The Impact of the COVID-19 Pandemic on Nursing FacilitiesThe article "Nursing Homes are Ground Zero for COVID-19 Pandemic" is the first to describe a major outbreak of SARS-CoV-2 infection in a U.S. nursing facility (NF) in Kirkland, Washington (1). Almost simultaneously, the world began learning about the large number of deaths in NFs throughout Italy and Spain (2). Close living quarters, the high incidence of cognitive impairment, the need for frequent daily caregiver interactions, and the advanced age and high comorbidity burden of NF residents, are some of the factors that have led to unmitigated disease spread. The high risk of this infection in older adults, especially those in congregate living settings, is well recognized (3,4). Although reporting of COVID-19 positive rates is now required in U.S. NFs, testing and reporting of positive rates has thus far been sporadic. Some reports now suggest that deaths of NF residents and workers may account for 35% or more of all COVID-19 deaths in the U.S. (5). New clusters of infection among NF residents could contribute to further spread outside the facility by staff, as well as potentially by visitors if visitor restrictions are relaxed. Evidence for Testing in Nursing FacilitiesAggressive testing has been a hallmark and best practice for countries to "flatten the curve" of this pandemic (6). Taking the same approach in NFs, as well as in other congregate settings such as assisted living facilities, seems essential because of the susceptibility of the population. A number of reports document the prevalence of NF outbreaks (7). Examining the characteristics of these outbreaks may provide approaches to containment and mitigation of this epidemic (8). "Unrecognized asymptomatic and pre-symptomatic infections might contribute to transmission in these settings," concluded an MMWR published on March 27 2020 (9). The article went on to state that "as testing availability improves, consideration might be given to test-based strategies for identifying (nursing

Coronavirus disease 2019 containment strategies created challenges with patient-centered ICU rounds. We examined how hybrid rounds with virtual communication added to in-person rounds could facilitate social distancing while maintaining patient-centered care. DESIGN: Continuous quality improvement.SETTING: Quaternary care referral pediatric hospital.PATIENTS: Daytime rounds conducted on PICU patients. INTERVENTIONS:Following a needs assessment survey and pilot trials, multiple technological solutions were implemented in a series of plan-do-study-act cycles. Hybrid rounds model was deployed where a videoconference platform was used to establish communication between the bedside personnel (nurse, patient/family, and partial ICU team) with remotely located remaining ICU team, ancillary, and consultant providers. Floor labels marking 6-feet distance were placed for rounders. MEASUREMENTS AND MAIN RESULTS:Outcome metrics included compliance with social distancing, mixed methods analysis of surveys, direct interviews of providers and families, and reports of safety concerns. The clinicians adopted hybrid rounds readily. Compliance with social distancing and use of floor labels needed reminders. One-hundred fourteen providers completed the feedback survey. Twenty-five providers and 11 families were interviewed. Feedback about hybrid rounds included inability to teach effectively, suboptimal audio-video quality, loss of situational awareness of patient/unit acuity, alarm interference, and inability to socially distance during other ICU interactions. Benefits noted were improved ancillary input, fewer interruptions, improved efficiency, opportunity to integrate with data platforms, and engage remote consultants and families. Nurses and families appreciated the efforts to ensure safety but wanted the ICU attending/fellow supervising the team to participate at bedside, during rounds. Clinicians appreciated the multidisciplinary input but felt that teaching was difficult. CONCLUSIONS:Hybrid rounds employed during pandemic facilitated social distancing while retaining patient-centered multidisciplinary ICU rounds but compromised teaching during rounds. A change to ingrained rounding habits needs team commitment and ongoing optimization. The hybrid rounds model has potential for generalizability to other settings.

In-hospital cardiac arrests that occur outside of the intensive care unit may require transportation during active cardiopulmonary resuscitation. Studies have shown that high-quality cardiopulmonary resuscitation is imperative for survival with preserved neurologic function. We sought to determine if high-quality cardiopulmonary resuscitation is maintained during simulated transportation of paediatric in-hospital cardiac arrest. Randomized crossover simulated study of paediatric in-hospital cardiac arrest with 10 teams composed of five providers (physicians, advanced practice providers, nurses and respiratory therapists). Teams remained in a simulation room or transported the mannequin between two rooms. The primary analysis compared chest compression fraction in stationary versus transport simulations. Secondary analyses included additional cardiopulmonary resuscitation quality metrics with comparison to the 2015 American Heart Association standards. There was no significant difference in chest compression fraction or rate between the transport and stationary groups. 92%, 72% and 26% of epochs met American Heart Association criteria for compression fraction, rate and depth, respectively. Stationary simulations were more likely to meet recommendations for combined quality metrics, including compression fraction and rate (77 vs. 53; Chest compression fraction was preserved during simulated in-hospital cardiac arrest with transport. However, the transport simulation was less likely to meet American Heart Association recommendations for combined metrics. Similar to previous cardiopulmonary resuscitation quality studies, both teams failed to meet depth requirements in the majority of simulations.

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