and doffing PPE

There is a lot of evidence emerging regarding the COVID19 patient with ARDS, that proning really can be of benefit. Here are some resources on this....perhaps we all need to become well versed in the technique? Click the top-right menu again to play the videos and pick which is easiest for you...

Check out this video on the sneeze!!

You can see why this virus gets around!! 🦠

This is even more harrowing!

Thinking CC!

COVID-19 - Respiratory Management: A Physiological Approach Webinar from @ThinkingCC / CCUS Institute on Vimeo.

19. Well Being for Staff

Thanks so much Shaan, keeping us up to date!

Anxiolysis through Medical Hypnosis!

Dr Paul Slater takes us through relaxation techniques and Anxiolysis (without Midazolam!)

Myself on ACE-i in COVID-19

Dave Lyness

See David's Tweetorials here.

Aoife Abbey

Aoife talks us through Corona here

Miguel Galan de Juana tells us how they coped

So this looks legit enough, and there may be a time where there is little else you can do! We hope not, but this is worth a look!

Portsmouth's DropBox resource!!

Brilliant stuff!

Buckinghamshire Trust Guidelines

# data[].attributes.attachment_link.description
Dr Matt Bigwood - Peer reviewer, moderator and research editor Dr Mia Van Manen - COVID Resource Pack Editor Welcome!! I hope this page will form a single resource, as up to date as possible, on everything to do with the topic that has hit us all so hard...Coronavirus!

# data[].attributes.attachment_link.readable_text
On the 11 March 2020 WHO characterised the spread of coronavirus as a pandemic.

The spread of the virus can be monitored through various websites including the COVID-19 Global Cases by Johns Hopkins CSSE

This novel coronavirus route of transmission and clinical presentation is similar to SARS, with flu-like symptoms (typically involving fever, cough, shortness of breath) and acute respiratory failure (commonly bilateral pneumonia, acute respiratory distress). However, patients may present with atypical symptoms.

While COVID-19 has been suggested to have a lower case fatality rate (2.5%) than SARS (9.6%), MERS (34.4%), or H1N1 (17.4%), the extent of spread means that the death toll is significant. Frontline healthcare workers are at high risk of becoming infected, and are also at risk of spreading infection.

Anaesthesiologists and other perioperative care providers are particularly at risk when providing respiratory care and tracheal intubation of patients with COVID-19. WFSA would like to draw anesthesia team attention to the importance of appropriate precautions when providing respiratory care and intubation for these patients.

WFSA Statement on health care providers safety and wellbeing during the COVID-19 pandemic (pdf)

Guidance on anaesthesia and COVID-19

Guidance on Airway Management

Guidance on Obstetric Anaesthesia

Guidance for Low Resource Settings

Ressources en français

Recursos en español

Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR) - Portal de información sobre coronavirus

Ministerio de Salud Español - Documentos técnicos para profesionales

Asociación de anestesiólogos - Información esencial

CLASA - Guías para manejo de pacientes con COVID-19.

SCARE - Página de recursos de COVID-19

Sociedad Ecuatoriana de Anestesiología - Check list de seguridad para el manejo perioperatorio covid positivo

FUS & UIS - Aproximacion practica via aerea en pacientes pandemia COVID19

WFSA - Declaración de la WFSA sobre la seguridad y el bienestar de los proveedores de atención médica durante la pandemia de COVID-19

Recursos em Português

Coronavirus - General Information

# data[].attributes.attachment_link.title
World Federation Of Societies of Anaesthesiologists - Coronavirus

# data[].attributes.attachment_link.description
On the 11 March 2020 WHO characterised the spread of coronavirus as a pandemic. The spread of the virus can be monitored through various websites including the COVID-19 Global Cases by Johns Hopkins CSSE This novel coronavirus route of transmission and clinical presentation is similar to SARS, with flu-like symptoms (typically involving fever, cough, shortness of breath) and acute respiratory failure (commonly bilateral pneumonia, acute respiratory distress).

# data[].attributes.body
Infographics

# data[].attributes.attachment_link.description
ECMO in COVID-19: What we have learned thus far? Lot of interesting topics & points of view discussed during this ELSO webinar, on April 22!

# data[].attributes.attachment_link.readable_text
COVID-19 continues to spread around the world at an alarming rate, demanding global action to contain the spread and ensure that care is available for the most vulnerable. The World Health Organization (WHO) is urging countries to improve efforts to contain the disease and protect health care workers, and notes that a solution calls for "aggressive preparedness," all around the world.

Partners In Health (PIH) knows that COVID-19 will disproportionately affect the most vulnerable and hit countries with weak health systems the hardest. The currently reported case fatality rate cannot be used to predict how this virus will devastate many areas globally where there are not high functioning and resourced health systems that can respond to an aggressive infectious disease, and where the population suffers from conditions such as malnutrition, HIV, and tuberculosis. Mortality is anticipated to be far worse in the places where PIH works, and it is unclear if the current global response accounts for the factors in these settings.

PIH is launching a comprehensive effort to support this response across its network of supported countries around the world to:

contain and control the spread of the virus,

ensure that patients are provided with dignified care, and

demonstrate to the world what aggressive action in vulnerable settings can achieve.

Our Full Response
Important Update on COVID-19 rapid diagnostic tests (RDTs)
Partners In Health has recently received newly available evaluation evidence regarding the accuracy of COVID-19 RDTs, which were being considered for deployment at PIH supported sites, with an initial order having been placed. Based on such evidence, our technical experts have determined that there is significant uncertainty about the accuracy of a specific product and it therefore would not be advisable to deploy this product. The RDT market landscape is changing day by day with multiple new products coming to market-clinical experience and scientific evidence regarding their use is quickly being generated. We continue to research the market for RDTs of high reliability and accuracy. The implementation of our four-pronged plan to stop COVID-19 goes forward unchanged, with its focus on Point of Care (POC) testing, providing care, assisting local governments, and tracing contacts. We remain committed to an aggressive, comprehensive approach that prevents the pandemic from devastating vulnerable communities.

For more information about our COVID-19 response, please contact Director of Impact, Emily Dally at edally@pih.org.

