CLUE: COVID‐19 lung ultrasound in emergency department

Lung ultrasound (LUS) plays a critical role in the SARS‐CoV‐2 pandemic. Evidence is mounting on its utility to diagnose, assess the severity and as a triage tool in the ED. Sonographic features correlate well to computed tomography (CT) chest findings and a bedside LUS performed by a trained clinician along with clinical examination, could be an alternative to chest X‐ray and CT chest in these highly infectious patients. In this article, we have described a step‐by‐step approach to LUS in COVID patients and the CLUE (COVID‐19 LUS in the ED) protocol, which involves an anatomical parameter, the severity of lung changes, objectively scored using the validated LUS scoring system and a physiological parameter, oxygen requirement. We believe this CLUE protocol can help risk‐stratify patients presenting to ED with suspected COVID‐19 and aid clinicians in making appropriate disposition decisions.     

Informing emergency care for COVID‐19 patients: The COVID‐19 Emergency Department Quality Improvement Project protocol

Objectives: There is an urgency to support Australian ED clinicians with real‐time tools as the COVID‐19 pandemic evolves. The COVID‐19 Emergency Department (COVED) Quality Improvement Project has commenced and will provide flexible and responsive clinical tools to determine the predictors of key ED‐relevant clinical outcomes. Methods: The COVED Project includes all adult patients presenting to a participating ED and meeting contemporary testing criteria for COVID‐19. The dataset has been embedded in the electronic medical record and the COVED Registry has been developed. Results: Outcomes measured include being COVID‐19 positive and requiring intensive respiratory support. Regression methodology will be used to generate clinical prediction tools. Conclusion: This project will support EDs during this pandemic.     

A qualitative analysis of nursing students' tweets during the COVID‐19 pandemic

The COVID‐19 outbreak has profoundly changed daily life and the ways in which students learn and interact. This study explores the nature and content of tweets posted by students enrolled in nursing programs (hereafter nursing students) in the United Kingdom, the United States, and South Korea during the COVID‐19 pandemic between March 4 and April 7, 2020. A total of 8856 tweets from the Twitter accounts of 95 self‐identified nursing students were included in our qualitative analysis. The findings revealed five categories of tweet content: (i) reactions to COVID‐19; (ii) everyday life; (iii) role as a student; (iv) social connections; and (v) sociopolitical issues. Students shared concerns about the impact of COVID‐19 on their education, discussed their experiences as nursing students, tweeted details of their daily lives, and sought social connections for support as well as for information sharing. The findings of this study can inform nurse educators to better understand their students' responses to and sentiments about the COVID‐19 pandemic. Nurse educators should incorporate this understanding into curricula for pandemic preparedness and response efforts.     

Coagulopathy in COVID‐19

The COVID‐19 pandemic has become an urgent issue in every country. Based on recent reports, the most severely ill patients present with coagulopathy, and disseminated intravascular coagulation (DIC)‐like massive intravascular clot formation is frequently seen in this cohort. Therefore, coagulation tests may be considered useful to discriminate severe cases of COVID‐19. The clinical presentation of COVID‐19‐associated coagulopathy is organ dysfunction primarily, whereas hemorrhagic events are less frequent. Changes in hemostatic biomarkers represented by increase in D‐dimer and fibrin/fibrinogen degradation products indicate the essence of coagulopathy is massive fibrin formation. In comparison with bacterial‐sepsis‐associated coagulopathy/DIC, prolongation of prothrombin time, and activated partial thromboplastin time, and decrease in antithrombin activity is less frequent and thrombocytopenia is relatively uncommon in COVID‐19. The mechanisms of the coagulopathy are not fully elucidated, however. It is speculated that the dysregulated immune responses orchestrated by inflammatory cytokines, lymphocyte cell death, hypoxia, and endothelial damage are involved. Bleeding tendency is uncommon, but the incidence of thrombosis in COVID‐19 and the adequacy of current recommendations regarding standard venous thromboembolic dosing are uncertain.     

Electronic medical record platform enhancements during COVID‐19 to support identify‐isolate‐inform strategy for initial detection and management of patients

Singapore was one of the earliest countries affected by COVID‐19, outside China. EDs in Singapore faced a surge of confirmed cases of COVID‐19 patients, which stretched their resources. Here we describe how we adopted strategic changes using the identify‐isolate‐inform tool to improve the evaluation, treatment and management of COVID‐19 patients. During this pandemic, information technology integration, modifications to the electronic medical record and essential enhancements to the dashboard were implemented in a timely manner to match the clinical needs. Considerations for an isolation facility within an ED are especially important for future outbreaks.     

