BMJ: Triaging of respiratory protective equipment on the assumed risk of SARS-CoV-2 aerosol exposure in patient-facing healthcare workers delivering secondary care: a rapid review #covid19rftlks

Ramaraj, P.  et al (2020) Triaging of respiratory protective equipment on the assumed risk of SARS-CoV-2 aerosol exposure in patient-facing healthcare workers delivering secondary care: a rapid review| BMJ Open | 10| e040321| doi: 10.1136/bmjopen-2020-040321

There is a paucity of evidence on the comparison of facemasks and respirators specific to SARS-CoV-2, and poor-quality evidence in other contexts, report the authors of a rapid review published in the BMJ Open. The rapid review intended to ascertain and evaluate the evidence base behind RPE policy specific to SARS-CoV-2 in order to most effectively protect HCWs from SARS-CoV-2 infection. This review adds to the rapidly expanding discussion on the use of RPE in the inpatient setting

Strengths and limitations of this study

  • The results of this study will allow for future study with a real and tangible effect towards the well-being of healthcare workers nationwide, and perhaps internationally.
  • This article has an exceptionally broad range—from infection control, to public health, to biomechanical engineering, to industry; the hope is to increase multidisciplinary discussion.
  • This study reviews evidence specific to a novel virus and inevitably there is a paucity of specific evidence.
Abstract

Objectives In patient-facing healthcare workers delivering secondary care, what is the evidence behind UK Government personal protective equipment (PPE) guidance on surgical masks versus respirators for SARS-CoV-2 protection?

Design Two independent reviewers performed a rapid review. Appraisal was performed using Critical Appraisal Skills Programme checklists and Grading of Recommendations, Assessment, Development and Evaluations methodology. Results were synthesised by comparison of findings and appraisals.

Data sources MEDLINE, Google Scholar, UK Government COVID-19 website and grey literature.

Eligibility criteria Studies published on any date containing primary data comparing surgical facemasks and respirators specific to SARS-CoV-2, and studies underpinning UK Government PPE guidance, were included.

Results Of 30 identified, only 3 laboratory studies of 14 different respirators and 12 surgical facemasks were found. In all three, respirators were significantly more effective than facemasks when comparing protection factors, reduction factors, filter penetrations, total inspiratory leakages at differing particle sizes, mean inspiratory flows and breathing rates. Tests included live viruses and inert particles on dummies and humans. In the six clinical studies (6502 participants) included the only statistically significant result found continuous use of respirators more effective in clinical respiratory illness compared with targeted use or surgical facemasks. There was no consistent definition of ‘exposure’ to determine the efficacy of respiratory protective equipment (RPE). It is difficult to define ‘safe’.

Conclusions There is a paucity of evidence on the comparison of facemasks and respirators specific to SARS-CoV-2, and poor-quality evidence in other contexts. The use of surrogates results in extrapolation of non-SARS-CoV-2 specific data to guide UK Government PPE guidance. The appropriateness of this is unknown given the uncertainty over the transmission of SARS-CoV-2.

This means that the evidence base for UK Government PPE guidelines is not based on SARS-CoV-2 and requires generalisation from low-quality evidence of other pathogens/particles. There is a paucity of high-quality evidence regarding the efficacy of RPE specific to SARS-CoV-2. UK Government PPE guidelines are underpinned by the assumption of droplet transmission of SARS-CoV-2.

These factors suggest that the triaging of filtering face piece class 3 respirators might increase the risk of COVID-19 faced by some (Source: Ramaraj, P.  et al (2020))

Full text article available from the BMJ

BJGP: Excess mortality in the first COVID pandemic peak: cross-sectional analyses of the impact of age, sex, ethnicity, household size, and long-term conditions in people of known SARS-Cov-2 status in England #covid19rftlks

Joy, M. et al. (2020). | Excess mortality in the first COVID pandemic peak: cross-sectional analyses of the impact of age, sex, ethnicity, household size, and long-term conditions in people of known SARS-Cov-2 status in England |BJGP|bjgp20X713393. DOI: https://doi.org/10.3399/bjgp20X713393

A new study published in the British Journal of General Practice sought to describe the rate of all-cause mortality throughout the first peak of SARS-CoV-2 as recorded in the Oxford RCGP RSC; the impact of age, sex, and household size on any excess mortality observed; and the association of SARS-CoV-2 status and demographic and clinical risks factors with mortality.

