Blockchain Papers

Abdulhammed Opeyemi Babatunde, Taofeeq Oluwatosin Togunwa, Olutola Awosiku, Mohd Faizan Siddiqui · 8 authors

OPINION article Front. Public Health, 24 October 2022Sec. Digital Public Health Volume 10 - 2022 | https://doi.org/10.3389/fpubh.2022.1024203

Sam Arman, Michael E. Hopkins, Simon McKean

In the United Kingdom, at the outbreak of the COVID-19 pandemic in March 2020, the national health service (NHS) took the unprecedented step of restructuring all of its services and workforce to cope with the expected influx of infected patients.1 Following a UK-wide lockdown and implementation of strict government guidelines, rates of COVID-19 infection reduced significantly and there was hope of a return to normal practice. However, the risks of exposure to the Sars-Cov2 virus to patients and healthcare staff remained. These risks were acutely felt amongst otolaryngologists due to the prevalence of the virus in the nose and throat in both symptomatic and asymptomatic patients.2 A significant number of extra measures and precautions were introduced to mitigate the potential spread of the virus amongst patients and healthcare staff during surgery. This was predicted to reduce the efficiency of surgical lists and limit the ability of departments to clear the backlog of patients awaiting surgery.3 The aim of this study was to investigate whether elective otolaryngology surgical services could return to pre-pandemic levels in an area where cases of COVID-19 infection were expected to, and indeed did, remain far below national rates. Retrospective and prospective data were collected for all fixed-term otolaryngology consultants at a single rural hospital during the period of 1 August-28 February for 2019/20 and 2020/21. Data recorded included number of theatre lists, number of planned (PLO) and performed operations (PFO), number of cancellations and reasons for cancellation. Data were also collected regarding the number of COVID-19 infections per week during 2020/21 at local and national levels. Statistical analysis was performed using SPSS statistical software and Chi-squared testing was used to compare categorical data. Our hospital trust covers a population of approximately 235 000 people with a population density of 8 people/Km2. The department normally performs approximately 1500 operations per year. Over the 2-year period, there were three substantive consultants performing surgery in the following sub-specialties: Otology, Rhinology, General ENT, General Paediatric ENT, Paediatric airway and Thyroid and Parathyroid surgery. The department also provides facial plastics services for the removal of all benign and malignant skin lesions from the head and neck under local anaesthetic. All surgical lists were planned and booked in advance by the operating consultant. At the beginning of August 2020, all ENT elective surgery was allowed to restart. New hospital protocols were introduced for all elective procedures under general anaesthetic (GA). These included patient shielding for a minimum of 2 weeks prior to surgery, a negative COVID-19 PCR test, mandatory FFP3 masks for all aerosol-generating procedures (AGPs) and fallow time following extubation. Our primary objective was to see whether normal ENT elective services could restart to pre-pandemic levels; this was interrupted by a surge in COVID-19 infections in December 2020 as all non-urgent surgery was cancelled. We therefore analysed the period 1 August-30 November (interwave recovery [IR]) and the period 1 December-28 February (second wave [SW]) with the previous year. There were zero cases of COVID-19 infection reported locally or nationally in August-February 2019/20. In 2020/21, there were 2949 cases of COVID-19 infection in our local authority area.4 This represents 0.07% of the 3 868 809 cases reported in the United Kingdom over the same period.5 The trend in the 7-day positive rate during this period at local and national levels is demonstrated in the graph (Figure 1). From 1 August 2019 to 28 February 2020, there were 123 planned theatre sessions compared to 111 in 2020/21 with the number of operations planned dropping from 4.5 to 4.1 per session. The total numbers of PLO, PFO and local anaesthetic skin procedures (LASP) are demonstrated in Table 1. In the year prior to COVID-19, 81% of PLO were performed and this was 9% higher than the second year, and this falls to a 5% decrease during the IR period. Overall, there was a 31.2% reduction in the number of PFO, and again, this falls in the IR to a 4.1% (144 vs. 138) decrease year on year. However, there were 1.8 operations performed per session during the IR in 2020/21 compared to 2.2 in 2019/20. There was a significant increase in the number of local anaesthetic skin procedures (LASP) in 2020/21 (p ≤ .00001) and this accounted for 27% of PFO in the IR compared to 6% the previous year. If we exclude LASP, there was a 26.1% decrease in the number of GA procedures performed between August and November year on year. There was a significant increase in the number of cancelled operations in 2020/21 compared to 2019/20 (p = .011); however, during August-November, there was no significant increase (p = .259). In 2019/20, 19% of PLO were cancelled compared to 28.3% in 2020/21. This percentage drops when analysing the IR (22%) to the same period in 2019/20 (17%). Overall, this represents a 15.5% increase in the number of cancellations and equates to a cancellation every 1.8 operational sessions; however, during the IR, this relates to a cancellation every 2.0 operational sessions. The reasons for cancelled operations are categorised and are shown in Figure 2. Our study shows that there has been a change in ENT elective surgical provision at our hospital since