2020’s goal was to survive!

If anyone had told you two years before that the biggest struggle of healthcare improvement would be to survive despite having world-class healthcare institutes, would you have believed this argument?

Related: How COVID-19 is affecting nurses’ mental health, and what to do about it

Before March 2020, our systems had a different list of priorities ranging from what were the most recent trends to improving healthcare, creating a sustained improvement culture and managing various improvement projects in every healthcare facility, which included acronyms such as PDCA, SIPOC, six sigma, lean, value stream mapping or similar. These were shining or shrinking based on organisational development but never just aiming to survive in very few C-suite meetings if any.

The pandemic was a new chapter for preventive healthcare

In March 2020, the WHO announced COVID-19 as a pandemic, and while people were advised to stay home, the white army had to protect their communities and themselves, putting aside all regular business strategies and putting patients as the top priority as usual.

Related: Quality Management experts emphasise the importance of patient engagement in digital innovation

While people were concerned about washing their hands, healthcare had to face washed out regular key performance measures, so the blue ocean strategy was the most cited by CEOs to go through the wave safely.

The paradox of (no time to improve) while improving

When improvement professionals tried to step in the process, as usual, they found a higher wave of no time to improve. We used to see, hear, face this attitude daily but it was never that preeminent. As a surveyor, it was for the first time to hear from hospitals that they hardly had few projects for one year, and the answer was we were in a pandemic.

The paradox here is that organisations were already implanting improvement techniques successfully; below is a look at some examples.

1. Visual management and visual cues

Thousands of posters everywhere nudging visitors and caregivers to wash their hands, the sign on the floor to stay here and keep distance, the yellow sign in the elevator to indicate the number of passengers allowed, the new coloured line on the floor for respiratory patient’s pathway, the exact marks on the floor for chairs to ensure safe social distancing, all are examples from lean management, especially the visual management.

2. Colour coding

This was frequently used in different formats; the app that most probably you use daily to categorise people according to infection and recent vaccination usually uses colour codes such as green, yellow, or red to categorise users.

3. Poka-Yoke

A Japanese term for error prevention includes removing chairs from waiting areas, and bright straps to block visitors from using those chairs.

Burnout, a new constant in the healthcare giver buy-in formula

The most important point thing to acknowledge is that the individual factor was different this time; regardless of your effort to focus on process improvement, it can barely beat the internal factor (burnout), cited as the mind pandemic.

In the following part, I will summarise for you my article (cooling the Burnout; how did the pandemic change healthcare workers’ safety priorities?) published by Saudi Patient Safety Center Newsletter, Oct 2020.

What is Burnout, “a combination of exhaustion, cynicism, and perceived inefficacy resulting from long-term job stress,” is long known as a side effect of a healthcare work environment that can reduce work performance and increase the risk of error.

Increase in burnout levels during the COVID-19 era

Let us check the literature about Burnout; in Wuhan, 60 per cent of 2014 nurses faced emotional exhaustion, 91 per cent had a high level of anxiety. In Italy, 50 per cent out of 1379 front liners had symptoms of post-traumatic stress, 25 per cent had symptoms of depression, and 20 per cent had symptoms of anxiety. In addition, 10 per cent reported insomnia, and 22 per cent reported elevated levels of perceived stress. Thus, healthcare workers’ mental safety started to be called the pandemic infecting the mind or a parallel pandemic.

Cooling the Burnout, improvement of the caregiver before the process

On a national level, it is important to provide funding for those experiencing mental health effects. The second is to integrate well-being programmes, COVID command centres and reporting mechanisms at the organisation level.

The Institute for Healthcare Improvement provided a stepwise approach to promote mental health and well-being “The Psychological PPE” with clear advice to individuals and team leaders. Individuals can start with a day off to maintain the right to Work-Life Balance, avoid excessive COVID news, receive mental health support, and reframe negative experiences. The team leaders can play a significant role by placing limits on shift time as appropriate, clear delineation of responsibilities, train leaders on how to monitor signs of stress, and provide peer support to the team.

Final thoughts

Improvement was there in the background of healthcare processes, trying, as usual, to reduce waste and deliver easier and better services; however, while the COVID-19 waves took all the world’s priorities, healthcare improvement shall take this as timeout for creating more engaging, flexible plans. These plans will have no time to improve because it should be part of the daily business and shall have new dimensions to consider. Burnout may see surge after surge especially that after 15 months there are still waves taking place in different parts of the world.

Unless burnout is made as one of healthcare improvement’s top priorities, you will keep hearing that there is no time to improve. Supporting the well-being programmes will be a critical milestone for businesses, individuals and patients.

References available on request

Dr. Elsheikh is involved with the following projects:

• Quality and Patient Safety director – Acting Director of Organizational Excellence and Development Security Forces Hospital Makkah (SFHM), Saudi Arabia
• Leadership, ESR and Visit team leader Surveyor – Saudi Central Board of Accreditation of Healthcare Institutions (CBAHI)
• Hospital Program Surveyor – General Authority for Healthcare Accreditation and Regulation (GAHAR) Egypt.

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.

As we enter a second year of the COVID-19 pandemic, important lessons on the role of effective healthcare systems have emerged. The pandemic has resulted in unprecedented stress on care systems around the world, revealing our Achille’s heel. In the U.S., while the focus of delivery system reform has been on delivering value-based care, the pandemic has illustrated an urgent need to redefine value by prioritising resilient healthcare systems.

Central to health systems resiliency is the role that surgical care provides in hospitals and health systems. For example, in March 2020, with the uncertainty of an alarming escalation of COVID-19 cases in major U.S. cities, one of the primary non-pharmacological interventions to preserve hospital capacity and critical shortages of personal protective equipment (PPE) was the cancellation of non-emergent surgical cases, an enormously expensive choice for hospitals with unknown potential impacts on the patients whose operations and procedures were delayed. This strategy, while initially necessary, has sparked conversations about the need to transition to a more robust, resilient post-pandemic healthcare system. Additionally, in many hospitals across the U.S., there was a realisation of the importance of generalism in an increasingly specialised world. As medical units became filled with COVID-19 patients and with increasing burnout among front-line clinicians, surgeons and surgical trainees were often cross-tasked with providing care to medical patients with COVID-19. Many intensive care units with intubated COVID-19 patients were staffed with general surgeons, who had undergone extensive critical care training during their graduate medical education.