Resources

Partners In Health Guides

Part I: Testing, Contact Tracing and Community Management of COVID-19 (Updated: 4.21.2020)

Part II: Clinical Management of COVID-19 (Updated: 4.21.2020)

Annex (Updated: 4.21.2020)
Watch on YouTube
Explainer Webinar

# data[].attributes.attachment_link.description
COVID-19 continues to spread around the world at an alarming rate, demanding global action to contain the spread and ensure that care is available for the most vulnerable.The World Health Organization (WHO) is urging countries to improve efforts to contain the disease and protect health care workers, and notes that a solution calls for "aggressive preparedness," all around the world.

# data[].attributes.attachment_link.provider_name
Life in the Fast Lane * LITFL * Medical Blog

# data[].attributes.attachment_link.readable_text
#CoVisuals are educational visual abstracts created by Dr. Chelsea Harris, MD, MS a General Surgery Resident at the University of Maryland.

Dr Harris (@ CAHarrisMD) is involved in multiple Diversity Equity and Inclusion initiatives at both the local and national levels. She is one of the study co-ordinators curriculum designers for Cultural Collaborators. Dr Harris is a former Creative Director at Annals of Surgery and one of the foremost experts on Visual Abstracts.

The Dirty Dozen: Common Errors On Discharging Patients Recovering From Critical Illness

Having some success stories and getting #COVID19 patients ready to discharge? Here is " The Dirty Dozen " 12 Questions and Considerations to set your patients up for success, from leading ICU docs.

The Dirty Dozen: Common Errors On Discharging Patients Recovering From Critical Illness. Theodore J Iwashyna. LITFL

Triage of Non-Emergent Surgical Procedures

How to Conserve Personal Protective Equipment. Guidance for Triage of Non-Emergent Surgical Procedures - Elective Surgery Acuity Scale (ESAS) from @AmCollSurgeons

Surgical Response to COVID-19

Recommendations regarding Surgical Response to #COVID19 as of March 2020. Summary of @SAGES_Updates

Managing COVID-19 in Surgical Systems

Managing COVID-19 in Surgical Systems from @AnnalsofSurgery from of Guidelines by @MaryEBrindle & @Atul_Gawande of @AriadneLabs

Resuscitation in patients with COVID-19

Summary of Resuscitation for #COVID19 from @SCCM

Infection Control with COVID-19

Summary of Infection Control for #COVID19 from @SCCM

Consensus Statement: Multiple Patients per Ventilator

Highlights of the Consensus Statement from @SCCM, @aarc_tweets, @ASALifeline, @APSForg, @AACNme, @accpchest on Multiple Patients per Ventilator for #COVID19

N95 reuse instructions

N95 reuse guide from @SAGES_Updates and @JAMASurgery based on conversation with Dr Tsai, INVENTOR of the filtration fabric in the N95 mask. N95 made of polypropylene and are designed to tightly fit over your face with little leakage.

Scarce Resource Allocation Team (SRAT)

As hospital systems prepare for a #COVID19 surge, creating a Scarce Resource Allocation Team (SRAT) may save bedside providers from having to make impossible decisions.

Chelsea Harris MD, MS

General Surgery resident at the University of Maryland

# data[].attributes.attachment_link.title
#CoVisuals - Visual Abstracts for COVID-19 * LITFL *

# data[].attributes.attachment_link.description
CoVisuals are educational visual abstracts created by Dr. Chelsea Harris, MD, MS a General Surgery Resident at the University of Maryland. Dr Harris (@ CAHarrisMD) is involved in multiple Diversity Equity and Inclusion initiatives at both the local and national levels. She is one of the study co-ordinators curriculum designers for Cultural Collaborators.

# data[].attributes.body
Managing Critically Ills Mech Vents

# data[].attributes.attachment_link.keywords[]
rox index to predict risk of intubation respirology critical care covid-19 rox

# data[].attributes.attachment_link.title
ROX Index to Predict Risk of Intubation | Calculate by QxMD

# data[].attributes.attachment_link.description
Calculate is a next-generation clinical calculator and decision support tool freely available to the medical community. To date it contains 250+ medical calculators in all manner of specialties.

# data[].attributes.attachment_link.readable_text
Dr. Raywat Deonandan is an Assistant Professor of Health Sciences at the University of Ottawa, an epidemiologist, a global health researcher, and best-selling novelist. His research interests include the epidemiological trends in global burdens of disease, the social and moral dimensions of risk perception, and other global health related topics. Furthermore, Dr. Deonandan is an award-winning journalist with features in the Toronto Star, the Huffington Post and other publications. Presently, he sits on the Board of Directors of the Canadian Society of Epidemiology and Biostatistics, and is the founder and Executive Editor of the Interdisciplinary Journal of Health Sciences.
Dr. Deonandan is keenly interested in spreading knowledge about epidemiology globally, be it through social media or via innovative teaching methods.

# data[].attributes.attachment_link.title
Lecturio: Study for Medical School, USMLE, MCAT & MBBS

# data[].attributes.attachment_link.description
Become fluent in medical concepts. The video course "COVID-19 Overview and Management" will boost your knowledge. Study for your classes, USMLE, MCAT or MBBS. Learn online with high-yield video lectures by world-class professors &earn perfect scores. Save time & study efficiently. ➨ Try now for free!

# data[].attributes.attachment_link.title
COVID-19: Knowledge for Healthcare Students & Professionals

# data[].attributes.attachment_link.description
Concept Card | Coronavirus disease 2019: Learn about Etiology, Transmission, Epidemiology, Clinical Presentation, Diagnostics, Management, Prevention of COVID-19.

# data[].attributes.attachment_link.readable_text
#criticalCare #airway #procedures #checklists

I use checklists every day to do important stuff, like making sure I closed the garage or buckled my kids in. I use checklists in the ICU too. This is the checklist I refer to every time I intubate. It's intended to be printed 4 to a page and folded up (it fits in your scrub pockets this way). You can laminate if you're fancy or just print a new one when it wears out.

# data[].attributes.attachment_link.description
criticalCare #airway #procedures #checklists I use checklists every day to do important stuff, like making sure I closed the garage or buckled my kids in. I use checklists in the ICU too. This is the checklist I refer to every time I intubate.

# data[].attributes.attachment_link.readable_text
Vanderbilt University Medical Center and Vanderbilt Institute for Global Health are committed to supporting healthcare providers in low- and middle-income countries during the global COVID-19 pandemic through education. In partnership with Assist International and Project ECHO, we are offering a tele-education series that will provide remote training and a platform for discussion and the sharing of best practices for healthcare providers caring for COVID patients in low-resource settings. The sessions are open to all and will be live-streamed via a video-conferencing platform. Recordings will also be available following the sessions. Details for upcoming sessions, including registration links can be found below.

