An increased NEWS on arrival at ED is associated with higher odds of adverse outcome among patients with sepsis. The use of NEWS could facilitate patient pathways to ensure triage to a high acuity area of the ED and senior clinician involvement at an early stage.
Introductioncontinuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) provide enhanced oxygen delivery and respiratory support for patients with severe COVID-19. CPAP and HFNO are currently designated as aerosol-generating procedures despite limited high-quality experimental data. We aimed to characterise aerosol emission from HFNO and CPAP and compare with breathing, speaking and coughing.Materials and methodsHealthy volunteers were recruited to breathe, speak and cough in ultra-clean, laminar flow theatres followed by using CPAP and HFNO. Aerosol emission was measured using two discrete methodologies, simultaneously. Hospitalised patients with COVID-19 had cough recorded using the same methodology on the infectious diseases ward.ResultsIn healthy volunteers (n=25 subjects; 531 measures), CPAP (with exhalation port filter) produced less aerosol than breathing, speaking and coughing (even with large >50 L/min face mask leaks). Coughing was associated with the highest aerosol emissions of any recorded activity. HFNO was associated with aerosol emission, however, this was from the machine. Generated particles were small (<1 µm), passing from the machine through the patient and to the detector without coalescence with respiratory aerosol, thereby unlikely to carry viral particles. More aerosol was generated in cough from patients with COVID-19 (n=8) than volunteers.ConclusionsIn healthy volunteers, standard non-humidified CPAP is associated with less aerosol emission than breathing, speaking or coughing. Aerosol emission from the respiratory tract does not appear to be increased by HFNO. Although direct comparisons are complex, cough appears to be the main aerosol-generating risk out of all measured activities.
Sepsis presentations are of variable frequency but have typical epidemiology and clinical outcomes. SSC bundle resuscitation uptake is poor in Scottish EDs.
BackgroundRisk of aerosolisation of SARS-CoV-2 directly informs organisation of acute healthcare and PPE guidance. Continuous positive airways pressure (CPAP) and high-flow nasal oxygen (HFNO) are widely used modes of oxygen delivery and respiratory support for patients with severe COVID-19, with both considered as high risk aerosol generating procedures. However, there are limited high quality experimental data characterising aerosolisation during oxygen delivery and respiratory support.MethodsHealthy volunteers were recruited to breathe, speak, and cough in ultra-clean, laminar flow theatres followed by using oxygen and respiratory support systems. Aerosol emission was measured using two discrete methodologies, simultaneously. Hospitalised patients with COVID-19 were also recruited and had aerosol emissions measured during breathing, speaking, and coughing.FindingsIn healthy volunteers (n = 25 subjects; 531 measures), CPAP (with exhalation port filter) produced less aerosols than breathing, speaking and coughing (even with large >50L/m facemask leaks). HFNO did emit aerosols, but the majority of these particles were generated from the HFNO machine, not the patient. HFNO-generated particles were small (<1μm), passing from the machine through the patient and to the detector without coalescence with respiratory aerosol, thereby unlikely to carry viral particles. Coughing was associated with the highest aerosol emissions with a peak concentration at least 10 times greater the mean concentration generated from speaking or breathing. Hospitalised patients with COVID-19 (n = 8 subjects; 56 measures) had similar size distributions to healthy volunteers.InterpretationIn healthy volunteers, CPAP is associated with less aerosol emission than breathing, speaking or coughing. Aerosol emission from the respiratory tract does not appear to be increased by HFNO. Although direct comparisons are complex, cough appears to generate significant aerosols in a size range compatible with airborne transmission of SARS-CoV-2. As a consequence, the risk of SARS-CoV-2 aerosolisation is likely to be high in all areas where patients with Covid-19 are coughing. Guidance on personal protective equipment policy should reflect