Association Between Mode of Transportation and Outcomes in Penetrating Trauma Across Different Prehospital Time Intervals: A Matched Cohort Study

BackgroundNational guidelines do not provide recommendations concerning optimal dispatch time for helicopter emergency medical services (HEMS) in the United States.ObjectivesThis study describes the association between mode of transport (ground vs. helicopter) and survival of patients with penetrating injury across different prehospital time intervals and proposes evidence-based time-related dispatch criteria for HEMS.MethodsA retrospective matched cohort study was conducted using the 2015 National Trauma Data Bank. Adult patients (age ≥ 16 years) with penetrating injuries were included. Patients transported via HEMS were selected and matched (1 to 1) for 17 variables to patients transported by ground ambulance (GEMS). Bivariate analyses were conducted to compare characteristics and outcomes (survival to hospital discharge) of patients across different prehospital time intervals.ResultsEach group consisted of 949 patients. Overall survival rate was similar in both groups (90.6% for HEMS vs. 87.9% for GEMS, p = 0.054). Patients transported by HEMS had significantly higher survival compared with those transported by GEMS (92.5% for HEMS vs. 87.0% for GEMS, p = 0.002) in the 0–60-min time interval from dispatch to arrival to hospital, and more specifically, in the 31–60-min interval (92.2% vs. 85.2%, p = 0.001). No difference in survival between the two groups was observed in the shortest (0–30 min) or in the extended prehospital time intervals (>60 min).ConclusionIn adult patients with penetrating trauma, HEMS transport was associated with improved survival in a specific total prehospital time interval (31 to 60 min). This finding can help emergency medicine service administrators develop evidence-based HEMS dispatch criteria.     

Prehospital management of acute respiratory distress in suspected COVID-19 patients

BackgroundIn December 2019, coronavirus disease (COVID-19) emerged in China and became a world-wide pandemic in March 2020. Emergency services and intensive care units (ICUs) were faced with a novel disease with unknown clinical characteristics and presentations. Acute respiratory distress (ARD) was often the chief complaint for an EMS call. This retrospective study evaluated prehospital ARD management and identified factors associated with the need of prehospital mechanical ventilation (PMV) for suspected COVID-19 patients.MethodsWe included 256 consecutive patients with suspected COVID-19-related ARD that received prehospital care from a Paris Fire Brigade BLS or ALS team, from March 08 to April 18, 2020. We performed multivariate regression to identify factors predisposing to PMV.ResultsOf 256 patients (mean age 60 ± 18 years; 82 (32%) males), 77 (30%) had previous hypertension, 31 (12%) were obese, and 49 (19%) had diabetes mellitus. Nineteen patients (7%) required PMV. Logistic regression observed that a low initial pulse oximetry was associated with prehospital PMV (ORa = 0.86, 95%CI: 0.73–0.92; p = 0.004).ConclusionsThis study showed that pulse oximetry might be a valuable marker for rapidly determining suspected COVID-19-patients requiring prehospital mechanical ventilation. Nevertheless, the impact of prehospital mechanical ventilation on COVID-19 patients outcome require further investigations.     

Contemporary Prehospital Emergency Medical Services Response Times for Suspected Stroke in the United States