Related: Patient Talk Podcast: How robotic surgery empowers the physician and ensures patient safety

A silver lining to the pandemic is the opportunity to reimagine and redesign surgical healthcare delivery. There will likely be a continuing accelerated transition to telehealth, a shift from inpatient to outpatient surgery, and a renewed focus on home-based care. During the COVID-19 pandemic, 30.1 per cent of all visits across medical specialties were provided via telemedicine. Especially for surgical care at academic tertiary referral centers, telemedicine visits create the opportunity for expanded patient access while minimising direct and indirect costs to patients. For elective operations, such as bariatric and metabolic surgery, with multiple preoperative multidisciplinary visits and life-long follow up, the flexibility of virtual visits may actually decrease patient attrition and loss to follow up. However, emerging data suggest that rates of telemedicine use were lower in communities with higher rates of poverty, and a rapid shift to telehealth could exacerbate existing structural inequalities in health care access. Expansion of telehealth, therefore, needs to ensure that care is expanded equitably across patient populations. This requires universal access to reliable, high-speed internet connections, which communities with high rates of poverty do not currently have.

Second, post-pandemic, there will be a rapid evolution of inpatient surgical procedures to the outpatient setting. In the U.S., the lifting of Medicare reimbursement restrictions on “inpatient only” procedures will have a profound effect on the trend of outpatient procedures. For example, after removal of total knee arthroplasty from the inpatient surgical list in 2018, the proportion of these operations performed as an outpatient went from 0.2 per cent in 2017 to over 35 per cent in 2018. On top of existing clinical innovations such as enhanced recovery after surgery protocols, the large-scale experimentation with postoperative care pathways caused by COVID-19 disruptions to elective surgical cases will likely continue to decrease inpatient lengths of stay and increase the transition towards outpatient procedures.

Related: How the COVID-19 pandemic has changed how we use medical evidence and knowledge

Lastly, there will likely be a trend towards home-based care, in what Medicare has called the “hospital without walls.” These will entail the adoption of home hospital models of care which provide inpatient-level care in the patient’s own home, avoiding the use of a hospital bed. While these programmes have mostly been utilised for medical patients within the United States, in November 2020 the Centers for Medicare and Medicaid Services announced the Acute Hospital Care at Home waiver, creating a path for more hospitals to establish home hospital programmes to create more capacity for acute hospital care. Home hospital care includes nursing/paramedic support, daily provider and therapist visits, point-of-care lab and imaging tests, and administration of IV medications, providing an opportunity for this modality to be used for pre-operative optimisation and post-operative care of surgical patients. Home hospital is the next frontier in patient-centered care that focuses on the patient and not around the physical infrastructure of the healthcare system.

While the COVID-19 pandemic has caused unprecedented stress to healthcare systems, it has also highlighted the need for flexible thinking around payment and delivery models that incentivise creative solutions for capacity building. Re-engineering health systems will necessarily involve re-engineering surgical care delivery to focus on patients, and this focus will accelerate the trends of increased telehealth, outpatient procedures, and home hospital adoption. Redefining healthcare value around resiliency will create the foundations of a stronger, more nimble system capable of responding to future pandemics, climate disasters, and other healthcare surges that we will undoubtedly face.

Dr Stanley W. Ashley                        Dr Ava Ferguson Bryan                     Dr Thomas C. Tsai

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.

COVID-19 has amplified the conversation around stress. Factors such as separation anxiety, work from home, uncertainty about the future and being fearful about the well-being of loved ones have plagued each one of us. Often, stress can contribute to various health problems such as an increased risk for high blood pressure, heart disease, obesity, diabetes, and anxiety or depression. In these challenging times, we all need a reminder to take a breather now and then to put our minds at ease. This is where wearables can come in and give a friendly nudge to take a timeout based on elevated levels of stress signals in the body.

Over the past few years, wearables have taken a big leap from counting steps for achieving fitness goals to providing sensors that can detect changes to well-being and even point out signs of a fever or illness. To keep up with these stressful times, companies such as Fitbit, Samsung, Garmin, and Apple have all introduced features such as stress scores, guided breathing and mindfulness.

Related: How your heart rates and why it matters to know

For instance, the Fitbit Sense reportedly features the world’s first electrodermal activity (EDA) sensor on a smartwatch to help manage stress, along with heart rate tracking, an ECG app, and an on-wrist skin temperature sensor. Built by behavioural health experts with expertise in diagnosing and treating mental health and guidance from medical experts, the device can also help track heart rate variability (HRV) and breathing rate. Recent research has found that monitoring HRV can detect stress with 90 per cent accuracy.

The EDA sensor works by putting your palm over the dial for two minutes. It looks at tiny changes in the sweat level of the skin, which may be due to stress factors such as movement, noise or temperature change. The app also provides guided mindfulness sessions to see how the body responds during meditation or relaxation. Over time progress can be understood through the EDA response graph displayed on the mobile app.

Related: The rise of femtech and SHEconomy

The device packs sensors to measure stress level, the amount of oxygen (SpO2) in blood, as well as changes in skin temperature and heart rhythm, while providing robust sleep and fitness tracking insights. The SpO2 feature makes it easier to track oxygen saturation levels while sleeping and provides insights on how difficult or easy it was to breathe during the night. Plus, it can calculate baseline skin temperature after wearing it to bed for three nights and allows one to observe nightly average variation versus baseline skin temperature.

