Introduction: Flexible bronchoscopy (FB) is a core competency for respiratory trainees. Access and experience can vary depending on level and location of training. Aims Simulation based training in FB has been shown to be a more efficient training method than the classic apprenticeship format (Naur, TMH et al. Respiration. 2017; 93(5):355-362). The course intended to improve candidates' knowledge and confidence in domains related to FB including endobronchial anatomy, sedation, indications, complications, and sampling techniques. Methods: The one day course included lectures, live FB observation and time dedicated to handling a FB simulator (ORSIM©). Pre- and post-test confidence questionnaires utilised the same 5-point Likert scales and yes-no questions. This enabled candidates to recognise specific skills gained as well as their newfound knowledge and confidence within the domains. Results: Candidates (n=11) were medical or respiratory trainees, the majority in year 3 (junior registrar). Prior exposure was limited, 82% had performed or observed fewer than 15 FB; 3 had never done either. 27% felt able to consent, sedate and intubate before the course. This increased to 100%, 82% and 91% in each skill respectively afterwards. Likert scales were converted to numerical values (1-5) for analysis. All candidates were more (or equally) confident in all assessed domains. Knowledge of sampling techniques and managing complications had the greatest increase (≥2/5). Conclusion: Live demonstration and simulation were utilised to formulate a focussed training experience. Skills acquired are directly transferrable to clinical practice enabling accelerated future development of proficiencies related to FB.

Background: Virtual wards are an increasingly important component of the NHS strategy to help early supported discharge. We present data from the COPD Virtual Hospital (VH) pathway in West Hertfordshire Teaching Hospitals NHS Trust and Herts & West Essex Integrated Care System. Methods: MDT was implemented for COPD inpatients. Patients were assessed at MDT for VH suitability and discharged with 7-days follow up: pulse oximetry monitoring, app and tablet provided, daily nursing virtual contact and consultant virtual ward round. Outcomes for VH group (n=81) were compared to non-VH group (n=792), from December 2021 to August 2022, and a standard care group (January to August 2019 admissions) (n=959). Results: Demographics were similar between VH group and a random selection of 50 patients in non-VH and standard care groups; there was no significant difference in to gender, age, co-morbidities, performance status, frailty score, spirometry (FEV1, FEV1/FVC ratio), smoking burden, home oxygen or NIV use. VH group however had more exacerbations than non-VH (p=0.037) or standard care groups (p=0.002). When comparing both VH and non-VH groups to standard care group there was a significant reduction in admissions per month (p=0.00011), readmissions within 30 days (p=0.00033) and 90 days (p = 0.00001) and fewer bed days utilised (p = 0.0006). Subgroup analysis suggested VH pathway led to a reduction in readmission within 30 days (RR 0.66, ARR 3.17%, p=0.354) and 90 days (RR 0.71, ARR 4.6%, p=0.291) compared to non-VH group, however did not reach significance. There were no deaths while on VH pathway and patient feedback was positive. Conclusion: Our data shows safety and benefit of virtual wards to assist future hospital and community care.

ObjectiveProspectively validate prognostication scores, SOARS and 4C Mortality Score, derived from the COVID-19 first wave, for mortality and safe early discharge in the evolving pandemic with SARS-CoV-2 variants (B.1.1.7 replacing D614) and healthcare responses altering patient demographic and mortality.DesignProtocol-based prospective observational cohort study.SettingSingle site PREDICT and multisite ISARIC (International Severe Acute Respiratory and Emerging Infections Consortium) cohorts in UK COVID-19 second wave, October 2020 to January 2021.Participants1383 PREDICT and 20 595 ISARIC SARS-CoV-2 patients.Primary outcome measuresRelevance of SOARS and 4C Mortality Score determining in-hospital mortality and safe early discharge in the evolving UK COVID-19 second wave.Results1383 (median age 67 years, IQR 52–82; mortality 24.7%) PREDICT and 20 595 (mortality 19.4%) ISARIC patient cohorts showed SOARS had area under the curve (AUC) of 0.8 and 0.74, while 4C Mortality Score had AUC of 0.83 and 0.91 for hospital mortality, in the PREDICT and ISARIC cohorts respectively, therefore, effective in evaluating safe discharge and in-hospital mortality. 19.3% (231/1195, PREDICT cohort) and 16.7% (2550/14992, ISARIC cohort) with SOARS of 0–1 were candidates for safe discharge to a virtual hospital (VH) model. SOARS implementation in the VH pathway resulted in low readmission, 11.8% (27/229) and low mortality, 0.9% (2/229). Use to prevent admission is still suboptimal, as 8.1% in the PREDICT cohort and 9.5% in the ISARIC cohort were admitted despite SOARS score of 0–1.ConclusionsSOARS and 4C Mortality Score remains valid, transforming complex clinical presentations into tangible numbers, aiding objective decision making, despite SARS-CoV-2 variants and healthcare responses altering patient demographic and mortality. Both scores, easily implemented within urgent care pathways for safe early discharge, allocate hospital resources appropriately to the pandemic’s needs while enabling normal healthcare services resumption.

