key: cord-0827035-91fpqej5 authors: Alrasheed, Abdullah; Boqaeid, Abdulaziz; Rajendram, Rajkumar; Qasim, Salman; Shamou, Jinan; Baharoon, Waleed; layqah, Laila; Baharoon, Salim title: Adequacy of physician clinical rounds and nursing care elements for non-COVID-19 infected patients admitted during the COVID-19 pandemic date: 2022-04-28 journal: J Infect Public Health DOI: 10.1016/j.jiph.2022.04.004 sha: c98787c7a135b4cf63dfff219bc7b0d74eb08f7d doc_id: 827035 cord_uid: 91fpqej5 BACKGROUND: The COVID-19 pandemic created many challenges for healthcare systems. Frontline workers and especially healthcare professionals were the most severely affected through increased working hours, burnout and major psychological distress OBJECTIVES: To evaluate the changes in standard care elements which occurred during the COVID-19 pandemic, specifically the physician clinical rounds and nursing care provided to non-COVID-19 infected patients DESIGN: Observational retrospective study SETTINGS: The study was conducted at King Abdulaziz Medical City, Riyadh Saudi Arabia. KAMC is a 1200 bed tertiary care referral academic medical center. PATIENTS (MATERIALS) AND METHODS: We compared the physician clinical rounds and nursing care elements in all admissions due to non-COVID-19 pneumonia and ST elevation myocardial infarction during the lockdown period with similar admissions in a baseline period in the same weeks in the previous pre-lockdown. MAIN OUTCOME MEASURES: To evaluates the changes occurring during the COVID-19 pandemic in terms of the standard care elements, such as the physician rounds and nursing care SAMPLE SIZE: Total of 113 patients records were analyzed RESULTS: During the lock down period, a total of 113 patients were admitted to the medical and cardiology wards, (95 patients with pneumonia and 18 patients with ST segment elevation myocardial infarction (STEMI) compared to 89 patients in the pre lockdown period (74 patients with pneumonia and 15 patients with STEMI). Both groups were similar in age, gender, disposition, length of stay, goal of care planning and outcome. Chronic respiratory disease and Diabetes were more present in patients admitted on the pre lockdown time. Azithromycin was more frequently used as part of the initial antibiotic regimen for pneumonia during the pre-lockdown while doxycycline was significantly more during the lockdown. For the 95 patients admitted in the medical wards during the lockdown, there were a total of 820 physicians’ clinical rounds opportunities for senior and junior physicians each. The residents missed 133 (16.2%) and consultant missed 252 (30.7%) of those clinical rounds opportunities. Missed clinical rounds opportunities during the pre-lock down period was higher for residents and consultants at 19.3% (P= 0.429) and 36.3% respectively (P= 0.027). Similarly, missed clinical rounds opportunities was less during the lockdown period from 35.2% to 25% (p 0.022) and from 38.8% to 30.6% (p =1) for junior staff and consultant cardiology respectively compared to pre lockdown period. For nursing care elements, there was a decrease in missed opportunities in vital signs measurement (p 0.47 and p 0.226), pain assessment (p 0.088 and p 0,366) and skin care (p 0.249 and p 0.576) for patients admitted during the lockdown period in medical and cardiology wards CONCLUSIONS: Caring for patients admitted for non COVID 19 infection reasons, physicians’ clinical rounds did marginally increase compared to pre lockdown period while nurses monitoring for those patients was significantly higher. No difference in mortality was observed for patients admitted pre and during lockdown. The number of missed opportunities to do clinical rounds by physicians remains high during both periods and measures to improve adherence of physicians to performed clinical rounds are needed To evaluate the changes in standard care elements which occurred during the COVID-19 pandemic, specifically the physician clinical rounds and nursing care provided to non-COVID-19 infected patients Observational retrospective study The study was conducted at King Abdulaziz Medical City, Riyadh Saudi Arabia. KAMC is a 1200 bed tertiary care referral academic medical center. We compared the physician clinical rounds and nursing care elements in all admissions due to non-COVID-19 pneumonia and ST elevation myocardial infarction during the lockdown period with similar admissions in a baseline period in the same weeks in the previous pre-lockdown. To evaluates the changes occurring during the COVID-19 pandemic in terms of the standard care elements, such as the physician rounds and nursing care Total of 113 patients records were analyzed During the lock down period, a total of 113 patients were admitted to the medical and cardiology wards, (95 patients with pneumonia and 18 patients with ST segment elevation myocardial infarction (STEMI) compared to 89 patients in the pre lockdown period (74 patients with pneumonia and 15 patients with STEMI). Both groups were similar in age, gender, disposition, length of stay, goal of care planning and outcome. Chronic respiratory disease and Diabetes were more present in patients admitted on the pre lockdown time. Azithromycin was more frequently used as part of the initial antibiotic regimen for pneumonia during the prelockdown while doxycycline was significantly more during the lockdown. Health care systems across the world faced significant challenges during the COVID-19 pandemic including and not limited to the bed crisis, especially critical care beds, the urgent need for healthcare resource re-allocation and fear of the unknown. (1, 2). Frontline workers especially healthcare professionals were the most severely affected. Healthcare workers experienced increasing working hours, burnout and major psychological distress (3) (4) (5) (6) (7) . In addition, they had to manage