The device also features a Health Metric dashboard and Stress Management Scores that analyse how the body responds to stress based on heart rate, sleep, and activity level. The scores range from 1 to 100. The higher score is an indicator that the body is showing fewer physical signs of stress. The score is calculated by tracking activity, heart rate, HRV, EDA activity and sleep patterns. The app also offers tips on how to manage stress better, improve stress scores, and allows to set a weekly mindfulness goal and log moods.

I have been wearing the device for over five months now and find myself to be calmer and more aware of my breathing and how my body works. Its sleek look, long battery life and focus on health and wellness are a big hit for me. The Stress Management Scores have really helped me monitor my well-being, and I was able to raise it from 74 to 82 from the time I have been tracking. My goal is to raise the score to 90 by the end of the year.

A session that has stuck with me is called the ‘Practice of Noting’ which suggests that noting and labelling thoughts and feelings can make one feel more aware of mental patterns that can affect behaviour. So, for instance, when the mind starts to wander, one can give a name to their feelings and then gently come back to focusing on the breathing. The exercise has helped me organise my thoughts better on waking up and has made me become more in tune with stressors in the environment and how to deal with them.

Taking this a step further, Fitbit has partnered with wellness coach Deepak Chopra, M.D., a pioneer in integrative health and well-being. The app features video and audio sessions featuring Chopra on topics such as mindfulness, sleep, stress management and mental wellness.

These features help to build a complete mental well-being picture that might even assist the wearables of the future to detect anxiety and panic disorders in advance. As technology involves and the latest upgrades come in, wearables show great promise in helping to understand mental health better as well as to detect other diseases and health conditions in the future.

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.  

Regenerative orthopaedic has gained its popularity in the last 15-20 years. But it was 1990 when Dr Philippe Hernigou started his research which would last until 2013, when the results were published. Dr Hernigou is a French orthopaedic surgeon, a true pioneer in regenerative orthopaedics. He investigated almost 2,000 patients who had their own stem cells injected and were followed up for 12.5 years on average. And the results were ground-breaking, showing that injecting stem cells was safe and did not cause increased risk of cancer.

This publication allowed an advent of clinical regenerative orthopaedic. Stem cells clinics started appearing like mushrooms, particularly in the United States. Regenerative treatments found themselves in the middle of media frenzy with celebrities getting treatments in the spotlight.

Related: The 2021 Orthopaedics Report

In the meantime, many credible providers along with academic researchers have been conducting clinical and laboratory research and gathering evidence. Over last 15 years the technique, its clinical applications and guidelines have evolved, based on new research and new evidence.

Today we have enough evidence to say with confidence that regenerative orthopaedic should be a part of treatment algorithm in many musculoskeletal conditions.

Platelet Rich Plasma (PRP)

Related: Orthotics: Is it Science or a Sham?

PRP is the best researched orthobiologic. The evidence has reached the highest level, i.e., meta-analysis. One of the most recent ones was published in 2021 in The Orthopaedic Journal of Sports Medicine. The authors included 21 randomised controlled studies (RCT) concerning knee osteoarthritis (OA). In conclusion they stated that “we found that the benefit of intra-articular PRP in the treatment of knee OA was clinically important when compared with intra-articular saline or corticosteroid solution injections”.

Another meta-analysis published in 2020 in the Clinical Rheumatology looked at 21 RCTs concerning knee OA and three RCTs concerning hip OA. The analysis confirmed beneficial effect in knee OA but less so in hip OA which accords clinical experience. Another interesting meta-analysis, published in 2020 in the Journal of Orthopaedic Surgery and Research looked into the RCTs comparing PRP and hyaluronic acid (HA). Twenty RCTs were analysed. The authors concluded that PRP was more efficacious and with less risk of adverse events. Meta-analysis concern not only knee OA.

The one published in 2021 analysed eight RCTs concerning rotator cuff tendinopathy. The authors concluded that “PRP is safe and more effective for long-term shoulder pain symptoms and shoulder function associated with injury to rotator cuff”. They also called for more robust studies better reporting the PRP preparations and injection technique. Other meta-analysis looked at PRP in the treatment of Carpal Tunnel Syndrome and discogenic lower back pain.

Both showed clinically relevant benefit of PRP injections. Randomised Controlled Trials concerning PRP treatments are numerous. As for 2021, 28 RCTs concerning knee OA were published, all of them showing the benefit of PRP injections. There were three RCTs concerning hip OA (two showing benefit), nine concerning shoulder (eight showing benefit), 13 concerning epicondylitis of which 12 showed benefit of PRP therapy. There was one concerning degenerative disc disease, one for facet joints and one for sacroiliac joint.

Mesenchymal Stem Cells

Let’s move on to the mesenchymal stem cells (MSC) research. The mesenchymal stem cells are derived in clinical orthopaedic practice either from bone marrow or from adipose (fat) tissue. In case of the former, stem cells are injected either as a bone marrow aspirate (BMA) or a bone marrow aspirate concentrate (BMAC). In case of the latter, in order to extract stem cells from the adipose tissue, an enzymatic reaction is required. Such advanced processing makes the stem cells a medicinal product and falls under different (and stricter) FDA and European regulations. The legal regulations and subsequent technical requirements make the whole process practically unavailable for clinics and remains the domain of academic and clinical research. The adipose tissue can be processed in much simpler way, allowed by FDA and European regulators but it is questionable whether such processed product contains any substantial number of stem cells. On the other hand, adipose tissue contains plenty of regeneratively potent cells and growth factors which make the product applicable in the regenerative orthopaedics. Most of the past research applies to mesenchymal stem cells derived from bone marrow (BMA or BMAC), however, there is a growing number of research focused on adipose tissue derived stem cells. The future will show which product will demonstrate better clinical features. It is also hoped and cautiously expected that the regulators such as FDA will change their stance on adipose derived stem cells and will ease their current regulations applied to the enzymatic processing of the fat tissue.

