Association between prehospital prognostic factors and out-of-hospital cardiac arrest: Effect of rural–urban disparities

BackgroundOut-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis and a highly variable survival rate. Few studies have focused on outcomes in rural and urban groups while also evaluating underlying diseases and prehospital factors for OHCAs.ObjectiveTo investigate the relationship between the patient's underlying disease and outcomes of OHCAs in urban areas versus those in rural areas.MethodsWe reviewed the emergency medical service (EMS) database for information on OHCA patients treated between January 2015 and December 2019, and collected data on pre-hospital factors, underlying diseases, and outcomes of OHCAs. Univariate and multivariate logistic regression analyses were used to evaluate the prognostic factors for OHCA.ResultsData from 4225 OHCAs were analysed. EMS response time was shorter and the rate of attendance by EMS paramedics was higher in urban areas (p < 0.001 for both). Urban area was a prognostic factor for >24-h survival (odds ratio [OR] = 1.437, 95% confidence interval [CI]: 1.179–1.761). Age (OR = 0.986, 95% CI: 0.979–0.993). EMS response time (OR = 0.854, 95% CI: 0.811–0.898), cardiac arrest location (OR = 2.187, 95% CI: 1.707–2.795), attendance by paramedics (OR = 1.867, 95% CI: 1.483–2.347), and prehospital defibrillation (OR = 2.771, 95% CI: 2.154–3.556) were independent risk factors for survival to hospital discharge, although the influence of an urban area was not significant (OR = 1.211, 95% CI: 0.918–1.584).ConclusionsCompared with rural areas, OHCA in urban areas are associated with a higher 24-h survival rate. Shorter EMS response time and a higher probability of being attended by paramedics were noted in urban areas. Although shorter EMS response time, younger age, public location, defibrillation by an automated external defibrillator, and attendance by Emergency Medical Technician-paramedics were associated with a higher rate of survival to hospital discharge, urban area was not an independent prognostic factor for survival to hospital discharge in OHCA patients.     

Prevalence of burnout risk and factors associated with burnout risk among ICU nurses during the COVID-19 outbreak in French speaking Belgium

ObjectiveBurnout is a global work-related phenomenon. Intensive care unit (ICU) nurses are at risk of burnout and the COVID-19 pandemic may increase this risk. The objectives of this study were to assess the prevalence of burnout risk and identify risk factors among ICU nurses during the COVID-19 pandemic.Research methodologyWeb-based survey performed during the first wave of the COVID-19 pandemic in French speaking Belgium.Main outcome measuresRisk of burnout was assessed with the Maslach Burnout Inventory scale.ResultsA total of 1135 ICU nurses responded to the questionnaire. The overall prevalence of burnout risk was 68%. A total of 29% of ICU nurses were at risk of depersonalisation (DP), 31% of reduced personal accomplishment (PA), and 38% of emotional exhaustion (EE). A 1:3 nurse-to-patient ratio increased the risk of EE (OR = 1.77, 95% CI: 1.07–2.95) and DP (OR = 1.38, 95% CI: 1.09–2.40). Those who reported having a higher perceived workload during the COVID-19 pandemic were at higher risk for all dimensions of burnout. Shortage of personal protective equipment increased the risk of EE (OR = 1.78, 95% CI: 1.35–3.34) and nurses who reported having symptoms of COVID-19 without being tested were at higher risk of EE (OR = 1.40, 95% CI: 1.68–1.87).ConclusionsTwo-thirds of ICU nurses were at risk of burnout and this risk was associated with their working conditions during the first wave of the COVID-19 pandemic. We recommend monitoring the risk of burnout and implementing interventions to prevent and manage it, taking into account the factors identified in this study.     

Changes in Field Termination of Resuscitation and Survival Rates After an Educational Intervention to Promote on Scene Resuscitation for Out-of-Hospital Cardiac Arrest