Background and Purpose: There are no contemporary national-level data on Emergency Medical Services (EMS) response times for suspected stroke in the United States (US). Because effective stroke treatment is time-dependent, we characterized response times for suspected stroke, and examined whether they met guideline recommendations. Methods: Using the National EMS Information System dataset, we included 911 calls for patients ≥ 18 years with an EMS provider impression of stroke. We examined variation in the total EMS response time by dispatch notification of stroke, age, sex, race, region, time of day, day of the week, as well as the proportion of EMS responses that met guideline recommended response times. Total EMS response time included call center dispatch time (receipt of call by dispatch to EMS being notified), EMS dispatch time (dispatch informing EMS to EMS starts moving), time to scene (EMS starts moving to EMS arrival on scene), time on scene (EMS arrival on scene to EMS leaving scene), and transport time (EMS leaving scene to reaching treatment facility). Results: We identified 184,179 events with primary impressions of stroke (mean age 70.4 ± 16.4 years, 55% male). Median total EMS response time was 36 (IQR 28.7–48.0) minutes. Longer response times were observed for patients aged 65–74 years, of white race, females, and from non-urban areas. Dispatch identification of stroke versus “other” was associated with marginally faster response times (36.0 versus 36.7 minutes, p < 0.01). When compared to recommended guidelines, 78% of EMS responses met dispatch delay of <1 minute, 72% met time to scene of <8 minutes, and 46% met on-scene time of <15 minutes. Conclusions: In the United States, time from receipt of 9-1-1 calls to treatment center arrival takes a median of 36 minutes for stroke patients, an improvement upon previously published times. The fact that 22%–46% of EMS responses did not meet stroke guidelines highlights an opportunity for improvement. Future studies should examine EMS diagnostic accuracy nationally or regionally using outcomes based approaches, as accurate recognition of prehospital strokes is vital in order to improve response times, adhere to guidelines, and ultimately provide timely and effective stroke treatment.     

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.     

Language preference does not influence stroke patients' symptom recognition or emergency care time metrics

IntroductionOur objective was to determine whether acute ischemic stroke (AIS) patients' language preference is associated with differences in time from symptom discovery to hospital arrival, activation of emergency medical services, door-to-imaging time (DTI), and door-to-needle (DTN) time.MethodsWe identified consecutive AIS patients presenting to a single urban, tertiary, academic center between 01/2003–05/2014 for whom language preference was available. Data were abstracted from the institution's Research Patient Data Registry and Get with the Guidelines-Stroke Registry. Bivariate and regression models evaluated the relationship between language preference and: 1) time from symptom onset to hospital arrival, 2) use of EMS, 3) DTI, and 4) DTN time.ResultsOf 3190 AIS patients, 300 (9.4%) were non-English preferring (NEP). Comparing NEP to English preferring (EP) patients in unadjusted or adjusted analyses, time from symptom discovery to arrival and rate of EMS utilization were not significantly different (overall median time 157 min, IQR 55–420; EMS utilization: 65% vs. 61.3% p = 0.21). There was also no significant differences in DTI or in likelihood of guideline-recommended DTI ≤ 25 min (overall median 59 min, IQR 29–127; DTI ≤ 25 min 24.3% vs. 21.3% p = 0.29) or DTN time or in likelihood of guideline-recommended DTN ≤ 60 min (overall median 53 min, IQR 36–73; DTN ≤ 60 min 62.5% vs. 58.2% p = 0.60).ConclusionConsistent with prior reports examining disparities in care, a systems-based approach to acute stroke prevents differences in hospital-based metrics. Reassuringly, NEP and EP patients also had similar speed of symptom recognition and EMS utilization.     

Time Is Brain: Prehospital Emergency Medical Services Response Times for Suspected Stroke and Effects of Prehospital Interventions

ObjectivesTo compare prehospital time for patients with suspected stroke in Florida with the American Stroke Association (ASA) time benchmarks, and to investigate the effects of dispatch notification and stroke assessment scales on prehospital time.Patients and MethodsA retrospective analysis was performed using data from Florida’s Emergency Medical Services Tracking and Reporting System database. All patients with suspected stroke transported to a treatment center from January 1, 2018, through December 31, 2018, were analyzed. Time intervals from 911 call to hospital arrival were evaluated and compared with ASA benchmarks.ResultsIn 2018, 11,577 patients with suspected stroke were transported to a hospital (mean age, 71.5±15.7 years; 51.5% women). The median alarm-to-hospital time was 33.98 minutes (27.8 to 41.4), with a total emergency medical services (EMS) time of 32.30 minutes (26.5 to 39.478). The on-scene time was the largest time interval with a median of 13.28 minutes (10.0 to 17.4). Emergency medical services encounters met the ASA benchmarks for time in 58% to 62% of the EMS encounters in Florida (recommended 90%; P<.001). The total EMS time was reduced when a stroke notification was reported by the dispatch center (32.00 minutes vs 32.62 minutes; P=.006) or when a stroke assessment scale was used by the EMS personnel (31.88 minutes vs 32.96 minutes; P=.005).ConclusionThis study reveals a substantial opportunity for improvement in stroke care in Florida. Two prehospital EMS stroke interventions seem to reduce prehospital time for patients with suspected stroke. Adoption of these interventions might improve the stroke systems of care.     