their fear of being infected or infecting their J o u r n a l P r e -p r o o f family members, particularly early in the pandemic when the modes of transmission were not fully understood and the news of several healthcare workers being infected (5, (8) (9) (10) . Although some hospitals were converted to receive COVID-19 infected patients only, many continued to admit both COVID-19 infected and non-infected patients. The usual workflow and treatment protocols and procedures for non COVID 19 infected patients were modified in many disciplines to minimize exposure to COVID-19 patients (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) . Bedside rounds, patients' physical assessments and nursing care components are some essential care elements routines that could potentially have been negatively impacted during the pandemic for the non COVID 19 infected patients admitted during the pandemic. Bedside rounds are essential to review the patient's condition and communicate a plan of care to patients. In this study, we aimed to evaluate the changes occurring during the COVID-19 pandemic in terms of the standard care elements, such as the physician rounds and nursing care. This was an observational retrospective comparative study of all non-COVID-19 infection In this study, standard statistical procedures were done with the Statistical Package for Social Sciences (SPSS, version 22). Descriptive and inferential statistics have been performed for the socio-demographic and clinical variables. The categorical variables are presented as frequency and percentage with the continuous variables as mean ± standard deviation. The categorical variables were compared using a chi-square test or Fisher's exact test, as appropriate. All tests were two-tailed and significance was accepted at a p-value < 0.05. In total, 95 patients were admitted with pneumonia and 18 patients with STEMI from 14 March 2020 to 30 June 2020. In the pre-lockdown period, there were 89 admissions with pneumonia and STEMI (Pneumonia 74, STEMI 15). The patients with pneumonia admitted during lockdown were non-significantly younger (67.4 ± 20.1) vs (70.7 ± 19.9) (P = 0.163). The male to female ratio was comparable during the two periods (Table 1) . There were more patients with diabetes mellitus (p<0.001) and chronic respiratory illness admitted during the pre-lockdown period (P=0.017). The patients were admitted to a general medical ward or ICU, which were similar between the two periods (P=1). The hospital length of stay (LOS) was not significantly longer in the patients admitted with pneumonia during the lockdown (mean of 8.6 ± 4.5 vs 7.2 ± 3.8, P=1) as was the hospital mortality (Table 1) The total number of chest X ray, CT images and blood test requested for patients with pneumonia were more in the lockdown period (Table 1) . Echocardiogram request was lower during the lockdown period in both medical and cardiac patients. Choices of initial antibiotic regimens were comparable except for azithromycin and doxycycline ( Figure 2 ). The patients admitted with STEMI during the two periods were similar in terms of mean age (55.67 ± 9.74, 54.5 ± 12.2, P=0.556), male to female ratio, comorbidity distribution and location of MI ( Table 2 ). The total admission days for the 18 There were no differences in the PCI use during the two periods (P=0.190). The use of the echocardiogram was marginally lower during the lockdown (p=0. 668). Two patients received thrombolytic therapy during the lockdown, compared with none in the pre-lockdown period. The majority of the patients presented more than 90 minutes after the chest pain onset in both J o u r n a l P r e -p r o o f periods (77.8% and 86.6%). The LOS was similar during both periods (6.9 ± 3.8) and (7.2 ± 2.6), (P=0.791) Most of the current generation of healthcare providers has never experienced a situation such as the current COVID-19 pandemic. Globally, healthcare systems were stressed and some collapsed totally during the peak of the pandemic (23) . Many hospitals were converted to COVID-19 infected patients only. This alteration of healthcare resources made it more difficult for patients with other medical conditions to access healthcare (24, 25). The current study did not find a significant decrease in the number of patients admitted with non COVID 19 pneumonia and STEMI during the two periods. There were fewer patients with diabetes and chronic respiratory diseases admitted during the lockdown however. The analysis is limited only to admit patients and did not include patients presenting at the Emergency Department (ED). A significant reduction in admissions through the Emergency Room due to the COVID-19 pandemic has been reported (3, 4 ). An American College of Emergency Physicians (ACEP) survey conducted in April 2020 reported that 80% of patients had fears of contracting COVID-19 during a hypothetical visit to an ED, and 73% were concerned about placing an unnecessary burden on the healthcare system (5). Patient disposition to ICU was more during the lockdown period. Patients admitted during the lockdown could be sicker than the pre lockdown period. During the lockdown, sicker patients usually present to ER while the less sick tend to presenting because of the COVID 19 fear. Alternatively, physicians during the lockdown may be more conservative preferring to early refer patients to ICU. Antibiotic choices expectedly showed less use of azithromycin which was used more as a therapeutic option for COVID 19 pneumonia at that time and the use of doxycycline for atypical pneumonia coverage. The number of PCI done during the lockdown were less compared to pre lockdown (p= 0.190), however the small number of patient was small in both period. Other studies have shown a significant decrease in PCI in patients with MI likely to the fear of infection spread specially at the early stages of the