April 9: In patients with COVID-19, what characteristics will suggest development of severe disease?

Download the summary of evidence (pdf)

The Question

The following is the interpretation of the question as stated:

In patients with COVID-19, what patient characteristics will suggest development of severe disease?

In patients with severe COVID-19, what treatments are shown to be most effective in reducing fatality or increasing survival rates?

Which populations have the highest ratio of severe to mild/moderate cases of COVID-19? 

In a nutshell

Based on data from EU/EEA countries2, 32% of the diagnosed cases have required hospitalisation and 2.4% have had severe illness requiring respiratory support or ventilation. The crude fatality rate was 1.5% among diagnosed cases and 11% among hospitalised cases. The likelihood of hospitalisation, severe illness and death increases in persons over 65 years of age and those with defined risk factors including hypertension, diabetes, cardiovascular disease, chronic respiratory disease, compromised immune status, cancer and obesity. In a systematic review and meta-analysis by Zhao et al.4, predictors for disease severity included old age (≥ 50 yrs, odds ratio [OR] = 2.61; 95% CI, 2.29-2.98), male (OR =1.348, 95% CI, 1.195-1.521), smoking (OR =1.734, 95% CI, 1.146-2.626) and any comorbidity (OR = 2.635, 95% CI, 2.098-3.309), especially chronic kidney disease (CKD, OR = 6.017; 95% CI, 2.192-16.514), chronic obstructive pulmonary disease (COPD, OR = 5.323; 95% CI, 2.613-10.847) and cerebrovascular disease (OR = 3.219; 95% CI, 1.486-6.972). In terms of laboratory results, increased lactate dehydrogenase (LDH), C-reactive protein (CRP) and D-dimer and decreased blood platelet and lymphocytes count were highly associated with severe COVID-19 [all for P < 0.001]. Meanwhile, old age (≥ 60 yrs, RR = 9.45; 95% CI, 8.09-11.04), followed by cardiovascular disease (RR = 6.75; 95% CI, 5.40-8.43) hypertension (RR = 4.48; 95% CI, 3.69-5.45) and diabetes (RR = 4.43; 95% CI, 3.49-5.61) were found to be independent prognostic factors for the COVID-19 related death.

Q1: In patients with COVID-19, what patient characteristics will suggest development of mild or severe disease?

IRISH AND INTERNATIONAL GUIDANCE

What does the Health Protection Surveillance Centre (Ireland) say?

Health Protection Surveillance Centre. Epidemiology of COVID-19 in Ireland: Report Prepared by HPSC on 06/04/2020[1]

Table 5: Number of confirmed cases of COVID-19 notified to midnight April 4th 2020 by age group and hospital, ICU and vital status, Ireland.

What does the European Centre for Disease Prevention and Control say?

European Centre for Disease Control and Prevention. Rapid risk assessment: coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK [Eighth update][2]

“Based on data from EU/EEA countries, 32% of the diagnosed cases have required hospitalisation and 2.4% have had severe illness requiring respiratory support or ventilation. The crude fatality rate was 1.5% among diagnosed cases and 11% among hospitalised cases. The likelihood of hospitalisation, severe illness and death increases in persons over 65 years of age and those with defined risk factors including hypertension, diabetes, cardiovascular disease, chronic respiratory disease, compromised immune status, cancer and obesity.” 

POINT-OF-CARE TOOLS

What does UpToDate say?

Coronavirus Disease 2019 (COVID-19)[3]

Severe illness can occur in otherwise healthy individuals of any age, but it predominantly occurs in adults with advanced age or underlying medical comorbidities. The impact of age is discussed elsewhere. Comorbidities that have been associated with severe illness and mortality include:

  • Cardiovascular disease
  • Diabetes mellitus
  • Hypertension
  • Chronic lung disease
  • Cancer
  • Chronic kidney disease

INTERNATIONAL LITERATURE

What does the international literature say?

Zhao et al. (2020). Incidence, clinical characteristics and prognostic factor of patients with COVID-19: a systematic review and meta-analysis[4]

A total of 30 studies including 53000 patients with COVID-19, were included in this study. The mean age was 49.8 years (95% CI, 47.5-52.2 yrs) and 55.5% were male. The pooled incidence of severity and mortality were 20.2% (95% CI, 15.1-25.2%) and 3.1% (95% CI, 1.9-4.2%), respectively. The predictor for disease severity included old age (≥ 50 yrs, odds ratio [OR] = 2.61; 95% CI, 2.29-2.98), male (OR =1.348, 95% CI, 1.195-1.521), smoking (OR =1.734, 95% CI, 1.146-2.626) and any comorbidity (OR = 2.635, 95% CI, 2.098-3.309), especially chronic kidney disease (CKD, OR = 6.017; 95% CI, 2.192-16.514), chronic obstructive pulmonary disease (COPD, OR = 5.323; 95% CI, 2.613-10.847) and cerebrovascular disease (OR = 3.219; 95% CI, 1.486-6.972). In terms of laboratory results, increased lactate dehydrogenase (LDH), C-reactive protein (CRP) and D-dimer and decreased blood platelet and lymphocytes count were highly associated with severe COVID-19 [all for P < 0.001]. Meanwhile, old age (≥ 60 yrs, RR = 9.45; 95% CI, 8.09-11.04), followed by cardiovascular disease (RR = 6.75; 95% CI, 5.40-8.43) hypertension (RR = 4.48; 95% CI, 3.69-5.45) and diabetes (RR = 4.43; 95% CI, 3.49-5.61) were found to be independent prognostic factors for the COVID-19 related death.

Steinberg et al. (2020) ‘Calculated decisions: COVID-19 calculators during extreme resource-limited situations[5]

This review discusses the use of clinical prediction scores for pneumonia severity at 3 main decision points to examine which scores may provide value in this unique situation. Initial data from a cohort of over 44,000 COVID-19 patients in China, including risk factors for mortality, were compared with data from cohorts used to study the clinical scores, in order to estimate the potential appropriateness of each score and determine how to best adjust results at the bedside.

Verity et al.(2020). Estimates of the severity of coronavirus disease 2019: a model-based analysis[6]

Using data on 24 deaths that occurred in mainland China and 165 recoveries outside of China, we estimated the mean duration from onset of symptoms to death to be 17·8 days (95% credible interval [CrI] 16·9-19·2) and to hospital discharge to be 24·7 days (22·9-28·1). In all laboratory confirmed and clinically diagnosed cases from mainland China (n=70 117), we estimated a crude case fatality ratio (adjusted for censoring) of 3·67% (95% CrI 3·56-3·80). However, after further adjusting for demography and under-ascertainment, we obtained a best estimate of the case fatality ratio in China of 1·38% (1·23-1·53), with substantially higher ratios in older age groups (0·32% [0·27-0·38] in those aged <60 years vs 6·4% [5·7-7·2] in those aged ≥60 years), up to 13·4% (11·2-15·9) in those aged 80 years or older. Estimates of case fatality ratio from international cases stratified by age were consistent with those from China (parametric estimate 1·4% [0·4-3·5] in those aged <60 years [n=360] and 4·5% [1·8-11·1] in those aged ≥60 years [n=151]). Our estimated overall infection fatality ratio for China was 0·66% (0·39-1·33), with an increasing profile with age. Similarly, estimates of the proportion of infected individuals likely to be hospitalised increased with age up to a maximum of 18·4% (11·0-7·6) in those aged 80 years or older.

Q2: In patients with severe COVID-19, what treatments are shown to be most effective in reducing fatality or increasing survival rates?

Oxford University Centre for Evidence Based Medicine (2020). What is the effectiveness and safety of antiviral or antibody treatments for coronavirus?[7]

54 studies were included in the review: three controlled trials, 10 cohort studies, seven retrospective medical record/database studies, and 34 case reports or series. These studies included patients with severe acute respiratory syndrome (SARs, n=33), middle east respiratory syndrome (MERS, n=16), COVID-19 (n=3), and unspecified coronavirus (n=2). The most common treatment was ribavirin (n=41), followed by oseltamivir (n=10) and the combination of lopinavir/ritonavir (n=7).  Additional therapies included broad spectrum antibiotics (n=30), steroids (n=39) or various interferons (n=12). No eligible studies examining monoclonal antibodies for COVID-19 were identified.

IRISH AND INTERNATIONAL GUIDANCE

World Health Organization (2020). Clinical management of severe acute respiratory infection when COVID-19 is suspected[8]

[Full document relevant]

POINT-OF-CARE TOOLS

What does BMJ Best Practice say?

Coronavirus disease 2019 (COVID-19) Treatment Algorithm[9]

Severe illness; mild illness with risk factors.

1st line – hospital admission

Plus – infection prevention and control procedures

Plus – treatment and care planning

Plus – monitoring

Adjunct – supportive care

Adjunct – empirical antimicrobials

Treatment recommended for some patients in selected patient groups: Patients with severe illness may require continued antimicrobial therapy once COVID-19 has been confirmed depending on the clinical circumstances.

Adjunct – antipyretic

Adjunct – antitussive

Adjunct – antitussive

Adjunct – advanced oxygen/ventilatory support

Adjunct – tailor management to comorbidities

Adjunct – experimental therapies

INTERNATIONAL LITERATURE

Alhazzani et al. (2020). Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)[10]

Poston, J.T., Patel, B.K. and Davis, A.M., 2020. Management of Critically Ill Adults With COVID-19[11]

Systematic review and critical appraisal of prediction models for diagnosis and prognosis of COVID-19 infection[12]

27 studies describing 31 prediction models were included for data extraction and critical appraisal. We identified three models to predict hospital admission from pneumonia and other events [as a proxy for COVID-19 pneumonia] in the general population; 18 diagnostic models to detect COVID-19 infection in symptomatic individuals; 13 of which were machine learning utilising computed tomography (CT) results; and ten prognostic models for predicting mortality risk, progression to a severe state, or length of hospital stay.”

Q3 Which populations have the highest ratio of severe to mild/moderate cases of COVID-19? 

Johns Hopkins University Center for Systems Science and Engineering (CSSE). Coronavirus COVID-19 Global Cases[xiii]

Dashboard outlining total number of cases, deaths and recoveries.

See full explanation at Dong et al. (2020). An interactive web-based dashboard to track COVID-19 in real time.[xiv] 

Oxford University Centre for Evidence-Based Medicine (2020). Global COVID-19 Case Fatality Rates [CFRs][xv]  

Our current best assumption as of the 22nd March is the CFR is 0.51%, the lowest end of the current prediction interval and in line with several other estimates.

Evaluating CFR during a pandemic is however a hazardous exercise and high-end estimates should be treated with caution as the H1N1 pandemic highlights that original estimates were out by a factor greater than 10.

We now want to draw your attention to the flaws in CFR estimation due to the changing nature of the testing regimes.

Italy: A change in strategy on Feb 25 limited testing to patients who had severe signs and symptoms also resulted in a 19% positive rate [21,157 of 109,170 tested as of Mar 14] and an apparent increase in the death rate—from 3.1% on Feb 24 to 7.2% on Mar 17—patients with milder illness were no longer tested.  In the UK, only patients deemed ill enough to require at least one night in hospital met the criteria for a COVID-19 test. Models are also starting to accrue that suggest the number of people infected is much higher than what testing alone identifies, and that the number infected is much higher in denser populations.

CFRs across countries are, therefore, highly variable, depending on who is tested for what reasons. There is no consistency.


[1] Health Protection Surveillance Centre. Epidemiology of COVID-19 in Ireland: Report Prepared by HPSC on 06/04/2020

https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/casesinireland/epidemiologyofcovid-19inireland/ Accessed 8th April 2020

[2] European Centre for Disease Control and Prevention. Rapid risk assessment: coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK [Eighth update] https://www.ecdc.europa.eu/en/rapid-risk-assessment-coronavirus-disease-2019-covid-19-pandemic-eighth-update

[3] UpToDate (2020). Coronavirus Disease 2019 (COVID-19). https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19#H943884075.

[4] Xianxian Zhao, Bili Zhang, Pan Li, Chaoqun Ma, Jiawei Gu, Pan Hou, Zhifu Guo, Hong Wu, Yuan Bai. Incidence, clinical characteristics and prognostic factor of patients with COVID-19: a systematic review and meta-analysis. https://www.medrxiv.org/content/10.1101/2020.03.17.20037572v1.

[5] Steinberg E, Balakrishna A, Habboushe J, Shawl A, Lee J. Calculated decisions: COVID-19 calculators during extreme resource-limited situations. Emerg Med Pract. 2020;22(4 Suppl):CD1–CD5. Published 2020 Apr 6.

[6] Verity R, Okell LC, Dorigatti I, et al. Estimates of the severity of coronavirus disease 2019: a model-based analysis [published online ahead of print, 2020 Mar 30]. Lancet Infect Dis. 2020;S1473-3099(20)30243-7. doi:10.1016/S1473-3099(20)30243-7.

[7] Rios, P, Radhakrishnan, A, Antony. J, Thomas, SM, Muller, M, Straus, SE, Tricco, A. What is the effectiveness and safety of antiviral or antibody treatments for coronavirus? https://www.cebm.net/covid-19/effectiveness-and-safety-of-antiviral-or-antibody-treatments-for-coronavirus/

[8] World Health Organization (2020). Clinical management of severe acute respiratory infection when COVID-19 is suspected. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected.

[9] BMJ Best Practice. Coronavirus disease 2019 (COVID-19) Treatment Algorithm. https://bestpractice.bmj.com/topics/en-gb/3000168/treatment-algorithm.

[10] Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19) [published online ahead of print, 2020 Mar 28]. Intensive Care Med. 2020;1–34. doi:10.1007/s00134-020-06022-5.

[11] Poston JT, Patel BK, Davis AM. Management of Critically Ill Adults With COVID-19 [published online ahead of print, 2020 Mar 26]. JAMA. 2020;10.1001/jama.2020.4914. doi:10.1001/jama.2020.4914

[12] Wynants L, Van Calster B, Bonten MMJ, et al. Prediction models for diagnosis and prognosis of covid-19 infection: systematic review and critical appraisal. BMJ. 2020;369:m1328. Published 2020 Apr 7. doi:10.1136/bmj.m1328

[xiii] Johns Hopkins University Center for Systems Science and Engineering (CSSE). Coronavirus COVID-19 Global Cases. https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

[xiv] Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time [published online ahead of print, 2020 Feb 19]. Lancet Infect Dis. 2020;S1473-3099(20)30120-1. doi:10.1016/S1473-3099(20)30120-1.

[xv] Oke, J, Heneghan, C. Oxford University Centre for Evidence-Based Medicine (2020). Global COVID-19 Case Fatality Rates. 

Jason Oke, Carl Heneghan, https://www.cebm.net/covid-19/global-covid-19-case-fatality-rates/

April 10: What is the current evidence-based treatment for COVID-19 patients with hypoxaemia?