Cardiac injury is associated with mortality and critically ill pneumonia in COVID-19: A meta-analysis

BackgroundIn this systematic review and meta-analysis, we aimed to explore the association between cardiac injury and mortality, the need for intensive care unit (ICU) care, acute respiratory distress syndrome (ARDS), and severe coronavirus disease 2019 (COVID-19) in patients with COVID-19 pneumonia.MethodsWe performed a comprehensive literature search from several databases. Definition of cardiac injury follows that of the included studies, which includes highly sensitive cardiac troponin I (hs-cTnl) >99th percentile.The primary outcome was mortality, and the secondary outcomes were ARDS, the need for ICU care, and severe COVID-19. ARDS and severe COVID-19 were defined per the World Health Organization (WHO) interim guidance of severe acute respiratory infection (SARI) of COVID-19.ResultsThere were a total of 2389 patients from 13 studies. This meta-analysis showed that cardiac injury was associated with higher mortality (RR 7.95 [5.12, 12.34], p < 0.001; I²: 65%). Cardiac injury was associated with higher need for ICU care (RR 7.94 [1.51, 41.78], p = 0.01; I²: 79%), and severe COVID-19 (RR 13.81 [5.52, 34.52], p < 0.001; I²: 0%). The cardiac injury was not significant for increased risk of ARDS (RR 2.57 [0.96, 6.85], p = 0.06; I²: 84%). The level of hs-cTnI was higher in patients with primary + secondary outcome (mean difference 10.38 pg/mL [4.44, 16.32], p = 0.002; I²: 0%).ConclusionCardiac injury is associated with mortality, need for ICU care, and severity of disease in patients with COVID-19.     

Association Between Clinical Manifestations and Prognosis in Patients with COVID-19

PurposeThe purpose of this study was to determine the risk factors associated with pneumonia, acute respiratory distress syndrome (ARDS), and clinical outcome among patients with novel coronavirus disease 2019 (COVID-19).MethodsThis was a cross-sectional multicenter clinical study. A total of 95 patients infected with COVID-19 were enrolled. The COVID-19 diagnostic standard was polymerase chain reaction detection of target genes of 2019 novel coronavirus (2019-nCoV). Clinical, laboratory, and radiologic results, as well as treatment outcome data, were obtained. ARDS was defined as an oxygenation index (arterial partial pressure of oxygen/fraction of inspired oxygen) ≤300 mm Hg.FindingsMultivariate analysis showed that older age (odds ratio [OR], 1.078; p = 0.008) and high body mass index (OR, 1.327; p = 0.024) were independent risk factors associated with patients with pneumonia. For patients with ARDS, multivariate analysis showed that only high systolic blood pressure (OR, 1.046; p = 0.025) and high lactate dehydrogenase level (OR, 1.010; p = 0.021) were independent risk factors associated with ARDS. A total of 70 patients underwent CT imaging repeatedly after treatment. Patients were divided in a disease exacerbation group (n = 19) and a disease relief group (n = 51). High body mass index (OR, 1.285; p = 0.017) and tobacco smoking (OR, 16.13; p = 0.032) were independent risk factors associated with disease exacerbation after treatment.ImplicationsThese study results help in the risk stratification of patients with 2019-nCoV infection. Patients with risk factors should be given timely intervention to avoid disease progression.     

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.     