BackgroundEmergency medical services (EMS) agencies with higher field termination-of-resuscitation (TOR) rates tend to have higher survival rates from out-of-hospital cardiac arrest (OHCA). Whether EMS agencies can improve survival rates through efforts to focus on resuscitation on scene and optimize TOR rates is unknown.ObjectiveThe goal of this study was to determine if an EMS agency's efforts to enhance on-scene resuscitation were associated with increased TOR and OHCA survival with favorable neurologic outcome.MethodsA single-city, retrospective analysis of prospectively collected 2017 quality assurance data was conducted. Patient demographics, process, and outcome measures were compared before and after an educational intervention to increase field TOR. The primary outcome measure was survival to hospital discharge with favorable neurologic status.ResultsThere were 320 cases that met inclusion criteria. No differences in age, gender, location, witnessed arrest, bystander cardiopulmonary resuscitation, initial shockable rhythm, or presumed cardiac etiology were found. After the intervention, overall TOR rate increased from 39.6% to 51.1% (p = 0.06). Among subjects transported without return of spontaneous circulation (ROSC), average time on scene increased from 26.4 to 34.2 min (p = 0.02). Rates of sustained ROSC and survival to hospital admission were similar between periods. After intervention, there was a trend toward increased survival to hospital discharge rate (relative risk [RR] 2.09; 95% confidence interval [CI] 0.74–5.91) and an increase in survival with favorable neurologic status rate (RR 5.96; 95% CI 0.80–44.47).ConclusionThis study described the association between an educational intervention focusing on optimization of resuscitation on scene and OHCA process and outcome measures. Field termination has the potential to serve as a surrogate marker for aggressively treating OHCA patients on scene.     

Caregivers' Willingness to Accept Expedited Vaccine Research During the COVID-19 Pandemic: A Cross-sectional Survey

PurposeThis study determined the predictors of caregivers' willingness to accept an accelerated regulatory process for the development of vaccines against coronavirus disease 2019 (COVID-19).MethodsAn international cross-sectional survey was administered to 2557 caregivers of children in 17 pediatric emergency departments (EDs) across 6 countries from March 26, 2020, to June 30, 2020. Caregivers were asked to select 1 of 4 choices with which they most agreed regarding a proposed COVID-19 vaccine–approval process, in addition to questions regarding demographic characteristics, the ED visit, and attitudes about COVID-19. Univariate analyses were conducted using the Mann–Whitney U test for comparing non–normally distributed continuous variables, an independent t test for comparing normally distributed continuous variables, and a χ² or Fisher exact test for categorical variables. Multivariate logistic regression analysis was used for determining independent factors associated with caregivers' willingness to accept abridged development of a COVID-19 vaccine. A P value of <0.05 was considered significant.FindingsAlmost half (1101/2557; 43%) of caregivers reported that they were willing to accept less rigorous testing and postresearch approval of a new COVID-19 vaccine. Independent factors associated with caregivers' willingness to accept expedited COVID-19 vaccine research included having children who were up to date on the vaccination schedule (odds ratio [OR] = 1.72; 95% CI, 1.29–2.31), caregivers' concern about having had COVID-19 themselves at the time of survey completion in the ED (OR = 1.1; 95% CI, 1.05–1.16), and caregivers' intent to have their children vaccinated against COVID-19 if a vaccine were to become available (OR = 1.84; 95% CI, 1.54–2.21). Compared with fathers, mothers completing the survey were less likely to approve of changes in the vaccine-development process (OR = 0.641; 95% CI, 0.529–0.775).ImplicationsLess than half of caregivers in this worldwide sample were willing to accept abbreviated COVID-19 vaccine testing. As a part of an effort to increase acceptance and uptake of a new vaccine, especially in order to protect children, public health strategies and individual providers should understand caregivers' attitudes toward the approval of a vaccine and consult them appropriately.     

Association of acute kidney injury with the severity and mortality of SARS-CoV-2 infection: A meta-analysis

Backgroundwe aimed to explore the relationship of acute kidney injury (AKI) with the severity and mortality of coronavirus disease 2019 (COVID-19).MethodsA systematic literature search was conducted in PubMed, EMBASE, Scopus, Web of Science, MedRxiv Database. We compared the laboratory indicators of renal impairment and incidences of AKI in the severe versus non-severe cases, and survival versus non-survival cases, respectively.ResultsIn 41 studies with 10,335 COVID-19 patients, the serum creatinine (sCr) in severe cases was much higher than that in non-severe cases (SMD = 0.34, 95% CI: 0.29–0.39), with a similar trend for blood urea nitrogen (BUN) (SMD = 0.66, 95%CI: 0.51–0.81), hematuria (OR = 1.59, 95% CI: 1.15–2.19), and proteinuria (OR = 2.92, 95% CI: 1.58–5.38). The estimated glomerular filtration rate decreased significantly in severe cases compared with non-severe cases (SMD = -0.45, 95% CI: −0.67– −0.23). Moreover, the pooled OR of continuous renal replacement therapy (CRRT) and AKI prevalence for severe vs. non-severe cases was 12.99 (95%CI: 4.03–41.89) and 13.16 (95%CI: 10.16–17.05), respectively. Additionally, 11 studies with 3759 COVID-19 patients were included for analysis of disease mortality. The results showed the levels of sCr and BUN in non-survival cases remarkably elevated compared with survival patients, respectively (SMD = 0.97, SMD = 1.49). The pooled OR of CRRT and AKI prevalence for non-survival vs. survival cases was 31.51 (95%CI: 6.55–151.59) and 77.48 (95%CI: 24.52–244.85), respectively.ConclusionsAKI is closely related with severity and mortality of COVID-19, which gives awareness for doctors to pay more attention for risk screening, early identification and timely treatment of AKI.     