Download the full summary of evidence (PDF)

IN A NUTSHELL

There is much research evidence for the treatment of hypoxaemia but not in the context of COVID-19 patients. According to Murthy et al. (2020)12: “The principal feature of patients with severe disease is the development of ARDS, a syndrome characterized by acute onset of hypoxemic respiratory failure with bilateral infiltrates. Evidence-based treatment guidelines for ARDS should be followed, including conservative fluid strategies for patients without shock following initial resuscitation, empirical early antibiotics for suspected bacterial co-infection until a specific diagnosis is made, lung-protective ventilation, prone positioning, and consideration of extra corporeal membrane oxygenation for refractory hypoxemia.”

Gattinoni et al. (2020)9, reporting from Northern Italy, state that “patients with COVID-19 pneumonia, fulfilling the Berlin criteria of ARDS, present an atypical form of the syndrome. Indeed, the primary characteristics we are observing, confirmed by colleagues in other hospitals, is the dissociation between their relatively well-preserved lung mechanics and the severity of hypoxemia.”

An American Thoracic Society led international task force4 agreed that patients with refractory hypoxemia due to progressive COVID-19 pneumonia [ie ARDS] should undergo prone ventilation. This was based on the assumption that ARDS due to COVID-19 behaves similarly to ARDS due to other causes for which the benefits of prone ventilation are well established. Agreement was not universal, however, as several task force members argued that ARDS in COVID-19 is unique because lung compliance is maintained and the effects of prone ventilation are more modest than in typical ARDS. Nevertheless, the task force concluded that prone ventilation is worth a trial since it is low risk and low cost. However, they warned that placing the patient in the prone position must be done with caution since there is a risk of transmitting infection to healthcare staff due to aerosolized secretions. Prone positioning is also supported by the Australian and New Zealand Intensive Care Society (ANZICS) COVID-19 Guidelines3.

Reporting from Italy, La Regina et al. (2020)8 recommend that “high-flow nasal oxygen (HFNO) or non-invasive ventilation [NIV, mainly c-PAP] should only be used in selected patients with hypoxemia, respiratory failure [P/F next to 300 for HFNO and 250-300 for NIV], but with alerts and with preserved ventilator dynamics.” Further strategies for managing severe hypoxaemia are high PEEP, recruitment manoeuvers and neuromuscular blocking agents (NMBAs)6.

IRISH AND INTERNATIONAL GUIDANCE

What does the HSE say?

Health Service Executive (2020). HSE Operational Pathway of Care [COVID-19][i]

The HSE Operational Pathway of Care advises to give supplemental oxygen at a rate of 10-15L/minute to patients with severe acute respiratory infection and respiratory distress, hypoxaemia or shock. Titrate flow rates to reach a target SpO2 ≥90%.

What does the World Health Organization say?

World Health Organization (2020). Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. Interim guidance 13 March 2020 [ii] 

See section 8. Management of critical COVID-19: acute respiratory distress syndrome (ARDS).

Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing standard oxygen therapy and prepare to provide advanced oxygen/ventilatory support. 

What do other international organizations say?

Australian and New Zealand Intensive Care Society (2020). Australian and New Zealand Intensive Care Society (ANZICS) COVID-19 Guidelines [iii]

See Section 3. Identification and Treatment of Patients with COVID-19 Infection: Fundamental Principles (pages 26-30).

5. Prone positioning: Current reports suggest prone ventilation is effective in improving hypoxia associated with COVID-19.

13. Rescue Therapies: Inhaled nitric oxide and prostacyclin: There is no evidence for routine use of inhaled nitric oxide, prostacyclin or other selective pulmonary vasodilators in acute respiratory failure. However, during emerging infectious disease outbreaks when resources are exhausted, inhaled nitric oxide and prostacyclin may be considered as a temporising measure when patients develop refractory hypoxemia despite prone ventilation, or in the presence of contraindications to prone ventilation or ECMO.

American Thoracic Society (2020). COVID19: Interim Guidance on Management Pending Empirical Evidence. From an American Thoracic Society‐led International Task Force [iv]

See pages 6–7.

The task force agreed that patients with refractory hypoxemia due to progressive COVID-19 pneumonia [ie ARDS] should undergo prone ventilation. This was based on the assumption that ARDS due to COVID-19 behaves similarly to ARDS due to other causes for which the benefits of prone ventilation are well established. Agreement was not universal, however, as several task force members argued that ARDS in COVID-19 is unique because lung compliance is maintained and the effects of prone ventilation are more modest than in typical ARDS. Nevertheless, the task force concluded that prone ventilation is worth a trial since it is low risk and low cost. However, they warned that placing the patient in the prone position must be done with caution since there is a risk of transmitting infection to healthcare staff due to aerosolized secretions.

Zhejiang University [China] (2020). Handbook of COVID-19 Prevention and Treatment [v]

See Section VII page 24ff: Anti-Shock and Anti-Hypoxemia Treatment.

POINT-OF-CARE TOOLS

What does UpToDate say?

UpToDate (2020). Coronavirus disease 2019 (COVID-19) patients: Airway management, anesthesia machine ventilation, and anesthetic care [vi]

See section:  Strategies for managing severe hypoxemia.

Prone positioning: For patients with COVID-19 ARDS that fail standard low tidal volume ventilation, prone ventilation is the preferred next step. Prone positioning is optimal for patients with severe ARDS because it decreases ventral alveolar distention and dorsal alveolar collapse. See [UpToDate] Coronavirus disease 2019 (COVID-19): Critical care issues, section on ‘Prone ventilation’ and [UpToDate] Prone ventilation for adult patients with acute respiratory distress syndrome and [UpToDate] Ventilator management strategies for adults with acute respiratory distress syndrome, section on ‘Refractory patients’.

It is critically important to adhere to appropriate precautions for prone positioning to avoid soft tissue injury: eg nerve damage, pressure-induced injury or ulceration, or compartment syndrome. See [UpToDate] Patient positioning for surgery and anesthesia in adults”, section on ‘Prone.

Other strategies: If prone positioning is inadequate for maintenance of adequate oxygenation, other ventilation strategies include:

  • High PEEP: Maintain tidal volumes at 6 cc per kg or down to 4 cc per kg with permissive hypercapnia and use higher levels of PEEP eg 15 to 20 cm H2O

as needed. See [UpToDate] Coronavirus disease 2019 (COVID-19): Critical care issues, section on ‘Ventilator management of acute respiratory distress syndrome’ and [UpToDate] Ventilator management strategies for adults with acute respiratory distress syndrome, section on ‘Further titration/increase in PEEP (high PEEP)’.  

INTERNATIONAL LITERATURE

What does the international literature say?

Cochrane Library [Special Collections] (2020). Coronavirus (COVID-19): evidence relevant to critical care [vii]

See section: Managing Hypoxaemia.

Acute or chronic hypoxaemia is a common reason for admission to intensive care and for provision of mechanical ventilation. Various refinements of mechanical ventilation or adjuncts are employed to improve patient outcomes.

La Regina et al. (2020). Patient Safety Recommendations for COVID-19 Epidemic Outbreak: Lessons from the Italian Experience [viii]

Author: Micaela La Regina et al.

See Part 3. RECOMMENDATIONS FOR HOSPITAL TREATMENT.

6. High-flow nasal oxygen (HFNO) or non-invasive ventilation [NIV, mainly c-PAP] should only be used in selected patients with hypoxemia, respiratory failure [P/F next to 300 for HFNO and 250-300 for NIV], but with alerts and with preserved ventilator dynamics. Monitor closely for clinical deterioration. 

7. Do not prolong HFNO or NIV for over 2 hours in the case of failure to improve [HFNO: respiratory rate ≥24/min, NIV: respiratory rate ≥28/min and/or worsening P/F for both].        

High flow nasal cannulas and non-invasive ventilation are not recommended in viral pandemics, based on studies conducted in influenza and MERS.

Gattinoni et al. (2020). COVID-19 Does Not Lead to a “Typical” Acute Respiratory Distress Syndrome[ix]

The clinical approach to these patients is the one typically applied to severe ARDS, namely high Positive End Expiratory Pressure (PEEP) and prone positioning. However, the patients with COVID-19 pneumonia, fulfilling the Berlin criteria of ARDS, present an atypical form of the syndrome. Indeed, the primary characteristics we are observing, confirmed by colleagues in other hospitals, is the dissociation between their relatively well preserved lung mechanics and the severity of hypoxemia.

A possible explanation for such severe hypoxemia occurring in compliant lungs is the loss of lung perfusion regulation and hypoxic vasoconstriction. Actually, in ARDS, the ratio between the shunt fraction to the fraction of gasless tissue is highly variable, with mean 1.25 ± 0.80. In eight of our patients with CT scan, however, we measured a ratio of 3.0 ± 2.1, suggesting remarkable hyperperfusion of gasless tissue. If so, the oxygenation increases with high PEEP and/or prone position are not primarily due to recruitment, the usual mechanism in ARDS, but instead, in these patients with a poorly recruitable pneumonia, to the redistribution of perfusion in response to pressure and/or gravitational forces. We should consider that: 1. Patients treated with Continuous Positive Airway Pressure or Non Invasive Ventilation, presenting with clinical signs of excessive inspiratory efforts, intubation should be prioritized to avoid excessive intrathoracic negative pressures and self-inflicted lung injury; 2. High PEEP in a poorly recruitable lung tends to result in severe hemodynamic impairment and fluid retention; 3. Prone positioning of patients with relatively high compliance results in a modest benefit at the price of a high demand for stressed human resources. After considering that, all we can do ventilating these patients is “buying time” with minimum additional damage: the lowest possible PEEP and gentle ventilation. We need to be patient.   

Flower et al. (2020). Management of hypoxaemia  in the critically ill patient[x]

Hypoxaemia is a common presentation in critically ill patients, with the potential for severe harm if not addressed appropriately. This review provides a framework to guide the management of any hypoxaemic patient, regardless of the clinical setting. Key steps in managing such patients include ascertaining the severity of hypoxaemia, the underlying diagnosis and implementing the most appropriate treatment. Oxygen therapy can be delivered by variable or fixed rate devices, and non-invasive ventilation; if patients deteriorate they may require tracheal intubation and mechanical ventilation. Early critical care team involvement is a key part of this pathway. Specialist treatments for severe hypoxaemia can only be undertaken on an intensive care unit and this field is developing rapidly as trial results become available. It is important that each new scenario is approached in a structured manner with an open diagnostic mind and a clear escalation plan.

Alhazzani et al. (2020). Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) [xi]

See especially: B Ventilatory Support.

… We formed a panel of 36 experts from 12 countries….We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations….

The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19.

Murthy et al. (2020). Care for Critically Ill Patients With COVID-19 [xii]

Management of severe COVID-19 is not different from management of most viral pneumonia causing respiratory failure [figure]. The principal feature of patients with severe disease is the development of ARDS: a syndrome characterized by acute onset of hypoxemic respiratory failure with bilateral infiltrates. Evidence-based treatment guidelines for ARDS should be followed, including conservative fluid strategies for patients without shock following initial resuscitation, empirical early antibiotics for suspected bacterial co-infection until a specific diagnosis is made, lung-protective ventilation, prone positioning, and consideration of extra corporeal membrane oxygenation for refractory hypoxemia.

Leeies et al. (2020). High-flow oxygen via nasal cannulae in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis.[xiii]

A systematic review and meta-analysis to evaluate the efficacy and safety of high-flow oxygen via nasal cannulae (HFNC) compared to non-invasive ventilation (NIV) and/or standard oxygen in patients with acute, hypoxemic respiratory failure … CONCLUSIONS: In patients with acute hypoxemic respiratory failure HFNC was not associated with a difference in mortality compared to NIV or standard oxygen. Secondary outcomes including dyspnea, tolerance, and safety were not systematically reported. Residual heterogeneity and variable reporting of secondary outcomes limit the conclusions that can be made in this review. Prospective trials designed to evaluate the efficacy and safety of HFNC in patients with acute hypoxemic respiratory failure are required.

OTHER

Rezaie (31 March 2020) [Blog]. “COVID-19 Hypoxemia: A Better and Still Safe Way” [xiv]

The reality is [that COVID-19] is not ARDS.  Lung compliance is often normal in these patients, and many patients are not in respiratory distress despite low O2 saturations.  Patients can have a bizarre hypoxemia that does not correlate with their symptoms.

Approaches to oxygen supplementation have stressed minimizing aerosolization of viral particles by avoiding HFNC and NIV.  This appears to be a fear-based statement as opposed to an evidence based one.  If we go straight from nasal cannula to intubation, we will simply run out of ventilators.

… I have yet to find a study that shows a mortality rate <50% once a patient is intubated.  Maybe a better way to deal with these patients is an intermediary step using HFNC or CPAP while proning patients while they are awake, before considering intubation. 


[i] Health Service Executive (2020). HSE Operational Pathway of Care [COVID-19]. https://hse.drsteevenslibrary.ie/c.php?g=679077&p=4841241. [Accessed 14 April 2020].

[ii] WHO (2020). Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. Interim guidance 13 March 2020.  https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected [Accessed 09/04/2020].

[iii] Australian and New Zealand Intensive Care Society (2020). Australian and New Zealand Intensive Care Society (ANZICS)   COVID-19 Guidelines. https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf [Accessed 10/04/2020].

[iv] American Thoracic Society (2020). COVID19: Interim Guidance on Management Pending Empirical Evidence https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/covid-19-guidance.pdf [Accessed 10/04/2020].

[v] The First Affiliated Hospital, Zhejiang University School of Medicine. “Handbook of COVID-19 Prevention and Treatment”. https://www.alibabacloud.com/universal-service/pdf_reader?spm=a3c0i.14138300.8102420620.dreadnow.6df3647fNEnE3r&pdf=Handbook_of_COVID_19_Prevention_en_Mobile.pdf [Accessed 09/04/2020].

[vi] UpToDate. (2020). Coronavirus disease 2019 (COVID-19) patients: Airway management, anesthesia machine ventilation, and anesthetic care. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-airway-management-anesthesia-machine-ventilation-and-anesthetic-care [Accessed 09/04/2020].

[vii] Brown, Michael and Herkner, Harald (2020). Coronavirus (COVID-19): evidence relevant to critical care. https://www.cochranelibrary.com/collections/doi/SC000039/full [Accessed 09/04/2020].

[viii] La Regina, Micaela  et al. (2020). PATIENT SAFETY RECOMMENDATIONS FOR COVID-19 EPIDEMIC OUTBREAK. https://www.isqua.org/images/COVID19/PATIENT_SAFETY_RECOMMENDATIONS_-_V1.2.pdf [Accessed 10/04/2020].

[ix] Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D. Covid-19 Does Not Lead to a “Typical” Acute Respiratory Distress Syndrome [published online ahead of print, 2020 Mar 30]. Am J Respir Crit Care Med. 2020;10.1164/rccm.202003-0817LE. doi:10.1164/rccm.202003-0817LE.

[x] Flower L, Martin D. Management of hypoxaemia in the critically ill patient. Br J Hosp Med (Lond). 2020;81(1):1–10. doi:10.12968/hmed.2019.0186.

