Responsive and resilient healthcare? ‘Moments of Resilience’ in post-hospitalisation services for COVID-19

Background COVID-19 caused disruption to healthcare services globally, resulting in high numbers of hospital admissions and with those discharged often requiring ongoing support. Within the UK, post-discharge services typically developed organically and were shaped over time by local need, funding, and government guidance. Drawing on the Moments of Resilience framework, we explore the development of follow-up services for hospitalised patients by considering the links between resilience at different system levels over time. This study contributes to the resilient healthcare literature by providing empirical evidence of how diverse stakeholders developed and adapted services for patients following hospitalisation with COVID-19 and how action taken at one system level influenced another. Methods Qualitative research comprising comparative case studies based on interviews. Across three purposively selected case studies (two in England, one in Wales) a total of 33 semi-structured interviews were conducted with clinical staff, managers and commissioners who had been involved in developing and/or implementing post-hospitalisation follow-up services. The interviews were audio-recorded and professionally transcribed. Analysis was conducted with the aid of NVivo 12. Results Case studies demonstrated three distinct examples of how healthcare organisations developed and adapted their post-discharge care provision for patients, post-hospitalisation with COVID-19. Initially, the moral distress of witnessing the impact of COVID-19 on patients who were being discharged coupled with local demand gave clinical staff the impetus to take action. Clinical staff and managers worked closely to plan and deliver organisations’ responses. Funding availability and other contextual factors influenced situated and immediate responses and structural adaptations to the post-hospitalisation services. As the pandemic evolved, NHS England and the Welsh government provided funding and guidance for systemic adaptations to post-COVID assessment clinics. Over time, adaptations made at the situated, structural, and systemic levels influenced the resilience and sustainability of services. Conclusions This paper addresses understudied, yet inherently important, aspects of resilience in healthcare by exploring when and where resilience occurs across the healthcare system and how action taken at one system level influenced another. Comparison across the case studies showed that organisations responded in similar and different ways and on varying timescales to a disruption and national level strategies.</p

The impact of the meta-analysis of pulmonary rehabilitation by Lacasse and colleagues: transforming pulmonary rehabilitation from “art to science”

Pulmonary rehab was transformed in the 1990s into the standard of care for COPD: this article focuses on the impact of the 1996 meta-analysis by Lacasse and colleagues which provided the evidence to silence the sceptics.</p

Breathless and awaiting diagnosis in UK lockdown for COVID-19…We’re stuck

During the COVID-19 pandemic, semi-structured interviews were undertaken with 20 adults awaiting a diagnosis for their chronic breathlessness. Three key themes were identified using thematic analysis: (1) de-prioritisation of diagnosis, (2) following UK ‘lockdown’ guidance for the general population but patients fearful they were more at risk, and (3) the impact of lockdown on coping strategies for managing breathlessness. The existing unpredictable pathway to diagnosis for those with chronic breathlessness has been further interrupted during the COVID-19 pandemic.</p

A comparison of daily physical activity profiles between adults with severe asthma and healthy controls.

Severe asthma is associated with a substantial burden of disease including premature death and reduced quality adjusted life years [1]. Care in specialist centres is associated with reduced exacerbation rates and healthcare utilisation, but at the cost of increased use of systemic steroids and increased body mass index (BMI) [2]. Common co-comorbidities such as metabolic syndrome and type 2 diabetes are associated with low levels of moderate-vigorous physical activity (MVPA) [3]. Guidelines recommend that adults accumulate either =150 minutes of moderate intensity activity or =75 minutes of vigorous intensity activity per week, accumulated in bouts of any length [4]. Adults with severe asthma may avoid MVPA due to negative expectations and fear-avoidance beliefs [5]. A few small studies have reported that daily step count and time spent in MVPA may be reduced in adults with severe asthma compared to controls [6–8]. However, results are conflicting when physical activity levels are adjusted for confounders such as age, gender, obesity and smoking [7]. Furthermore, adults with severe asthma have reduced health-related quality of life (HRQoL) but whether physical activity levels impact on HRQoL is unknown [9].</p

Submaximal eccentric cycling in people with COPD: acute whole-body cardiopulmonary and muscle metabolic responses

BackgroundEccentric cycling (ECC) may be an attractive exercise modality in COPD due to both low cardiorespiratory demand and perception of effort compared to conventional concentric cycling (CON) at matched mechanical loads. However, it is unknown whether ECC can be performed by individuals with COPD at an intensity able to cause sufficient metabolic stress to improve aerobic capacity.Research questionWhat are the cardiopulmonary and metabolic responses to ECC in people with COPD and healthy volunteers when compared to CON at matched mechanical loads?Study Designand Methods: 13 individuals with COPD (mean ± SD age 64 ± 9 years, FEV 1 %pred 45 ± 19%, BMI 24 ± 4 kg.m -2, V̇O 2peak 15 ± 3 ml.kg -1.min -1) and 9 age matched controls (FEV 1 %pred 102 ± 13%, BMI 28 ± 5 kg.m -2, V̇O 2peak 23 ± 5 ml.kg -1.min -1), performed up to six 4 min bouts of ECC and CON at matched mechanical loads of increasing intensity. In addition, 12 individuals with COPD underwent quadriceps muscle biopsies before and after 20 min of ECC and CON at 65% peak power.ResultsAt matched mechanical loads, oxygen uptake, minute ventilation, heart rate, systolic blood pressure, RER (all pInterpretationCardiopulmonary and blood lactate responses during submaximal ECC were less compared to CON at equivalent mechanical workloads in health and COPD, and this was confirmed at a muscle level in COPD. Submaximal ECC was well tolerated and allowed greater mechanical work at lower ventilatory cost. However, in people with COPD, a training intervention based on ECC is unlikely to stimulate cardiovascular and metabolic adaptation to the same extent as CON.</div

