Mechanical Ventilation Supply and Options for the COVID-19 Pandemic: Leveraging All Available Resources for a Limited Resource in a Crisis

The novel Coronavirus disease (COVID-19) has exposed critical supply shortages both in the United States and worldwide including those in ICU and hospital bed supply, hospital staff, and mechanical ventilators. Many of those critically ill have required days to weeks of supportive mechanical invasive ventilation (MV) as part of their treatment. Previous estimates set the US availability of mechanical ventilators at approximately 62,000 full-featured ventilators, with 98,000 non-full featured devices (including non-invasive devices). Given the limited availability of this resource both in US and in low- and middle-income countries, we provide a framework to approach the shortage of MV resources. Here we discuss evidence and possibilities to reduce overall MV needs, strategies to maximize the availability of MV devices designed for invasive ventilation, the literature underlying methods to create and fashion new sources of potential ventilation that are available to hospitals and front-line providers, and discuss the staffing needs necessary to support MV efforts. The pandemic has already pushed cities like New York and Boston well beyond previous ICU capacity in its first wave. As hotspots continue to develop around the country and the globe, it is evident that issues may arise ahead regarding the efficient and equitable use of resources. This unique challenge may continue to stretch resources and require care beyond previously set capacities and boundaries. The approaches presented here provide a review of the known evidence and strategies for those at the front-line facing this challenge.

Does in-hospital trauma mortality in urban Indian academic centres differ between “office-hours” and “after-hours”?

Introduction
Trauma services within hospitals may vary considerably at different times across a 24 h period. The variable services may negatively affect the outcome of trauma victims. The current investigation aims to study the effect of arrival time of major trauma patients on mortality and morbidity.

Method
Retrospective analysis of the Australia-India Trauma Systems Collaboration (AITSC) registry established in four public university teaching centres in India Based on hospital arrival time, patients were grouped into “Office-hours” and “After-hours”. Outcome parameters were compared between the above groups.

Results
5536 (68.4%) patients presented “after-hours” (AO) and 2561 (31.6%) during “office-hours” (OH). The in-hospital mortality for “after-hours” and “office-hours” presentations were 12.1% and 11.6% respectively. On unadjusted analysis, there was no statistical difference in the odds of survival for OH versus AH presentations. (OR,1.05, 95% CI 0.9‐1.2). Adjusting for potential prognostic factors (injury severity, presence of shock on arrival, referral status, sex, or extremes of age), there was no statistically significant odds of survival for OH versus AH presentations (OR,1.02, 95%CI 0.9–1.2).ICU length of stay and duration of mechanical ventilation was longer in the AH group.

Conclusion
The in-hospital mortality did not differ between trauma patients who arrived during “after-hours” compared to ‘“office-hours”.

Diagnostic assistance to improve acute burn referral and triage : assessment of routine clinical tools at specialised burn centres and potential for digital health development at point of care

Background: Inappropriate referral of patients for specialised care leads to overburdened health systems and improper treatment of patients who are denied transfer due to a scarcity of resources. Burn injuries are a global health problem where specialised care is particularly important for severe cases while minor burns can be treated at point of care. Whether several solutions, existing or in development, could be used to improve the diagnosis, referral and triage of acute burns at admission to specialised burn centres remains to be evaluated.

Aim: The overarching aim of this thesis is to determine the potential of diagnostic support tools for referral and triage of acute burns injuries. More specifically, sub-aims include the assessment of routine and digital health tools utilised in South Africa and Sweden: referral criteria, mortality prediction scores, image-based remote consultation and automated diagnosis.