Frequency of Advanced Cardiac Life Support Medication Use and Association With Survival During In-hospital Cardiac Arrest

PurposeCardiopulmonary resuscitation is common in the United States, with >200,000 people experiencing an in-hospital cardiac arrest (IHCA) annually. Recent medication shortages have raised the question of the frequency and type of medication used during cardiac arrest resuscitation. We sought to determine the frequency and quantity of medications used during IHCA.MethodsThis retrospective, single-center, medical record review was performed at a large, urban teaching hospital. Adults ≥18 years old who had an IHCA with confirmed loss of pulse between January 2017 and March 2018 were identified. A standardized data collection tool was used to extract data from the electronic medical record. The primary outcome was the frequency and quantity of medications used during the IHCA. Secondary outcomes included median time to defibrillation and frequency of sodium bicarbonate use, including among patients with end-stage renal disease (ESRD).FindingsCriteria were met for 181 IHCA events. Demographic characteristics were 71% black, 17% white, mean age of 65 years, and 46% women. Epinephrine was given in 86.7% of the arrests, with a mean cumulative dose of 4.2 mg. Sodium bicarbonate was given in 63.5% of the arrests, with a mean cumulative dose of 9.0 g (1.9 amps). Amiodarone was given in 30.9% of the arrests, with a mean cumulative dose of 311.8 mg. Median time to defibrillation was 2 min (interquartile range, 1–4 min). Preexisting ESRD was present in 24.8% of patients, of whom 71.1% received sodium bicarbonate. Sodium bicarbonate administration was associated with a lower likelihood of survival to discharge (odds ratio [OR] = 0.27; 95% CI, 0.11–0.66) as well as a lower rate of return to spontaneous circulation (ROSC) (OR = 0.35; 95% CI, 0.13–0.95). Magnesium administration was associated with a lower rate of ROSC (OR = 0.39; 95% CI, 0.15–0.98). Of note, in patients with preexisting ESRD, no medications were significantly associated with a change in likelihood of survival to discharge or rate of ROSC. In patients without preexisting ESRD, magnesium was associated with a lower rate of ROSC (OR = 0.23; 95% CI, 0.08–0.77).ImplicationsWe found that in a hospital with established rapid response and code blue teams, numerous medications that are not recommended for routine use in cardiac arrest are still administered at significant frequencies. Furthermore, substantial amounts of drugs with known recent shortage are used in IHCA. Inc.     

The impact of SARS and COVID-19 on major trauma in Hong Kong

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has been enormously disruptive and harmful to people around the world, but its impact on other illnesses and injuries has been more variable. To evaluate the ramification of infectious disease outbreaks on major traumatic injuries, we compared changes in the incidence of major trauma cases during the 2003 Severe Acute Respiratory Syndrome (SARS) period with COVID-19 in 2020.MethodsData were analyzed from the trauma registry of a major, tertiary-care teaching hospital in Hong Kong. Patients presenting with major traumatic injuries during the first six months of 2001–03 and 2018–20 were retrieved for analysis. Patient characteristics, injury mechanism, admitting service, and emergency department (ED)/hospital lengths of stay (LOS) were recorded. Raw and adjusted survival rates (using the modified Trauma Injury Severity Score (TRISS)) were recorded.ResultsThe number of trauma cases fell dramatically during 2003 and 2020 compared with previous years. In both 2003 and 2020, the number of trauma registry patients fell by 49% in April (compared to the preceding reference years of 2001/02 and 2018/19, respectively). Patient characteristics, treatments, and outcomes were also different during the outbreak years. Comparing 2003 to 2020 relative to their respective reference baselines, the percentages of injuries that happened at home, patients without co-morbidities, and patients' mean age all increased in 2003 but decreased in 2020. Work-place injuries drastically dropped in 2003, but not in 2020. Average ED LOS dropped in 2003 by 36.4 min (95% CI 12.5, 60.3) but declined by only 14.5 min (95% CI -2.9, 32.1) in 2020. Both observed and expected 30-day mortality declined in 2020 vs. 2003 (observed 4.5% vs. 11.7%, p = 0.001, OR 0.352, 95% CI 0.187, 0.661) (expected 4.5% vs 11.6%, p = 0.002, OR 0.358, 95% CI 0.188, 0.684).ConclusionMajor trauma cases dropped by half during both the peak of the 2003 SARS and 2020 COVID-19 pandemics in Hong Kong, suggesting a trend for future pandemic planning. If similar findings are seen at other trauma centers, proactive personnel and resource allocations away from trauma towards medical emergency systems may be more appropriate for future pandemics.     