[xi] Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19) [published online ahead of print, 2020 Mar 28]. Intensive Care Med. 2020;1–34. doi:10.1007/s00134-020-06022-5.

[xii] Murthy S, Gomersall CD, Fowler RA. Care for Critically Ill Patients With COVID-19 [published online ahead of print, 2020 Mar 11]. JAMA. 2020;10.1001/jama.2020.3633. doi:10.1001/jama.2020.3633.

[xiii] Leeies M, Flynn E, Turgeon AF, et al. High-flow oxygen via nasal cannulae in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis. Syst Rev. 2017;6(1):202. Published 2017 Oct 16. doi:10.1186/s13643-017-0593-5.

[xiv] Rezaie, Salim (2020) https://rebelem.com/covid-19-hypoxemia-a-better-and-still-safe-way/ [Accessed 10/04/2020].

Date: April 10 – What are the approaches to modelling the COVID-19 pandemic within and across countries with a specific focus on health service implications? How are countries using modelling to inform the response of health services to the pandemic? [Keywords:Modelling, Health Preparedness]

Download the full summary (pdf)

Key Themes : Modelling does not predict the future; it is a tool to explore scenarios and the potential impact of actions we might take. The lack of real data on COVID-19 makes it difficult to build accurate models but this will improve as access to data specific to a particular country becomes more available. Models seem to focus on two strategies – suppression vs mitigation – with the aim of guiding governments as to how they can ensure that health services are able to respond so that sufficient capacity is available: ie buying time or delaying. A second peak may follow the lifting of containment measures.

What does the European Centre for Disease Prevention and Control say?

European Centre for Disease Control and Prevention. Rapid risk assessment: Coronavirus disease 2019 (COVID-19) pandemic [Eighth Update][i]

Over the past few weeks, EU/EEA countries and the UK have implemented a range of measures to reduce further transmission of the virus, focussing in particular on physical distancing to decrease the burden on healthcare services, protect populations at risk of severe disease and reduce excess mortality. There is evidence from countries in Asia that were affected early in the pandemic, which is supported by modelling studies, and preliminary signs from Italy and Austria, that a combination of stringent measures can achieve meaningful reductions in transmission.

Information on modelling COVID-19

Chapman (09/04/2020). [Cochrane] Quarantine for controlling COVID-19 (coronavirus). New Cochrane evidence[ii]

The COVID-19 modelling studies in the review consistently report a benefit of quarantine in reducing the number of people who get infected and who die from COVID-19. The studies on SARS and MERS have similar results.

Adam (2020). Special report: The simulations driving the world’s response to COVID-19: How epidemiologists rushed to model the coronavirus pandemic[iii]

Many of the models simulating how diseases spread are unique to individual academic groups that have been developing them for years, but the mathematical principles are similar. They are based around trying to understand how people move between three main states, and how quickly: individuals are either susceptible (S) to the virus; have become infected (I); and then either recover (R) or die. The R group is presumed to be immune to the virus, so can no longer pass on the infection. People with natural immunity would also belong to this group.

The simplest SIR models make basic assumptions, such as that everyone has the same chance of catching the virus from an infected person because the population is perfectly and evenly mixed, and that people with the disease are all equally infectious until they die or recover. More-advanced models, which make the quantitative predictions policymakers need during an emerging pandemic, subdivide people into smaller groups — by age,

sex, health status, employment, number of contacts, and so on — to set who meets whom, when and in which places.

Jefferson, Heneghan [Oxford University Centre for Evidence Based Medicine] (2020). Modelling the models[iv]

Those that have a mathematical basis are usually referred to as models.  According to Wikipedia “a model may help to explain a system and to study the effects of different components, and to make predictions about behaviour”. If applied to biomedicine and specifically to infectious diseases, models may help to understand the interactions of the different variables such as characteristics of the agent, target population, evolution of the spread and possible future scenarios. All models, be they prospective or retrospective, if they are based on scientific principles, have substantial uncertainty as to their starting point and are incompatible with oracle-like statements of certainty.

Jia at al. (01/04/2020). Modelling COVID-19 transmission: from data to intervention[v]

Mathematical models have been used to simulate scenarios and predict evolution of infectious diseases since the early 20th century. Models are usually driven by a disease’s intrinsic mechanism or fitted through sufficient data, but they are frequently expected to provide quick insights of and predictive power on a new pathogen in the early stages of an outbreak, which are seemingly contradictory expectations. Indeed, it is not clear whether early cases of COVID-19 were from infection by animal or human, and data are limited and unreliable. In this case, models fitted by early data probably produce results divorced from reality. Early modelling studies have proved overly optimistic about the situation in Wuhan. The closer to reality, the more resources a model requires. Modellers must compromise with reality most of the time. As data are shared and computing performance improves [including artificial intelligence, we believe that the above contradictions will be alleviated. Mathematical modelling will have a greater role in supporting clinical diagnosis and optimising a combination of strategies. In view of substantial data accumulated for COVID-19, an essential next step is to estimate whether a second wave of COVID-19 will appear in China.

Wynants at al. (24/03/2020). Prediction models for diagnosis and prognosis of covid-19 infection: systematic review and critical appraisal [vi]

COVID-19 related prediction models are quickly entering the academic literature, to support medical decision making at a time where this is urgently needed. Our review indicates proposed models are poorly reported and at high risk of bias. Thus, their reported performance is likely optimistic and using them to support medical decision making is not advised. We call for immediate sharing of the individual participant data from COVID-19 studies to support collaborative efforts in building more rigorously developed prediction models and validating [evaluating] existing models. The aforementioned predictors identified in multiple included studies could be considered as candidate predictors for new models. We also stress the need to follow methodological guidance when developing and validating prediction models, as unreliable predictions may cause more harm than benefit when used to guide clinical decisions.

International approaches

Ireland

[RTE News] More time needed for reliable surge projection: NPHET[vii]

The chair of the NPHET Irish Epidemiological Modelling Advisory Group has said it was not possible to make a prediction on the surge in COVID-19 cases at this time, as more time was needed for a more reliable picture. Speaking at this evening’s COVID-19 briefing at the Department of Health, Professor Philip Nolan said that to make projections now on what things will be like in a few weeks or months would be inappropriate and based on assumptions that would be too broad. Ms O’Connor added that they are not working to a traditional model and are examining how to have ventilated beds in areas they would not have been previously. Under the worst-case scenario, the peak number of patients requiring intensive care a day would be 546 by 13 April. Some experts believe this scale of cases is unlikely to be seen because of the stay at home and other major measures announced by Government and recommended last Friday by the National Public Health Emergency Team and because the number of contacts per confirmed case is now down to under five.

[Journal.ie] [reaction to IHME report] ‘It simply isn’t true’: Health officials dismiss US report which says Ireland is past COVID-19 peak[viii]

Northern Ireland

‘Minister Highlights Key Findings of NI COVID-19 Modelling’[ix]

Health Minister Robin Swann has set out key findings of an expert NI modelling study which will inform intensive hospital planning for the forthcoming surge in COVID-19 cases.

UK

Imperial College [London]. Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand[x]

Researchers from Imperial College, London have analysed the likely impact of multiple public health measures on slowing and suppressing the spread of coronavirus. The latest analysis comes from a team modelling the spread and impact COVID-19 and whose data are informing current UK government policy on the pandemic. The findings are published in the ninth report from the WHO Collaborating Centre for Infectious Disease Modelling within the Imperial College London.

They have also published further reports including: Report 13: Estimating the number of infections and the impact of non-pharmaceutical interventions on COVID-19 in 11 European countries[xi]

London School of Hygiene and Tropical Medicine (2020). Estimates for the relative impact of different COVID-19 control measures in the UK[xii]

The London School of Hygiene and Tropical Medicine’s Centre for the Mathematical Modelling of Infectious Diseases (CMMID) is conducting crucial work on the COVID-19 pandemic. Since February, CMMID has been asked by governmental advisory bodies to project the possible trajectory of the COVID-19 epidemic in the UK under a range of different scenarios, including introduction of non-pharmaceutical interventions such as school closures, social distancing shielding of the elderly and adults in high-risk groups. These large-scale interventions, including home isolation, aim to reduce coronavirus transmission. Estimates [not peer-reviewed] in a new pre-print combine some of the work CMMID has been conducting for the government in February and March with more current data which has become available as this fast-moving epidemic evolves.

Australia

Australian Government (2020). Impact of COVID-19: theoretical modelling of how the health system can respond[xiii]

Modelling for COVID-19 involves making assumptions about how the virus behaves. Under the pandemic plan the Australian Government immediately started to develop possible scenarios. We used early data from China and other countries and our understanding of how other coronaviruses behave. The model also considers the impact of different levels of isolation and distancing.

The baseline for the modelling is not a realistic scenario. It is a theoretical, uncontrolled pandemic. It assumes the virus moves through the community with each infected person spreading it to 2.5 other people. It assumes no health system or community action to slow the spread.

The modelling finds our ICUs will cope if we continue to:

  • have effective social distancing,
  • increase our health system capacity
  • isolate people with the virus and their close contacts

Moss at al.. [Preprint not yet submitted for peer-review]. Modelling the impact of COVID-19 in Australia to inform transmission reducing measures and health system preparedness[xiv]

The ability of global health systems to cope with increasing numbers of COVID-19 cases is of major concern. In readiness for this challenge, Australia has drawn on clinical pathway models developed over many years in preparation for influenza pandemics. These models have been used to estimate health care requirements for COVID-19 patients in the context of broader public health measures.

USA

Institute of Health Metrics and Evaluation (IHME) at the University of Washington. COVID-19 Projections[xv]

A modelling tool that predicts peak of virus and death rate by August, as well as bed capacity for all countries.  [NB: the predictions for Ireland have been challenged8].

CANADA

Scarabel at al.. (30/03/2020) [Pre-proof to appear in Infectious Disease Modelling] Canada needs to rapidly escalate public health interventions for its COVID-19 mitigation strategies[xvi]

The present paper aims to predict the trend of the COVID-19 outbreak in Canada by means of comparative modelling, using Italy as comparison.

In conclusion, Canada will not become the next Italy, but will fail to achieve better results in controlling the outbreak if a comprehensive package of public health interventions is not quickly enforced. Considering the delayed effect of intervention measures and the hospital bed shortage, it is imperative to take prompt actions to reduce the epidemic growth rate and to avoid overwhelming the capacity of the Canadian health system.

International literature

Leung at al. (08/04/2020) First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment[xvii]

The interventions China implemented in response to the COVID-19 outbreak had a real and dramatic effect on interrupting transmission in all areas outside of Hubei. As economic activity continues to resume in the coming weeks, real-time assessment by monitoring the instantaneous effective reproduction number could allow policy makers to tune relaxation decisions to maintain transmissibility to below the self-sustaining threshold of 1. CFRs vary between provinces, which might be determined by health-care availability, quality, and surge capacity. Therefore, health services planning should be optimised to minimise mortality related to COVID-19.

Steinberg at al. (06/04/2020). Calculated decisions: COVID-19 calculators during extreme resource-limited situations[xviii]

In the near future, clinicians may face scenarios in which there are not have enough resources – ventilators, ECMO machines, etc. – available for the number of critically sick COVID-19 patients. There may not be enough healthcare workers, as those who are positive for COVID-19 or those who have been exposed to the virus and need to be quarantined. During these worst-case scenarios, new crisis standards of care and thresholds for intensive care unit (ICU) admissions will be needed. Clinical decision scores may support the clinician’s decision-making, especially if properly adapted for this unique pandemic and for the patient being treated. This review discusses the use of clinical prediction scores for pneumonia severity at 3 main decision points to examine which scores may provide value in this unique situation. Initial data from a cohort of over 44,000 COVID-19 patients in China, including risk factors for mortality, were compared with data from cohorts used to study the clinical scores, in order to estimate the potential appropriateness of each score and determine how to best adjust results at the bedside.

Kim at al. (06/04/2020). School Opening Delay Effect on Transmission Dynamics of Coronavirus Disease 2019 in Korea: Based on Mathematical Modeling and Simulation Study[xix]

Nonpharmaceutical intervention strategy is significantly important to mitigate the coronavirus disease 2019 (COVID-19) spread. One of the interventions implemented by the government is a school closure. The Ministry of Education decided to postpone the school opening from March 2 to April 6 to minimize epidemic size. We aimed to quantify the school closure effect on the COVID-19 epidemic.

Hou at al. (03/04/2020). The effectiveness of the quarantine of Wuhan city against the Corona Virus Disease 2019 (COVID-19): well-mixed SEIR model analysis[xx]

The present study shows that by reducing the contact rate of latent individuals interventions such as quarantine and isolation can effectively reduce the potential peak number of COVID-19 infections and delay the time of peak infection.

Bayham at al. (03/04/2020). Impact of school closures for COVID-19 on the US health-care workforce and net mortality: a modelling study[xxi]

The coronavirus disease 2019 (COVID-19) pandemic is leading to social physical distancing policies worldwide, including in the USA. Some of the first actions taken by governments are the closing of schools. The evidence that mandatory school closures reduce the number of cases and, ultimately, mortality comes from experience with influenza or from models that do not include the effect of school closure on the health-care labour force. The potential benefits from school closures need to be weighed against costs of health-care worker absenteeism associated with additional child-care obligations. Our model estimates that if the infection mortality rate of COVID-19 increases from 2·00% to 2·35% when the health-care workforce declines by 15·0%, school closures could lead to a greater number of deaths than they prevent. School closures come with many trade-offs and can create unintended child-care obligations. Our results suggest that the potential contagion prevention from school closures needs to be carefully weighted with the potential loss of health-care workers from the standpoint of reducing cumulative mortality due to COVID-19 in the absence of mitigating measures.

Moghadas SM at al. (03/04/2020). Projecting hospital utilization during the COVID-19 outbreaks in the United States[xxii]

In the wake of community coronavirus disease 2019 (COVID-19) transmission in the United States, there is a growing public health concern regarding the adequacy of resources to treat infected cases. Hospital beds, intensive care units and ventilators are vital for the treatment of patients with severe illness. Our estimates underscore the inadequacy of critical care capacity to handle the burgeoning outbreak. Policies that encourage self-isolation, such as paid sick leave, may delay the epidemic peak, giving a window of time that could facilitate emergency mobilization to expand hospital capacity

Sun Y at al. (25/03/2020). Epidemiological and Clinical Predictors of COVID-19[xxiii]

Rapid identification of COVID-19 cases, which is crucial to outbreak containment efforts, is challenging due to the lack of pathognomonic symptoms and in settings with limited capacity for specialized nucleic acid-based reverse transcription polymerase chain reaction (PCR) testing. Rapidly ascertainable clinical and laboratory data could identify individuals at high risk of COVID-19 and enable prioritization of PCR-testing and containment efforts. Basic laboratory test results were crucial to prediction models.