To receive email notifications for upcoming sessions, please write to us here and request to be added to our COVID-19 Tele-Education Series list. Please add "Subscribe to COVID-19 Tele-Education Series" to the subject line.

PREVIOUS SESSIONS

# data[].attributes.attachment_link.description
Vanderbilt University Medical Center and Vanderbilt Institute for Global Health are committed to supporting healthcare providers in low- and middle-income countries during the global COVID-19 pandemic through education. In partnership with Assist International and Project ECHO, we are offering a tele-education series that will provide remote training and a platform for discussion and the sharing of best practices for healthcare providers caring for COVID patients in low-resource settings.

# data[].attributes.attachment_link.description
Assist International is committed to supporting the Global South amidst the COVID-19 pandemic by bringing our experience, resources, and partners together in response to this crisis.

# data[].attributes.attachment_link.readable_text
Welcome to the UW Medicine COVID-19 Public Site. The clinical and administrative teams throughout our system (Harborview Medical Center, UW Medical Center-Montlake, UW Medical Center-Northwest, Valley Medical Center, UW Neighborhood Clinics and Airlift Northwest) and partners Seattle Cancer Care Alliance have developed policies and protocols in response to the outbreak in Western Washington. Most of these documents have been written since Monday, February 24th 2020 and are undergoing frequent revisions as the COVID-19 situation evolves. When using the documents, we caution you to be mindful of the date the document was produced and to check that against current knowledge and evolving clinical standards.

Since the outbreak began, our colleagues, locally and nationally, have been reaching out to us for assistance as they start to see cases. We hope that by sharing our work, we can assist your teams and facilities to move more quickly and to spend more time responding and less time typing.

This is a "rough" draft of what we hope will be much more to come. Our vision is to continue to add the many more protocols and flow diagrams we have ranging from the Airlift Northwest team to our exposure protocol. We hope to add a discussion board and maybe even the ability for others to upload their documents (ex. from the LTCF community).

Please feel free to contact us with questions and recommendations at covid19@uw.edu.

# data[].attributes.attachment_link.description
Welcome to the UW Medicine COVID-19 Public Site. The clinical and administrative teams throughout our system (Harborview Medical Center, UW Medical Center-Montlake, UW Medical Center-Northwest, Valley Medical Center, UW Neighborhood Clinics and Airlift Northwest) and partners Seattle Cancer Care Alliance have developed policies and protocols in response to the outbreak in Western Washington.

# data[].attributes.attachment_link.readable_text
#criticalCare #airway #procedures #checklists

I use checklists every day to do important stuff, like making sure I closed the garage or buckled my kids in. I use checklists in the ICU too. This is the checklist I refer to every time I intubate. It's intended to be printed 4 to a page and folded up (it fits in your scrub pockets this way). You can laminate if you're fancy or just print a new one when it wears out.

# data[].attributes.attachment_link.description
criticalCare #airway #procedures #checklists I use checklists every day to do important stuff, like making sure I closed the garage or buckled my kids in. I use checklists in the ICU too. This is the checklist I refer to every time I intubate.

# data[].attributes.headline
Covid 19: A primer on ICU care for the non-intensivist. St Emlyn's • St Emlyn's

# data[].attributes.subject
Covid 19: A primer on ICU care for the non-intensivist. St Emlyn's • St Emlyn's

# data[].attributes.attachment_link.readable_text
In the coming weeks and months we are likely to see clinicians working in areas that are previously unfamiliar to them. Here in Virchester we've identified that emergency medicine, acute medicine, and intensive care medicine (ICU) are likely to be the areas with the highest numbers of redeployed staff.

Of these the one that appears to be causing the greatest concern is intensive care and with good reason. You cannot simply grow an intensivist overnight! In the UK it's a highly competitive, high tech, high demand speciality that attracts some of best and brightest clinicians who deliver a consultant based service. However, we may very soon be in a different situation where we will not have enough fully (or partially) trained intensivists to go around all the beds that we are currently creating/making/knitting 😉 . Here in Virchester our escalation plans involve using our wider anaesthetic team (docs/nurses/ODPs/EAPs) to staff beds in the first instance (who may have completed blocks of ICU training in the past), but if that resource is exhausted we may call on other clinicians to work under the supervision of a senior clinician with ICU training.

This blog and podcast are here to try and start answering some of the anxieties that we have heard in recent weeks. It's not a complete guide, but hopefully a reassuring starting point to learn, one that will guide you to do further online learning and at your place of work with face to face lectures and workshops (Ed - if they are not happening yet, they probably should be). There are some great links at the bottom of the page to get you started which I will try and keep adding to as more resources come online. Start by listening to the podcast below. In this we do not underestimate the concern and worry that is genuine and real for many people who face taking on new skills and roles. ICU is far more than twiddling knobs on the vent (a phrase which woefully underestimates the complexities), but it is also something that you can help with, so long as you can access good training, guidance and supervision. That's really the main message of this blog and podcast. No-one can turn you into an intensivist in the time frame we have, but we can help you support the service and our patients. If in doubt about the way that intensivists/anaesthetists value education you can always pop onto twitter and follow some of the amazing clinicians out there who exemplify a supportive, education focused, evidence based approach. There are many such people whom I hope typify who you might work with in the next few months.

The bottom line is that NOW is the time to identify and train clinicians who may have to work on ICU, but who may have never worked there before, or who worked there many years ago.

Dr. Sarah Thornton is an anaesthetist and intensivist in a hospital somewhere NW of Virchester University Hospital, who together with colleagues has put together an aide memoire for ventilation and general ICU management which you can download and adapt below (this one was designed by @jplomas based on designs seen in Salford and Cardiff). She has also agreed to join our podcast to talk through how we see the expansion of critical care beds working in the UK (we suspect it will be similar elsewhere too). We encourage you to develop a similar resource in your local units and to use this and other resources to start training staff now. Remember that you need to train a multiprofessional workforce and not just doctors.

F - Feeding.
A - Analgesia
S - Sedation
T - Thromboprophylaxis
H - Head up (keep them sitting up)
U - Ulcer (stomach) Prophylaxis
G - Glucose control
S - Skin and stuff -> Lines, pressure areas.

Review the need for these daily. It's the basic things on ITU that saves lives.
- Dave Jones 🏴󠁧󠁢󠁷󠁬󠁳󠁿🏳️‍🌈 (@WelshGasDoc) March 22, 2020

The idea behind this is that we can use ARDSnet strategies for Covid patients in the first instance.