The effect of higher-intensity dosing of anticoagulation on the clinical outcomes in hospitalized patients with COVID-19: A meta-analysis of randomized controlled trials

ObjectiveWe aimed to perform a meta-analysis to summarize the overall evidence from randomized controlled trials related to higher-intensity anticoagulation in hospitalized patients with COVID-19.MethodsA systematic literature search was performed in electronic databases to identify randomized controlled trials comparing the clinical outcomes between intermediate/ therapeutic anticoagulation and prophylactic anticoagulation. Meta-analyses with random-effects models were used to estimate the pooled odds ratio (OR) for outcomes of interest at a 95% confidence interval (CI).ResultsEight randomized controlled trials were included, with a total of 5405 hospitalized patients with COVID-19. The meta-analysis revealed no statistically significant difference in the odds of mortality (pooled OR = 0.92; 95% CI 0.71–1.19) but a statistically significant reduction in the odds of development of thrombotic events (pooled OR = 0.55; 95% CI 0.42–0.72), and significantly increased odds of development of major bleeding (pooled OR = 1.81; 95% CI 1.20–2.72) with the use of intermediate/therapeutic anticoagulation, relative to prophylactic anticoagulation. Subgroup analysis in patients with a severe course of COVID-19 observed a statistically significant reduction in the odds of development of thrombotic events (pooled OR = 0.66; 95% CI 0.45–0.98) but no significant difference in the odds of development of major bleeding events (pooled OR = 1.37; 95% CI 0.74–2.56), with the use of intermediate/therapeutic anticoagulation, relative to prophylactic anticoagulation.ConclusionThere could be net clinical benefits with higher-intensity dosing of anticoagulation relative to prophylactic-dosing of anticoagulation among hospitalized patients with severe COVID-19.     

Potential risk factors for case fatality rate of novel coronavirus (COVID-19) in China: A pooled analysis of individual patient data

Background and objectiveSince the first case of the pneumonia caused by 2019 novel coronavirus (COVID-19) is found in Wuhan, there have been more than 70,000 cases reported in China. This study aims to perform the meta-analysis of risk factors for the case fatality rate (CFR) of the 2019 novel coronavirus (COVID-19).Design and methodsWe have searched PubMed, Google scholar and medRxiv for the cohort studies involving risk factors for the CFR of COVID-19. This meta-analysis compares the risk factors of CFR between fatal patients and non-fatal patients.ResultsTwo cohort studies are included in this study. After comparing the patients between fatal cases and non-fatal cases, several important factors are found to significantly increase the CFR in patients with COVID-19, and include the age ranging 60–70 (OR = 1.85; 95% CI = 1.62 to 2.11; P < .00001) and especially≥70 (OR = 8.45; 95% CI = 7.47 to 9.55; P < .00001), sex of male (OR = 1.88; 95% CI = 1.30 to 2.73; P = .0008), occupation of retirees (OR = 4.27; 95% CI = 2.50 to 7.28; P < .00001), and severe cases (OR = 691.76; 95% CI = 4.82 to 99,265.63; P = .01). As the advancement of early diagnosis and treatment, the CFR after January 21 (or 22), 2020 is substantially decreased in COVID-19 than before (OR = 0.21; 95% CI = 0.19 to 0.24; P < .00001).ConclusionsSeveral factors are confirmed to significantly improve the CFR in patients with COVID-19, which is very important for the treatment and good prognosis of these patients.     

An international perspective of out-of-hospital cardiac arrest and cardiopulmonary resuscitation during the COVID-19 pandemic