Abstract

Background The SARS-CoV-2 pandemic has passed its first peak in Europe.

Aim To describe the mortality in England and its association with SARS-CoV-2 status and other demographic and risk factors.

Design and setting Cross-sectional analyses of people with known SARS-CoV-2 status in the Oxford RCGP Research and Surveillance Centre (RSC) sentinel network.

Method Pseudonymised, coded clinical data were uploaded from volunteer general practice members of this nationally representative network ( n = 4 413 734). All-cause mortality was compared with national rates for 2019, using a relative survival model, reporting relative hazard ratios (RHR), and 95% confidence intervals (CI). A multivariable adjusted odds ratios (OR) analysis was conducted for those with known SARS-CoV-2 status ( n = 56 628, 1.3%) including multiple imputation and inverse probability analysis, and a complete cases sensitivity analysis.

Results Mortality peaked in week 16. People living in households of more than or equal to 9 had a fivefold increase in relative mortality. The ORs of mortality were 8.9 and 9.7 for virologically and clinically diagnosed cases respectively, using people with negative tests as reference. The adjusted mortality for the virologically confirmed group was 18.1% . Male sex, population density, black ethnicity (compared to white), and people with long-term conditions, including learning disability had higher odds of mortality.

Conclusion The first SARS-CoV-2 peak in England has been associated with excess mortality. Planning for subsequent peaks needs to better manage risk in males, those of black ethnicity, older people, people with learning disabilities, and people who live in multi-occupancy dwellings.

Excess mortality in the first COVID pandemic peak: cross-sectional analyses of the impact of age, sex, ethnicity, household size, and long-term conditions in people of known SARS-Cov-2 status in England

Consultant workforce shortages and solutions: Now and in the future

British Medical Association | October 2020 | Consultant workforce shortages and solutions: Now and in the future

This document from the BMA gives consideration to short, medium and long -term staffing problems, their causes and potential amelioration strategies. It is aimed at the Government, employers and arms-length bodies, and details how we can protect patients, consultants and the NHS from an emerging consultant workforce crisis.

Executive Summary

Prior to the COVID-19 pandemic the NHS workforce faced a perfect storm of consultants
choosing to retire earlier, a significant proportion approaching retirement age and a growing trend of younger doctors walking away from a career in the NHS. COVID-19 added significant additional pressure on the workforce with doctors working long hours, in new settings, sometimes whilst risking their own lives. Now the NHS is facing a growing backlog of unmet need on top of the existing staff and resource shortages. Every consultant has become more precious than ever; retention is crucial to the success of any plans for continuing to deliver safe patient care and catching up with existing and developing backlogs.
Projections of future demand indicate that the NHS needs to respond quickly to address
the workforce crisis, both by increasing supply and improving retention. Vacancies reported nationally are high and are likely to represent a significant underestimate. Future consultant workforce gaps need to be filled by expanding medical student and FP (Foundation Programme) places now to meet current and future patient demand. At the same time, more staff/educators and supporting resources are required to deliver the increased educational workload. The Government is not on track to deliver the commitments set out in the NHS Long Term Plan.
This report highlights some of the factors driving consultant retention problems and why retaining and growing the consultant workforce must be a top priority for the NHS.