One of the first RCTs concerning bone marrow concentrate used for symptomatic knee OA was published by Dr Chris Centeno and collaborators in 2018 in the Journal of Translational Medicine. The study included 48 patients with grade II and III OA, who were followed up for two years. The study showed beneficial effect of BMA. The same author published a mid-term analysis of the RCT of the treatment of rotator cuff tears with BMAC. Fifty patients were included with two years follow up. The mid-term analysis showed that BMAC could be a useful alternative to other treatments. Dr Hernigou and his collaborators published a very interesting study in 2021. In a prospective RCT on 120 knees in 60 patients they compared subchondral (into the bone) and intra-articular injection of BMAC. The follow up time was 15 years. The results indicated the superiority of the subchondral injection over the intra-articular one. Twenty per cent of patients in the subchondral group required a knee replacement within 15 years compared to 70 per cent in the intra-articular group.

In 2020, American Society of Interventional Pain Physicians (ASIPP) published in the Pain Physician Journal their Position Statement regarding bone marrow concentrate (BMC) therapy in musculoskeletal disorders. The statement 2 states: “Assessment of clinical effectiveness based on extensive literature shows emerging evidence for multiple musculoskeletal and spinal conditions”. In their statement 3, the author’s state: “Based on an extensive review of the literature, there is strong evidence for the safety of BMC when performed by train physician with the appropriate precautions under image guidance utilising a sterile technique”.

In summary, orthobiologics have gained a well-deserved position in the musculoskeletal medicine as a new and promising non-invasive treatment applicable to many spine and musculoskeletal conditions. Every month witnesses new publications bringing more evidence, changing the practice and opening new perspectives for the future. There are excellent training opportunities across the world which hopefully will popularise the regenerative orthopaedics further. Thousands of satisfied patients are the best testimonial for the regenerative treatments provided by credible physicians. 

Dr Zbigniew M Kirkor 

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.  

After a year of lockdowns, there is hope at last. Millions of COVID-19 vaccines have been administered worldwide, and the global rollout continues to accelerate. This is good news, as there have been positive signs of impact in countries where uptake has been highest.  For example, one study found the Pfizer BioNTech vaccine rollout in Israel has helped reduced cases by 94 per cent.

However, the pandemic is far from over. Several new virus variants have emerged across multiple continents over the last six months, with some appearing to be more transmissible or resistant to early vaccine formulations. Despite severe travel restrictions and quarantines, the B.1.1.7 COVID-19 variant that first emerged in the UK in late 2020 became the most dominant strain in the United States by April, the Centers for Disease Control and Prevention (CDC) recently confirmed.

Related: Effective supply chains speed up vaccine distribution

And scientists have said there is greater potential for dangerous new strains to appear the longer we allow COVID-19 to spread. That means accelerating the global vaccine rollout with extreme efficiency which is more essential than ever.

Logistics challenges such as supply chain gaps, vaccine output variability and a lack of transparency from fragmented healthcare and administrative bodies have delayed and disrupted vaccine drives in both developing nations and the wealthiest European countries. Consequently, advanced logistics and tracking technology has become vital in helping to overcome these difficulties.

Related: How to create a patient-centric supply chain: A simple guide for hospitals

If we can digitise every step of the vaccine distribution and administration processes, it becomes easier to make critical supply chain links. This, in turn, helps to improve coordination among stakeholders – many of whom may have never worked together before this effort. Eliminating data black holes with digital technologies also helps to increase efficiency, speed, and accountability. These include real-time track and trace technology; smart, handheld mobile computers and tablets; highly accurate barcode scanners; temperature-monitoring sensors, and next-generation analytics. Properly integrated, these can help every company and individual involved in the distribution and administration of COVID-19 vaccines confidently and accurately execute key actions.

Supply chain transparency is key

Every step in the vaccine distribution process – and each handoff between suppliers, distributors, logistics providers and administration site staff – increases the risk of vaccine damage, delay or even loss. But with the right internet of things (IoT) technology in place to maintain first-to-last-mile supply chain visibility, many of these issues can be mitigated.

For example, affixing wireless track and trace devices such as RFID tags and electronic data loggers to the pallets and packaging used to ship vaccines can enable both location and temperature data, respectively, to be collected and shared among those charged with logistics planning and reporting. Depending on the type of technology used, the data may be aggregated and distributed via the cloud in easy-to-understand graphs. In other instances, the data might be available for download onto mobile apps via Bluetooth enabled devices upon arrival at a destination. Either way, location technology is key to achieving:

• Fast confirmation of shipment status at every hand-off point.
• Enhanced teamwork across multiple logistics and healthcare providers.
• Better identification and resolution of bottlenecks impacting vaccine distribution and administration.
• Confidence in the performance of the cold chain. 

However, logistics monitoring – and vaccine temperature monitoring – doesn’t stop once vaccines arrive at their final destinations.

Combining technology and data to streamline point of care

We’re familiar with the “last mile” concept in logistics. But when it comes to achieving an efficient vaccine rollout, it’s critical to recognise that this extends beyond the doorway threshold and all the way to the vaccination station, which could be inside a grocery store or individual’s vehicle in a parking lot. Therefore, healthcare providers and others hosting vaccination clinics must have the same visibility into distribution operations as traditional supply chain logistics managers. Furthermore, they need technology tools that allow them to securely collect, store and share patient records (i.e., vaccine credentials), daily vaccination figures, potential side effects of various vaccines, fluctuating supply levels (to include inventory use/waste), and even storage temperature once the vaccines have been delivered.

That’s a daunting challenge when point of care facilities in national vaccination drives can range from the largest hospitals and sports stadiums to local pharmacies, schools and places of worship. Not all of these sites traditionally have the technology resources needed for real time data collection – and not all are digitally connected to government and public health agency databases (yet).

How do we link them all to establish a baseline system of high-quality data accessible across such diverse administration facilities?

In a perfect world, every site would have mobile computers, tablets and wireless printers built for healthcare or enterprise use. Radio frequency identification (RFID)-enabled mobile handhelds can quickly capture data about vaccine inventory and other medical supplies (i.e., needles and personal protective equipment) that have been properly tagged. Barcode scanning devices can help staff retrieve a patient’s data to confirm identity, synchronise records and even read data on a vaccine credential to confirm first dose information before a second dose is administered. The less time spent on manually completing paperwork, the more time staff can commit to other high-value tasks that are key to increasing vaccination appointment volume. Also, automating data capture like this reduces the risk of data input errors and misinformed patient care actions.