Mandal S at al. (23/03/2020). Prudent public health intervention strategies to control the coronavirus disease 2019 transmission in India: A mathematical model-based approach[xxiv]

Coronavirus disease 2019 (COVID-19) has raised urgent questions about containment and mitigation, particularly in countries where the virus has not yet established human-to-human transmission. The objectives of this study were to find out if it was possible to prevent or delay the local outbreaks of COVID-19 through restrictions on travel from abroad and if the virus has already established in-country transmission, to what extent would its impact be mitigated through quarantine of symptomatic patients? These questions were addressed in the context of India, using simple mathematical models of infectious disease transmission. While there remained important uncertainties in the natural history of COVID-19, using hypothetical epidemic curves, some key findings were illustrated that appeared insensitive to model assumptions, as well as highlighting critical data gaps.

Port-of-entry-based entry screening of travellers with suggestive clinical features and from COVID-19-affected countries would achieve modest delays in the introduction of the virus into the community. Acting alone, however, such measures would be insufficient to delay the outbreak by weeks or longer. Once the virus establishes transmission within the community, quarantine of symptomatics may have a meaningful impact on disease burden. Model projections are subject to substantial uncertainty and can be further refined as more is understood about the natural history of infection of this novel virus. As a public health measure, health system and community preparedness would be critical to control any impending spread of COVID-19 in the country.

Koo at al. (23/03/2020). Interventions to mitigate early spread of SARS-CoV-2 in Singapore: a modelling study[xxv]

Since the coronavirus disease 2019 outbreak began in the Chinese city of Wuhan on Dec 31, 2019, 68 imported cases and 175 locally acquired infections have been reported in Singapore. We aimed to investigate options for early intervention in Singapore should local containment [eg preventing disease spread through contact tracing efforts] be unsuccessful.

We adapted an influenza epidemic simulation model to estimate the likelihood of human-to-human transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a simulated Singaporean population. Implementing the combined intervention of quarantining infected individuals and their family members, workplace distancing and school closure once community transmission has been detected could substantially reduce the number of SARS-CoV-2 infections. We therefore recommend immediate deployment of this strategy if local secondary transmission is confirmed within Singapore. However, quarantine and workplace distancing should be prioritised over school closure because at this early stage, symptomatic children have higher withdrawal rates from school than do symptomatic adults from work. At higher asymptomatic proportions, intervention effectiveness might be substantially reduced requiring the need for effective case management and treatments, and preventive measures such as vaccines.

Martín-Calvo at al. (22/03/2020). Effectiveness of social distancing strategies for protecting a community from a pandemic with a data driven contact network based on census and real-world mobility data[xxvi]

The current situation of emergency is global. As of today, March 22nd 2020, there are more than 23 countries with more than 1.000 infected cases by COVID-19, in the exponential growth phase of the disease. Furthermore, there are different mitigation and suppression strategies in place worldwide, but many of them are based on enforcing to a more or less extent the so-called social distancing. The impact and outcomes of the adopted measures are yet to be contrasted and quantified. Our report contains preliminary results that aim at answering the following questions in relation to the spread and control of the COVID-19 pandemic:

  • What is the expected impact of current social distancing strategies?
  • How long should such measures need to be in place?
  • How many people will be infected and at which social level?
  • How do R(t) and the epidemic dynamic change based on the adopted   strategies?
  • What is the probability of having a second outbreak: ie a re-emergence?
  • If there is a re-emergence, how much time do we have to get ready?
  • What is the best strategy to minimize the current epidemic and get ready for a second wave?

National Academies of Sciences, Engineering, and Medicine (21/3/2020). Rapid Expert Consultation on Data Elements and Systems Design for Modeling and Decision Making for the COVID-19 Pandemic[xxvii]

Whether for a known infectious pathogen or a novel one, the ability to model the pathogenesis, transmission, effective control strategies and spread of a disease can provide crucial information to those needing to make decisions about the distribution of limited resources. An example of a successful collaborative effort is the Models of Infectious Disease Agent Study (MIDAS). This effort, funded by the National Institute of General Medical Sciences at the NIH, is a global network of research scientists and practitioners who develop and use computational, statistical and mathematical models to understand infectious disease dynamics. MIDAS has an online portal to share data and information regarding the COVID-19 pandemic and could be used as a resource for decision-makers. To assist with forecasting disease progression and identifying important clinical markers before we obtain more data on COVID-19 in the US, data from other countries, such as the daily number of hospitalizations, intensive care admissions, ventilator use and deaths, can be used in forecasting expected epidemic progression and assist with clinical care decisions. Assessing the capacity of medical facilities to provide intensive care to those in need will facilitate the allocation of ICU beds and ventilators. Programs at local and regional levels currently monitor the availability of hospital beds and other resources, and expanding these programs would provide a national view of areas most in need. Tracking mortality from disease in relation to resources can aid in the interpretation of fatality rates and inform future pandemic preparedness.

Lin at al. (04/03/2020). A conceptual model for the coronavirus disease 2019 (COVID-19) outbreak in Wuhan, China with individual reaction and governmental action[xxviii]

The ongoing coronavirus disease 2019 (COVID-19) outbreak, emerged in Wuhan, China in the end of 2019, has claimed more than 2600 lives as of 24 February 2020 and posed a huge threat to global public health. The Chinese government has implemented control measures including setting up special hospitals and travel restriction to mitigate the spread. We propose conceptual models for the COVID-19 outbreak in Wuhan with the consideration of individual behavioural reaction and governmental actions: eg holiday extension, travel restriction, hospitalisation and quarantine. We employed the estimates of these two key components from the 1918 influenza pandemic in London, incorporated zoonotic introductions and the emigration, and then compute future trends and the reporting ratio. The model is concise in structure, and it successfully captures the course of the COVID-19 outbreak, and thus sheds light on understanding the trends of the outbreak.


[i] European Centre for Disease Control and Prevention (2020).  Rapid risk assessment: Coronavirus disease 2019 (COVID-19) pandemic [Eighth Update] https://www.ecdc.europa.eu/en/rapid-risk-assessment-coronavirus-disease-2019-covid-19-pandemic-eighth-update.  [Accessed 09 April 2020].

[ii] Chapman (09/04/2020). [Cochrane] Quarantine for controlling COVID-19 (coronavirus). New Cochrane evidence. https://www.evidentlycochrane.net/quarantine-covid-19/.[Accessed 09 April 2020].

[iii] Adam D. Special report: The simulations driving the world’s response to COVID-19. Nature. 2020;580(7803):316–318. doi:10.1038/d41586-020-01003-6.

[iv] Jeferson, T, Heneghan, C. Modelling the models. https://www.cebm.net/2020/04/modelling-the-models/ [Accessed 09 April 2020].

[v] Jia Z, Lu Z. Modelling COVID-19 transmission: from data to intervention [published online ahead of print, 2020 Apr 1]. Lancet Infect Dis. 2020;S1473-3099(20)30258-9. doi:10.1016/S1473-3099(20)30258-9

[vi] Wynants L, Van Calster B, Bonten MMJ, at al.. Prediction models for diagnosis and prognosis of covid-19 infection: systematic review and critical appraisal. BMJ. 2020;369:m1328. Published 2020 Apr 7. doi:10.1136/bmj.m1328.

[vii] RTE. https://www.rte.ie/news/coronavirus/2020/0330/1127224-coronavirus-health-covid19/. [Accessed 09 April 2020].

[viii] Journal.ie. https://www.thejournal.ie/coronavirus-us-model-ireland-peak-passed-5069341-Apr2020/.[Accessed 09 April 2020].

[ix] Department of Health (UK). https://www.health-ni.gov.uk/news/minister-highlights-key-findings-ni-covid-19-modelling. [Accessed 09 April 2020].

[x]  Imperial College [London]. https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-9-impact-of-npis-on-covid-19/ [Accessed 09 April 2020].

[xi] Imperial College [London]. https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-13-europe-npi-impact [Accessed 09 April 2020].

[xii] London School of Hygiene and Tropical Medicine. https://www.lshtm.ac.uk/newsevents/news/2020/estimates-relative-impact-different-covid-19-control-measures-uk

[xiii] Australian Government (2020). Impact of COVID-19: theoretical modelling of how the health system can respond. https://www.pm.gov.au/sites/default/files/files/covid19-icu-modelling-summary.pdf. [Accessed 09 April 2020].

[xiv] Moss at al. [Preprint not yet submitted for peer-review]. Modelling the impact of COVID-19 in Australia to inform transmission reducing measures and health system preparedness. https://www.doherty.edu.au/uploads/content_doc/McVernon_Modelling_COVID-19_07Apr1_with_appendix.pdf. [Accessed 09 April 2020].

[xv] Institute of Health Metrics and Evaluation (IHME) at the University of Washington. COVID-19 Projections. http://www.healthdata.org/.

[xvi] https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3559929. [Accessed 09 April 2020].

[xvii] Leung at al. (08/04/2020) First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930746-7. [Accessed 09 April 2020].

[xviii] Steinberg E, Balakrishna A, Habboushe J, Shawl A, Lee J. Calculated decisions: COVID-19 calculators during extreme resource-limited situations. Emerg Med Pract. 2020;22(4 Suppl):CD1–CD5. Published 2020 Apr 6.

[xix] Kim S, Kim YJ, Peck KR, Jung E. School Opening Delay Effect on Transmission Dynamics of Coronavirus Disease 2019 in Korea: Based on Mathematical Modeling and Simulation Study. J Korean Med Sci. 2020;35(13):e143. Published 2020 Apr 6. doi:10.3346/jkms.2020.35.e143

[xx] Hou C, Chen J, Zhou Y, at al.. The effectiveness of the quarantine of Wuhan city against the Corona Virus Disease 2019 (COVID-19): well-mixed SEIR model analysis [published online ahead of print, 2020 Apr 3]. J Med Virol. 2020;10.1002/jmv.25827. doi:10.1002/jmv.25827.

[xxi] Bayham J, Fenichel EP. Impact of school closures for COVID-19 on the US health-care workforce and net mortality: a modelling study [published online ahead of print, 2020 Apr 3]. Lancet Public Health. 2020;S2468-2667(20)30082-7. doi:10.1016/S2468-2667(20)30082-7.

[xxii] Moghadas SM, Shoukat A, Fitzpatrick MC, at al.. Projecting hospital utilization during the COVID-19 outbreaks in the United States [published online ahead of print, 2020 Apr 3]. Proc Natl Acad Sci U S A. 2020;202004064. doi:10.1073/pnas.2004064117.

[xxiii] Sun Y, Koh V, Marimuthu K, at al.. Epidemiological and Clinical Predictors of COVID-19 [published online ahead of print, 2020 Mar 25]. Clin Infect Dis. 2020;ciaa322. doi:10.1093/cid/ciaa322.

[xxiv] Mandal S, Bhatnagar T, Arinaminpathy N, at al.. Prudent public health intervention strategies to control the coronavirus disease 2019 transmission in India: A mathematical model-based approach [published online ahead of print, 2020 Mar 23]. Indian J Med Res. 2020;10.4103/ijmr.IJMR_504_20. doi:10.4103/ijmr.IJMR_504_20.

[xxv] Koo JR, Cook AR, Park M, at al.. Interventions to mitigate early spread of SARS-CoV-2 in Singapore: a modelling study [published online ahead of print, 2020 Mar 23] [published correction appears in Lancet Infect Dis. 2020 Mar 27;:]. Lancet Infect Dis. 2020;S1473-3099(20)30162-6. doi:10.1016/S1473-3099(20)30162-6.

[xxvi] Martín-Calvo at al. (22/03/2020). Effectiveness of social distancing strategies for protecting a community from a pandemic with a data driven contact network based on census and real-world mobility data. https://comdig.unam.mx/2020/03/25/effectiveness-of-social-distancing-strategies-for-protecting-a-community-from-a-pandemic-with-a-data-driven-contact-network-based-on-census-and-real-world-mobility-data/[Accessed 09 April 2020].

[xxvii] National Academies of Sciences, Engineering, and Medicine (21/3/2020). Rapid Expert Consultation on Data Elements and Systems Design for Modeling and Decision Making for the COVID-19 Pandemic. https://www.nap.edu/catalog/25755/rapid-expert-consultation-on-data-elements-and-systems-design-for-modeling-and-decision-making-for-the-covid-19-pandemic-march-21-2020[Accessed 09 April 2020].

[xxviii] Lin Q, Zhao S, Gao D, at al.. A conceptual model for the coronavirus disease 2019 (COVID-19) outbreak in Wuhan, China with individual reaction and governmental action [published online ahead of print, 2020 Mar 4]. Int J Infect Dis. 2020;93:211–216. doi:10.1016/j.ijid.2020.02.058.

Date: April 6th – What has been the impact of mitigation and restriction measures in curtailing the spread of COVID 19? [Keywords: Mitigation, containment]

Download the full summary (pdf)

What is the best evidence currently?

The evidence base is still very limited in answering this question. However, there are a few key messages which have emerged from the research literature:

  • No single measure is successful in isolation. Only a package of measures including contract tracing, social distancing, quarantine and isolation as appropriate are effective when used in conjunction
  • The timing and duration of these initiatives is hugely important
  • Success or relative success of these initiatives is driven by a high level [over 80%] of personal compliance from the population

Imperial College [London] COVID-19 Response Team. Estimating the number of infections and the impact of nonpharmaceutical interventions on COVID-19 in 11 European countries[i]

Modelling estimates are becoming more accurate as the pandemic progresses. A recent study from the Imperial College COVID-19 Response Team indicates that mitigation and restriction methods have saved in the region of 59,000 lives globally.

Contact Tracing

Contact tracing has been shown to be valuable in the early stages of the COVID-19 pandemic.  However, it requires a significant investment of resources. 

Fong et al. (2020). Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings: Social Distancing Measures[ii]

Fong et al. reviewed 4 simulation studies, all of which found contact tracing to be effective when used in combination with other interventions, including isolation, quarantine, and prophylactic treatment with antiviral drugs. However, Wu et al.[iii] estimated that the addition of contact tracing to an existing combination of quarantine, isolation, and antiviral prophylaxis measures would only provide modest benefit, while increasing considerably the proportion of population in quarantine and the consequent costs.

Contact tracing requires substantial resources to sustain after the early phases of a pandemic because the number of case-patients and contacts grows exponentially within a short generation time. Therefore, there is no obvious rationale for the routine use of contact tracing in the general population for control of pandemic influenza. However, contact tracing might be implemented for other purposes, such as identification of case-patients in high-risk groups to enable early treatment. There are some specific circumstances in which contact tracing might be more feasible and justified, such as to enable short delay of widespread transmission in small, isolated communities, or within aircraft settings to prevent importation of cases.

Keeling at al. Efficacy of Contact Tracing for the Containment of the 2019 Novel Coronavirus (COVID-19)[iv]

Contact tracing is a central public health response to infectious disease outbreaks, especially in the early stages of an outbreak when specific treatments are limited. Using detailed survey information on social encounters coupled to predictive models, we investigate the efficacy of the current UK definition of a close contact – within 2 meters for 15 minutes or more – and the distribution of secondary cases that may go untraced. Taking recent estimates for COVID-19 transmission, we show that less than 1 in 5 cases will generate any subsequent untraced cases, although this comes at a high logistical burden with an average of 36.1 individuals (95th percentiles 0-182) traced per case. Changes to the definition of a close contact can reduce this burden, but with increased risk of untraced cases; we estimate that any definition where close contact requires more than 4 hours of contact is probable to lead to uncontrolled spread.