Read the full document from the BMA

Deaths in people from Black, Asian and minority ethnic communities from both COVID-19 and non-COVID causes in the first weeks of the pandemic in London: a hospital case note review #covid19rftlks

Perkin MR, Heap S, Crerar-Gilbert A, et al (2020). Deaths in people from Black, Asian and minority ethnic communities from both COVID-19 and non-COVID causes in the first weeks of the pandemic in London: a hospital case note review |BMJ Open|10|e040638| doi: 10.1136/bmjopen-2020-040638

A case review of deaths in a London teaching hospital has reviewed deaths in the first few weeks of the pandemic by the medical examiner team at St George’s University NHS Hospital Trust. Their review compares mortality rates in 2020 compared with the same 6 week period last year, it shows that deaths from BAME communities was higher for both covid related mortality and non-covid related deaths.

Abstract

Objective To undertake a case review of deaths in a 6-week period during the COVID-19 pandemic commencing with the first death in the hospital from COVID-19 on 12th of March 2020 and contrast this with the same period in 2019.

Setting A large London teaching hospital.

Participants Three groups were compared: group 1—COVID-19-associated deaths in the 6-week period (n=243), group 2—non-COVID deaths in the same period (n=136) and group 3—all deaths in a comparison period of the same 6 weeks in 2019 (n=194).

Primary and secondary outcome measures This was a descriptive analysis of death case series review and as such no primary or secondary outcomes were pre-stipulated.

Results Deaths in patients from the Black, Asian and minority ethnic (BAME) communities in the pandemic period significantly increased both in the COVID-19 group (OR=2.43, 95% CI=1.60–3.68, p<0.001) and the non-COVID group (OR=1.76, 95% CI=1.09–2.83, p=0.02) during this time period and the increase was independent of differences in comorbidities, sex, age or deprivation. While the absolute number of deaths increased in 2020 compared with 2019, across all three groups the distribution of deaths by age was very similar. Our analyses confirm major risk factors for COVID-19 mortality including male sex, diabetes, having multiple comorbidities and background from the BAME communities.

Conclusions There was no evidence of COVID-19 deaths occurring disproportionately in the elderly compared with non-COVID deaths in this period in 2020 and 2019. Deaths in the BAME communities were over-represented in both COVID-19 and non-COVID groups, highlighting the need for detailed research in order to fully understand the influence of ethnicity on susceptibility to illness, mortality and health-seeking behaviour during the pandemic.

Strengths and limitations of this study

  • Large timely analysis from detailed case note review by independent medical examiners capturing data from all deaths (intensive care and ward-based care) in the hospital.
  • All swab-positive deaths associated with COVID-19 were included and compared with non-COVID deaths and historical data from the previous year.
  • We identified important ethnic differences with increased mortality in the Black, Asian and minority ethnic communities in both COVID-19 and non-COVID deaths in the early weeks of the pandemic.
  • The principle limitation was that this was a single-centre study and focused on hospital mortality data alone and not out of hospital deaths and therefore the full picture of regional mortality could not be ascertained.
  • All such studies are limited by the quality of the clinical records and in particular detailed data about the demographics of the whole admission population.

Article text Deaths in people from Black, Asian and minority ethnic communities from both COVID-19 and non-COVID causes in the first weeks of the pandemic in London: a hospital case note review

Living with Covid19 #covid19rftlks

NIHR | October 2020 | Living with Covid 19

NIHR have produced a dynamic review of the evidence around ongoing Covid19 symptoms (often called Long Covid). The review uses rapid and dynamic review draws on the lived experience of patients and expert consensus as well as published evidence to better understand the impact of ongoing effects of Covid19, how health and social care services should respond, and what future research questions might be. NIHR’s steering group concluded:

  • There is a widespread perception that people either die, get admitted to hospital or recover after two weeks. It is increasingly clear that for some people there is a distinct pathway of ongoing effects. There is an urgent need to better understand the symptom journey and the clinical risks that underlie that. People, their families and healthcare professionals need realistic expectations about what to expect.
  • A major obstacle is the lack of consensus on diagnostic criteria for ongoing Covid19. A working diagnosis that is recognised by healthcare services, employers and government agencies would facilitate access to much needed support and provide the basis for planning appropriate services. Whilst it is too early to give a precise definition, guidance on reaching a working diagnosis and a code for clinical datasets is needed.
  • The fluctuating and multisystem symptoms need to be acknowledged. A common theme is that symptoms arise in one physiological system then abate only for symptoms to arise in a different system.
  • There are significant psychological and social impacts that will have long-term consequences for individuals and for society if not well managed.
  • The multisystem nature of ongoing Covid19 means that it needs to be considered holistically (both in service provision and in research). The varying degrees of dependency mean support in the community should be considered alongside hospital one-stop clinics. Social support needs to be understood together with the financial pressures on previously economically active people.
  • Covid19 has a disproportionate effect on certain parts of the population, including care home residents. Black and Asian communities have seen high death rates and there are concerns about other minority groups and the socially disadvantaged. These people are already seldom heard in research as well as travellers, the homeless, those in prisons, people with mental health problems or learning difficulties; each having particular and distinct needs in relation to ongoing Covid19 that need to be understood (Source: NIHR)

Living with Covid19

Assessment of mental health services in acute trusts

Care Quality Commission | October 2020 | Assessment of mental health services in acute trusts

A new report from the Care Quality Commission (CQC) reviews the findings from over 100 acute hospital inspections, between September 2017 and March 2019. They looked at how well the mental health care needs of patients were met and where trusts, and the wider system, it also identifies areas that need to improve, and steps to improve practices.

The report finds:

  • People faced barriers in accessing help at a time of crisis
  • Boards did not always see mental health as integral to physical health
  • Patients were not always provided with a safe, therapeutic environment
  • Acute trusts need to improve staff education and governance in relation to the Mental Health Act
  • Staff feel unsupported and unprepared to care for patients with mental health needs

Read the full report available from the CQC

Nuffield Trust: Measuring mortality during Covid-19: a Q & A #covid19rftlks

Nuffield Trust | October 2020 | Measuring mortality during Covid-19: a Q&A

Updated to include new data this explainer from Nuffield Trust –originally published in May, answers some key questions on how mortality figures are collected and measured during the pandemic.

How do the numbers relate to the daily figures reported, and are all the extra deaths due to the coronavirus? 

Measuring mortality during Covid-19: a Q&A

New report on workplace health and wellbeing interventions

NHS Employers | October 2020 | New report on workplace health and wellbeing interventions

NHS Employers commissioned a report from The Institute of Employment Studies (IES), the report’s focuses on the evidence base of health and wellbeing interventions used in healthcare and their implications for wellbeing outcome. The authors classify interventions into either preventative initiatives, and treatments.

They suggest their findings add to the current evidence base, as well as underlining further research that needs undertaking in this area

  • There is no single one-size-fits-all solution for workforce wellbeing. Interventions with good take-up and which led to positive wellbeing outcomes were those where healthcare staff had options as to which interventions they could engage with and suited their wellbeing needs.
  • The quality and extent of the evidence base is variable and needs more attention. Organisations often use a broad range of interventions, focusing on both mental and physical wellbeing, treatment-based and prevention focused interventions. The extent to which these interventions are robustly evaluated is variable. Organisations should pay great attention to evaluating their approaches, including both wellbeing outcomes and process evaluation, and may find it useful to partner with research organisations to do this robustly.
  • A whole-system approach to wellbeing should be considered alongside interventions. This includes a focus on the whole employment experience, including element such as workload, autonomy, employee voice and management processes.

Report available from IES or download via this link

RCN: Day Surgery for Children and Young People

Royal College of Nursing | October 2020 | Day Surgery for Children and Young People

This publication from the Royal College of Nursing (RCN) highlights the specific needs of children and young people undergoing day surgery, outlining pre- and post-operative ‘aspects of care and preparation, parental involvement and facilitating discharge. 

Day Surgery for Children and Young People