its re-introduction. It is unclear why fewer procedures were planned per list in 2020/21, but may possibly represent the expected delays caused by changes in standard operating procedures in response to the pandemic. These changes have been seen globally with the introduction of donning and doffing of personal protective equipment (PPE), the adaptation of theatres to protect essential apparatus from contamination and the refinement of surgical techniques to reduce the risk of transmission.6 The 31.2% reduction in PFO during 2020/21 can be mainly attributed to the second wave and the cancellation of all non-urgent surgery from the end of December 2020. During the IR period, there was a 4.1% decrease in PFO; however, on a per-session basis, this equates to an 18.1% reduction. This suggests that during periods of low community COVID-19 transmission, elective services are still unable to return to pre-pandemic levels. The reasons for this are likely multifactorial; however, the impact of wearing PPE during surgery cannot be underestimated, as it is known to affect surgical performance and non-technical skills.7 The return of near-normal operating surgical volume during the IR period may be explained by the significant increase in the number of LASP, as this accounted for 27% of all PFO. This significant increase (p ≤ .00001) is important as without LASP, the number of PFO would likely have dropped further, as LASP were not required to isolate pre-operatively or undergo covid-19 PCR testing as were not deemed AGPs. Consequently, last-minute vacancies left by cancellations could be filled at short notice. We found a significant increase in the number of operations cancelled in 2020/21 (p = .011). This was expected with a surge of COVID-19 during the winter months, as there was no significant increase in cancellations seen between August and November. We can therefore assume that during periods of low community transmission, hospital capacity is not affected and patients are willing to undergo surgery despite the extra safety and shielding requirements. Despite low numbers of community infections, necessary safety protocols have reduced the efficiency of surgical lists and their ability to adapt to change. The current NHS elective waiting list currently stands at over 4.5 million patients8 and previous studies have estimated that clearing a backlog of cases created by the pandemic may take 84 weeks, but this assumes activity returning at 110% of pre-pandemic levels.9 Our study suggests that this level of activity would be difficult to attain in otolaryngology and therefore we would expect clearance of waiting lists to take significantly longer. We suggest extensive triaging of patients on long waiting lists to ensure that procedures are still clinically indicated, as it is likely that in some cases, such as otitis media with effusion, criteria for intervention may no longer be met. However, we recognise that sufficient time will need to be provided to clinicians in order to facilitate this effectively. Surgical trainees across all specialties have been adversely affected by the pandemic with a significant reduction in operative experience and a greater than 50% reduction in logbook numbers.10 This has resulted in GMC-approved curriculum derogations by the joint committee on surgical training (JCST) to enable the progression of trainees at all levels.11 Our study has demonstrated that a rapid return to pre-pandemic activity is unlikely in the near-term even as rates of COVID-19 infection fall following a successful vaccination programme. The challenges trainees have faced in gaining sufficient operative experience will likely continue, although improve from present. This is important to acknowledge, as it will have implications for trainees attaining Certification of Completion of Training (CCT) this year and in the future. The study has its limitations. A lower-than-average number of COVID-19 cases cannot be assumed to have had less of an impact on the hospital providing ENT elective services. A smaller population and a smaller number of hospital beds available would mean even small increase in the 7-day positive rate could potentially impact the hospital's ability to provide elective surgery. Due to a lack of full-time substantive consultants, we were only able to compare a small number directly year to year. Our hospital was also without a full-time head & neck consultant during the second year and this meant sending patients to other centres in order to facilitate their care. The policies and guidelines implemented prior to restarting elective surgery were based on the best practice at that time and may not reflect advances in knowledge and the impact vaccination may have on future elective services. Low rates of COVID-19 infection do not necessarily mean that ENT elective services can return to pre-COVID levels. Implementation of new safety protocols to protect patients and staff has reduced the efficiency and speed at which elective ENT surgery can be delivered. This is likely to continue to impact waiting lists at a time when surgical activity is needed to exceed pre-pandemic levels. It is likely that workloads will increase, as extra theatre lists become more commonplace; however, in order to clear the backlog, NHS trusts will need to become more innovative in their approach. None. This study took the form of an audit, so National Research Ethics Service approval was not required. The local audit department approved the study. Sam Arman: Project lead involved with design, data collection and data analysis. Michael Hopkins: Involved with data analysis, editing and proofing final submission. Simon McKean: Project supervisor, involved with editing final publication None.