An additional daily ward round aide-memoire is the FASTHUGS system which we employ on the Major Trauma Service in Virchester. I find this also helps me remember the routine, but vital aspects of care for our more severely injured patients.

All these systems are designed to make critical care a structured and systematic approach where the basics are completed in a regular and reliable way. For clinicians like myself this is absolutely the approach that we need to work efficiently under the guidance of a (proper) intensivist.

You should also look out for some materials coming out of the Royal College of Anaesthetists soon to support e-learning on this issue. We'd also recommend you finding out about the escalation policies in your hospital and availing yourself of any local learning opportunities. You can also look online for guides, such as this excellent examples below, but be aware that strategies may differ between countries. More are listed at the end of this blog.

Best I've seen so far (but not actually done myself) is an online course form University of Cork as highlighted b y Andy Neill. Link here https://ucc.instructure.com/courses/22984/pages/modified-basic-icu-course-13-03-20

Lastly, and perhaps most importantly, never, ever forget that critical care nurses have incredible knowledge, expertise, skills and wisdom. They will probably be looking after other nurses who may have been redeployed just like you. However, that's not how your hierachies should work. EM and Crit Care thrive on flat hierachies and total respect for all the different tribes and teams that work there. Your nurses will save you and your patient if you work well with them. Work with them and listen to them, not only will the patient get a better deal, you'll also learn loads.

If you haven't already, do n't forget to read and listen to our other Covid-19 resources here. Good luck everyone and we'll see you on the other side.

vb

Simon Carley and Sarah Thornton

Other resources

EMCRIT - The Internet book of Critical Care https://emcrit.org/ibcc/covid19/

EMCRIT - Dominating the vent part 1 https://emcrit.org/emcrit/vent-part-1/

BroomeDocs - Airways, Safety and Strategy for SARS-Cov2 https://broomedocs.com/2020/03/airways-safety-and-strategy-for-sars-cov2/

Free lectures on Continulus (needs registration) https://www.continulus.com/covid-19-free-lectures/

Royal College of Anaesthetists page on Covid-19 https://icmanaesthesiacovid-19.org/

Critical Care Northampton has an amazing site with loads of relevant resources for new ICU clinicians https://criticalcarenorthampton.com/

AliEM https://www.aliem.com/paucis-verbis-ventilator-settings-for-acute-lung-injury-and-ards/

This book was specifically written for this!

And royalties go to charity. So no DOI@shond3

The Beginner's Guide to Intensive Care: A Handbook for Junior Doctors and Allied Professionals https://t.co/G6FCuCHg0A
- Nitin. Wash Your 🙏🏼 (@aroradrn) March 24, 2020

This book has a cost, but I am assured that royalties go to charity (I've not personally checked https://www.amazon.co.uk/dp/1138035785/ref=cm_sw_r_cp_api_i_fVKEEb869GKZ4)

University College Cork Basic ICU course https://ucc.instructure.com/courses/22984/pages/modified-basic-icu-course-13-03-20
Help keep St Emlyn's running

Covid Quick reference guide https://www.saferinsulin.org/

How you can support St Emlyn's

# data[].attributes.attachment_link.title
Covid 19: A primer on ICU care for the non-intensivist. St Emlyn's * St Emlyn's

# data[].attributes.attachment_link.description
In the coming weeks and months we are likely to see clinicians working in areas that are previously unfamiliar to them. Here in Virchester we've identified that emergency medicine, acute medicine, and intensive care medicine (ICU) are likely to be the areas with the highest numbers of redeployed staff.

# data[].attributes.headline
Critical Care Wellbeing resources for staff

# data[].attributes.subject
Critical Care Wellbeing resources for staff

# data[].attributes.headline
Beyond the ED: COVID-19 and Critical Care • COVID-19 at St Emlyn's

# data[].attributes.subject
Beyond the ED: COVID-19 and Critical Care • COVID-19 at St Emlyn's

# data[].attributes.attachment_link.readable_text
In this podcast, we talk about the clinical journey of a COVID-19 patient and some insights from the critical care unit. There are some concepts here that we probably don't do full justice to in the time we had, so here are some accompanying notes and links to help those of you who want to deep dive into certain areas

The Podcast

Get the basics right

A thorough history and evaluation for everyone with suspected or confirmed COVID-19 coming through the doors into ED is absolutely essential. Don't miss dual pathology. Think hard about whether they need a CT or a CTPA to evaluate the lungs further and use the national decision support tools. Evaluate work of breathing and think about physiology - don't make decisions about referral/escalation based purely on numbers. Consider early arterial lines for those previously fit patients that look like they are heading towards ICU. And consider early Clinical Frailty Scoring and sensible discussions for those patients who look sick, but you have doubts about whether intensive care is really appropriate.

What happens then?

For patients with evidence of respiratory failure who are less sick, CPAP is now encouraged by NHSE to reduce work of breathing and increase lung recruitment. This is considered to be an aerosol generating procedure currently, although there is ongoing discussion on that. Local factors and individual patient trajectory will determine where and when this can happen. Intensive Care Society (ICS) knowledge sharing information and statements on CPAP may be helpful. Alternatively, you could get involved and recruit to the Recovery RS trial. This is great - takes the complex decisions out of your hands and contributes to the evidence base to boot.

In the really sick patients, MERIT teams are encouraged and can scoop people up from the ED in order to deliver airway management and expertise in a dedicated and prestocked 'intervention room', somewhere within or adjacent to the ICU. There are huge benefits to this: an overall reduction in PPE use; psychological safety of a prepared and familiar environment; limited personnel exposure to AGPs and sequential interventions delivered by expert teams doing these things regularly in PPE. But, of course, this will depend on local engagement and whether patients are clinically safe to be transferred out of the Emergency Department.

What about the sicker patients? What interventions other than CPAP can we consider immediately?

I always struggle to identify the benefits of prone positioning off the cuff, but we tried in the podcast! The rationale is explained better in this comprehensive review, by real experts in the field. Here is one of the key papers to support prone positioning for severe ARDS. The ICS have produced some UK guidance on when you might think about doing this, and a proposed P/F ratio (see below) to help guide proning teams.