Of course, the digital capture and distribution of information captured by electronic data loggers located in freezers and refrigerators also makes it easy for facility staff to monitor and verify that the proper temperature is being maintained for vaccines on hand without having to physically check the temperature on a regular cadence. If an excursion occurs, they will be able to quickly investigate and take appropriate actions to mitigate further inventory losses. If doses do have to be disposed of, patients can be notified before they arrive for their appointments and rescheduled accordingly.

Cutting-edge artificial intelligence (AI)-based prescriptive analytics solutions can also be deployed with workforce management applications to quickly forecast first-dose demand, inform second-dose appointment planning, and help define both supplies and labour requirements as vaccine availability and appointment volume fluctuate.

The takeaway

The COVID-19 vaccine rollout is the biggest logistics challenge of our generation, but digital solutions exist that will help us succeed. Used together, real time track and trace technology, enterprise-grade mobile computers, and cloud-based prescriptive analytics software can optimise vaccine distribution and administration so that we can, in turn, execute an effective global campaign that will curb this pandemic.

Daniel Dombach

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.  

The task we set ourselves for our Round Table discussion at this year’s Arab Health Critical Care Focus Day was to review how technology can help to improve outcomes of COVID-19 patients in ICU.

Critical care nursing staff are highly trained, in short supply, and are our most valuable asset. They are essential to good patient outcomes. It is logical, therefore, to apply technology to protecting them and to reducing their risk of exposure. We have heard so much about ‘intermediate technology’ in the form of PPE in the last year, but high-level technology also has a part to play here.

Related: Streamlining for safety: Barcode medication administration for intravenous medications

IV medication administration commonly requires a two-nurse check. With highly infectious isolation patients this can potentially expose two nurses to the risk of infection during patient identification. In highly developed IV infusion medication safety systems the second nurse can be replaced by barcode medication administration (BCMA) during which the smart pump, via a bidirectional wireless communication with the patient’s electronic medication administration record (EMAR), undertakes the bedside checks of right patient, right medication, and right timing, auto-populates the pump with the correct starting rate and dose, and automatically documents administration in the patient’s EMAR. This also significantly reduces the risk of making an IV medication error for staff who may be working outside of their normal working environment, and under tremendous pressure. Given the hemodynamic effects of COVID-19 related sepsis we would expect also to see a significant amount of titration of vasoactive medications. Smart pumps with Dose Error Reduction Systems (DERS) reduce the risk of inadvertent toxic or untherapeutic dosing with the application of hard limits for dose/rate, and concentration of continuous infusions.

Updating DERS libraries on pumps with alternate drugs due to international shortages of opiates and sedatives has been a major challenge during the COVID-19 emergency. One hospital reported Propofol requirements for ventilated patients increasing by over 1,900 per cent over the course of a few days during the first wave of the pandemic. Being able to substitute 1 per cent Propofol with 2 per cent Propofol (rarely used outside of anaesthesia) was a partial solution for this facility but updating DERS libraries rapidly and safely to match such changes in the central formulary can only really be achieved when there is the capability to deploy the new library to connected pumps via extensive wired or wireless networks. This, of course, also allows facilities to respond to emergent changes in treatment protocols such as the new protocol for Dexamethasone use in COVID-disease. Wirelessly integrated infusion devices enable the deployment of updated DERS libraries to react to practice and formulary changes, even in Field Hospitals. Being able to add new medication regimes to our frontline medical devices so they can be safely used by clinicians is fundamental to good ICU patient outcomes.

Related: COVID-19 vaccines: The most precious medications in the world?

The maintenance of continuous critical short half-life infusions (CSHLI) such as noradrenaline is vital, as with critically ill COVID-disease patients in the ICU any prolonged interruption of CSHLI infusion delivery could be fatal. Monitoring of these infusions is crucial for isolated ICU patients, as nursing staff must respond promptly to any infusion alarm, and certainly within the short plasma half-life of these medications if serious cardiovascular events are to be avoided.

During the Arab Health ICU Focus Day, we were also able to discuss studies such as a three-year retrospective study in The University Hospital of Antwerp, Belgium that identified how centralised monitoring of isolated neonates in an NICU with 60 single rooms reduced nurse reaction times to CSHLI alarms by 31 per cent and reduced the total number of alarms that nurses are exposed to by 56.25 per cent. We, therefore, recommend central monitoring of all infusions delivered to isolated COVID-19 ICU patients. This has an extension beyond the pandemic to immunocompromised critical-care patients who require protective isolation. The use of wireless pumps in single rooms that can transmit their infusion data and any alarms to a centrally based monitor is extremely valuable in this respect.

We have learnt a lot about managing COVID-19 disease in the ICU over the last year. With novel drug treatments and with the protocolising of treatments becoming more common a large capacity DERS library with multiple profiles can allow for a specific library for critically ill COVID-disease patients, giving rapid and easy access to specific medications used to care for these patients along with specialist concentrations for those patients with COVID-related kidney dysfunction and pulmonary oedema.