ABSTRACTIntroductionRisk factors of adverse outcomes in COVID-19 are defined but stratification of mortality using non-laboratory measured scores, particularly at the time of pre-hospital SARS-CoV-2 testing, is lacking.MethodsMultivariate regression with bootstrapping was used to identify independent mortality predictors in a derivation cohort of COVID-19 patients. Predictions were externally validated in a large random sample of the ISARIC cohort (N=14,231) and a smaller cohort from Aintree (N=290).Results983 patients (median age 70, IQR 53-83; in-hospital mortality 29.9%) were recruited over an 11-week study period. Through sequential modelling, a 5-predictor score termed SOARS (SpO2, Obesity, Age, Respiratory rate, Stroke history) was developed to correlate COVID-19 severity across low, moderate and high strata of mortality risk. The score discriminated well for in-hospital death, with area under the receiver operating characteristic values of 0.82, 0.80 and 0.74 in the derivation, Aintree and ISARIC validation cohorts respectively. Its predictive accuracy (calibration) in both external cohorts was consistently higher in patients with milder disease (SOARS 0-1), the same individuals who could be identified for safe outpatient monitoring. Prediction of a non-fatal outcome in this group was accompanied by high score sensitivity (99.2%) and negative predictive value (95.9%).ConclusionThe SOARS score uses constitutive and readily assessed individual characteristics to predict the risk of COVID-19 death. Deployment of the score could potentially inform clinical triage in pre-admission settings where expedient and reliable decision-making is key. The resurgence of SARS-CoV-2 transmission provides an opportunity to further validate and update its performance.

Introduction We aimed to develop and validate a prediction table for a simplified measure of rightward shift of the fetal oxyhaemoglobin saturation (SpO 2 ) versus inspired oxygen pressure ( P I O 2 ) curve as an objective marker of lung disease severity in very preterm infants, independent of unit altitude or oxygen prescribing policies. Methods Very preterm infants (n=219) had an oxygen reduction test at median (IQR) test age of 35 4 (34 5 –36 0 ) weeks’ postmenstrual age (PMA). Shift was derived from at least three paired SpO 2 versus P I O 2 measurements using a computer algorithm, using the fetal oxyhaemoglobin dissociation curve as the reference. Linear regression of resultant shift values enabled construction of a table to predict shift using a single paired SpO 2 versus P I O 2 measurement, validated subsequently in a separate infant cohort using Bland-Altman analysis. Receiver operating curve analysis provided threshold values equating to a clinical diagnosis of mild bronchopulmonary dysplasia (BPD) or moderate to severe BPD. Results The median (IQR) age of 63 infants in the validation cohort was 36 0 (35 6 –36 2 ) weeks’ PMA. Mean difference (95% CI) between predicted and measured shift was 2.1 (−0.8% to 4.9%) with wide limits of agreement (−20.7% to 24.8%). Predicted shift >10.1 kPa identified mild BPD with 71% sensitivity and 88% specificity while values>13.0 kPa identified moderate to severe BPD with 81% sensitivity and 100% specificity. Discussion Shift predicted from a single paired SpO 2 versus P I O 2 measurement using our validated table enables objective bedside screening of lung disease severity in very preterm infant cohorts at 36 weeks’ PMA.

ABSTRACTObjectiveProspectively validate two prognostic scores, pre-hospitalisation (SOARS) and hospitalised mortality prediction (4C Mortality Score), derived from the coronavirus disease 2019 (COVID-19) first wave, in the evolving second wave with prevalent B.1.1.7 and parent D614 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants, in two large United Kingdom (UK) cohorts.DesignProspective observational cohort study of SOARS and 4C Mortality Score in PREDICT (single site) and multi-site ISARIC (International Severe Acute Respiratory and Emerging Infections Consortium) cohorts.SettingProtocol-based data collection in UK COVID-19 second wave, between October 2020 and January 2021, from PREDICT and ISARIC cohorts.Participants1383 from single site PREDICT cohort and 20,595 from multi-site ISARIC cohort.Main outcome measuresRelevance of SOARS and 4C Mortality Score derived from the COVID-19 first wave, determining in-hospital mortality and safe discharge in the UK COVID-19 second wave.ResultsData from 1383 patients (median age 67y, IQR 52-82; mortality 24.7%) in the PREDICT and 20,595 patients from the ISARIC (mortality 19.4%) cohorts showed both SOARS and 4C Mortality Score remained relevant despite the B.1.1.7 variant and treatment advances. SOARS had AUC of 0.8 and 0.74, while 4C Mortality Score had an AUC of 0.83 and 0.91 for hospital mortality, in the PREDICT and ISARIC cohorts respectively, therefore effective in evaluating both safe discharge and in-hospital mortality. 19.3% (231/1195, PREDICT cohort) and 16.7% (2550/14992, ISARIC cohort) with a SOARS of 0-1 were potential candidates for home discharge to a virtual hospital (VH) model. SOARS score implementation resulted in low re-admission rates, 11.8% (27/229), and low mortality, 0.9% (2/229), in the VH pathway. Use is still suboptimal to prevent admission, as 8.1% in the PREDICT cohort and 9.5% in the ISARIC cohort were admitted despite SOARS score of 0-1.ConclusionSOARS and 4C Mortality Score remains valid, providing accurate prognostication despite evolving viral subtype and treatment advances, which have altered mortality. Both scores are easily implemented within urgent care pathways with a scope for admission avoidance. They remain safe and relevant to their purpose, transforming complex clinical presentations into tangible numbers, aiding objective decision making.Trial registrationNHS HRA registration and REC approval (20/HRA/2344, IRAS ID 283888).