What are the novel findings of this work? Preterm delivery occurred in a higher proportion of women with SARS-CoV-2 infection in the PAN-COVID and AAP-SONPM registries compared to contemporaneous and historical national data from uninfected women in the UK and USA. The majority of preterm deliveries occurred between 32 + 0 and 36 + 6 weeks' gestation. SARS-CoV-2 infection in pregnancy did not appear to be associated with a clinically significant effect on fetal growth, adverse neonatal outcome or the rate of stillbirth. Although maternal death was uncommon, the rate was higher than expected based on UK and USA population data, which is likely explained by underascertainment of women affected by milder or asymptomatic infection in pregnancy in the PAN-COVID study, although not in the AAP-SONPM study. What are the clinical implications of this work? Pregnant women should be counseled that SARS-CoV-2 infection increases the risk of preterm delivery but not stillbirth, early neonatal death or a small baby. Healthcare providers should recommend SARS-CoV-2 vaccination in pregnant women and women planning pregnancy, alongside enhanced social distancing.

BackgroundIntensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.ObjectivesTo explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.MethodsA mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.ResultsInfluences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.LimitationsLimitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.ConclusionsDecision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.Future workFurther research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.Study registrationThe systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.

Summary Predicting who will benefit from admission to an intensive care unit is not straightforward and admission processes vary. Our aim was to understand how decisions to admit or not are made. We observed 55 decision‐making events in six NHS hospitals. We interviewed 30 referring and 43 intensive care doctors about these events. We describe the nature and context of the decision‐making and analysed how doctors make intensive care admission decisions. Such decisions are complex with intrinsic uncertainty, often urgent and made with incomplete information. While doctors aspire to make patient‐centred decisions, key challenges include: being overworked with lack of time; limited support from senior staff; and a lack of adequate staffing in other parts of the hospital that may be compromising patient safety. To reduce decision complexity, heuristic rules based on experience are often used to help think through the problem; for example, the patient’s functional status or clinical gestalt. The intensive care doctors actively managed relationships with referring doctors; acted as the hospital generalist for acutely ill patients; and brought calm to crisis situations. However, they frequently failed to elicit values and preferences from patients or family members. They were rarely explicit in balancing burdens and benefits of intensive care for patients, so consistency and equity cannot be judged. The use of a framework for intensive care admission decisions that reminds doctors to seek patient or family views and encourages explicit balancing of burdens and benefits could improve decision‐making. However, a supportive, adequately resourced context is also needed.

PurposeThere is a significant volume of literature relating to the mentoring needs of new principals and vice/deputy principals, but little is known about the mentoring needs of recently appointed middle leaders in an educational setting. This study explored the mentoring needs of five female middle leaders at a K–12 case study school of 550 students in Perth, Australia.Design/methodology/approachEach participant had three mentoring sessions, followed by a semi-structured interview using open-ended questions to provide data on the participants' mentoring needs. The research was framed within an interpretive phenomenology paradigm that focussed on the participants' perceived experiences and how they then interpreted these experiences. One of the researchers was active in this research, acting as the mentor (Neubauer et al., 2019; Smith and Osborn, 2021).FindingsThe findings of this study revealed the importance of the mentor being a “critical friend”. In addition, the participants referred to leadership identity, leadership from the middle, managing relationships and gender as other important mentoring needs.Originality/valueThis empirical study contributes original findings on the mentoring needs of a previously neglected group of educational leaders who provide an essential bridge between classroom practitioners and senior leadership in Australian schools. This study is unique because it links these mentoring needs to the practice architectures, factors at the case study school that either constrained or enabled middle leading (Kemmis et al., 2014).

AFTER the long haul through veterinary school, the last thing many new graduates contemplate is taking further exams, let alone returning to university. Like many of her fellow graduates, Caroline Blake wanted to work in a mixed practice, to gain a broad level of early experience. However, quite quickly she became keen to specialise and felt the need for a further intellectual challenge. A postgraduate certificate was the solution, and here she describes the process of studying for it at university. The alternative route of taking a certificate while in practice will be discussed in the next issue.