Methods: Studies I and II were two retrospective studies of patients admitted to the paediatric (I) and the adult (II) specialised burn centres of the Western Cape province in South Africa. Study I examined adherence to referral criteria at admission of 1165 patients. Logistic regression was performed to assess the associations between adherence to the referral criteria and patient management at the centre. Study II assessed mortality prediction at admission of 372 patients. Logistic regression was performed to evaluate associations between patient, injury and admission-related characteristics with mortality. The performance of an existing mortality prediction model (the ABSI score) was measured. Study III and IV were related to two image-based digital-health tools for remote diagnosis. In Study III, 26 burns experts provided a diagnosis in terms of burn size and depth for 51 images of acute burn cases using their smartphone or tablet. Diagnostic accuracy was measured with intraclass correlation coefficient. In Study IV, two deep-learning algorithms were developed using 1105 annotated acute burn images of cases collected in South Africa and Sweden. The first algorithm identifies a burn area from healthy skin, and the second classifies burn depth. Differences in performances by patient Fitzpatrick skin types were also measured.

Results: Study I revealed a 93.4% adherence to the referral criteria at admission. Children older than two years (not fulfilling the age criterion) as well as those fulfilling the severity criterion were more likely to undergo surgery or stay longer than seven days at the centre. At the adult burn centre (Study II), mortality affected one in five patients and was associated with gender, burn size, and referral status after adjustments for all other variables. The ABSI score was a good estimate of mortality prediction. In Study III experts were able to accurately diagnose burn size, and to a lesser extent depth, using handheld devices. A wound identifier and a depth classifier algorithm could be developed with assessments of relatively high accuracy (Study IV). Differences were observed in performances by skin types of the patients.

Conclusions: Altogether the findings inform on the use in clinical practice of four different tools that could improve the accuracy of the diagnosis, referral and triage of patients with acute burns. This would reduce inequities in access to care by improving access for both paediatric and adult patient populations in settings that are resource scarce, geographically distant or under high clinical pressure.

Antibiotic prophylaxis in a global surgical context

Surgical site infection (SSI) is a global problem, and has been highlighted as the foremost research priority for perioperative researchers across high-, middle- and low-income settings. Depending on the degree of intraoperative contamination, baseline patient risk and other infection control measures, as many as 50% of patients can suffer surgical wound infections within the 30-days after an operation. As a result, SSI has been the focus of several recent global initiatives including randomised controlled trials of health technologies, quality improvement bundle studies, and prospective cohort studies.

Association between volume resuscitation & mortality among injured patients at a tertiary care hospital in Kigali, Rwanda

Background
Injuries cause significant morbidity and mortality in sub-Saharan African countries such as Rwanda. These burdens may be compounded by limited access to intravenous (IV) resuscitation fluids such as crystalloids and blood products. This study evaluates the association between emergency department (ED) intravenous volume resuscitation and mortality outcomes in adult trauma patients treated at the University Teaching Hospital-Kigali (UTH- K).

Methods
Data were abstracted using a structured protocol for a random sample of ED patients treated during periods from 2012 to 2016. Patients under 15 years of age were excluded. Data collected included demographics, clinical aspects, types of IV fluid resuscitation provided and outcomes. The primary outcome was facility-based mortality. Descriptive statistics were used to explore characteristics of the population. Kampala Trauma Scores (KTS) were used to control for injury severity. Magnitudes of effects were quantified using multivariable regression models adjusted for gender, KTS, time period, clinical interventions, presence of head injury and transfer to a tertiary care centre to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Results
From the random sample of 3609 cases, 991 trauma patients were analysed. The median age was 32 [IQR 26, 46] years and 74.3% were male. ED volume resuscitation was given to 50.1% of patients with 43.5% receiving crystalloid and 6.4% receiving crystalloid and packed red blood cell (PRBC) transfusions. The median KTS score was 13 [IQR 12, 13]. In multivariable regression, mortality likelihood was increased in those who received crystalloid (aOR = 4.31, 95%CI 1.24, 15.05, p = 0.022) and PRBC plus crystalloid (aOR = 9.97, 95%CI 2.15,46.17, p = 0.003) as compared to trauma patients not treated with IV resuscitation fluids.

Conclusions
Injured ED patients treated with volume resuscitation had higher mortality, which may be due to unmeasured confounding or therapies provided. Further studies on fluid resuscitation in trauma populations in resource-limited settings are needed.