these updated risks.FundingNIHR-UKRI Rapid COVID call (COV003), Wellcome Trust GW4-CAT Doctoral Training Scheme (FH), MRC CARP Fellowship(JD, MR/T005114/1). Natural Environment Research Council grant (BB, NE/P018459/1)Research in contextEvidence before this studyPubMed was searched from inception until 10/1/21 using the terms ‘aerosol’, and variations of ‘non-invasive positive pressure ventilation’ and ‘high-flow nasal oxygen therapy’. Studies were included if they measured aerosol generated from volunteers or patients receiving non-invasive positive pressure ventilation (NIV) or high flow nasal oxygen therapy (HFNO), or provided experimental evidence on a simulated human setting. One study was identified (Gaeckle et al, 2020) which measured aerosol emission with one methodology (APS) but was limited by high background concentration of aerosol and a low number of participants (n = 10).Added value of this studyThis study used multiple methodologies to measure aerosol emission from the respiratory tract before and during CPAP and high-flow nasal oxygen, in an ultra-clean, laminar flow theatre with near-zero background aerosol and recruited patients with COVID-19 to ensure similar aerosol distributions. We conclude that there is negligible aerosol generation with CPAP, that aerosol emission from HFNO is from the machine and not the patient, coughing emits aerosols consistent with airborne transmission of SARS CoV2 and that healthy volunteers are a reasonable proxy for COVID-19 patients.Implications of all the available evidenceCPAP and HFNO should not be considered high risk aerosol generating procedures, based on our study and that of Gaeckle et al. Recorded aerosol emission from HFNO stems from the machine. Cough remains a significant aerosol risk. PPE guidance should be updated to ensure medical staff are protected with appropriate PPE in situations when patients with suspected or proven COVID-19 are likely to cough.
AimsTo identify risk factors for re-admission to an acute inpatient general adult mental health ward. There is need to ensure that mental health services adapt to the increasing demand for inpatient bedsMethodWe conducted a single centre retrospective analysis of electronic records of 85 discharges from an adult mental health unit from 4th March 2019 – 5th August 2019. We collected information on demographics, admission details, substance use, forensic history, diagnosis as per the International Classification of Diseases 10th Edition (ICD-10), and discharge details and compared two cohorts; those re-admitted within three months of discharge and those who were not. Odds ratio (OR), 95% confidence intervals (CI) and p values were calculated where possible.ResultAmong seventeen service users who were re-admitted within the three month period there were nine women and eight men. There was no difference in ethnicity, employment or marital status. The mean length of admission for those readmitted was 48.2 days (range 1–140 days) and 47.1 days (range 1–350 days) for those who were not readmitted. Certain features were more prevalent among the readmitted group including forensic history (58.8% [10] vs 26.5% [18], OR 3.97, CI 1.31–11.9, p value 0.007), substance misuse history (70.6% [12] vs 55.9% [38], OR 1.89, CI 0.60–5.97, p value 0.138), previous contact with mental health services (100% [17] vs 76.5% [52]) and the rate of detention under the Mental Health Act at point of admission (76.5% [13] vs 66.2% [45], OR 1.66, CI 0.49, 5.67, p value 0.209).Among those readmitted, a diagnosis of emotionally unstable personality disorder (17.6% [3] vs 10.3% [7], OR 1.87, CI 0.43,-8.14, p values 0.203) and substance misuse disorder (41.2 % [7] vs 17.6 % [12], OR 3.27, CI 1.04–10.31, p value 0.218) were more prevalent. They were more likely to use illicit substances whilst they were an inpatient (23.5% [4] versus 7.6% [5], OR 3.88, CI 0.92–16.43, p value 0.033) and to be involved in police incidents (35.3% [6] versus 17.6% [12], OR 2.55, CI 0.79–8.23, p value 0.059).ConclusionOur trends demonstrate that people with substance misuse, emotionally unstable personality disorder and forensic history are more likely to be readmitted to an adult mental health inpatient unit. They were more likely to misuse illicit substances and be involved with police during admission.
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