Oxford University Big Data Institute (31 March 2020). Controlling coronavirus transmission using a mobile app to trace close proximity contacts

Several international partners are assessing the feasibility of developing mobile apps for contact tracing in record time. If rapidly and widely developed, these mobile apps could help to significantly slow the rate of transmission, and support countries to emerge from lockdowns safely, as restrictions are gradually eased. 

Professor Christophe Fraser, Oxford University Big Data Institute, explains: “We need a mobile contact tracing app to urgently support health services to control coronavirus transmission, target interventions and keep people safe. Our analysis suggests that about half of transmissions occur in the early phase of the infection, before you show any symptoms of infection. Our mathematical models also highlight that traditional public health contact tracing approaches provide incomplete data and cannot keep up with the pace of this pandemic.” 

Dr David Bonsall, Oxford University Nuffield Department of Medicine, explains: “The mobile app concept we’ve mathematically modelled is simple and doesn’t need to track your location; it uses a low-energy version of Bluetooth to log a memory of all the app users with whom you have come into close proximity over the last few days. If you then become infected, these people are alerted instantly and anonymously, and advised to go home and self-isolate.”

The authors argue that a mobile app can reduce transmission at any stage of the epidemic, in countries or regions where the epidemic is just emerging, at the peak of the epidemic, or to support a safe transition out of restricted movement or lockdown.  It could also help to reduce the serious social, psychological and economic impacts caused by widespread lockdowns. Critically, the researchers suggest a mobile app can help slow the spread of infection until vaccines and antiviral treatments become widely available. 

Professor Fraser explains: “A contact tracing app can foster good citizenship by alerting people at risk, it can also help ease us out of confinement If we know we’ve not been in contact with anyone infected we can leave home safely, whilst still protecting our loved ones and avoiding a broader resurgence of coronavirus in our community.” 

The Oxford team highlight that the mobile contact tracing app should still be combined with isolation of cases, tracing and quarantine of contacts, physical distancing, scaled-up diagnostic testing, decontamination and hygiene measures; and point to the importance of rigorous ethical standards underpinning the successful and appropriate use of mobile phone technology in addressing the coronavirus pandemic, including a number of ethical requirements needed to foster well-founded public trust and confidence. 

Social Distancing

European Centre for Disease Prevention and Control. Considerations Relating to Social Distancing Measures in Response to the COVID-19 Epidemic[v]

Social distancing measures comprise one category of non-pharmaceutical countermeasures aimed at reducing disease transmission and thereby also reducing pressure on health services.

Social distancing aims through a variety of means to minimise contact between individuals and thereby to reduce the possibility for new infections. Decisions on when and how to implement social distancing measures should always be informed by evidence, but they will very rarely be purely evidence-based. Social and political considerations will also need to be taken into account. The detection of COVID-19 cases and deaths outside of known chains of transmission is a strong signal that social distancing measures should be considered. The early, decisive, rapid, coordinated and comprehensive implementation of closures and quarantines is more effective in slowing the spread of the virus than a delayed implementation.

Shenjie et al. Effect of Non-Pharmaceutical Interventions for Containing the COVID-19 Outbreak: An Observational and Modelling Study[vi]

Without non-pharmaceutical interventions (NPIs) the number of COVID-19 cases would have shown a 67-fold increase with the effectiveness of different interventions varying. The early detection and isolation of cases was estimated to prevent more infections than travel restrictions and contact reductions, but integrated NPIs would achieve the strongest and most rapid effect. If NPIs could have been conducted one week, two weeks or three weeks earlier in China, cases could have been reduced by 66%, 86% and 95% respectively, together with significantly reducing the number of affected areas. However, if NPIs were conducted one week, two weeks or three weeks later, the number of cases could have shown a 3-fold, 7-fold and 18-fold increase across China, respectively. Results also suggest that the social distancing intervention should be continued for the next few months in China to prevent case numbers increasing again after travel restrictions were lifted on February 17, 2020. Conclusion: The NPIs deployed in China appear to be effectively containing the COVID-19 outbreak, but the efficacy of the different interventions varied, with the early case detection and contact reduction being the most effective. Moreover, deploying the NPIs early is also important to prevent further spread. Early and integrated NPI strategies should be prepared, adopted and adjusted to minimize health, social and economic impacts in affected regions around the World.

Quarantine and Isolation

A recent paper by Wilder-Smith notes that in the absence of any one effective measure to mitigate COVID 19, governments have had to revert to tried and tested public health measures such as quarantine and isolation. 

Wilder-Smith et al. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak[vii]

Public health measures were decisive in controlling the SARS epidemic in 2003. Isolation is the separation of ill persons from non-infected persons. Quarantine is movement restriction, often with fever surveillance, of contacts when it is not evident whether they have been infected but are not yet symptomatic or have not been infected. Community containment includes measures that range from increasing social distancing to community-wide quarantine. Whether these measures will be sufficient to control 2019-nCoV depends on addressing some unanswered questions.

Oxford University Centre for Evidence Based Medicine. What is the evidence for social distancing [and quarantine] during pandemics?[viii]

Although the evidence for home quarantine was moderate, there was a large enough signal to suggest that it may be effective in slowing transmission, particularly with high adherence [>70%]. Rashid (2015)[ix] included a modelling study where quarantining 50% of all case contacts over a period of 4 weeks before the epidemic peak, reduced the peak case-load and attack rate by 25% and 1.5% respectively and delayed the peak by around 1 week.

Fong et al. highlighted the need to consider the economic and social costs of these interventions. For example, the benefits of quarantine would need to be taken in the context of the risk to other household members, a risk that might increase the longer the period of quarantine continues.

Similarly, Rashid highlighted the risk of cross house contamination.

Quarantine however is a shock tactic that can only be employed for a relatively short period of time. As Brooks notes, increasingly we are beginning to see evidence of the psychological impacts from prolonged periods of quarantine. 

Brooks et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence[x]

Most reviewed studies reported negative psychological effects including post-traumatic stress symptoms, confusion and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss and stigma. Some researchers have suggested long-lasting effects. In situations where quarantine is deemed necessary, officials should quarantine individuals for no longer than required, provide clear rationale for quarantine and information about protocols, and ensure sufficient supplies are provided. Appeals to altruism by reminding the public about the benefits of quarantine to wider society can be favourable.

Hellewell et al. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts[xi]

In most scenarios, highly effective contact tracing and case isolation is enough to control a new outbreak of COVID-19 within 3 months. The probability of control decreases with long delays from symptom onset to isolation, fewer cases ascertained by contact tracing, and increasing transmission before symptoms. This model can be modified to reflect updated transmission characteristics and more specific definitions of outbreak control to assess the potential success of local response efforts.

Anderson et al. How will country-based mitigation measures influence the course of the COVID-19 pandemic?[xii]

Model-based predictions can help policy makers make the right decisions in a timely way, even with the uncertainties about COVID-19. Indicating what level of transmission reduction is required for social distancing interventions to mitigate the epidemic is a key activity.

However, it is easy to suggest a 60% reduction in transmission will do it or quarantining within 1 day from symptom onset will control transmission, but it is unclear what communication strategies or social distancing actions individuals and governments must put in place to achieve these desired outcomes. A degree of pragmatism will be needed for the implementation of social distancing and quarantine measures. Ongoing data collection and epidemiological analysis are therefore essential parts of assessing the impacts of mitigation strategies, alongside clinical research on how to best manage seriously ill patients with COVID-19.

There are difficult decisions ahead for governments. How individuals respond to advice on how best to prevent transmission will be as important as government actions, if not more important. Government communication strategies to keep the public informed of how best to avoid infection are vital, as is extra support to manage the economic downturn.

At present the limited evidence means that it is not possible to pinpoint a single measure as being the most effective in reducing the spread of COVID 19. What the evidence does show is that at present only an aggressive lockdown strategy, supplemented with contact tracing and social distancing has slowed or flattened the curve of the spread of the infection. These measures rely on a high degree of continued public co-operation.


[i] Imperial College [London] COVID-19 Response Team (2020). Estimating the number of infections and the impact of nonpharmaceutical interventions on COVID-19 in 11 European countries. https://www.imperial.ac.uk/media/imperial-college/medicine/mrc-gida/2020-03-30-COVID19-Report-13.pdf. [Accessed 8 April 2020].

[ii] Fong MW, Gao H, Wong JY, et al. Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings-Social Distancing Measures [published online ahead of print, 2020 May 17]. Emerg Infect Dis. 2020;26(5):10.3201/eid2605.190995. doi:10.3201/eid2605.190995.

[iii] Wu JT, Riley S, Fraser C, Leung GM. Reducing the impact of the next influenza pandemic using household-based public health interventions. PLoS Med. 2006;3(9):e361. doi:10.1371/journal.pmed.0030361.

[iv] Keeling at al. (2020). Efficacy of Contact Tracing for the Containment of the 2019 Novel Coronavirus (COVID-19). https://www.medrxiv.org/content/10.1101/2020.02.14.20023036v1. [Accessed 8 April 2020].

[v] ECDC (2020). Considerations Relating to Social Distancing Measures in Response to the COVID-19 Epidemic. https://www.ecdc.europa.eu/en/publications-data/considerations-relating-social-distancing-measures-response-covid-19-second. [Accessed 23 March 2020].

[vi] Shenjie et al.  https://doi.org/10.1101/2020.03.03.20029843. [Accessed 23 March 2020].

[vii] Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Travel Med. 2020;27(2):taaa020. doi:10.1093/jtm/taaa020.

[viii] Oxford University Centre for Evidence Based Medicine. What is the evidence for social distancing [and quarantine] during pandemics? https://www.cebm.net/covid-19/what-is-the-evidence-for-social-distancing-during-global-pandemics/. [Accessed 8 April 2020].

[ix] Rashid H, Ridda I, King C, et al. Evidence compendium and advice on social distancing and other related measures for response to an influenza pandemic. Paediatr Respir Rev. 2015;16(2):119–126. doi:10.1016/j.prrv.2014.01.003.

[x] Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912–920. doi:10.1016/S0140-6736(20)30460-8.

[xi] Hellewell J, Abbott S, Gimma A, et al. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts [published correction appears in Lancet Glob Health. 2020 Mar 5;:]. Lancet Glob Health. 2020;8(4):e488–e496. doi:10.1016/S2214-109X(20)30074-7.

[xii] Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic?. Lancet. 2020;395(10228):931–934. doi:10.1016/S0140-6736(20)30567-5.

Date: April 8th – What is the best evidence on care pathways for patients with COVID-19? What care pathways or models of care have been implemented internationally for COVID-19 suspected or confirmed positive patients? [Keywords: Care Pathways]

Download full evidence summary (pdf)

Key themes emerging from the literature:

  • The importance of optimising community delivered care
  • Increased utilisation of telehealth/telemedicine

What does the World Health Organization say?

Operational considerations for case management of COVID-19 in health facility and community[i]

Key action steps to be taken are presented by transmission scenario to enable timely surge of clinical operations. Strategic priorities are outlined by scenario, including the 7 recommended steps to deal with community transmission. Referral pathway overviews are provided for:

  • Screening and Triage
  • Hub and Spoke Model [community transmission]

What does the international literature say?

Europe

Health Protection Surveillance Centre and HSE

Assessment and Testing Pathways for COVID-19[ii]

The HPSC has made available specific pathways such as: COVID-19 Assessment and testing pathway for use in a hospital setting. The current HSE Operational Pathway of Care is also available here.

The European Centre for Disease Prevention and Control

Guidance for Health System contingency planning during widespread transmission of SARS-CoV-2 with high impact on healthcare services[iii]

ECDC provide guiding principles for contingency planning in primary care, hospital and long-term care settings. This features modifications to community care, inpatient and outpatient care which may be useful to consider when developing care pathways.

Scotland

COVID-19 CMO clinical advice 3 April 2020[iv]

This report provides a detailed outline of how care should be planned, organised and delivered:

  • Community Assessment and Referral to Secondary Care [Section 4] and includes a 2-page clinical assessment tool for assessment at hospital or community management
  • Anticipatory Care Plans in COVID-19 [Section 5]
  • Hospital Admission and Management [Section 6]
  • Critical Care [Section 7]
  • Management of Special Populations [including flowcharts for Paediatric and Obstetric patients in Section 8] 
  • End-of-Life Care [Section 9]

The importance of Scotland’s community hubs and assessment centres is emphasised. They will triage patients presenting with suspected COVID-19 to ensure that the best possible location of care is identified. It is vital they are adequately resourced and supported. New pathways of care for patients are clearly described.

The report also describes how care should be delivered in surge conditions: 

  • Prioritisation of active treatment for those acutely ill from all conditions
  • Redeployment of staff and resources to deliver maximum level of care service, potentially in non-standard acute settings;
  • Curtailment and suspension of non-emergency work such as elective surgery
  • Utilisation of primary and community care to reduce demand on acute care settings and support patients discharged to home or to the community

It recommends a focus on best practice in alignment with the principles of realistic medicine:

  • Identification of those who will benefit from medical interventions
  • Provision of supportive or end-of-life care for all acutely ill patients in whom extensive medical interventions are futile
  • Discussions with patients about their preferences in the event of becoming acutely unwell with COVID-19 or other illnesses
  • Ensuring cohesive working across health and social care in Scotland to reduce unwarranted variation in care

England

Much has been written about the evolving pathways of care in England for COVID-19 patients, with changes to primary care and the establishment of a dedicated temporary hospital, the NHS Nightingale London Hospital.

COVID-19 and the rapid reorganisation of general practice: triage, hubs and pathways to care in hospital and the community: a discussion paper[v]

This discussion paper describes the reorganisation of general practice into ‘cold’ and ‘hot’ sites to reduce the rate of spread, optimise use of critical care beds and ensure high quality care for those choosing not to be admitted. It outlines the practical considerations, such as:

  • Site location and configuration
  • Electronic health record systems and digital solutions
  • Preventing staff illness and PPE
  • Practicalities of each potential point of assessment/pathway
  • Professional education and learning
  • Patient education

The discussion paper features a COVID-19 Hub Generic Model (5).

Greenhalgh et al. (2020). COVID-19: a remote assessment in primary care[vi]

Greenhalgh and colleagues determined that:

  • Most patients with COVID-19 can be managed remotely with advice on symptomatic management and self-isolation
  • Although such consultations can be done by telephone, in many cases video provides additional visual cues and therapeutic presence
  • Breathlessness is a concerning symptom, though there is currently no validated tool for assessing it remotely
  • Safety-netting advice is crucial because some patients deteriorate in week 2, most commonly with pneumonia

Razai et al. (2020). Coronavirus disease 2019 (COVID-19): a guide for UK GPs[vii]

This practical guide for GPs describes when to suspect COVID-19 and how to respond. Regarding care pathways it suggests that: “GP surgeries should develop protocols for managing patients with possible infection, including triaging remotely, postponing non-urgent services, isolation procedures, PPE provision, seeking specialist advice, decontamination, and collaborating with community services.”