BackgroundOut-of-hospital cardiac arrest (OHCA) accounts for a substantial proportion of sudden cardiac events globally, with hundreds of thousands of cases reported annually in the United States. The mortality rate of patients who suffer OHCA remains high despite extensive utilization of resources.ObjectivesWe aim to describe the current landscape of OHCA during the COVID-19 pandemic and provide an overview of the logistical challenges and resuscitation protocols amongst emergency medical service (EMS) personnel.DiscussionRecent studies in Italy, New York City, and France characterized a significant increase in OHCA incidence in conjunction with the arrival of the 2019 coronavirus disease (COVID-19) pandemic. The presence of the pandemic challenged existing protocols for field resuscitation of cardiac arrest patients as the pandemic necessitated prioritization of EMS personnel and other healthcare providers' safety through stringent personal protective equipment (PPE) requirements. Studies also characterized difficulties encountered by the first responder system during COVID-19, such as dispatcher overload, increased response times, and adherence to PPE requirements, superimposed on PPE shortages. The lack of guidance by governmental agencies and specialty organizations to provide unified safety protocols for resuscitation led to the development of different resuscitative protocols globally.ConclusionsThe ongoing COVID-19 pandemic modified the approach of first responders to OHCA. With the rise in OCHA during the pandemic in several geographic regions and the risks of disease transmission with superimposed equipment shortages, novel noninvasive, adjunct tools, such as point of care ultrasound, warrant consideration. Further prehospital studies should be considered to optimize OHCA and resource management while minimizing risk to personnel.     

The effect of the severity COVID-19 infection on electrocardiography

ObjectiveAcute myocardial damage is detected in a significant portion of patients with coronavirus 2019 disease (COVID-19) infection, with a reported prevalence of 7–28%. The aim of this study was to investigate the relationship between electrocardiographic findings and the indicators of the severity of COVID-19 detected on electrocardiography (ECG).MethodsA total of 219 patients that were hospitalized due to COVID-19 between April 15 and May 5, 2020 were enrolled in this study. Patients were divided into two groups according to the severity of COVID-19 infection: severe (n = 95) and non-severe (n = 124). ECG findings at the time of admission were recorded for each patient. Clinical characteristics and laboratory findings were retrieved from electronic medical records.ResultsMean age was 65.2 ± 13.8 years in the severe group and was 57.9 ± 16.0 years in the non-severe group. ST depression (28% vs. 14%), T-wave inversion (29% vs. 16%), ST-T changes (36% vs. 21%), and the presence of fragmented QRS (fQRS) (17% vs. 7%) were more frequent in the severe group compared to the non-severe group. Multivariate analysis revealed that hypertension (odds ratio [OR]: 2.42, 95% confidence interval [CI]:1.03–5.67; p = 0.041), the severity of COVID-19 infection (OR: 1.87, 95% CI: 1.09–2.65; p = 0.026), presence of cardiac injury (OR: 3.32, 95% CI: 1.45–7.60; p = 0.004), and d-dimer (OR: 3.60, 95% CI: 1.29–10.06; p = 0.014) were independent predictors of ST-T changes on ECG.ConclusionST depression, T-wave inversion, ST-T changes, and the presence of fQRS on admission ECG are closely associated with the severity of COVID-19 infection.     

Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: An observational cohort study

Background

Some Emergency Medical Services currently use just one component of the Universal Termination of Resuscitation (TOR) Guideline, the absence of prehospital return of spontaneous circulation (ROSC), as the single criteria to terminate resuscitation, which may deny transport to potential survivors.

Objective

This study aimed to report the survival to hospital discharge rate in non-traumatic, adult out-of-hospital cardiac arrest (OHCA) patients transported to hospital without a prehospital ROSC.

Methods

An observational study of OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport to hospital with ongoing resuscitation. Multivariable logistic regression was used to determine the association of each variable with survival to hospital discharge.

Results

Of 20,207 OHCA treated by EMS, 3374 (16.4%) did not have a prehospital ROSC but met the Universal TOR guideline for transport to hospital with ongoing resuscitation. Of these patients, 122 (3.6%) survived to hospital discharge. Survival to discharge was associated with initial shockable VF/VT rhythms (OR 5.07; 95% CI 2.77–9.30), EMS-witnessed arrests (OR 3.51; 95% CI 1.73–7.15), bystander-witnessed arrests (OR 2.11; 95% CI 1.18–3.77), and public locations (OR 1.57; 95% CI 1.02–2.40).

Conclusion

In OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport with ongoing resuscitation survival rates were above the 1% futility rate. Employing only the lack of ROSC as criteria for termination of resuscitation may miss survivors after OHCA.     