Antonio Fusco, Grazia Dıcuonzo, Vittorio Dell’Atti, Marco Tatullo

The SARS-CoV2 pandemic has impacted risk management globally. Blockchain has been increasingly applied to healthcare management, as a strategic tool to strengthen operative protocols and to create the proper basis for an efficient and effective evidence-based decisional process. We aim to validate blockchain in healthcare, and to suggest a trace-route for a COVID19-safe clinical practice. The use of blockchain in combination with artificial intelligence systems allows the creation of a generalizable predictive system that could contribute to the containment of pandemic risk on national territory. A SWOT analysis of the adoption of a blockchain-based prediction model in healthcare and SARS-CoV-2 infection has been carried out to underline opportunities and limits to its adoption. Blockchain could play a strategic role in future digital healthcare: specifically, it may work to improve COVID19-safe clinical practice. The main concepts, and particularly those related to clinical workflow, obtainable from different blockchain-based models have been reported here and critically discussed.

Jeannine W.C. Blake, Karen K. Giuliano

In late 2019 the novel coronavirus disease 2019 (COVID-19) emerged in China, causing severe respiratory illness with persistent person-to-person transmission.1–3 The first diagnosed case in the United States was reported in late January, sparking an initial US public health response that included restricted travel, traveler screening, and required quarantine.1 Because of the growing number of cases, the World Health Organization (WHO) declared a global health emergency on January 30, 2020; on March 11, 2020, the WHO issued a pandemic declaration.4,5 With the disease showing a high transmission rate, atypical symptoms, high rates of mortality, and documented transmission from patient to health care worker, fear grew as countries hurried to prepare.3When a previously unknown pathogen causes an epidemic rate of infection, the success of national health systems relies on reserves of health care supplies and their appropriate allocation.4 Effective distribution, training, and use of personal protective equipment (PPE) is key to preventing spread between patients and health care workers.4 In the setting of COVID-19, PPE that was once taken for granted as a disposable commodity quickly became a treasured resource to maintain the personal health and safety of health care workers.4Patients who contract COVID-19 experience a wide spectrum of symptom severity that requires care ranging from at-home symptom management to inpatient intensive care.6 The COVID-19 pandemic introduced a need to increase hospital intensive care capacity rapidly in order to be able to provide adequate care for the patients presenting with this disease.2 Although SARS-CoV-2, the virus that causes COVID-19, is primarily transmitted via droplets, aerosol-generating procedures can cause the virus to remain in the air for up to 3 hours and be infective through simple inhalation.7,8 Aerosol-generating procedures performed on patients positive for COVID-19 present an elevated infection risk for health care workers.5,8 Most studies suggest that aerosol-generating procedures include preintubation ventilation, intubation, tracheostomy, open-airway suctioning, cardiopulmonary resuscitation, and noninvasive ventilation.8In order to provide the complex care required by critically ill patients infected with the highly contagious SARS-CoV-2, frontline clinicians have had to implement practice changes to address patient care needs while simultaneously conserving PPE and reducing personal exposure risk. One of the resultant practice changes was to move medical devices, most commonly intravenous (IV) infusion pumps, away from the bedside and into the anterooms or hallways outside of patient rooms. This article aims to provide nurses with the information needed to support clinical decision-making during IV infusion therapy when IV infusion devices are located away from the patient bedside.Adversity drives people to change habits, adjust protocols, and innovate. In the case of COVID-19, the scarcity of PPE pushed health care workers to conserve and make do with what was available. As a result, health care workers were quickly required to balance unimaginable clinical demands for the sickest patients while also preserving personal safety.In intensive care units (ICUs), where the most-critical patients go for care, aerosol-generating procedures are required frequently and, in some cases, continuously. To mitigate the risk of exposure and effectively manage the use and conservation of PPE, the doors to patient rooms must be kept closed, and nurses and other clinicians must limit contact frequency and time in COVID-19 isolation rooms. With the doors closed and PPE required to enter, nurses are unable to enter into patient rooms quickly or easily to manage the multiple lines and infusions required to care for critically ill patients. For very sick patients, even a brief pause in a life-sustaining infusion from an occlusion, air in the line, or the completion of a medication bag can have dire consequences. Because infusion pumps cannot be controlled without direct device interaction, the use of longer-than-usual extension tubing allows for placement and operation of the pumps outside of patient rooms. This practice has been rapidly adopted for care of critically ill patients with COVID-19 and is permitted by the US Food and Drug Administration (FDA) for the duration of this public health emergency under Emergency Use Authorization.9 One goal of this FDA policy is to “help foster technologies that maintain a safer physical distance between the health care provider and patient affected by COVID-19.”9 A modification that the FDA determines would not create undue risk is “remote monitoring and/or manual control of infusion pumps to manage the care of a patient without physically