The BMJ also provides infographics for GPs:

 

Twitter posts from Irish and British GPs:

 

Dr Trisha Greenhalgh:

§  Sharing her concerns about hothubs

§  Quick survey on hothubs

Dr Craig Seymour:

 

Dr Mark Murphy:

§  Ireland’s plan to set up 40 “community assessment hubs” 

 

NHS Nightingale London Hospital[viii]

NHS Nightingale London, opened on April 3rd 2020, is a specially built hospital to care for patients who have already been intubated and ventilated at a London hospital and require further intensive care treatment for COVID-19. It provides up to 4,000 beds, fully equipped with ventilators and oxygen. These are a mixture of intensive care and recovery beds and it will use a multidisciplinary team approach. 

According to the BBC three more temporary hospitals are to be built, in Birmingham, Manchester and Glasgow, and NHS England said other sites were being considered. 

Italy

White Paper: Patient Safety Recommendations for Covid19 Epidemic Outbreak: Lessons from the Italian Experience[ix]

The Italian Network for Safety in Healthcare (INSH) has compiled key lessons on the optimal environment, team, equipment and staffing for COVID-19 patient care. It outlines ‘reliable’ pathways of care that they recommend for: diagnosis; hospital treatment; surgery; pregnant women; paediatric patients; hospital discharge; home isolation; quarantine; oncology and immunosuppressed patients; mortuary procedures; mental wellbeing of staff and patients.

In includes sample outcome measures which can support healthcare providers in monitoring their response to the pandemic and capacity to treat other commonly presenting conditions.

Nacoti et al. (2020). At the Epicenter of the COVID-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation[x]

Italian clinicians suggest that:

 

§  Western health care systems have been built around the concept of patient-centred care but they recommend a move to epidemic community-centred care.

§  Hospitals may be the main COVID-19 carriers, facilitating transmission from infected to uninfected patients.

§  Massive deployment of outreach services is required. Home care and mobile clinics avoid unnecessary movements and release pressure from hospitals. Early oxygen therapy, pulse oximeters, and nutrition can be delivered to the homes of mildly ill and convalescent patients, setting up a broad surveillance system with adequate isolation and leveraging innovative telemedicine instruments.

§  Hospitalisation should be limited by disease severity.

§  Measures to prevent infection must be widely implemented, in all locations and including vehicles. Dedicated COVID-19 hospital pavilions and operators are required, separated from virus-free areas.

§  This outbreak is a public health and humanitarian crisis and requires a broad response such as social scientists, epidemiologists, experts in logistics, psychologists, and social workers.

§  A long-term plan for the next pandemic is required.

Pisano et al. (2020). Lessons from Italy’s Response to Coronavirus[xi]

This article highlights the importance of a shift from patient-centred models of care to a community-system approach that offers pandemic solutions for the entire population with a specific emphasis on home care. A comparison of Lombardy and Veneto’s approaches to COVID-19 is outlined. Veneto’s strategy was multi-pronged and more effective:

  • Extensive testing of symptomatic and asymptomatic cases early on.
  • Proactive tracing of potential positives: families and neighbours.
  • A strong emphasis on home diagnosis and care. Whenever possible, samples were collected directly from a patient’s home and then processed in regional and local university labs.
  • Specific efforts to monitor and protect health care and other essential workers.

The authors highlight the importance of learning from strategies and policies in Italy and elsewhere and of collecting and disseminating accurate data.

Asia

China

Handbook of COVID-19 Prevention and Treatment [xii]

This handbook which outlines experience from Chinese clinicians emphasises the importance of personalised, collaborative and multidisciplinary patient care (18-19): “A comprehensive multidisciplinary diagnosis and treatment mechanism has been established in which doctors both inside and outside the isolation wards can discuss patients’ conditions every day via video conference … The goal of MDT discussion is to achieve personalized treatment. The treatment plan should be adjusted to each person when considering the differences among individuals, courses of disease, and patient types. Our experience is that MDT collaboration can greatly improve the effectiveness of the diagnosis and treatment of COVID-19.”

Xihong (2020) [Presentation]. Learning from 26,000 cases in Wuhan[xiii]

Suggested lessons using Chinese data with a view to directing the US approach:

  • Centralised quarantine is effective, reducing household and community transmission
  • Provision of accommodation for healthcare workers will help protect their families
  • Undiagnosed community cases, some of which are asymptomatic, will infect others which underscores the importance of widespread testing
  • A multi-pronged approach is necessary: screening; mitigation and suppression
  • Protect vulnerable groups: healthcare workers; elderly people; family members and close contacts; children [as their risk may increase with time periods]
  • Early diagnosis and early medical care are essential

[i] World Health Organization. 19th March 2020. Operational considerations for case management of COVID-19 in health facility and community. https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf [Accessed 7 April 2020].

[ii] Health Protection Surveillance Centre. 2020. Assessment and testing pathways for COVID-19. https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/algorithms/ [Accessed 7 April 2020].

[iii] European Centre for Disease Control and Prevention. March 2020. Guidance for health system contingency planning during widespread transmission of SARS-CoV-2 with high impact on healthcare services. https://www.ecdc.europa.eu/en/publications-data/guidance-health-system-contingency-planning-during-widespread-transmission-sars [Accessed 7 April 2020].

[iv] Scotland (3 April 2020). Coronavirus (COVID-19): Clinical Advice: Guidance from the Chief Medical Officer (CMO) on treating patients with COVID-19. https://www.gov.scot/publications/coronavirus-covid-19-clinical-advice/ [Accessed 7 April 2020].

[v] National Institute for Health Research (6 April 2020). COVID-19 and the rapid reorganisation of general practice: Triage, hubs and pathways to care in hospital and the community: a discussion paper. Version 2. 6/4/20 https://www.arc-swp.nihr.ac.uk/general-practice-hubs [Accessed 7 April 2020].

[vi] Greenhalgh T, Koh GCH, Car J. COVID-19: a remote assessment in primary care. BMJ. 2020;368:m1182. Published 2020 Mar 25. doi:10.1136/bmj.m1182.

[vii] Razai MS, Doerholt K, Ladhani S, Oakeshott P. Coronavirus disease 2019 (covid-19): a guide for UK GPs [published correction appears in BMJ. 2020 Mar 11;368:m989] [published correction appears in BMJ. 2020 Apr 7;369:m1398]. BMJ. 2020;368:m800. Published 2020 Mar 5. doi:10.1136/bmj.m800.

[published correction appears in BMJ. 2020 Apr 7;369:m1398]. BMJ. 2020;368:m800. Published 2020 Mar 5. doi:10.1136/bmj.m800.

[viii] NHS (2020) NHS Nightingale London Hospital. https://www.nightingale-london.nhs.uk/about-us [Accessed 7 April 2020].

[ix] Italian Network for Safety in Healthcare (7 April 2020). White Paper: Patient Safety Recommendations for Covid19 Epidemic Outbreak: Lessons from the Italian Experience. Version 1.2

https://www.isqua.org/resources-blog/blog/patient-safety-recommendations-for-covid19-epidemic-outbreak.html [Accessed 7 April 2020].

[x] Nacoti et al. 21 March 202. At the Epicenter of the COVID-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0080 [Accessed 7 April 2020].

[xi] Pisano et al. 27 March 2020. Lessons from Italy’s Response to Coronavirus. Harvard Business Review. https://hbr.org/2020/03/lessons-from-italys-response-to-coronavirus  

[xii] The First Affiliated Hospital, Zhejiang University School of Medicine. “Handbook of COVID-19 Prevention and Treatment”. https://www.alibabacloud.com/universal-service/pdf_reader?spm=a3c0i.14138300.8102420620.dreadnow.6df3647fNEnE3r&pdf=Handbook_of_COVID_19_Prevention_en_Mobile.pdf. [Accessed 7 April 2020].

[xiii] Xihong Li, Harvard. Learning from 26,000 cases in Wuhan https://docs.google.com/presentation/d/1-rvZs0zsXF_0Tw8TNsBxKH4V1LQQXq7Az9kDfCgZDfE/mobilepresent#slide=id.p2 [Accessed 7 April 2020].

Date: April 7th – Social work and family liaison during COVID-19? [Keywords: Social Work, Family liaison]

Question: What is the role of social work and family liaison during global pandemics [such as COVID-19?

What does the World Health Organization say?

Social Work and family liaison during global pandemics such as COVID-19 – Updated April 7th – Download evidence summary

Mental health and psychosocial considerations during the COVID-19 outbreak [i]

WHO and public health authorities around the world are acting to contain the COVID-19 outbreak. However, this time of crisis is generating stress throughout the population. The considerations presented in this document have been developed by the WHO Department of Mental Health and Substance Use as a series of messages that can be used in communications to support mental and psychosocial well-being in different target groups during the outbreak.

Irish Association of Social Workers

Guidance for Medical Social Workers Responding to the COVID-19 Pandemic[ii]

This guidance document aims to support the professional response of Irish medical social work departments to the COVID-19 pandemic. It is informed by the limited literature available on the role of social workers in epidemics, broader research on the implications of epidemic or pandemic work on frontline staff and by preliminary consultation with healthcare staff in Italy. Proactive leadership is required during the management of disease outbreak. Fortunately, the experience of medical social workers during the SARS outbreaks in 3 hospitals in Toronto and Singapore helps inform what constitutes effective social work leadership during a pandemic.

What does the international literature say?

Experiences and implications of social workers practicing in a pediatric hospital environment affected by SARS[iii]

This study is the first using qualitative research to investigate the unique perspective of social workers in an epidemic environment. The results reflect the social workers’ subjective experience of their interventions with patients and families and indicate that a number of professional tenets, such as advocacy, family-centered approach, knowledge of systems, open communication and ethics effectively supported social work practice in a crisis environment.

Medical Social Work Practice and SARS in Singapore

This article reports on the findings of a qualitative study exploring the impact of SARS on social work practice in 5 different hospitals in Singapore. The study sought to examine the range of interventions adopted by 28 medical social workers and the theoretical orientations underpinning them. The findings discussed include the impact of infection control practices on social work intervention, the range of interventions undertaken, respondents’ reflections and self-awareness, the role of values and ethics, creativity and training, and their recommendations for future emergencies. While the findings of the study relate specifically to hospital social work practice, the crisis and trauma nature of the work makes it applicable to a broader range of practice in these areas and a range of populations. The findings from this study could also inform the development of training programs for social work and other clinical health workers and emergency management planning. 

Immediate Psychological Responses and Associated Factors During the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic Among the General Population in China[v]

The 2019 coronavirus disease (COVID-19) epidemic is a public health emergency of international concern and poses a challenge to psychological resilience. Research data are needed to develop evidence-driven strategies to reduce adverse psychological impacts and psychiatric symptoms during the epidemic. The aim of this study was to survey the general public in China to better understand their levels of psychological impact, anxiety, depression and stress during the initial stage of the COVID-19 outbreak. The data will be used for future reference.  During the initial phase of the COVID-19 outbreak in China, more than half of the respondents rated the psychological impact as moderate-to-severe, and about one-third reported moderate-to-severe anxiety. Our findings identify factors associated with a lower level of psychological impact and better mental health status that can be used to formulate psychological interventions to improve the mental health of vulnerable groups during the COVID-19 epidemic.

 

The Impact of COVID-19 Epidemic Declaration on Psychological Consequences: A Study on Active Weibo Users[vi]

COVID-19 has significantly resulted in a large number of psychological consequences. The aim of this study is to explore the impacts of COVID-19 on people’s mental health, to assist policy makers to develop actionable policies, and help clinical practitioners such as social workers, psychiatrists and psychologists to provide timely services to affected populations. People were concerned more about their health and family, while less about leisure and friends. The results contribute to the knowledge gaps of short-term individual changes in psychological conditions after the outbreak. It may provide references for policy makers to plan and fight against COVID-19 effectively by improving stability of popular feelings and urgently prepare clinical practitioners to deliver corresponding therapy foundations for the risk groups and affected people.

The Ethics of Care: Social Workers in an Influenza Pandemic[vii]

The challenges of caring for the incurable, the uncured, healthcare workers and the survivors and their families will place almost unprecedented demands on mental health workers. This article discusses these ethical and medical challenges and the role that social workers will be called on to play.

 

Psychosocial Impacts of Quarantine During Disease Outbreaks and Interventions That May Help to Relieve Strain[viii]

The threat of outbreak of infectious disease such as non-seasonal influenza A (H1N1) can provoke the implementation of public health control measures such as quarantine. This paper summarises the psychosocial consequences that may follow for patients and health care and other front-line workers when using quarantine controls. Those affected by quarantine are likely to report distress due to fear and risk perceptions. This distress can be amplified in the face of unclear information and communication that is common in the initial period of disease outbreaks. This paper outlines recommendations for care of those in quarantine and those working with them, such as helping to identify stressors and normalising their impact as much as possible. This should take place at all levels of response, from public information and communication messages to individual face-to-face advice and support.

 

Impact of SARS-related restrictions on residents and family members[ix]

During the SARS outbreak in Toronto, infection control measures were implemented throughout the region. One of the measures was a total ban on visitors to long-term care facilities. In a retrospective of what is being learned about the SARS crises a social worker deployed to a nursing home environment describes the impact the restrictions had on residents, family members and staff.

 

Impact of SARS visiting restrictions on relatives of long-term care residents[x]

Social workers and other staff had to be creative in order to support families and to keep them informed and involved. The research described here was conducted in order to understand families‘ experiences and evaluate the effectiveness of social work interventions during the SARS visiting restrictions. Focus groups were conducted with spouses and adult children of residents of a large long-term care facility, to examine how they experienced the visiting restrictions and attempts to mitigate distress caused by the restrictions, including interventions by social workers and others. Participants described the impact on themselves and their worries about the well-being of their relatives during the time when families, friends and privately paid caregivers could not visit the facility.

 

The SARS (Severe Acute Respiratory Syndrome) Pandemic in Hong Kong: Effects on the Subjective Wellbeing of Elderly and Younger People[xi]

This study examined the impact of the SARS outbreak in Hong Kong in 2003 on the subjective wellbeing of elderly people and a younger comparative sample. The Personal Wellbeing Index (PWI), a contemporary instrument employed to measure subjective wellbeing, was also examined for its psychometric performance to substantiate its use.Psychological resilience was identified among both the elderly and younger age-groups in Hong Kong during the SARS pandemic. The PWI is verified as a suitable instrument for subjective wellbeing measurements.

Ageing and Psychological response during the post-SARS period[xii]

After controlling for depression, residents in high SARS-prevalent regions, regardless of age, consistently developed more intense post-traumatic disturbance than residents in low SARS-prevalent regions. Furthermore, the prevalence of probable post-traumatic stress disorder cases was significantly higher in older people and in residents of SARS-prevalent regions. Our findings suggest the importance of mental health aftercare in the post-epidemic period of disease epidemics.