Impact on hospital pharmacy

The pressures in the ICU during the pandemic have also impacted on the hospital pharmacy. To reduce the pressure on already overstretched nursing staff there has been a move to increased production and compounding of IV medications via Central Intravenous Additive Services (CIVAS) in central or satellite pharmacies. This can give rise to an issue of the storage of bulky and high-volume CIVAS infusions requiring refrigeration with issues of track and control as, commonly, the refrigerators used in facilities are not connected to the pharmacy system. Equally, manual reporting of continuous infusion rates and the patient census by ICU staff to calculate critical care medication requirements in the central pharmacy is a serviceable but not ideal workaround. Fuller integration of infusion pumps allows the central pharmacy to view dashboards of each ICU bed’s infusion rates (and therefore obtain exact medication consumption rates in each ICU) allowing for a rapid response to ‘supply-shocks’ and ensuring that Just In Time (JIT) delivery can be achieved. Aggregation of this data and integration with par-level reporting data from Automated Dispensing Cabinets (ADC) and integrated medication fridges also allows for more accurate forecasting going forward as the current emergency evolves and can be used as real-world data to forecast for future crises. Good critical care COVID-19 patient outcomes are dependent on the consistent and uninterrupted supply of maintenance medications and of antibiotics for the treatment of secondary infections. Full information flow and the ability to locate a compounded or pre-mixed medication at any point in the production-delivery-administration chain is key to ‘feeding’ the ICU’s needs and also allows for rapid data gathering from both in-house medication stock levels and consumption rates of critical medications. This can potentially improve how minimum and par levels of medications are set for each care unit and provides incredibly useful information for the setting up of ADCs supplying ‘pop-up’ ICUs to manage surge during biological disasters such as the COVID-19 pandemic. This data can also theoretically feed directly into regional and national systems, many of which currently rely on individual facilities regularly reporting stock-levels. These are currently often calculated from weighted averages, and projected needs based on historical order volumes and extra ‘daily-loads’ reported by the ICUs. National or regional coordination needs a more dynamic real-time data-feed to allow for centralised ordering and distribution and inter-facility ‘lending’ arrangements for critical need. We are truly all in this together and sharing of scarce medications during crises has been a central part of the strategy to increase survival rates across healthcare systems.

Assessing the impact of our ICU interventions is made easier by data-analytics. ‘Big data’ allows for rapid review of therapies and for guiding us to do ‘the right thing in the right way’.

A significant change in the management of controlled medications has been a noticeable feature of the challenge to ICUs of the COVID-19 emergency. In many countries their management was very much a paper-based exercise, with double signatures and wastage accounting through returns of empty ampoules to the pharmacy required for all transactions. As a positive result of the COVID-19 emergency, many healthcare systems have now begun to adopt and accept electronic signature solutions and to use automation to both secure opiates and sedatives and to maintain account and wastage records that can be viewed centrally and on shared dashboards.

The response of critical care clinicians to the COVID-19 emergency has been magnificent and has commonly extended to mentoring and supporting staff working outside of their usual specialties as well as undertaking their ‘usual’ duties in these unusual times. Clinicians have stated that wholesale changes have been undertaken in facilities with the creation of numerous ICU beds so rapidly that it has often felt like working in ‘a brand-new organization.’ Facilities have had to quickly cross-train existing staff and recruit new staff to ease the burden, and clinical facilitators have been tasked with upskilling nurses who usually work in non-critical care areas to care for critically ill patients. ICUs can benefit here from partnerships with medical device vendors, providing educational resources and clinical training to ensure best practices. For example, infusion therapy during a pandemic is multi-faceted and challenging, engaging with pump vendors to seek expert advice, the application of technology, and creative strategies that build on, or adapt, existing safeguarding processes and strategies are the keys to keeping both critically ill patients, and the staff caring for them, safe.

With such intense activity inside facility ICUs, tracking of medications and the ability to reintroduce unused but highly valuable medications back into the system is a real challenge. Monitoring of ADC refills and discrepancies between items dispensed from central pharmacy and those that are acknowledged in the ADC network can help with reconciling open-shelf items that are difficult to track. Other suggestions on medication stock tracking include integration between pharmacy applications and ERP systems for ‘stock-in stock-out’ reconciliation. Connected inventories servicing high medication-turnover units in critical care could be further enhanced by the rollout of GS-1 and GTIN barcodes, with accounting for expiry dates, lot numbers, and real-time identification of available medication stock.

Integrating infusion pumps and automated dispensing cabinets allows for more accurate forecasting of ICU medication needs as infusion rates can be viewed in real-time and overall medication consumption can be assessed and shared across facilities.

Of course, as organisations and as a community of ICUs we also need to answer one key question: Have we improved outcomes of our COVID-19 patients in critical care?

We can only show that our work, strategies, and techniques have made a difference through the assessment of data. ICU medication usage data integrated into Electronic Medical Records (EMR) and made available as ‘big data’ has the potential to be a real asset for rapid review of therapies and for guiding us to do ‘the right thing in the right way’, data is the bedrock of Evidence Based Medicine. Therapy data tied to patient demographics helps us to create evidence of its effectiveness. This approach utilising specialist tracking technology has already shown an impact on the tracking of Antibiotic Microbial Resistance in ICUs, it is now being applied to help track and share COVID-19 insights with hospitals across the United States and has shown in a recent publication that the work of dedicated and skilled ICU clinicians and the therapies they deploy have indeed made a huge difference to survival rates from severe COVID-19 disease.

In summary, the pandemic has challenged ICUs and critical care services, driven change to working practices, and accelerated the application and integration of technology solutions. To effectively meet future crises, there can be no return to ‘traditional’ ICU models of work.

References available on request

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.  

The physician workforce has changed significantly over time, particularly when it comes to gender distribution. There are clearly many opportunities out there for female physicians, but it’s still useful to hear insight from those who’ve succeeded.

To gain perspective, St. George’s University School of Medicine female graduates share what they have to say about their experiences as women in medical school, residency, and becoming doctors.

5 insights women doctors want future practitioners to know

Related: Enhancing the role of women in scientific research

There’s a tight-knit community of women in medicine, and they’re happy to share what they’ve learned with aspiring doctors. Some of this advice could even help physicians get ready for their first year of medical school.

1. Use the resources that are available

Medical schools offer an array of student support services designed to help future physicians succeed, so it’s wise to leverage any resources that can help you perform to the best of your ability. You might consider attending tutoring sessions, group reviews, and workshops to help you develop good study habits.

“We actually have a Department of Educational Services that provides those services for free,” says Dr. Devon Thomas, a St. George’s University (SGU) graduate and urology resident physician at the University of Florida College of Medicine – Jacksonville. “They can help you and tell you exactly what kind of test-taker you are and what kind of studier you are.”