entering a patient’s room.”9The complex care of critically ill patients often requires the simultaneous administration of multiple IV medications using large-volume IV smart pumps (IVSPs). Under normal circumstances, most IVSPs are located at the bedside only a few feet from the patient, where the nurse can see the patient and the pump when administering and adjusting medications. Frequent nursing intervention is necessary to manage concurrent IV medication administration, including infusion titrations, bolus/loading of medication doses, and intermittent medication dosing. Nursing intervention is also necessary to ensure that the correct volume of each individual infusion is completely delivered through the lengthy extension tubing. Managing IVSPs outside the rooms of patients with COVID-19 may also entail infusing multiple compatible medications together to reduce the use of extension tubing and the potential need to attend to frequent nuisance alarms or other tasks necessary to ensure continuous flow. Even when IVSPs are located at the bedside, IV infusion is associated with high rates of adverse drug events and medication errors, many of which can be life threatening.10 Remote IV infusion also makes it more difficult to verify patient identity during dual nurse medication checks. Operation of the IVSP in these circumstances is intricate, requires high levels of cognitive attention, and can be error prone.10,11 Nurses must recognize the potential for error associated with IV infusion under normal circumstances and keep in mind the added risk when moving the IVSPs farther from the patient, especially when both cannot be seen concurrently.Moving IVSPs outside of patient rooms requires modifications to allow the IV tubing to reach the patient; the Figure includes images of real-world use and modifications. Various methods for increasing the length of IV tubing are now being used so patients can continue to receive their medications even while the IVSPs are placed outside the room at distances of 15 feet or more. Placing the pumps outside the rooms improves nursing workflow when managing patients with COVID-19 in isolation, allows for easier interaction with the IVSP, and helps reduce risk of exposure for the nurses. Although this practice can be effective in helping to manage competing patient care demands, it is important for nurses to understand the safety implications in order to ensure that medications are still being delivered as expected.BD Alaris, Baxter Sigma, B. Braun Space Series, and ICU Medical Plum Series are the 4 most commonly used IVSPs in US acute care. The BD Alaris, Baxter Sigma, and B. Braun IVSPs use peristaltic pump technology to infuse fluid, whereas the ICU Medical Plum Series pumps use cassette-based volumetric technology. The Ivenix IVSP, which is not yet in clinical use but has recently received FDA approval, also uses cassette-based volumetric technology. A peristaltic pump uses rollers to propel fluid forward by pinching down on the length of tubing.12,13 Cassette-based pumps contain a flow regulator and a set of valves to administer fluids properly.13,14 Refer to the Table for additional definitions and technology features.With peristaltic IVSPs, flow rate accuracy of the pumping segment is impacted by variations in system resistance in the form of intake and outlet pressures.14 When intake pressure decreases and/or outlet pressure increases during IV medication administration, decreases in both flow rate and flow rate accuracy will occur.14 Most troubling is that the IVSP will continue to display the intended flow rate, making these errors extremely difficult to detect. When volumetric delivery is provided by cassette-based systems (eg, ICU Medical Plum Series or Ivenix IVSPs) the IV infusion is delivered at the programmed rate regardless of system resistance.14In addition to changes in system resistance, increasing the tubing length between the IVSP and patient presents additional challenges that must be considered. There is a significant increase in tubing dead volume, increased priming requirements, and elevated risk for air in line and medication adhering to the tubing because of increased tubing surface area. All of these factors can lead to portions of medication doses being left nonadministered or underinfused, which presents various safety concerns for the patient. Overinfusion may also be a concern in the setting of large amounts of medication left in the dead volume and then subsequently flushed into the patient at a higher-than-intended flow rate. A discussion of clinical implications, ways to mitigate effects, and dosing considerations is provided in the Table.New practice norms will no doubt continue to develop to address the complex care requirements for patients with COVID-19. The remote use of IVSPs addresses many salient clinical and workflow issues. As the primary users of IVSPs, nurses must be aware of the impact of this practice on the accuracy of IV medication administration and the increased potential for error. The most important aspects of IV medication administration should be patient safety, delivery of medication dosing as intended, and achievement of the desired therapeutic effect and/or measurable patient outcome. Improved understanding of the impact of remote IVSP system set-up can help the health care team make more informed decisions for individual patients and situations. With education and continued vigilance regarding the implications these changes can have, nurses can take steps to decrease risk of flow inaccuracy and other complications to support the safest and most accurate remote IVSP medication administration practices.The authors wish to thank Michelle Mandrack, MSN, RN, Director of Consulting Services for the Institute for Safe Medication Practices, for her generosity and expertise in providing a review of this brief report. Also thanks to to Robert Butterfield of RDB Consulting for his ongoing willingness to share his expertise.