The Role of Social Work for Foreign Residents in an Epidemic: The MERS Crisis in the Republic of Korea[xiii]

This article explores the experiences of foreign residents during the period of the Middle East Respiratory Syndrome (MERS) outbreak in South Korea and discusses from a social work perspective the implications of their experiences and their needs. Data were obtained from interviews with 22 foreigners who either live and work or study in Korea. The data were then interpreted using a thematic analysis approach in a multilingual research context. The findings from the study show that foreign residents experienced a wide range of social and psycho-emotional difficulties during the MERS health threat. Implications for social work practice in an epidemic emergency are presented.

Date: April 2nd – What guidance is available for healthcare workers on the provision of CPR for patients with suspected or confirmed Covid-19 in hospital settings, including community assessment hubs and intermediate care facilities? [Keywords: CPR]

QUESTION: What guidance is available for healthcare workers on the provision of CPR for patients with suspected or confirmed Covid-19 in hospital settings, including community assessment hubs and intermediate care facilities?

CPR for patients with suspected or confirmed Covid-19 in hospital settings –  Updated April 2nd Download summary pdf

What does the existing international guidance say?

International Liaison Committee on Resuscitation: COVID-19 infection risk to rescuers from patients in cardiac arrest[i]

[Draft for Public Comment released on 30 March 2020]

Treatment Recommendations

  • We suggest that chest compressions and cardiopulmonary resuscitation have the potential to generate aerosols. [weak recommendation, very low certainty evidence]
  • We suggest that in the current COVID-19 pandemic lay rescuers consider compression-only resuscitation and public-access defibrillation. [good practice statement]
  • We suggest that in the current COVID-19 pandemic, lay rescuers who are willing, trained and able to do so, may wish to deliver rescue breaths to children in addition to chest compressions. [good practice statement]
  • We suggest that in the current COVID-19 pandemic, healthcare professionals should use personal protective equipment for aerosol generating procedures during resuscitation. [weak recommendation, very low certainty evidence]
  • We suggest it may be reasonable for healthcare providers to consider defibrillation before donning aerosol generating personal protective equipment in situations where the provider assesses the benefits may exceed the risks. [good practice statement]

Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in healthcare settings[ii]

Key points

  • Ensure “do not attempt cardiopulmonary resuscitation” (DNACPR) decisions are well documented and communicated.
  • Do not listen or feel for breathing by placing your ear and cheek close to the patient’s mouth
  • If a defibrillator is readily available defibrillate shockable rhythms rapidly prior to starting chest compressions.
  • No chest compressions or airway procedures such as those detailed below should be undertaken without full AGP PPE.  If the patient is already receiving supplemental oxygen therapy using a face mask, leave the mask on the patient’s face during chest compressions as this may limit aerosol spread. If not in situ, but one is readily available, put a simple oxygen mask on the patient’s face.
  • Airway interventions – eg supraglottic airway (SGA) insertion or tracheal intubation – must be carried out by experienced individuals
  • Identify and treat any reversible causes – eg severe hypoxaemia – before considering stopping CPR.
  • Dispose of or clean all equipment used during CPR following the manufacturer’s recommendations and local guidelines.
  • Remove PPE safely to avoid self-contamination and dispose of clinical waste bags as per local guidelines.
  • Post resuscitation debrief is important and should be planned.

NICE COVID-19 rapid guideline: critical care in adults[i]

Section 2.4

“Sensitively discuss a possible “do not attempt cardiopulmonary resuscitation” decision with all adults with capacity and an assessment suggestive of increased frailty: eg a CFS score of 5 or more. Include in the discussion:

  • the possible benefits of any critical care treatment options
  • the possible risks of critical care treatment options
  • the possible likely outcomes.”

The Faculty of Intensive Care Medicine, Intensive Care Society, Association of Anaesthetists and Royal College of Anaesthetists – Critical care preparation and management in the COVID-19 pandemic[ii]

Cardiac arrest

  • Appropriate PPE must be worn as with aerosol-generating procedures. Facemask ventilation should be avoided where possible.
  • Compression-only CPR is advised until airway-experienced personnel are available.
  • Use of an automated chest compression device may be used.
  • Early intubation by an experienced operator is advised.”

What does the Health Protection Surveillance Centre (Ireland) say?

Use of PPE to support Infection Prevention and Control Practice when performing aerosol generating procedures on confirmed or  clinically suspected Covid-19 cases in a pandemic situation[iii]  

The guidance states that all staff working in an area where aerosol generating procedures are being performed must wear appropriate PPE.  The minimum number of staff required must be present.  The guidance includes a table entitled: “Aerosol generating procedures which have been associated with increased risk of transmission of respiratory infection.”  CPR [pre-intubation due to manual ventilation] has a consistently recognised, AGP-related increased risk of pathogen transmission, and PPE is recommended. Recommended PPE to include: hand hygiene, FFP2 respiratory mask, eye protection, gloves, and long sleeved gown.

What do WHO, ECDC and CDC say?

As CPR is an aerosol-generating procedure. The guidance from these organisations are:

Derived from CDC guidance, the American Heart Association has produced:

What does the international literature say?

Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients[vii]

Intubation of critically ill patients with SARS-CoV was associated with episodes of healthcare worker transmission. The reasons for this are likely multifactorial, including high-level viral shedding due to severity of patient illness, procedures associated with resuscitation or intubation that may generate aerosols, and healthcare worker use of PPE: high-risk patient + high-risk procedure = higher level of precautions.

Patients infected with 2019-nCoV should be monitored for early signs of respiratory deterioration and intubated electively rather than emergently. If possible, patients isolated with 2019-nCoV should be monitored in a critical care area with airborne isolation and continuous physiologic monitoring. 

During the SARS outbreak, the concept of “Protected Code Blue” was created to distinguish usual resuscitation from those requiring special procedures and precautions. More information about PCB http://sars.medtau.org/simulatedprotectedcodeblue.pps and https://emergencymedicinecases.com/biohazard-preparedness-protected-code-blue/.

Once designated as requiring 2019-nCoV isolation: 

  • Resuscitation should take place in an airborne isolation room if possible, as it is an AGP.
  • The resuscitation team must be wearing appropriate airborne/droplet/contact PPE.
  • Given the greater risk of infection during a dynamic resuscitation use of powered air purifying respirators (PAPRs) by specially trained resuscitation teams should be strongly considered. Although PAPRs have a higher protective factor compared with N95 respirators, there is no definitive evidence that PAPRs reduce the likelihood of viral transmission in the setting of potential airborne spread. Nonetheless PAPRs may be more comfortable to wear for prolonged resuscitations, eliminate concerns of unexpected poor N95 respirator fit, and are less likely to be dislodged when managing an agitated patient. PAPRs with hoods covering the entire head and neck may provide additional protection against contamination.
  • Initial resuscitation efforts by first responders wearing usual airborne/droplet/contact PPE to an acute crisis should focus on measures that are most likely to help the patient and have low risk for viral transmission.
  • A list of specific low and hrisk resuscitation interventions is provided in the full text of the article.
  • Once the PCB team has donned PPE and been checked by an infection control coach, they can enter the room. Team size should be minimal to avoid unnecessary viral exposure ¾ typically four people with designated roles.
  • Consider use of a specialized cart containing modular packs of equipment, with PCB team members bringing in the necessary defibrillator and packs rather than an entire resuscitation cart.
  • Following resuscitation, team members can exit when appropriate and should remove PPE under careful supervision of an infection control coach using a checklist to avoid self-contamination.


COVID-19: A critical care perspective informed by lessons learnt from other viral epidemics[viii]

Cardiopulmonary resuscitation

The increased transmission of SARS-CoV to HCW previously reported during cardiopulmonary resuscitation (CPR) was likely due to virus aerosolisation during BVM ventilation. Preventive measures may include using apnoeic oxygenation during CPR, or careful two-person BVM ventilation to allow an effective face seal by two handed mask holding (with inline bacterial/viral filter), and early intubation when indicated. The use of mechanical CPR devices to replace HCW CPR may reduce the risk of facemask leakage for the HCW, and decreases their own minute ventilation, thus potentially reducing the risk of disease transmission. For patients already receiving mechanical ventilation in ICU, the ventilator may be set to volume control, with a large negative pressure trigger and high-pressure alarm setting to avoid a need for disconnection and change to manual BVM ventilation.”

Considerations for Cardiac Catheterization Laboratory Procedures During the COVID-19 Pandemic Perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates[ix]

The authors recommend using appropriate PPE, disinfection and cleaning of all surfaces and if CPR is required in the Cardiac Catheterization Lab “consider using automated CPR devices for chest compression to minimize personnel exposure”.

Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic[x]

“In the event of a cardiac arrest, efforts at cardiopulmonary resuscitation causing aerosolized pathogens could result in the wide dissemination of virus particles to clinicians, health care workers, and other patients. One measure which may help protect health care workers in the setting of cardiac arrest and chest compressions is the use of external mechanical compression devices to minimize direct contact with infected patients. Another important consideration for the catheterization laboratory is appropriate post-intervention cleaning of all equipment potentially contaminated with SARS-CoV2. The necessary downtime required for cleaning may seriously impact the availability of catheterization laboratory-based treatments for other patients. As such, many hospitals are minimizing or cancelling elective procedures during the growth phase of the outbreak. Another consideration is the fact that catheterization laboratories and operating rooms are typically configured with positive pressure ventilation, and there have been reports of centers in China converting such facilities to negative pressure isolation in the setting of COVID-19. Guidance and recommendations in this space will be forthcoming from interventional communities, including the ACC and SCAI”.

[NEWS Article: DEBATE] Covid-19: Doctors are told not to perform CPR on patients in cardiac arrest[xi]

This article discusses the appropriateness of CPR guidance given to staff in University Hospitals Birmingham NHS Foundation Trust.

Possible SARS coronavirus transmission during cardiopulmonary resuscitation[xii]

Based on experience from the SARS coronavirus a continuous quality improvement framework was developed providing interventions for preventing future episodes of transmission:

Administrative controls

Policies and protocols for emergency resuscitation should include:

  • description of the roles and responsibilities of healthcare workers responding to the emergency
  • mechanisms to alert responders that the emergency involves a potentially contagious patient (e.g., announcing the code as an “isolation code blue”)
  • steps to limit the number of healthcare workers involved to minimize potential exposures
  • plans for having auxiliary staff staged in a safe area where they can be easily called on if needed but otherwise preventing unnecessary exposure
  • plans for safe disposal and cleaning of equipment used during the emergency response
  • procedures for disposition of the patient after the emergency, either to the ICU if resuscitation is successful or the morgue if unsuccessful.

Environmental engineering controls

  • Physical engineering elements such as negative pressure rooms, dilution ventilation, high-efficiency particulate air filtration, ultraviolet lights, and scavenging devices.
  • Aims to contain the infectious agent in a limited area and to minimize or rapidly decrease the viral load in the environment.

PPE

  • Discuss the use of 4 personal protective system versus PAPR.
  • Regardless of what PPE is used for AGPs, it is essential that they are distributed throughout the hospital in areas where they are most likely to be required by primary responders in an emergency situation as opposed to a central area where teams must wait for them to be brought to the emergency.
  • Extra protection equipment should be included as part of any crash cart used by the responding code team.

Quality Control

  • It is important not to forget the basics of infection control procedures such as glove changing and hand hygiene.
  • HCWs must remain vigilant about not only protecting themselves and protecting against patient-to-patient transmission.
  • After developing good policies and training staff who are rehearsed for emergencies and provided with appropriate protection equipment, the last step is to ensure ongoing adherence to the standards set. This adherence is achieved through quality control.
  • Without an effective quality control program in place, lapses in infection control procedures will occur, particularly as healthcare workers become fatigued during a prolonged outbreak.

UpToDate

Coronavirus Disease 2019 (COVID-19)[xiii]

Interventions

In the event of a cardiac arrest, cardiopulmonary resuscitation should proceed with all members of the team wearing appropriate PPE. Practicing a test run of a COVID-19 patient cardiac arrest is prudent. Bag-mask ventilation should be avoided if feasible and the ventilator can be used instead to deliver a respiratory rate of 10bpm.

Articles relating to Advance Care Planning, Palliative Care and Do Not Resuscitate Orders to reduce futile life sustaining treatments such as CPR and ensure rational usage of PPE resources

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The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19)[xiv]

Curtis et al. emphasise the importance of patients and clinicians working together on advance care planning, particularly regarding life-sustaining treatments such as cardiopulmonary resuscitation (CPR) or mechanical ventilation. The COVID-19 pandemic heightens the importance of implementing do-not-resuscitate (DNR) orders for appropriate hospitalized patients.

They suggest that the implementation of DNR orders can occur in 3 situations:

  • Communicated by patients/surrogate decision makers
  • Patients/surrogate decision makers may follow the recommendation of a clinician to forgo CPR; this may occur through informed consent/informed assent
  • In extreme situations in which CPR cannot possibly be effective, clinicians in some health care settings may unilaterally decide to write a DNR order. This latter approach is not uniformly accepted and, prior to COVID-19, it rarely had a role. During this pandemic, however, in extreme situations such as a patient with severe underlying chronic illness and acute cardiopulmonary failure who is getting worse despite maximal therapy, there may be a role for a unilateral DNR to reduce the risk of medically futile CPR to patients, families, and health care workers.

Creating a Palliative Care Inpatient Response Plan for COVID19 – The UW Medicine Experience[xv]

UW Medicine developed a strategy to implement a palliative care response for a multi-hospital healthcare system that incorporates conventional capacity, contingency capacity, and crisis capacity. This strategy included among other measures:

  • Palliative care specialists provided guidance and tools for primary teams conducting goals-of-care and code status discussions in order to preserve resources by avoiding unwanted or non-beneficial cardiopulmonary resuscitation and mechanical ventilation.
  • Digital health/telehealth was used where possible for palliative care consultations, to reduce PPE usage.

 

Goals of Care in a Pandemic: Our Experience and Recommendations[xvi]

Adams shares the experience of her institution in dealing with COVID-19 patients from a palliative care perspective.  She recommends earlier goals of care conversations, multidisciplinary team work, and enhanced use of technology and telemedicine to address the care goals of patients, which reducing the need for rationing of resources.


[i] NICE. 20 March 2020. COVID-19 rapid guideline: critical care in adults

 https://www.nice.org.uk/guidance/ng159/resources/covid19-rapid-guideline-critical-care-pdf-66141848681413 [Accessed 01/04/2020].

[ii] The Faculty of Intensive Care Medicine, Intensive Care Society, Association of Anaesthetists and Royal College of Anaesthetists – Critical care preparation and management in the COVID-19 pandemic. (2020). https://icmanaesthesiacovid-19.org/critical-care-preparation-and-management-in-the-covid-19-pandemic [Accessed 01/04/2020].