Dr. Thomas also recommends tapping into your professional network as you progress through your education and career. For her, contacting other SGU graduates proved invaluable as she prepared for residency. It can be even more beneficial if you’re able to connect with graduates who are practising or completing their training at hospitals that have residency programmes in your chosen area, according to Dr. Diane Day, an SGU graduate and family medicine physician at Gainesville Family Physicians. She herself has put in a good word for students.

“I’m able to vouch for them,” Dr. Day says. “And I had left a good impression, so they wanted more SGU students.”

2. Keep an open mind during clinical rotations

After you’ve started school, you need to begin thinking about which medical specialties you’re interested in sooner than you might expect.

While you should explore options and recognise what types of interactions and procedures you most enjoy, it’s equally as important to recognise that you might change your mind during clinical rotations.

“Keep an open mind,” offers Dr. Maham Mahmood, an SGU graduate and anaesthesiology resident physician at the Indiana University School of Medicine. “Give every single rotation your best effort, put your 100 per cent into it, and see what you end up loving the most.”

In fact, Dr. Mahmood changed her career trajectory by remaining flexible. She initially thought she would pursue paediatrics because working with children sounded like a great way to make a living.

But once she realised how much she enjoys being in the operating room and performing procedures, it became clear that anaesthesiology was the best fit for her.

“I’m very happy with what I do on a daily basis, and I wouldn’t trade it for anything,” she says.

3. Pursue what you’re truly passionate about

It’s true that certain specialties attract more female physicians than male. That said, you should feel empowered to carve your own path—even if that means choosing a field that’s heavily populated with male practitioners.

Dr. Thomas chose urology, a specialty for which females make up a very small percentage of the physician workforce. The gender gap is actually part of what inspired her to enter the field, particularly when she realised how many female patients she would see.

“I thought I could be there for women who wanted a female physician who kind of understood them a little bit more,” Dr. Thomas shares.

4. Know that women in medicine can achieve work-life balance

Medicine offers so many avenues for physicians to shape their own career, and it’s helpful to know that ahead of time. Think about the lifestyle you want, and then you can start determining ways to achieve it. This is possible even for female physicians who pursue procedure-oriented fields.

“I get to be in the operating room. I get to do all the procedures I want,” Dr. Mahmood states. “And also, I can eventually have a job where I can be done at 5 pm.”

Aspiring female physicians who plan to have children should feel encouraged to know it’s possible to balance a medical career you love with family life. Dr. Day recently became a mother, and she enjoys her life at home and at work.

“My youngest patient is five years old, and the oldest patient I saw today was 92, so it’s wonderful,” she says. “I’m really happy, and I’m also able to have a home life and tailor my patient load to have that balance.”

5. Believe in yourself

Remember, the gender gap in medicine has nothing to do with female doctors’ capability. Many of the most respected and influential physicians have been women. Furthermore, you might be surprised at how many of your future patients turn out to be males.

“There are a lot of men that want a female physician,” Dr. Day says, reflecting on your own experiences. “They feel like they can open up and better talk about their problems.”

Women who are somewhat small in stature should also feel confident that it’s their skill—not their size—that matters. Dr. Mahmood says her co-workers have been surprised by her ability to expertly perform procedures like intubation despite her petite frame.

“Once people see you doing your job well, they start to trust you more,” Dr. Mahmood offers.

Female physicians are an undeniably important part of the medical workforce. They’ll continue to make positive contributions as even more join their ranks as women in medicine.

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.  

As the scientific community finds encouraging results within vaccine development to counter the spread of the COVID-19 pandemic, it is crucial for continued multisectoral collaboration to address antimicrobial resistance as a priority. COVID-19 may not be the last of the virus outbreaks that we as a community would witness. While it is impossible to predict when its likelihood must push us to adopt the highest order of antimicrobial (and antiviral) stewardship within which we must identify best practices to avoid the spread of superbugs and drug-resistant infections.

While the U.S. Food and Drug Administration approved the first antiviral medication for the treatment of COVID-19, it came as a result of more than a decade of research, experimentation and iteration by Gilead’s scientists. Prior to being identified for treatment, Gilead’s scientists had been studying its impact in haemorrhagic fever syndromes caused by Ebola and Marburg viruses as well as other diseases caused by other coronaviruses such as SARS and MERS. This work allowed Gilead to move very quickly into COVID-19 clinical trials when the novel coronavirus emerged. Gilead has a long-term commitment to advancing antivirals innovation for almost three decades.

Related: Multi-Drugs Resistant Organisms: Alarming Threat for Infectious Disease Management

Antivirals are the first line of defence for several life-threatening conditions including HIV and Hepatitis. When viruses resist a medication, it makes infections harder to treat, increasing the cost of treatment with second and third lines, it will also increase the risk of illness and possible death. In countries where the healthcare industry is underregulated, misuse of medicines and poor sanitary conditions have accelerated this phenomenon.

Antiviral resistance and noncompliance to therapeutic guidelines are significant causes of treatment failure in patients across disease areas. This is concerning especially within impoverished and immune-compromised patient populations, where ongoing viral replication and prolonged drug exposure lead to the selection of resistant strains to antivirals.

Related: Need of the Hour – Addressing the Challenges of Multi-drug Resistance of Hospital Acquired Infections and the Role of the Laboratory in Lowering the Infection Rates

How antiviral drugs work vary, ranging from targeting viral proteins to cellular proteins and strengthening the immune response, alongside several types of interferons, immunoglobulins, and vaccines, to the viral infection. While immunisation programmes support against identifiable strains and subtypes, they however will not be able to replicate success against unseen types. While some form of viral resistance against any specific and potent drug is virtually might be inevitable, we can work to minimise it. To prevent worst-case scenarios, combination drug therapy and prophylaxis are often proposed to stem and challenge emerging antiviral resistance.

