Code status documentation at admission in COVID-19 patients: a descriptive cohort study

Objectives The COVID-19 pandemic pressurised healthcare with increased shortage of care. This resulted in an increase of awareness for code status documentation (ie, whether limitations to specific life-sustaining treatments are in place), both in the medical field and in public media. However, it is unknown whether the increased awareness changed the prevalence and content of code status documentation for COVID-19 patients. We aim to describe differences in code status documentation between infectious patients before the pandemic and COVID-19 patients. Setting University Medical Centre of Utrecht, a tertiary care teaching academic hospital in the Netherlands. Participants A total of 1715 patients were included, 129 in the COVID-19 cohort (a cohort of COVID-19 patients, admitted from March 2020 to June 2020) and 1586 in the pre-COVID-19 cohort (a cohort of patients with (suspected) infections admitted between September 2016 to September 2018). Primary and secondary outcome measures We described frequency of code status documentation, frequency of discussion of this code status with patient and/or family, and content of code status. Results Frequencies of code status documentation (69.8% vs 72.7%, respectively) and discussion (75.6% vs 73.3%, respectively) were similar in both cohorts. More patients in the COVID-19 cohort than in the before COVID-19 cohort had any treatment limitation as opposed to full code (40% vs 25%). Within the treatment limitations, 'no intensive care admission' (81% vs 51%) and 'no intubation' (69% vs 40%) were more frequently documented in the COVID-19 cohort. A smaller difference was seen in 'other limitation' (17% vs 9%), while 'no resuscitation' (96% vs 92%) was comparable between both periods. Conclusion We observed no difference in the frequency of code status documentation or discussion in COVID-19 patients opposed to a pre-COVID-19 cohort. However, treatment limitations were more prevalent in patients with COVID-19, especially 'no intubation' and 'no intensive care admission'.Pathophysiology, epidemiology and therapy of agein

Modern methods in vital signs monitoring

Vital signs provide an indication of the patient's health and stability. Technological innovation, which has been boosted by the COVID-19 pandemic, creates the possibility to measure vital parameters continuously and remotely, without restricting the patient's mobility. Consequently, deterioration might be seen earlier than with current intermittent measurements. In this thesis we highlight several aspects of these modern methods of measurement. In the first part we show that a circadian rhythm can be seen in the continuously measured data, and explore how continuous data can best be summarized. Both aspects are important for the interpretation of the data and for use in prediction models. The second part shows that there is currently still a lot of variation in how doctors and nurses interpret continuous data. In addition to training, the aforementioned prediction models could help to achieve a more standardized assessment. Furthermore, we show that the use of continuous monitoring does not result in less patient visits by nurses, even though they can assess vital signs remotely. In the last part, we describe a randomized trial of a common intervention during the pandemic: hospital care at home assisted by remote monitoring. We could not demonstrate a clear gain in number of days at home in this study. Notably, only a small proportion of the patients were eligible and wanted to participate. In the last study we therefore focus on developing a similar intervention for internal medicine patients with an infection. We explore for which group of patients this could be a valuable intervention, and what care is needed to make it successful. In the discussion, reflections on the studies in this dissertation and suggestions for future research and interventions are discussed. Important points that emerge regarding continuous monitoring are: 1). Aspects of data that a predictive algorithm should take into account. 2). Ways to improve the interpretation by healthcare providers. 3). How continuous monitoring can be integrated into daily practice at the ward. Regarding hospital care at home using remote monitoring, the following topics are discussed: 1). The selection of the right patient population. 2). Providing the right intervention for the right patient population. 3). Considerations involving effectiveness and costs. Important research questions that will need to be answered in the future are discussed in the last part. Ultimately, modern vital signs measurement methods can help bring the patient even further to the center of care

Can continuous remote vital sign monitoring reduce the number of room visits to patients suspected of COVID-19: A quasi-experimental study

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