[iii] Health Protection Surveillance Centre Ireland. Use of PPE to support Infection Prevention and Control Practice when performing aerosol generating procedures on confirmed or clinically suspected Covid-19 cases in a pandemic situation. Guidance V 2, 23.3.2020. https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/infectionpreventionandcontrolguidance/aerosolgeneratingprocedures/AGPs%20for%20confirmed%20or%20possible%20COVID19_v2.0_23032020.pdf [Accessed 01/04/2020].

[iv] WHO. 19 March 2020. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125 [Accessed 01/04/2020].

[v] European Centre for Disease Prevention and Control. 31st March 2020. Infection prevention and control and preparedness for COVID-19 in healthcare settings Technical Report. https://www.ecdc.europa.eu/sites/default/files/documents/Infection-prevention-control-for-the-care-of-patients-with-2019-nCoV-healthcare-settings_update-31-March-2020.pdf [Accessed 01/04/2020].

[vi] Centres for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html [Accessed 01/04/2020].

[vii] Wax & Christian (12 February 2020) Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Canadian Journal of Anaesthesia. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7091420/ [Accessed 01/04/2020].

[viii] Ling et al. COVID-19: A critical care perspective informed by lessons learnt from other viral epidemics. 20 February 2020. Anaesthesia, Critical Care & Pain Medicine.  https://www.ncbi.nlm.nih.gov/pubmed/?term=32088344 [Accessed 01/04/2020].

[ix] Szerlip et al. (2020) Considerations for Cardiac Catheterization Laboratory Procedures During the COVID-19 Pandemic Perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates.  Catheter & Cardiovascular Interventions. https://www.ncbi.nlm.nih.gov/pubmed/?term=32212409 [Accessed 01/04/2020].   

[x] Driggin et al. (2020) Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic. Journal of the American College of Cardiology. https://www.ncbi.nlm.nih.gov/pubmed/?term=32201335 [Accessed 01/04/2020].

[xi] Mahase, E. and Kmietowicz, Z. (2020) Covid-19: Doctors are told not to perform CPR on patients in cardiac arrest, BMJ, 368, m1282.  https://www.ncbi.nlm.nih.gov/pubmed/?term=32224494 [Accessed 01/04/2020].

[xii] Christian et al. (2004) Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerging Infectious Diseases. 10(2):287-93. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3322904/ [Accessed 01/04/2020].

[xiii] UpToDate. “Advanced cardiac life support (ACLS) in adults”.  https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-critical-care-issues [Accessed 31st March 2020].

[xiv] Curtis et al. (27 March 2020) The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19). JAMA https://www.ncbi.nlm.nih.gov/pubmed/?term=32219360 [Accessed 01/04/2020].

[xv] Fausto et al. March 2020. Creating a Palliative Care Inpatient Response Plan for COVID19 – The UW Medicine Experience. Journal of Pain and Symptom Management. Article in Press: Accepted Manuscript https://doi.org/10.1016/j.jpainsymman.2020.03.025 [Accessed 01/04/2020].

[xvi] Adams, C. 31 March 2020. Goals of Care in a Pandemic: Our Experience and Recommendations. https://doi.org/10.1016/j.jpainsymman.2020.03.018 [Accessed 01/04/2020].


[i] International Liaison Committee on Resuscitation. COVID-19 infection risk to rescuers from patients in cardiac arrest. Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR), 30 March 2020. https://costr.ilcor.org/document/covid-19-infection-risk-to-rescuers-from-patients-in-cardiac-arrest [Accessed 01/04/2020].

[ii] Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in healthcare settings

30 March 2020. https://www.resus.org.uk/media/statements/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation/covid-healthcare/ [Accessed 01/04/2020].

Bereavement supports for frontline healthcare staff following the death of a colleague due to COVID-19?

QUESTION : What supports are needed for frontline healthcare staff following the death of a colleague due to COVID-19?

Updated April 2nd – Download rapid reviewDownload evidence summary

The HSE Employee Assistance Programme has produced guidance for healthcare workers affected by the death in service of a colleague due to COVID-19. For further details or assistance, please contact your local Employee Assistance Programme or email Ann.Callanan@hse.ie or Morgan.Lucey@hse.ie.

Our co-workers are very much an extended family. We spend most of our waking hours with them, forging special bonds of trust and friendship that are unlike our other relationships.

Numerous aspects of hospital work, including the death or suffering of a patient or colleague, can make health care workers vulnerable to cumulative grief and stress.

Peer support is helpful to bereaved survivors, reducing grief symptoms and increasing well-being and personal growth. There are also benefits to providers of peer support, including increased personal growth and positive meaning in life. Several studies address the growing trend of Internet-based peer support programs, finding that these are beneficial in part due to their easy accessibility.

Debriefing sessions can enhance grief management strategies, normalize grief responses, and aid in identifying need for further support. Prolonged unresolved events building up over time can lead to mental, spiritual or physical distress and burnout.

Trauma in the workplace can be precipitated by a number of tragedies, but death of an employee is the most common occurrence. Bereavement, mourning, and grief are common reactions. In most cases, people successfully cope with the death within two months, but some develop chronic grief, which is also referred to as complicated grief.

The death of a colleague sets the team upon a path that will transform individuals and alter the group’s dynamics. In an instant, the workplace takes on a surreal feel as team members learn of their colleague’s death and begin to accept the loss. The team will never be the same as they struggle together to discover a new norm.

Staff will be distracted to different extents and all will need to adjust to the distraction and refocus on the needs of the day, in their own way and own time. The time of readjusting and reflection will take weeks to months. This time of adjustment is particularity important if the staff are clinicians. If the clinician is too distracted, patient safety could be in jeopardy.

Some on the team will be more resilient than others. It is a good thing for the team to talk and discuss their feelings, but some on the team will use denial as a coping mechanism around their loss. As a leader, pay attention to your own needs while offering care to the team. Take time to reflect on your feelings and grief around the loss of your colleague. Utilize your own support system and support staff as needed.

Bereavement doesn’t have a predictable pattern. Be understanding of the inner turmoil and stress your co-worker is experiencing as he or she moves through the grief process. The support work colleagues can provide, also called social capital, goes a long way toward building a workplace culture that’s conducive to a healthy recovery. A workplace with social capital supports mental health. Such workplaces are rewarded in the longer term with job satisfaction, fewer absences and greater loyalty.

SOURCES*

APA Help Centre

https://www.apa.org/helpcenter/coworker [Accessed 30/03/2020]

Peer Support Services for Bereaved Survivors: A Systematic Review

Bartone, PT et al (2019) [Omega]

https://www.ncbi.nlm.nih.gov/pubmed/28871835 [Accessed 30/03/2020]

Bereavement debriefings: Enhancing grief management strategies and staff wellness (Conference Abstract)

Zadeh, S et al (2017) [Psycho-Oncology] https://onlinelibrary.wiley.com/doi/epdf/10.1002/pon.4353 [Accessed 30/03/2020]

Trauma in the workplace: grief counseling 101

Zanni, G R et al (2014) [Consultant Pharmacist] https://www.ncbi.nlm.nih.gov/pubmed/24413016 [Accessed 30/02/2020]

Supporting coworkers after a personal loss

Chichester, M et al (2018) [Nursing 2019] https://journals.lww.com/nursing/Fulltext/2018/03000/Supporting_coworkers_after_a_personal_loss.15.aspx [Accessed 30/03/2020]

Getting the team through the death of a colleague

Wilson, T (2011) [Gastroenterol Nurs] https://www.ncbi.nlm.nih.gov/pubmed/21814067 [Accessed 30/03/2020]

A model for supporting grief recovery following traumatic loss: the Tragedy Assistance Program for Survivors (TAPS)

Dooley, C et al (2019) [Military Medicine] https://www.ncbi.nlm.nih.gov/pubmed/31132122 [Accessed 30/03/2020)

Grieving in exceptional times

Irish Hospice Foundation

https://hospicefoundation.ie/bereavement-2-2/covid19-care-and-inform/grieving-in-exceptional-times/ [Accessed 30/03/2020]

Grief in the workplace

Irish Hospice Foundation https://hospicefoundation.ie/bereavement-2-2/working-in-bereavement-and-loss/grief-in-the-workplace/ [Accessed 30/03/2020]

Grief at work: developing a bereavement policy

McGuinness, Breffni (2007) https://issuu.com/laurarooneyf/docs/griefatwork [Accessed 30/03/2020]


BMJ Best Practice Now Available Nationally

The National Health Library and Knowledge Service (NHLKS) are delighted to be making BMJ’s decision support tool BMJ Best Practice available to healthcare professionals and patients across the Republic of Ireland.

Click to visit BMJ Best Practice

BMJ Best Practice provides healthcare professionals with quick, easy access to the latest information and evidence for diagnosis and treatment decisions. Its content is updated daily and draws on the latest evidence-based research, guidelines and expert opinion to offer step-by-step guidance on diagnosis, prognosis, treatment and prevention.

This development provides doctors, nurses, paramedics and community care professionals with guidance on the most common medical conditions to improve knowledge and support delivery of the very best care to patients.

Access is automatically enabled via the national IP. BMJ Best Practice can also be accessed anytime via the mobile responsive website or the app. 
Paul Reid, Director General of HSE said: “This clinical resource gives Irish health professionals immediate access to the latest clinical evidence and diagnostic tools, no matter where they are based. It will have a very significant impact on patient care.”

Access Best Practice Now

BMJ BEST PRACTICE GUIDE

HSE eLibrary Survey

We are currently developing the HSE National Health Library and Knowledge Services (NHLKS) e-library and digital services.

As a user of NHLKS we would like to get your input on the electronic and online resources we offer. 

We would also like to get your input to ensure the NHLKS e-library and digital services are meeting our users needs and expectations.   

Please take the time to fill in this short survey and provide details of your experiences of and suggestions for our online resources. It should take about 5 minutes.          

FILL IN THE SURVEY NOW>>>

Launch of the first HSE National Health Library and Knowledge Service Strategy

Turning knowledge into action: enabling care, improving health

The new National Health Library and Knowledge Service strategy ‘Turning knowledge into action: enabling care, improving health 2018 – 2023′ was launched today by HSE Director General Tony O’ Brien.

  

Enabling evidence-based practice

The strategy, which was launched in the Edward Worth Library, Dr Steevens Hospital sets out a roadmap  for the development and expansion of an integrated national knowledge service.

Speaking at the launch Dr Ana Terres HSE Head of Research and Development spoke of the role of the library service in providing a foundation of evidence saying ‘Without libraries there would be no evidence-based practice’

The strategy and implementation will be delivered in two phases with the next two years laying the foundation for delivery of our integrated national services. Central to delivery will be the the establishment of five national virtual teams; Knowledge Search and Summary Service, Digital Knowledge Service, Knowledge Broker Service, Information skills development and a coordinated network of library sites and resources.

Read the Strategy

For more detail on the strategy you can read the full document HERE 

Athens registration – Loss of access April 14 -16

OpenAthens

The OpenAthens system will be migrating to a new platform from April 14th to 16th. During this time the Athens registration option will not be available.

If you have an existing Athens account you will still be able to access using the ‘log in’ button on the home page. The Athens account registration option should be fully restored by Tuesday April 17th please try registering again after this date.

If you have any additional problems contact your local library.

Therese Brady Bereavement Library – Irish Hospice Foundation

The Irish Hospice Foundation’s Therese Brady Library and Information service is Ireland’s only dedicated specialist library with a focus on bereavement, palliative care and end-of-life care. The library is central to the Bereavement Information and Education functions of the Irish Hospice Foundation. These include an Msc in Bereavement Studies, a Professional Certificate in Children and Loss and workshops on bereavement, loss and end-of-life care.

Bereavement Library

The library collection includes topics such as:

  • Bereavement theory
  • Psychology and counselling
  • Research methods
  • Bereavement in children and adolescents
  • Children’s story and picture books on bereavement
  • Peadiatric palliative care
  • Death and dying in society
  • Palliative care
  • Hospice care
  • Chronic life limiting illness
  • Dementia
  • Neurological conditions
  • End of life care ethics

Bereavement Bibliotherapy Collection

As part of the Irish Hospice Foundation’s bereavement support services members of the public who have been bereaved can borrow from the library’s bereavement bibliotherapy collection.

Access and membership

The library is open to all Irish Hospice Foundation staff and affiliates, students currently enrolled on Irish Hospice Foundation Education courses. Professionals, students and researchers who want to have continued access to the collection and to access the library’s electronic resources can sign up for library membership. Full details of access and membership options are available HERE.

Irish Blood Transfusion Service (IBTS) Library

The Irish Blood Transfusion Service (IBTS) Library is located on the second floor of the National Blood Centre on the St James’s Hospital campus in Dublin 8.

They deliver a Library and Research Service to the IBTS and provide access to resources to meet the research and education needs of IBTS staff as well as visiting students/registrars.

Collections and Services

The IBTS Library is a specialist Library for Transfusion Medicine, the branch of medicine that is concerned with the process of collecting (donation), testing, processing, storing, and transfusing blood and its components. The Library holds core text books and print and online journals as well as industry relevant manuals, standards and guidelines.

Subjects covered by the library book and journal collections include:

  • Transfusion
  • Haematology
  • Bone Marrow Transplantation
  • Blood and Platelet Collection
  • Apheresis
  • Blood Banking
  • Cellular Therapy
  • Tissue/Eye Banking
  • Donor Recruitment
  • Donor Psychology/Motivation
  • Infectious Diseases, Immunology
  • Nursing
  • Laboratory Management and Practices
  • General medical reference material

They also hold articles, publications and theses written by former and current IBTS staff. Their non-medical book collection has been expanded in recent years to include publications on Marketing, Management, Organisational Behaviour, Human Resources, Leadership, Psychology, Sociology, Marketing and Self-Development.

Visiting the IBTS Library

Health service professionals and anyone with an interest in the field of Transfusion Medicine can visit and use facilities free of charge. There are three quiet study desks available for use in the main Library. Access to the collection is reference only and books and journals cannot be borrowed by visitors.

Library Services Brochure (pdf link)

Opening hours

The Library is staffed by a Research Officer/Librarian and a Library Assistant and is open from 10.00am to 4.00pm Monday to Friday.

If you would like to make an appointment please contact (01) 432-2848 or email the Librarian at niamh.osullivan@ibts.ie 

 

South Infirmary Victoria University Hospital Medical Library – Cork

South Infirmary Victoria University Hospital Library

SIVUH Library supports the hospital’s role in teaching patient-centered care. The library provides access to a range of collections and resources to meet the research and education needs of SIVUH staff and students on clinical placement, and to facilitate decision-making in patient care.

Opening Hours

Monday – Friday from 9.00am – 5.00pm

staffed by a Senior Library Assistant.

Collections and Services

Library collections include

  • medical, nursing and allied health textbooks
  • print and online journals
  • online databases ProQuest Medical Library, CINAHL Plus with Full Text and clinical resource tool UpToDate
  • audiovisual collection
  • inter-library loan service
  • internet access with eight computer work stations
  • study area

Access and membership

External membership is offered to non-SIVUH employees who are employed in the health sector on payment of an annual fee. Further details on the SIVUH website

To contact the library email: library@sivuh.ie or phone 021 – 4926348.