Prone positioning in awake patients has a negligible evidence base. I have only ever seen a few case series which report transient improvement in oxygenation. Having said that, if patients will tolerate it then the risks seem low. The ICS has produced a document to support trials of awake prone positioning. Perhaps worth a try? Don't expect miracles though.

What are the challenges with invasive ventilation in COVID-19 patients?

Initial safety around RSI in these patients should focus on ensuring adequate preload, a stable cardiovascular drug induction and maximising the chances of first pass success. The RCOA/ICS/FICM repository is an excellent resource that goes into great depth here.

Bronchoscopy is useful for sputum clearance and to assess tube patency. We are changing a lot of tubes after short periods and secretions are tenacious and challenging to manage. Have you got an ambuscope or other way of doing this in ED if your ICU is backed up? If not, you could think about it.

Inhaled nitric oxide therapy is being muted again as a pulmonary vasodilating agent to help reduce shunt. Limited evidence in support of its use in prior ARDS studies, but these are new times and with new times everyone likes to get the old machines back out. HFOV (High Frequency Oscillation Ventilation) anyone ....?

Here are some nice cheat sheet resources for inspiratory and expiratory holds which we discuss briefly in the podcast.

What's a P/F ratio and what's all this about shunt and dead space? Some physiology revision...

The Horowitz index (P/F ratio) tries to provide a reliable estimate of the trade-off between inspired oxygen and the oxygen pressure in the blood. It is popular, so much so that it has made it into the official Berlin definition of ARDS and it has formed part of the entry criteria for multiple clinical trials in this area. Make sure you know your mmHg from your kPa if you are using it, how to convert between the 2 and what the output means.

Shunt refers to perfusion without ventilation.

Dead space refers to ventilation without perfusion.

In truth, it is a bit more complicated than that and the two often interlink, but the above describe good back to basics principles. Unfortunately in COVID-19, there is often a problem with both....

What's autoPEEP again?

This was an interesting sideline, but it should be noted that we aren't seeing a huge amount of gas trapping and autoPEEP in COVID-19. Read more about it here .

You mentioned specific problems with HME condensation/clotting. What's all this about?

A standard HME offers some degree of heat and moisture exchange while also filtering out bacterial and viral pathogens. Unfortunately, these filters appear to be clogging with secretions and condensation more than ever in COVID-19, which limits delivery of gas flow. This has been such an issue that the Faculty of Intensive Care Medicine (FICM) have issued a safety update on it. Be wary of this and consider introducing a HME check/change as part of your daily rounds on these patients.

What about outcomes - what is happening to these patients?

ICNARC will continue to produce data on this and you should keep an eye out for it. The latest report has figures on >5500 patients. There are also opinion pieces on different phenotypes of COVID-19 lung.

Best practice guidelines for management of late stage ARDS, much of which are applicable to the later stages of COVID-19, can be found here.

And what's it really been like on the ICU?

In a word, tough. Looking after sick colleagues is really difficult. There are some psychological support and wellbeing resources and we would encourage anyone who has encountered this to talk about it with friends, mentors and psychology colleagues. PPE is an ongoing debate, but even when you have enough and you get it on, the challenges of staying in it for long periods of time are real.

Also, the pace and scale of change has been mentally exhausting. However, there have been lots of fantastic examples of broken silo's, teamworking and kindness. We have also been lucky enough to receive exemplary support from relevant health professionals and digital colleagues. The way we are delivering research during this time has also been fairly revolutionary, and a thing to behold.

I hear that about once a day at the moment. Well done Dickens. Still relevant.

Stay safe everyone.

Dan.

# data[].attributes.attachment_link.title
Beyond the ED: COVID-19 and Critical Care * St Emlyn's

# data[].attributes.attachment_link.description
In this podcast, we talk about the clinical journey of a COVID-19 patient and some insights from the critical care unit.

# data[].attributes.headline
What tests could potentially be used for the screening, diagnosis and monitoring of COVID-19 and what are their advantages and disadvantages?  - CEBM

# data[].attributes.subject
What tests could potentially be used for the screening, diagnosis and monitoring of COVID-19 and what are their advantages and disadvantages?  - CEBM

# data[].attributes.attachment_link.readable_text
April 20, 2020

¹NIHR Newcastle In Vitro Diagnostics Co-operative
Newcastle University, Newcastle upon Tyne, NE2 4HH
²NIHR Newcastle In Vitro Diagnostics Co-operative
Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, NE1 4LP
³Kleijnen Systematic Reviews Ltd
Unit 6, Escrick Business Park, York, YO19 6FD
⁴Institute of Applied Health Research
University of Birmingham B15 2TT
PDF to Download

VERDICT
Many diagnostic tests for coronavirus disease 2019 (COVID-19) are available so far, with more gaining emergency approval every day. These tests are largely based on four different techniques, 1) reverse transcription polymerase chain reaction (RT-PCR) - the current standard test for COVID-19, 2) loop-mediated isothermal amplification (LAMP) - a simple, but less developed testing method, 3) lateral flow - hand-held single-use assays providing results for an individual patient in as short as 15 minutes, and 4) enzyme-linked immunosorbent assay (ELISA) - quick and technically simple assays that are easily read and offer relatively high throughput.

BACKGROUND
A range of molecular techniques ranging from central laboratory testing to point-of-care tests are under development or already available for the diagnosis and management of COVID-19 patients. These techniques, while well-known to researchers and clinicians with a background in deoxyribonucleic acid (DNA) amplification, as well as antibody and antigen assays, may be relatively unknown to the broader community. This document was written to outline and explain the basic principles of the main COVID-19 diagnostic tests currently in use or in trials.

GLOSSARY
Key terms used in this document (highlighted in bold) are described here:

Antibody - Antibodies are protective proteins produced naturally in response to seeing foreign structures (antigens), e.g. during a viral infection. The body produces early `prototype' antibodies (IgM) with intermediate strength for binding to the virus. These are able to start working to clear virus about five days after a new infection started. Typically eight to ten days after the start of the infection, IgG antibodies with high binding strength, can work to help more rapid virus clearance. Antibodies act by developing a matching contoured surface to stick to antigens, using a sophisticated selection process to amplify antibodies with the best surface match and strongest binding.

Antigen - An antigen is a structure recognised as foreign by the human body that triggers the immune system to produce self defence systems to clear pathogens from blood and tissues. Antigen clearance is spearheaded by antibodies and white blood cells.

COVID-19 - Coronavirus disease-19 - A respiratory illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), colloquially referred to as coronavirus. The family of coronaviruses includes not only SARS (-1 and -2) and MERS, but also milder forms (causing 15-20% of common colds).