COVID‐19 and acute coagulopathy in pregnancy

We present a putative link between maternal COVID‐19 infection in the peripartum period and rapid maternal deterioration with early organ dysfunction and coagulopathy. The current pandemic with SARS‐CoV‐2 has already resulted in high numbers of critically ill patients and deaths in the non‐pregnant population, mainly due to respiratory failure. During viral outbreaks, pregnancy poses a uniquely increased risk to women due to changes to immune function, alongside physiological adaptive alterations, such as increased oxygen consumption and edema of the respiratory tract. The laboratory derangements may be reminiscent of HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, and thus knowledge of the COVID‐19 relationship is paramount for appropriate diagnosis and management. In addition to routine measurements of D‐dimers, prothrombin time, and platelet count in all patients presenting with COVID‐19 as per International Society on Thrombosis and Haemostasis (ISTH) guidance, monitoring of activated partial thromboplastin time (APTT) and fibrinogen levels should be considered in pregnancy, as highlighted in this report. These investigations in SARS‐CoV‐2‐positive pregnant women are vital, as their derangement may signal a more severe COVID‐19 infection, and may warrant pre‐emptive admission and consideration of delivery to achieve maternal stabilization.     

Job satisfaction and subjective well‐being among Czech nurses

The aim of the present study was to investigate the relationship between domains of the job satisfaction and components of subjective well‐being in nurses. A convenience sample of hospital nurses was recruited from six hospitals in Czech Republic. Data were collected using a set of questionnaires that included the McCloskey/Mueller Satisfaction Scale, the Positive Affect Scale, the Negative Affect Scale and the Personal Well‐being Index. We confirmed low association between job satisfaction and subjective well‐being of nurses. Satisfaction with extrinsic rewards, co‐workers and family/work balance accounted for only a small percentage of variance in cognitive component of subjective well‐being. Positive affect was predicted by interaction opportunities and scheduling. Negative affect was predicted by interaction opportunities and scheduling and intention to leave the actual workplace. Low percentage of the variance suggests that subjective well‐being is not strongly influenced by job satisfaction.     

Fibrinolysis and COVID‐19: A plasmin paradox

The COVID‐19 pandemic has provided many challenges in the field of thrombosis and hemostasis. Among these is a novel form of coagulopathy that includes exceptionally high levels of D‐dimer. D‐dimer is a marker of poor prognosis, but does this also imply a causal relationship? These spectacularly raised D‐dimer levels may actually signify the failing attempt of the fibrinolytic system to remove fibrin and necrotic tissue from the lung parenchyma, being consumed or overwhelmed in the process. Indeed, recent studies suggest that increasing fibrinolytic activity might offer hope for patients with critical disease and severe respiratory failure. However, the fibrinolytic system can also be harnessed by coronavirus to promote infectivity and where antifibrinolytic measures would also seem appropriate. Hence, there is a clinical paradox where plasmin formation can be either deleterious or beneficial in COVID‐19, but not at the same time. Hence, it all comes down to timing.     

An economic evaluation of water birth: the cost‐effectiveness of mother well‐being

Purpose To assess the cost‐effectiveness of water compared with normal land delivery. Methods A retrospective controlled study was conducted over a two‐year period in a Northern Italian hospital. The cohort included all the 110 women who completed a water birth and 110 women who had a land birth during the same period. The two groups were compared with respect to labour duration, perineal tear and newborn's health status. The economic evaluation adopted a cost‐effectiveness approach in relation to presence/absence of perineal tears. Results In the water delivery group 58 women (52.7%) experienced at least one perineal tear versus 80 (72.7%) in the traditional delivery group. The mean duration of labour was similar in the two groups. Neonatal well‐being, expressed as Apgar score, did not differ significantly among the two groups at the first minute (9.48 vs. 9.28) and was slightly higher at 5 minutes in the water delivery group (9.95 vs. 9.84; P = 0.0269). Water delivery was found to be both more costly [ΔC = €279; 95% confidence interval (CI): 262–296] and more effective in terms of avoided perineal tears. The incremental health care cost per avoided perineal tear because of water delivery was estimated of €1395.7 (95% CI: 1049.2–3608.5). Conclusion Water birth, as compared with traditional delivery, allows for an increase in maternal well‐being and is cost‐effective.