A low dose heparinized saline protocol is associated with improved duration of arterial line patency in critically ill COVID-19 patients

PurposeCritically ill patients with Coronavirus Disease 2019 (COVID-19) have high rates of line thrombosis. Our objective was to examine the safety and efficacy of a low dose heparinized saline (LDHS) arterial line (a-line) patency protocol in this population.Materials and MethodsIn this observational cohort study, patients ≥18 years with COVID-19 admitted to an ICU at one institution from March 20–May 25, 2020 were divided into two cohorts. Pre-LDHS patients had an episode of a-line thrombosis between March 20–April 19. Post-LDHS patients had an episode of a-line thrombosis between April 20–May 25 and received an LDHS solution (10 units/h) through their a-line pressure bag.ResultsForty-one patients (pre-LDHS) and 30 patients (post-LDHS) were identified. Baseline characteristics were similar between groups, including age (61 versus 54 years; p = 0.24), median Sequential Organ Failure Assessment score (6 versus 7; p = 0.67) and systemic anticoagulation (47% versus 32%; p = 0.32). Median duration of a-line patency was significantly longer in post-LDHS versus pre-LDHS patients (8.5 versus 2.9 days; p < 0.001). The incidence of bleeding complications was similar between cohorts (13% vs. 10%; p = 0.71).ConclusionsA LDHS protocol was associated with a clinically significant improvement in a-line patency duration in COVID-19 patients, without increased bleeding risk.     

COVID-19 Preliminary Case Series: Characteristics of EMS Encounters with Linked Hospital Diagnoses

Abstract

Background

Few studies have examined the prehospital presentation, assessment, or treatment of patients diagnosed with coronavirus disease 2019 (COVID-19). The objective of this preliminary report is to describe prehospital encounters for patients with a COVID-19 hospital diagnosis and/or COVID-19 EMS suspicion versus those with neither a hospital diagnosis nor EMS suspicion of the disease.     

Establishing biennial paramedic experience benchmarks

Objective. Since stroke symptoms are often vague, and acute therapies for stroke are more recently available, it has been hypothesized that stroke patients may not be treated with the same urgency as myocardial infarction (MI) patients by emergency medical services (EMS). To examine this hypothesis, EMS transport times were examined for both stroke and MI patients who used a paramedic-level, county-based EMS system for transportation to a single hospital during 1999. Methods. Patients were first identified by their hospital discharge diagnosis as stroke (ICD-9 430–436, n = 50) or MI (ICD-9 410, n = 55). Trip sheets with corresponding transport times were retrospectively obtained from the 911 center. A separate analysis was performed on patients identified by dispatchers with a chief complaint of stroke (n = 85) or MI (n = 372). Results. Comparing stroke and MI patients identified by ICD-9 codes, mean EMS transport times in minutes did not meaningfully differ with respect to dispatch to scene arrival time (8.3 vs 8.9, p = 0.61), scene time (19.5 vs 21.4, p = 0.23), and transport time (13.7 vs 16.2, p = 0.10). Mean total call times in minutes from dispatch to hospital arrival were similar between stroke and MI patients (41.5 vs 46.4, p = 0.22). Results were similar when comparing patients identified by dispatchers with a chief complaint indicative of stroke or MI. Conclusion. In this single county, EMS response times were not different between stroke and MI patients. Replication in other EMS settings is needed to confirm these findings.     

Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports

Introduction: Prehospital intravenous (IV) access in children may be difficult and time-consuming. Emergency Medical Service (EMS) protocols often dictate IV placement; however, some IV catheters may not be needed. The scene and transport time associated with attempting IV access in children is unknown. The objective of this study is to examine differences in scene and transport times associated with prehospital IV catheter attempt and utilization patterns of these catheters during pediatric prehospital encounters. Methods: Three non-blinded investigators abstracted EMS and hospital records of children 0–18 years of age transported by EMS to a pediatric emergency department (ED). We compared patients in which prehospital IV access was attempted to those with no documented attempt. Our primary outcome was scene time. Secondary outcomes include utilization of the IV catheter in the prehospital and ED settings and a determination of whether the catheter was indicated based on a priori established criteria (prehospital IV medication administration, hypotension, GCS < 13, and ICU admission). Results: We reviewed 1,138 records, 545 meeting inclusion criteria. IV catheter placement was attempted in 27% (n = 149) with success in 77% (n = 111). There was no difference in the presence of hypotension or median GCS between groups. Mean scene time (12.5 vs. 11.8 minutes) and transport time (16.9 vs. 14.6 minutes) were similar. Prehospital IV medications were given in 38.7% (43/111). One patient received a prehospital IV medication with no alternative route of administration. Among patients with a prehospital IV attempt, 31% (46/149) received IV medications in the ED and 23% (34/396) received IV fluids in the ED. Mean time to use of the IV in the ED was 70 minutes after arrival. Patients with prehospital IV attempt were more likely to receive IV medication within 30 minutes of ED arrival (39.1% vs. 19.0%, p = 0.04). Overall, 34.2% of IV attempts were indicated. Conclusions: Prehospital IV catheter placement in children is not associated with an increase in scene or transport time. Prehospital IV catheters were used in approximately one-third of patients. Further study is needed to determine which children may benefit most from IV access in the prehospital setting.     

Prehospital lactate clearance is associated with reduced mortality in patients with septic shock

BackgroundAssessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, blood lactate measurement is broadly used in combination with the clinical evaluation of patients as the clinical picture alone is not sufficient for assessing disease severity and outcomes.MethodsFrom 15th April 2017 to 15th April 2019, patients with SS requiring prehospital mobile Intensive Care Unit intervention (mICU) were prospectively included in this observational study. Prehospital blood lactate clearance was estimated by the difference between prehospital (time of first contact between the patients and the mICU prior to any treatment) and in-hospital (at hospital admission) blood lactate levels divided by prehospital blood lactate.ResultsAmong the 185 patients included in this study, lactate measurement was missing for six (3%) in the prehospital setting and for four (2%) at hospital admission, thus 175 (95%) were analysed for prehospital blood lactate clearance (mean age 70 ± 14 years). Pulmonary, digestive and urinary infections were probably the cause of the SS in respectively 56%, 22% and 10% of the cases. The 30-day overall mortality was 32%.Mean prehospital blood lactate clearance was significantly different between patients who died and those who survived (respectively 0.41 ± 2.50 mmol.l⁻¹ vs 1.65 ± 2.88 mmol.l⁻¹, p = 0.007).Cox regression analysis showed that 30-day mortality was associated with prehospital blood lactate clearance > 10% (HRa [CI95] = 0.49 [0.26–0.92], p = 0.028) and prehospital blood lactate clearance < 10% (HRa [CI95] = 2.04 [1.08–3.84], p = 0.028).ConclusionA prehospital blood lactate clearance < 10% is associated with 30-day mortality increase in patients with SS handled by the prehospital mICU. Further studies will be needed to evaluate if prehospital blood lactate clearance alone or combined with clinical scores could affected the triage decision-making process for those patients.     

Effect of COVID19 on prehospital pronouncements and ED visits for stroke and myocardial infarction