Identifying patients with symptoms suspicious for COVID-19 at elevated risk of adverse events: The COVAS score

ObjectiveDevelop and validate a risk score using variables available during an Emergency Department (ED) encounter to predict adverse events among patients with suspected COVID-19.MethodsA retrospective cohort study of adult visits for suspected COVID-19 between March 1 – April 30, 2020 at 15 EDs in Southern California. The primary outcomes were death or respiratory decompensation within 7-days. We used least absolute shrinkage and selection operator (LASSO) models and logistic regression to derive a risk score. We report metrics for derivation and validation cohorts, and subgroups with pneumonia or COVID-19 diagnoses.Results26,600 ED encounters were included and 1079 experienced an adverse event. Five categories (comorbidities, obesity/BMI ≥ 40, vital signs, age and sex) were included in the final score. The area under the curve (AUC) in the derivation cohort was 0.891 (95% CI, 0.880–0.901); similar performance was observed in the validation cohort (AUC = 0.895, 95% CI, 0.874–0.916). Sensitivity ranging from 100% (Score 0) to 41.7% (Score of ≥15) and specificity from 13.9% (score 0) to 96.8% (score ≥ 15). In the subgroups with pneumonia (n = 3252) the AUCs were 0.780 (derivation, 95% CI 0.759–0.801) and 0.832 (validation, 95% CI 0.794–0.870), while for COVID-19 diagnoses (n = 2059) the AUCs were 0.867 (95% CI 0.843–0.892) and 0.837 (95% CI 0.774–0.899) respectively.ConclusionPhysicians evaluating ED patients with pneumonia, COVID-19, or symptoms suspicious for COVID-19 can apply the COVAS score to assist with decisions to hospitalize or discharge patients during the SARS CoV-2 pandemic.     

Mental well-being of intensive care unit nurses after the second surge of the COVID-19 pandemic: A cross-sectional and longitudinal study

ObjectivesTo determine the impact of the second surge of the COVID-19 pandemic (October 2020 to June 2021) on mental well-being of intensive care unit nurses and factors associated with mental health outcomes.MethodsAn online survey was available for Dutch intensive care unit nurses in October 2021, measuring mental health symptoms; anxiety, depression (Hospital Anxiety and Depression Scale), and post-traumatic stress disorder (Impact of Event Scale-6). Additionally, work-related fatigue was measured using the Need For Recovery-11 questionnaire. Previous data from the first surge (March until June 2020) were used to study mental well-being longitudinally in a subgroup of intensive care unit nurses. Logistic regression analyses were performed to determine factors associated with mental health symptoms.ResultsIn total, 589 nurses (mean age 44.8 [SD, 11.9], 430 [73.8 %] females) participated, of whom 164 also completed the questionnaire in 2020. After the second surge, 225/589 (38.2 %) nurses experienced one or more mental health symptoms and 294/589 (49.9 %) experienced work-related fatigue. Compared to the first measurement, the occurrence of mental health symptoms remained high (55/164 [33.5 %] vs 63/164 [38.4 %], p = 0.36) and work-related fatigue was significantly higher (66/164 [40.2 %] vs 83/164 [50.6 %], p = 0.02). Granted holidays as requested (aOR, 0.54; 95 % CI, 0.37–0.79), being more confident about the future (aOR, 0.59; 95 % CI, 0.37–0.93) and a better perceived work-life balance (aOR, 0.42; 95 % CI, 0.27–0.65) were significantly associated with less symptoms.ConclusionThe second surge of the COVID-19 pandemic further drained the mental reserves of intensive care unit nurses, resulting in more work-related fatigue.     

The Impact of COVID-19 Surge on Clinical Palliative Care: A Descriptive Study From a New York Hospital System

ContextIn spring 2020, New York experienced a surge of patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) disease, as part of a global pandemic. There are limited data on populations of COVID-19–infected patients seen by palliative care services.ObjectiveTo describe a palliative care population at one New York hospital system during the initial pandemic surge.MethodsThis repeated cross-sectional, observational study collected data on palliative care patients in a large health system seen during the COVID-19 outbreak and compared it with pre-COVID data.ResultsPalliative service volume surged from 678 (4% of total admissions) before COVID-19 to 1071 (10% of total admissions) during the COVID-19 outbreak. During the outbreak, 695 (64.9%) of the total palliative patients tested positive for the virus. Compared with a preoutbreak group, this COVID-19–positive group had higher rates of male (60.7% vs. 48.6%, P < 0.01) and Latino (21.3% vs. 13.3%; P < 0.01) patients and less white patients (21.3% vs. 13.3%; P < 0.01). Our patients with COVID-19 also had greater prevalence of obesity and diabetes and lower rates of end-stage organ disease and cancers. The COVID-19–positive group had a higher rate of intensive care unit admissions (58.9% vs. 33.9%; P < 0.01) and in-hospital mortality rate (57.4% vs. 13.1%; P < 0.01) than the preoutbreak group. There was increased odds of mortality in palliative care patients who were COVID-19 positive (odds ratio = 3.21; 95% confidence interval = 2.43–4.24) and those admitted to the intensive care unit (odds ratio = 1.45; 95% confidence interval = 1.11–1.9).ConclusionDuring the initial surge of the COVID-19 pandemic in New York, palliative care services experienced a large surge of patients who tended to be healthier at baseline and more acutely ill at the time of admission than pre–COVID-19 palliative patients.     