Change in V̇O2peak in response to aerobic exercise training and the relationship with exercise prescription in people with COPD: A systematic review and meta-analysis

BackgroundDespite the wide-ranging benefits of pulmonary rehabilitation, conflicting results remain regarding whether people with COPD can improve their peak oxygen uptake (O2peak) with aerobic training.Research QuestionThe goal of this study was to investigate the effect of aerobic training and exercise prescription on O2peak in COPD.Study Design and MethodsA systematic review was performed by using MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases for all studies measuring O2peak prior to and following supervised lower-limb aerobic training in COPD. A random effects meta-analysis limited to randomized controlled trials comparing aerobic training vs usual care was conducted. Other study designs were included in a secondary meta-analysis and meta-regression to investigate the influence of program and patient factors on outcome.ResultsA total of 112 studies were included (participants, N = 3,484): 21 controlled trials (n = 489), of which 13 were randomized (n = 288) and 91 were uncontrolled (n = 2,995) studies. Meta-analysis found a moderate positive change in O2peak (standardized mean difference, 0.52; 95% CI, 0.34-0.69) with the intervention. The change in O2peak was positively associated with target duration of exercise session (P = .01) and, when studies > 1 year duration were excluded, greater total volume of exercise training (P = .01). Similarly, the change in O2peak was greater for programs > 12 weeks compared with those 6 to 12 weeks when adjusted for age and sex. However, reported prescribed exercise intensity (P = .77), training modality (P > .35), and mode (P = .29) did not affect O2peak. Cohorts with more severe airflow obstruction exhibited smaller improvements in O2peak (P InterpretationOverall, people with COPD achieved moderate improvements in O2peak through supervised aerobic training. There is sufficient evidence to show that programs with greater total exercise volume, including duration of exercise session and program duration, are more effective. Reduced effects in severe disease suggest alternative aerobic training methods may be needed in this population.</div

Supplementary information files for The effect of COVID rehabilitation for ongoing symptoms post hospitalisation with COVID-19 (PHOSP-R): protocol for a randomised parallel group controlled trial on behalf of the PHOSP consortium

Supplementary files for article The effect of COVID rehabilitation for ongoing symptoms post hospitalisation with COVID-19 (PHOSP-R): protocol for a randomised parallel group controlled trial on behalf of the PHOSP consortium   Introduction: Many adults hospitalised with COVID-19 have persistent symptoms such as fatigue, breathlessness and brain fog that limit day-to-day activities. These symptoms can last over 2 years. Whilst there is limited controlled studies on interventions that can support those with ongoing symptoms, there has been some promise in rehabilitation interventions in improving function and symptoms either using face-to-face or digital methods, but evidence remains limited and these studies often lack a control group. Methods and analysis: This is a nested single-blind, parallel group, randomised control trial with embedded qualitative evaluation comparing rehabilitation (face-to-face or digital) to usual care and conducted within the PHOSP-COVID study. The aim of this study is to determine the effectiveness of rehabilitation interventions on exercise capacity, quality of life and symptoms such as breathlessness and fatigue. The primary outcome is the Incremental Shuttle Walking Test following the eight week intervention phase. Secondary outcomes include measures of function, strength and subjective assessment of symptoms. Blood inflammatory markers and muscle biopsies are an exploratory outcome. The interventions last eight weeks and combine symptom-titrated exercise therapy, symptom management and education delivered either in a face-to-face setting or through a digital platform (www.yourcovidrecovery.nhs.uk). The proposed sample size is 159 participants, and data will be intention-to-treat analyses comparing rehabilitation (face-to-face or digital) to usual care. Ethics and dissemination: Ethical approval was gained as part of the PHOSP-COVID study by Yorkshire and the Humber Leeds West Research NHS Ethics Committee, and the study was prospectively registered on the ISRCTN trial registry (ISRCTN13293865). Results will be disseminated to stakeholders, including patients and members of the public, and published in appropriate journals.   Article summary Strengths and limitations of this study • This protocol utilises two interventions to support those with ongoing symptoms of COVID-19 • This is a two-centre parallel-group randomised controlled trial • The protocol has been supported by patient and public involvement groups who identified treatments of symptoms and activity limitation as a top priority</p

Residual Lung Abnormalities Following COVID-19 Hospitalization:Interim Analysis of the UKILD Post-COVID Study

RationaleShared symptoms and genetic architecture between COVID-19 and lung fibrosis suggests SARS-CoV-2 infection may lead to progressive lung damage.ObjectivesThe UKILD Post-COVID study interim analysis was planned to estimate the prevalence of residual lung abnormalities in people hospitalized with COVID-19 based on risk strata.MethodsThe Post-HOSPitalisation COVID Study (PHOSP-COVID) was used for capture of routine and research follow-up within 240 days from discharge. Thoracic CTs linked by PHOSP-COVID identifiers were scored for percentage of residual lung abnormalities (ground glass opacities and reticulations). Risk factors in linked CT were estimated with Bayesian binomial regression and risk strata were generated. Numbers within strata were used to estimate post-hospitalization prevalence using Bayesian binomial distributions. Sensitivity analysis was restricted to participants with protocol driven research follow-up.Measurements and main resultsThe interim cohort comprised 3700 people. Of 209 subjects with linked CTs (median 119 days, interquartile range 83-155), 166 people (79.4%) had >10% involvement of residual lung abnormalities. Risk factors included abnormal chest X-ray (RR 1·21 95%CrI 1·05; 1·40), percent predicted DLcoConclusionsResidual lung abnormalities were estimated in up to 11% of people discharged following COVID-19 related hospitalization. Health services should monitor at-risk individuals to elucidate long-term functional implications. This article is open access and distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/)