DNA - Deoxyribonucleic acid - The molecule that humans and most organisms use to store their genetic code. DNA contains the information that cells use to make proteins. It is formed from two strands that bind together forming a helix shape.

Enzyme - An enzyme is a protein that speeds up chemical reactions by adapting or changing other proteins and molecules.

Fluorescence - This is the light given off by certain molecules when they absorb energy.

Herd-Immunity - This method of protection from the spread of disease provides population immunity by vaccinating a large percentage of the population, thereby protecting those who are not immune by reducing their chance of exposure to the disease.

RNA - Ribonucleic acid - In humans RNA has many functions, but a main one is to copy sentences of DNA to make proteins. Some viruses use RNA instead of DNA to store their genetic code, including the virus that causes COVID-19.

Sensitivity - The ability of a diagnostic test to give a positive result when it is supposed to be positive.

Serum - Serum is a yellowish fluid which is part of the blood. It is the liquid component of blood once the blood cells have been removed.

Specificity - The ability of a diagnostic test to indicate a negative result when it is supposed to be negative.

Swab - A small piece of gauze or other absorbent material attached to a stick used for collecting patient samples. Both long and short swabs are used in coronavirus testing. Long swabs are used by a clinician to take nasal swabs, but short swabs can be used by patients themselves. Different protocols may require different swab types.
Reverse-Transcription Polymerase Chain Reaction (RT-PCR) Technology overview
PCR is a very common scientific technique that has been widely used in research and medicine for around 20-30 years to detect genetic information. RT-PCR is a special version used when RNA is being detected and it is now being used as a test to detect SARS-CoV-2, the virus causing COVID-19. This type of test has frequently been used as a frontline test for COVID-19 as it directly tests for the presence of the virus RNA.

RT-PCR tests are fairly quick, sensitive and reliable, capable of producing results in 3-4 hours, although this usually takes longer if samples must first be sent to specialised external laboratories (6-8 hours on average).

Many diagnostic and research companies produce RT-PCR products, tests and machines so the technology is widely available. Some RT-PCR tests are developed as an `all in one' kit, reducing laboratory handling and potential for contamination.
How it works
Once a sample has been collected, chemicals are used to remove any proteins, fats and other molecules, leaving only RNA behind. This will be a mixture of a person's genetic material as well as any viral RNA that might be present.

The test kit enzymes copy the RNA to DNA, which is amplified to allow virus detection by using a PCR machine which cycles the test temperature so that roughly 35 billion copies of viral DNA are made for each viral RNA strand that was originally present.

Fluorescent markers are typically used to bind to the amplified DNA and produce light, which can be read by the machine to produce the test result. If the intensity of the light produced within the sample reaches a certain threshold, this is classed as a positive test. The number of PCR temperature cycles that were required before the fluorescence threshold was reached is recorded and gives an estimate of how much virus was present in the patient sample.

What does the test detect?
RT-PCR detects whether or not viral RNA is present in samples from a patient. It does this by capturing and amplifying regions of the virus' genetic material, usually the Spike protein, N protein or Envelope (see picture).
To measure the viral RNA, it is converted to DNA, copied many times using repeated temperature cycles in a PCR machine and then fluorescent markers are used to detect the virus. If the amount of fluorescence goes above a certain level, this confirms that the virus is present. The number of temperature cycles the machine performs to reach this threshold is recorded to estimate how much virus was present in the patient sample. The lower the number of cycles, the more virus was present.Commonly these samples are taken from the nose or throat using either long or short swabs, but samples can be collected in other ways too. Collecting samples from where the virus is shedding or multiplying, improves the accuracy of the test.

What does the result mean?
An RT-PCR test is highly sensitive and fairly reliable if performed on a sample from an infected part of the body whilst an active infection is occurring.

Positive test result: - A positive PCR result means that the person the sample was taken from is currently infected by the virus.
Negative test result: - A negative PCR result could mean that the person is not currently infected by this virus, the virus is not present at the site the sample was taken from, the sample taken was of poor quality, or that it is too early, or too late in the infection to detect replicating virus. This is why negative test results require new patient samples to be taken a few days later to reduce the chance of incorrectly missing an infected person.

RT-PCR is accepted by scientists and medical staff as a robust and well documented technique.

With RT-PCR being so common in research and medicine, the technology is already in place to test for COVID-19.

RT-PCR can detect current infections of disease, allowing medical staff to determine who is currently infected and who is not.

Disadvantages:

RT-PCR relies on capturing and detecting the virus and so it is possible to miss patients who have cleared virus and recovered from disease.

The distribution of virus across the respiratory tract varies between patients, so even if a person is infected, the virus may only be detectable in sputum or nasopharyngeal swab but not necessarily at both locations at the same time.

RT-PCR for COVID-19 can only tell if a person is currently infected with this particular coronavirus. It can't provide information on other diseases or symptoms.

The RT-PCR test cannot detect if a person has had the virus and then cleared it after the end of the COVID-19 disease, i.e. whether a person had the disease, as it only detects when active virus is present.

Further information
Please see the links below for more information about RT-PCR.
Loop-Mediated Isothermal Amplification (LAMP)
Basic summary of RT-PCR (short video slideshow):
https://www.youtube.com/watch?v=EaGH1eKfvC0
Scientific Principles of RT-PCR (20 minute video of the principles of RT-PCR):
https://www.youtube.com/watch?v=DH7o9Df5_50
How coronavirus is detected by RT-PCR (short article on COVID-19 testing by RT-PCR):
https://www.iaea.org/newscenter/news/how-is-the-covid-19-virus-detected-using-real-time-rt-pcr

Loop-mediated Isothermal Amplification (LAMP) is a similar process to RT-PCR, but instead of using a series of temperature changes to produce copies of the viral DNA, LAMP is conducted at a constant temperature of 60-65°C.
The amount of DNA produced in LAMP is much higher than in RT-PCR and a positive test result can be seen visually without requiring a machine to read the results.
LAMP is a newer technique compared to RT-PCR, but is technically simple and easy for a trained scientist to perform, making it a potentially useful technique for detection of COVID-19. As it is a newer technology, there is less evidence on its use, but diagnostic companies are currently performing clinical trials to support it.