Out-of-hospital cardiac arrest volumes and characteristics during the COVID-19 pandemic

AimThe COVID-19 pandemic has significantly impacted Emergency Medical Services (EMS) operations throughout the country. Some studies described variation in total volume of out-of-hospital cardiac arrests (OHCA) during the pandemic. We aimed to describe the changes in volume and characteristics of OHCA patients and resuscitations in one urban EMS system.MethodsWe performed a retrospective cohort analysis of all recorded atraumatic OHCA in Marion County, Indiana, from January 1, 2019 to June 30, 2019 and from January 1, 2020 to June 30, 2020. We described patient, arrest, EMS response, and survival characteristics. We performed paired and unpaired t-tests to evaluate the changes in those characteristics during COVID-19 as compared to the prior year. Data were matched by month to control for seasonal variation.ResultsThe total number of arrests increased from 884 in 2019 to 1034 in 2020 (p = 0.016). Comparing 2019 to 2020, there was little difference in age [median 62 (IQR 59–73) and 60 (IQR 47–72), p = 0.086], gender (38.5% and 39.8% female, p = 0.7466, witness to arrest (44.3% and 39.6%, p = 0.092), bystander AED use (10.1% and 11.4% p = 0.379), bystander CPR (48.7% and 51.4%, p = 0.242). Patients with a shockable initial rhythm (19.2% and 15.4%, p = 0.044) both decreased in 2020, and response time increased by 18 s [6.0 min (IQR 4.5–7.7) and 6.3 min (IQR 4.7–8.0), p = 0.008]. 47.7% and 54.8% (p = 0.001) of OHCA patients died in the field, 19.7% and 19.3% (p = 0.809) died in the Emergency Department, 21.8% and 18.5% (p = 0.044) died in the hospital, 10.8% and 7.4% (p = 0.012) were discharged from the hospital, and 9.3% and 5.9% (p = 0.005) were discharged with Cerebral Performance Category score ≤ 2.ConclusionTotal OHCA increased during the COVID-19 pandemic when compared with the prior year. Although patient characteristics were similar, initial shockable rhythm, and proportion of patients who died in the hospital decreased during the pandemic. Further investigation will explore etiologies of those findings.     

Examining emergency medical services' prehospital transport times for trauma patients during COVID-19

IntroductionLonger prehospital times were associated with increased odds for survival in trauma patients. The purpose of this study was to determine how the COVID-19 pandemic affected emergency medical services (EMS) prehospital times for trauma patients.MethodsThis retrospective cohort study compared trauma patients transported via EMS to six US level I trauma centers admitted 1/1/19–12/31/19 (2019) and 3/16/20–6/30/20 (COVID-19). Outcomes included: total EMS pre-hospital time (dispatch to hospital arrival), injury to dispatch time, response time (dispatch to scene arrival), on-scene time (scene arrival to scene departure), and transportation time (scene departure to hospital arrival). Fisher's exact, chi-squared, or Kruskal-Wallis tests were used, alpha = 0.05. All times are presented as median (IQR) minutes.ResultsThere were 9400 trauma patients transported by EMS: 79% in 2019 and 21% during the COVID-19 pandemic. Patients were similar in demographics and transportation mode. Emergency room deaths were also similar between 2019 and COVID-19 [0.6% vs. 0.9%, p = 0.13].There were no differences between 2019 and during COVID-19 for total EMS prehospital time [44 (33, 63) vs. 43 (33, 62), p = 0.12], time from injury to dispatch [16 (6, 55) vs. 16 (7, 77), p = 0.41], response time [7 (5, 12) for both groups, p = 0.27], or on-scene time [16 (12−22) vs. 17 (12,22), p = 0.31]. Compared to 2019, transportation time was significantly shorter during COVID-19 [18 (13, 28) vs. 17 (12, 26), p = 0.01].ConclusionThe median transportation time for trauma patients was marginally significantly shorter during COVID-19; otherwise, EMS prehospital times were not significantly affected by the COVID-19 pandemic.     