It is also important to beat viruses as early as possible, as antiviral drugs may not work as well in viruses with reduced susceptibility, or sometimes the virus replication phase is happening at the first stage of the disease like what we have seen in COVID 19. As the virus progresses and mutates, when treatments are not being delivered promptly, testing and diagnostics remain very important, as patients with COVID-19 display symptoms shared with several other diseases, the importance of starting antiviral treatment as early as possible emerges. Attention must be paid towards ensuring the continuation of child and adult vaccination services to protect from other forms of infections and diseases, applying rigorous hygiene procedures when being administered. While sanitising is heavily encouraged during the pandemic, the overuse of biocidal agents for environmental and personal disinfection can select for drug-resistant strains and enhance the risk of cross resistance.

Antiviral resistance is not only a cost to the healthcare system, but it deprives the patient of the full value and therapeutic benefit of the years of innovation and expenditure that went into the drug’s development. To ensure that regional healthcare systems are able to realise their strategic goals of universal health coverage, there must be industry-wide investments made to encourage assays, diagnostic procedures, therapeutic regimen and clinical guidelines that are endorsed and vetted by the relevant medical community within adopting antimicrobial stewardship as we move closer to beating COVID-19. 

References available on request

Ayman Elsayes

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.  

Digital health solutions have arrived in everyday GCC healthcare over the last 12 months. At its peak – during the first COVID-19 wave – GCC health providers reportedly saw up to 30 per cent of patient encounters shift to some form of digital interaction – phone, video, sometimes even email.

From this peak, numbers have come down again, yet many GCC health providers still report stable telemedicine ranges between 10-15 per cent, highlighted Dr Sven-Olaf Vathje, Partner and Head of the Health and Life Sciences Practice at consulting firm Oliver Wyman Middle East and Africa, in an interview with Omnia Health Magazine. “This compares with virtually non-existent telemedicine before the pandemic. COVID-19 has accelerated a nascent, steady trend towards digital health,” he said. “We are seeing adoption rates today that many experts would have expected only by 2030.”

By design, the main impact from the accelerated use of digital health has been improved access to healthcare. All segments in the population and especially vulnerable segments (e.g., frail elderly, chronic disease patients) have found a safe and convenient way of accessing their physicians without the danger of infection through physical contact. Typically, telemedicine encounters have related to low acuity routine visits and administrational encounters (e.g., obtain a regular prescription).

Vathje said: “Accordingly, GCC health providers do not report any improved patient outcomes – but neither is there any widespread reports of quality challenges. It is fair to say that both physicians and patients have adopted quickly to telemedicine as a new channel.”

The real value of an increasing shift to digital health is yet to come. Telemedicine is still an isolated channel. Data gathered is often not systematically collected and combined with offline health records. GCC health systems are still far away from having “digital twins” of their patients, according to Vathje. Still, healthcare providers and insurers have invested significantly into their digital infrastructure in recent years. Physicians and patients are increasingly open to having clinical data collected, shared, analysed and deployed in patient care. This will open the doors towards effective public health management and personalised prevention. At that point, health outcomes will significantly improve and health system costs sustainably dampened.

Recovery of primary care demand

The impact of COVID-19 on primary care demand in the GCC has been comparable to many parts of the world. After a short-term drop of utilisation numbers for primary care providers by up to 50 per cent in the early days of the pandemic, shared Vathje, volumes of primary care encounters and outpatient visits quickly stabilised closer back to pre-pandemic levels.

He said: “After a brief spike in pent-up demand, GCC primary care providers typically report around 80-85 per cent of pre-pandemic utilisation levels. The speed of recovery was mostly determined by how quickly clinics embraced new access channels (e.g., telemedicine), but also by their specific patient clientele. Some clinics that were predominantly frequented by expatriate workers or visitors saw their patient numbers drop because of residents (temporarily) relocating away from the GCC. This explains why public clinics often saw stronger demand recovery than private clinics.”

Trends reshaping the field of play for health insurers

The COVID-19 pandemic has been shaking up GCC health insurers’ business. The pandemic dust has not quite settled yet on health insurers’ balance sheets; in the short term, policyholders’ somehow lower health services utilisation is partially compensating direct COVID-19 related costs.

In the medium term, Vathje emphasised, the trend towards digital health could have the below implications for health insurers:

Cost pressures: Viable digital health solutions will require capital investments by providers. This may create upward cost pressure on reimbursement rates. Utilisation could rise if telemedicine is lowering the barrier to entry into the health system.

Rising policyholder expectations: Consumers are realising that health delivery can become more convenient. They will scrutinise their health policies with respect to support for access to “new front doors to healthcare.”

New customer segments: It remains to be seen how quickly public GCC health providers will be able to scale up attractive digital health offerings. GCC nationals may require access to a modern front door to health services and opt into optional health policies that specifically cover private digital health channels.

Cost savings opportunity from vertical integration: Insurers may decide to offer comprehensive digital access points themselves, providing a more integrated consumer experience (regulation permitting). Studies show that more than half of primary care episodes can be taken care of remotely by telemedicine channels. Controlling the front door to health would put health insurers into a favourable position to help members navigate the most adequate pathways, ultimately removing unnecessary spend from the system.

“Agile health insurers with a willingness to invest will be able to fight the challenges and embrace the opportunities. The scale will gain in importance, so we may observe a consolidation trend in the health insurance market,” he added.

Furthermore, pent up demand will likely give speciality care (e.g., dental) and preventative screening programmes a demand boost. Elective surgeries that had been postponed during the pandemic will most likely provide utilisation support for hospitals and ambulatory surgery facilities, possibly beyond this year.

He concluded: “Across the board, I expect to see new digital offerings come to market along the care continuum. In particular, primary care and disease management programmes will benefit since digital solutions are scalable in those areas. In the expansion of ad hoc digital solutions provided during the pandemic, data integration and analysis will gain in importance – for better patient management and a more personalised experience. Insurers will support the digitisation journey, anticipating more cost-effective care pathways.”

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.