LAMP assays for COVID-19 start with the collection of samples from the nose or throat using a swab, but can also use samples collected using other methods too such as mucus produced from hard coughing.
Like RT-PCR, the viral RNA in the sample is converted to DNA which allows it to be copied.
The amplification of the viral DNA using LAMP technology and reagents can be detected when the reaction mixture is turned cloudy due to the production of a chemical called 'magnesium pyrophosphate'. As this cloudiness can be seen by the naked eye, it allows for easy diagnosis of COVID-19 by scientists and clinicians.
The accuracy of the results can be improved by using special fluorescent dyes or colour changing dyes in the reaction mixture.
As the dyes interact with the viral DNA, the intensity of the light or colour change can be measured to give the approximate number of viral RNA molecules that were initially in the sample.
What does the result mean?
What does the test detect?
Like RT-PCR, LAMP detects whether or not viral RNA is present in samples from a patient. It does this by capturing and amplifying regions of the virus' genetic material, usually the Spike protein, N protein, Envelope or multiple regions at once (see virus diagram in RT-PCR section above).
Samples can be collected in the same way as they are for RT-PCR, usually from the nose or throat using long or short swabs, or through mucus produced when a person coughs strongly. In order to measure the viral RNA, it must be converted to DNA using an enzyme and copied many times. The results of the test are determined based on the cloudiness or colour change of the reaction mixture.

Like RT-PCR, LAMP tests are highly sensitive and reliable if performed on a sample from an infected part of the body whilst an active infection is occurring.

Positive test result: - A positive LAMP result means that the person the sample was taken from is currently infected by the virus.
Negative test result: - A negative LAMP result could mean that the person is not currently infected by this virus, the virus is not present at the site the sample was taken from, or that it is too early, or too late in the infection to detect replicating virus. This is why when test results are negative, new patient samples are taken a few days later to reduce the chance of incorrectly missing an infected person.
Advantages and limitations Advantages:

LAMP is a quick technique that can produce results in 2-3 hours.

Results can be read by eye.

The simple and cheap method can be done within hospital laboratories, improving the time between taking a sample and getting a diagnosis.

LAMP can detect current infections of disease, allowing medical staff to determine who is currently infected and who is not.

Disadvantages:

The technology is newer than RT-PCR and does not have such a large background of research behind it. Tests using LAMP technology for COVID-19 are still being assessed in clinical settings.

The science behind building these tests is more difficult than RT-PCR.

LAMP tests rely on capturing and detecting the virus and so it is possible to miss patients who have cleared virus and recovered from disease.

The distribution of virus varies across the respiratory tract between patients, so even if a person is infected the virus may only be detectable in sputum or nasopharyngeal swab but not necessarily at both locations at the same time.

LAMP tests for COVID-19 can only tell if a person is currently infected with this particular coronavirus. It can't provide information on other diseases or symptoms and does not tell staff if a patient has been previously infected with the virus or if a patient has any immunity to the virus.

LAMP tests cannot detect if a person has had the virus and then cleared it after the end of the COVID-19 disease, i.e. whether a person had the disease, as it only detects when active virus is present.
Lateral Flow / Colloidal Gold Immunochromatography
Further information
Please see the links below for more information about LAMP assays.

Lateral flow assays have commonly been referred to as ' Antibody tests' in the media as they are currently used to detect antibodies to disease in a patient's blood. The technology is also being tested for antigen use too.
Lateral flow assays use the same technology commonly used for pregnancy tests. Lateral flow tests can detect antibody to virus from patient blood indicating that the patient has COVID-19 or has recovered from COVID-19. Less commonly, lateral flow tests can be used to detect the presence of active virus by detecting virus proteins directly.

Antibody lateral flow tests for SARS-CoV-2 are produced as test kits used by a specialist or clinician rather than by patients themselves. They require a drop of patient blood, either from a vein or from a small finger prick, similar to a finger prick test used for blood sugar monitoring in certain types of diabetes.
These types of tests work very differently to RT-PCR and LAMP techniques and detect the patient's immune antibody response to the virus rather than detecting the virus itself.
Lateral flow antibody tests can be completed rapidly and the tests can be produced cheaply, so multiple diagnostics companies are working hard to develop lateral flow tests for SARS-CoV-2.
A major advantage for this type of test is also the ability to see if patients are currently infected or have recovered from COVID-19 even if they have fully recovered and cleared the virus months ago. However, it cannot distinguish between an active and a previous infection.

Lateral flow immunoassays for COVID-19 are simple devices that can detect antibodies in the blood.
A small sample of patient blood is taken from a vein or from a finger-prick by a clinician and dropped onto a spongey pad within the test device. A few drops of a diluting liquid called a 'buffer' are added to help the blood sample flow across the device.
As the sample moves through the device, antibodies against SARS-CoV-2 that are present in the sample will attach to chemicals in the device, capturing the antibodies on the test and control lines. This capturing and binding process results in a colour change along the test and control lines which can be seen by eye, producing one, two or three lines depending on the type of antibodies are present (IgM or IgG).

What does the test detect?
Lateral flow immunoassays for SARS-CoV-2 detect two types of protective antibodies that are produced by the body when the immune system recognises a foreign structure, in this case SARS-CoV-2, the virus causing COVID-19.
These antibodies help fight the disease and remain in the blood for months after the virus and disease is cleared. The presence of antibodies in the body is often referred to as immunity or that a person is immune to a virus, as these antibodies protect against re-infection and return of the same disease.
When we are infected by virus, our immune system produces early `prototype' antibodies (IgM) with intermediate strength binding to virus, that are able to start working to clear virus about 5 days after a new infection. Typically at 8 to 10 days after infection, IgG antibodies with high binding strength, can work to help more rapid virus clearance. Antibodies act by developing a matching contoured surface to stick to foreign antigens, using a sophisticated selection process to amplify antibodies with the best surface match and strongest binding.

Antibody lateral flow immunoassays can be designed to detect IgM or IgG alone or both together.

Antigen lateral flow immunoassays are an even newer technology with additional scientific and technical challenges which mean they are not likely to be developed during the pandemic period. These antigen assays detect the virus directly without the amplification steps of RT-PCR and LAMP, and like those tests are only able to detect current active viral infection but not past infection.
Advantages and limitations Advantages:

Lateral flow assays are extremely quick per patient, giving results in just 15 minutes.

Testing levels of antibody in blood allows a single patient sample from one accessible part of the body where sampling is non-invasive to be tested for presence of virus.

These tests require very little training to perform and don't rely on specialist laboratories or scientists to analyse.