pandemic (26). The physician rounds and nursing care elements to non-COVID-19 infected patients admitted during the lockdown both has shown improvement during the lockdown period. The physicians, both juniors and seniors, were attending to their rounds more frequently compared to prelockdown. The decrease in the missed opportunities to do clinical rounds was significant among senior physicians in the medical wards. During the lockdown, there is a mobilization of all healthcare resources. Consultants from all other subspecialty services were participating in general medicine rounds. Senior physicians presence is emphasized to help management decisions including discharge and bed management. On the nursing care elements, there was also a general improvement, the number of missed opportunities were low in both periods however. The improvement in clinical care elements early in the pandemic could be related to administrative encouragement and increased sense of engagement by primary teams. Other studies also reported that the elements of care delivered to non-COVID patients, admitted during the pandemic, were not reduced but possibly improved (27) . Hospital mortality did not differ between the two periods, which is in contrast to other studies (16) . The small number of patients included preclude from making a solid conclusion of outcome difference however. Our study has a number of limitations. The sample size is small and the duration was short (4 months). We were limited by the total duration of the lockdown applied at the city of Riyadh, J o u r n a l P r e -p r o o f Kingdome of Saudi Arabia. Our hospital is a tertiary care hospital whose main patients are of military sector (National Guard) which along with an overall internationally reported decrease in non COVID 19 related admissions may give an explanation to the small number of patients admitted during the COVID 19 lockdown. The retrospective nature of the study where information source is only the data documented in healthcare system is another important limitation. Although our findings are limited to our healthcare system, we think further quality research to address the quality and adequacy in clinical rounds in other heath sectors. Caring for patients admitted for non COVID 19 infection reasons, physicians' clinical rounds did marginally increase compared to pre lockdown period while nurses monitoring for those patients was significantly higher. No difference in mortality was observed for patients admitted pre and during lockdown. The number of missed opportunities to do clinical rounds by physicians remains high during both periods and measures to improve adherence of physicians to performed clinical rounds are needed. Ethical approval was obtained from Institutional Review Board of King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia (approval number RC20/432/R). Patient confidentiality was ensured, and the patients' data were collected and used by the research team only. Due to the retrospective nature of the study, and the use of anonymized patient data, the requirement for informed consent was waived. Admissions to Veterans Affairs Hospitals for Emergency Conditions During the COVID-19 Pandemic The Untold Toll -The Pandemic's Effects on Patients without Covid-19 Impact of coronavirus disease 2019 on healthcare workers: beyond the risk of exposure Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain, behavior, and immunity The effect of the COVID-19 pandemic on healthcare workers' mental health Health care worker burnout during the COVID-19 pandemic Moral Distress and Perceived Community Views Are Associated with Mental Health Symptoms in Frontline Health Workers during the COVID-19 Pandemic Covid-19: Don't forget the impact on US family physicians Stroke priorities during COVID-19 outbreak: acting both fast and safe Unprotected stroke management in an undiagnosed case of Severe Acute Respiratory Syndrome Coronavirus 2 infection Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment-Elevation Myocardial Infarction Care in Hong Kong Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During Delayed access or provision of care in Italy resulting from fear of COVID-19. The Lancet Child & adolescent health Assessment of trends and clinical presentation in the emergency department of patients with renal colic during the COVID-19 pandemic era COVID-19: Stroke Admissions, Emergency Department Visits, and Prevention Clinic Referrals. The Canadian journal of neurological sciences Le journal canadien des sciences neurologiques Collateral Effect of Covid-19 on Stroke Evaluation in the United States Non-COVID-19 visits to emergency departments during the pandemic: the impact of fear The Baffling Case of Ischemic Stroke Disappearance from the Casualty Department in the COVID-19 Era An Analysis of Changes in Emergency Department Visits After a State Declaration During the Time of COVID-19 Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US Effect of lockdown on the management of ischemic stroke: an Italian experience from a COVID hospital. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology Longitudinal study of interventional radiology activity in a large metropolitan Italian tertiary care hospital: how the COVID-19 pandemic emergency has changed our activity Collapse of the public health system and the emergence of new variants during the second wave of the COVID-19 pandemic in Brazil Barriers and coping mechanisms to accessing healthcare during the COVID-19 lockdown: a crosssectional survey among patients with chronic diseases in rural Rwanda Pandemic on Percutaneous Coronary Intervention in England: Insights From the British Cardiovascular Intervention Society PCI Database Cohort Providing essential clinical care for non-COVID-19 patients in a Seoul metropolitan acute care hospital amidst ongoing treatment of