Benefits of ozone on mortality in patients with COVID-19: A systematic review and meta-analysis

BackgroundThe Coronavirus disease-2019 (COVID-19) pandemic continues, and the death toll continues to surge. Ozone therapy has long been used in the treatment of a variety of infectious diseases, probably through its antioxidant properties and the supply of oxygen to hypoxic tissues. This systematic review and meta-analysis aimed to determine the efficacy of ozone on mortality in patients with COVID-19.MethodsA systematic search was made of PubMed, Embase, Cochrane Library, and clinicaltrials.gov, without language restrictions. Prospective controlled trials on treatment of COVID-19 with ozone, compared with placebo or blank, were reviewed. Studies were pooled to risk ratios (RRs) and weighted mean differences (WMDs), with 95% confidence intervals (CIs).ResultsEight trials (enrolling 371 participants) met the inclusion criteria. Ozone therapy showed significant effects on mortality (RR 0.38, 95% CI 0.17–0.85; P = 0.02), length of hospital stay (WMD −1.63 days, 95% CI −3.05 to −0.22 days; P = 0.02), and polymerase chain reaction (PCR) positivity (RR 0.07, 95% CI 0.01–0.34; P = 0.001).ConclusionsOzone therapy significantly reduced mortality, PCR positivity, and length of stay in hospitalized patients with COVID-19. Ozone therapy should be considered for COVID-19 patients.     

Biphasic Defibrillation Does not Improve Outcomes Compared to Monophasic Defibrillation in Out-of-Hospital Cardiac Arrest

Study Objective. To compare the outcomes of out-of hospital cardiac arrest (OHCA) victims treated with monophasic truncated exponential (MTE) versus biphasic truncated exponential (BTE) defibrillation in an urban EMS system. Methods. We conducted a retrospective review of electronic prehospital andhospital records for victims of OHCA between August 2000 andJuly 2004, including two years before andafter implementation of biphasic defibrillators by the Fresno County EMS agency. Main outcome measures included: return of spontaneous circulation (ROSC), number of defibrillations required for ROSC, survival to hospital discharge, anddischarge to home versus an extended care facility. Results. There were 485 cases of cardiac arrest included. Baseline characteristics between the monophasic andbiphasic groups were similar. ROSC was achieved in 77 (30.6%, 95% CI 25.2–36.5%) of 252 patients in the monophasic group, andin 70 (30.0% 95% CI 24.5–36.2%) of 233 in the biphasic group (p =. 92). Survival to hospital discharge was 12.3% (95% CI 8.8–17%) for monophasic and10.3% (95% CI 7.0–14.9%) for biphasic (p =. 57). Discharge to home was accomplished in 20 (7.9%, 95% CI 5.1–12.0%) of the monophasic, andin 15 (6.4%, 95% CI 3.9–10.4%) of the biphasic group (p =. 60). More defibrillations were required to achieve ROSC (3.5 vs. 2.6, p =. 015) in the monophasic group. Conclusions. We found no difference in ROSC or survival to hospital discharge between MTE andBTE defibrillation in the treatment of OHCA, although fewer defibrillations were required to achieve ROSC in those treated with biphasic defibrillation.     

The association between chest compression release velocity and outcomes from out-of-hospital cardiac arrest

BackgroundPrevious studies have demonstrated significant relationships between cardiopulmonary resuscitation (CPR) quality metrics and survival to hospital discharge from out-of-hospital cardiac arrest (OHCA). Recently, it has been suggested that a new metric, chest compression release velocity (CCRV), may be associated with improved survival from OHCA.Methods and resultsWe performed a retrospective review of all treated adult OHCA occurring over a two year period beginning January 1, 2012. CPR metrics were abstracted from accelerometer measurements during each resuscitation. Multivariable regression analysis was used to examine the impact of CCRV on survival to hospital discharge. Secondary outcome measures were the impact of CCRV on return of spontaneous circulation (ROSC) and neurologically intact survival (MRS ≤ 3). Among 1800 treated OHCA, 1137 met inclusion criteria. The median (IQR) age was 71.6 (60.6, 82.3) with 724 (64%) being male. The median (IQR) CCRV (mm/s) amongst 96 survivors was 334.5 (300.0, 383.2) compared to 304.0 (262.6, 354.1) in 1041 non survivors (p < 0.001). When adjusted for Utstein variables, the odds of survival to hospital discharge for each 10 mm/s increase in CCRV was 1.02 (95% CI: 0.98, 1.06). Similarly the odds of ROSC and neurologically intact survival were 1.01 (95% CI: 0.99, 1.03) and 1.02 (95% CI: 0.98, 1.06), respectively.ConclusionsWhen adjusted for Utstein variables, CCRV was not significantly associated with outcomes from OHCA. Further research in other EMS systems is required to clarify the potential impact of this variable on OHCA survival.