Disadvantages:

The technology is new and the evidence for its accuracy in coronavirus diagnosis is still being evaluated.

So far, available lateral flow tests can only determine if a patient has at some point been infected with COVID-19. Further testing would be needed to check if a patient is currently infected. Future versions of this technology might allow clinicians to detect current infections.

Lateral flow tests are more expensive and time consuming for large batch testing than specialist laboratory based antibody tests such as ELISA.

What does the result mean?
Antibody lateral flow immunoassays detect antibodies to the virus in the blood. They don't detect the virus itself. The ability to detect the immune system response reliably using only one sample (blood) is a huge advantage, as is the amplification of the detection signal generated by the body immune response. Using the antibody response alone does not allow distinction between individuals who are currently infected and those who have cleared the virus infection.
Antibody tests provide a hugely important ability to detect past infection with virus to identify people who were asymptomatic, people who have cleared the virus and so no longer risk being infected or spreading the virus to others. In addition, antibody tests are critical for assessing population spread of the virus and the level of 'herd' immunity in the population. This is important for understanding the potential consequences of lifting or enforcing measures to control the virus such as quarantine, social distancing, school and workplace closures.
The antibody IgG and IgM lateral flow immunoassay tests are very simple to read:
A control line must appear to show that the assay has worked correctly.
Then, test lines will appear if either of the antibody types are found in the sample. The appearance of lines for IgG or IgM, or both indicate a positive test - showing that the patient has been infected with the COVID-19 coronavirus.
How coronavirus is detected by RT-PCR and lateral flow (short FAQ article on COVID-19 testing by RT-PCR and lateral flow):
https://www.bivda.org.uk/News-Events/Blog/ArticleID/270/A-short-FAQ-on-COVID-19-Testing
Further information
Please see the links below for more information about Lateral flow technology.

Enzyme-Linked Immunosorbent Assay (ELISA)
An Enzyme-Linked Immunosorbent Assay (ELISA) is a common biochemical technique that can be used to detect antigens or antibodies, depending on the type of test used.
ELISAs use enzymes linked to antibodies that can attach to the molecule that is being tested for and cause a colour change that can be measured by a specialised machine. The strength of the colour change gives scientists and clinicians an idea of the number of molecules of interest in the sample.
ELISAs can be done as standard batches of up to 96 assays completed at the same time, allowing cheap and time effective method for batch testing of large numbers of patient samples at the same time. This technology could help speed up the number of patients that can be tested for SARS-CoV-2. The most effective ELISA assays in monitoring prior infection detect antibodies against SARS-CoV-2. Future ELISA could be used to test for active virus infection by detection of virus protein ( antigen) testing, but this testing will not be as accurate and is as yet unproven.

An ELISA detects antibodies produced in patient blood due to infection with SARS-CoV-2. The whole test can be performed in one tube or well and involves mixing patient samples, antibodies, antigens and enzymes together with a colour changing molecule. The example below describes a typical antibody ELISA test.

What does the test detect?
ELISA tests to detect antibodies are detecting the antibody response to COVID-19 infection.
Detecting antibodies to SARS-CoV-2 could tell a clinician if a patient has been infected with COVID-19, either currently or in the past. However infected patients will not be detected immediately on infection, but only when the immune system to the virus can be detected in blood, roughly 5 days after infection for a test detecting IgM antibodies, which is about the same time that symptoms occur. Current knowledge suggests once a person has been infected with virus, their immune system will prevent a future infection with the same virus.
This antibody ELISA test provides very important information for diagnosis, management and recovery from COVID-19 and will also help researchers evaluate how many people in the population have been infected, which is important to planning infection control.
Advantages and limitations Advantages:

ELISA is a simple and cheap laboratory technique.

ELISA is well established and documented within science and medicine.

Results can typically be produced within 1 to 3 hours of collecting a patient sample.

Because it is so quick to perform it can be done in a hospital laboratory, cutting down the time to diagnosis.

ELISA testing can be completed on multiple samples at once, so it can be used for rapid testing scaled up to test larger numbers of patients.

Disadvantages:
ELISA tests are not yet well established for SARS-CoV-2 COVID-19 testing, although many companies are working hard to produce them and test them in patients.

What does the result mean?
An antibody test using ELISA would show a positive result (colour change) if the patient has antibodies to COVID-19. This might not mean that they currently have the virus, only that they have had it at some point. This is because antibodies stay in the blood even after the infection is gone to help provide the body with immunity if they come into contact with the virus again.
A negative result (no colour change) would mean that the patient has not been infected with COVID-19 and may have no immunity against it.
CONCLUSIONS

Four main types of tests are being used or being developed to test for SARS-CoV-2, the virus causing COVID-19.

These tests are at different stages of development, validation and production.

Each test type has its own distinct advantages and disadvantages inherent to the underlying technology.

A combination of testing types used at different times may be useful for patient management and population pandemic control of COVID-19.

ELISA antigen tests may be developed in the future to detect current infections. Such an antigen test using ELISA would show a positive result (colour change) if a patient has COVID-19 in their blood. This would indicate that the patient is currently infected with the COVID-19. A negative result (no colour change) would indicate that no COVID-19 antigens were found in the patient's sample. This could mean that the patient does not have COVID-19, but might also mean that they are too early in their infection to be positive. If they have symptoms of COVID-19 they should be tested again a few days later to make sure.

Further information
Please see the links below for more information about ELISA technology.

While individual tests differ in their properties, commonly the types of test listed in this document have the following profiles:

End.

Disclaimer: the article has not been peer-reviewed; it should not replace individual clinical judgement and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health and Social Care. The views are not a substitute for professional medical advice.

# data[].attributes.attachment_link.title
What tests could potentially be used for the screening, diagnosis and monitoring of COVID-19 and what are their advantages and disadvantages? - CEBM

# data[].attributes.attachment_link.description
April 20, 2020 1NIHR Newcastle In Vitro Diagnostics Co-operative Newcastle University, Newcastle upon Tyne, NE2 4HH 2NIHR Newcastle In Vitro Diagnostics Co-operative Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, NE1 4LP 3Kleijnen Systematic Reviews Ltd Unit 6, Escrick Business Park, York, YO19 6FD 4Institute of Applied Health Research University of Birmingham B15 2TT PDF to Download VERDICT Many diagnostic tests for coronavirus disease 2019 (COVID-19) are available so far, with more gaining emergency approval every day.