ObjectiveThe Novel Coronavirus19 (COVID19) arrived in northern New Jersey (NJ) in early March 2020, peaked at the beginning of April, and then declined. Starting in March, some patients who called 911 and required advanced life support (ALS) may have decompensated more rapidly than would have been expected, possibly because of concomitant COVID19 infection and/or delays in seeking medical care because of fear of exposure to the virus, and social isolation. In this study, our goal was to determine if there was an increase in prehospital ALS pronouncements and a decrease in ED visits for potentially serious conditions such as MI and stroke during the peak of the COVID-19 pandemic in northern NJ.Methods study designRetrospective cohort of prehospital patients pronounced dead by paramedics and patients with MI and stroke in the EDs of receiving hospitals of these paramedics. Study Setting and Population: Ten ground ALS units in northern NJ and nine receiving hospital EDs. Each ALS unit is staffed by two NJ-certified mobile intensive care paramedics and respond with a paramedic flycar in a two-tiered dispatch system. Data Analysis: We identified prehospital pronouncements using the EMSCharts electronic record (Zoll Medical, Chelmsford, Massachusetts). We tabulated the number of pronouncements by week from January 1 to June 30 in 2019 and 2020. We tabulated the combined total number of pronouncements and ED visits by month along with visits for MI and stroke and calculated the changes during the same timeframe. We used Chi-square to test for statistical significance for the monthly changes from 2019 to 2020.ResultsFor January through June in 2019 and 2020, there were 12,210 and 13,200 ALS dispatches, and 366 and 555 prehospital pronouncements, respectively. In 2020, pronouncements rose from a weekly baseline of 13 in early March, reached a peak of 45 at the beginning of April, then returned to the baseline level by the end of May. April 2020, the month with the most pronouncements, had 183% more pronouncements than April 2019 but total ED visits and visits for MI and stroke were 49%, 46% and 42% less, respectively (p < 0.0001 for each of these changes).ConclusionFollowing the arrival of the COVID-19 pandemic in northern NJ, we found pre-hospital ALS death pronouncements increased and ED visits for MI and stroke decreased. Although we have speculated about the reasons for these findings, further studies are needed to determine what the actual causes were.     

The ongoing impact of COVID-19 on asthma and pediatric emergency health-seeking behavior in the Bronx,an epicenter

BackgroundThe Bronx has the highest prevalence of asthma in the United States (US), and was also an early COVID-19 epicenter, making it a unique study location. Worldwide reports describe significant declines in pediatric emergency department (PED) visits during COVID-19. The ongoing impact of COVID-19 on all PED presentations, including asthma, at an early epicenter has not been studied beyond the pandemic peak and into the early phases of state re-opening.ObjectivesTo compare PED health-seeking behaviors and clinical characteristics during the 2020 pandemic and subsequent initial New York State (NYS) phased re-opening to the same period in 2019.MethodsRetrospective chart review of children <21 years utilizing the PED at a high-volume quaternary children's hospital in The Bronx, NY from March 15th 2020 – July 6th 2020 (pandemic cohort) and the same interval in 2019 (comparison cohort). Visits were assigned to pre-determined diagnostic categories. Demographic and clinical data were compared.Results19,981 visits were included. Visits declined by 66% during 2020. Proportions of asthma visits (2% vs. 7%, p < 0.0001) and minor medical problems (61% vs. 67%, p < 0.0001) had significant declines in the pandemic cohort, while major medical problems (13% vs. 8%, p < 0.0001), appendicitis (1% vs. 0.4%, p < 0.0001) and other surgical complaints (1% vs. 0.5%, p < 0.0001) had proportional increases in the pandemic cohort. No significant proportional changes were noted among psychosocial and trauma groups between the two cohorts.ConclusionThe pandemic cohort experienced a substantial decrease in PED volume, but an increase in acuity and admission rates, which was sustained through the NYS phase-II re-opening. Despite being located in an asthma hub, the incidence of asthma-related PED visits declined appreciably in the pandemic cohort. Future studies examining the effects of indoor allergens in isolation on pediatric asthma are warranted.     

Time to antibiotic administration: Sepsis alerts called in emergency department versus in the field via emergency medical services

IntroductionThe Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) identifies patients with “severe sepsis” and mandates antibiotics within a specific time window. Rapid time to administration of antibiotics may improve patient outcomes. The goal of this investigation was to compare time to antibiotic administration when sepsis alerts are called in the emergency department (ED) with those called in the field by emergency medical services (EMS).MethodsThis was a multi-center, retrospective review of patients designated as sepsis alerts in ED or via EMS in the field, presenting to four community emergency departments over a six-month period.Results507 patients were included, 419 in the ED alert group and 88 in the field alert group. Mean time to antibiotic administration was significantly faster in the field alert group when compared to the ED alert group (48.5 min vs 64.5 min, p < 0.001). Patients were more likely to receive antibiotics within 60 min of ED arrival in the field alert group (59.1% vs 44%, p = 0.01). Secondary outcomes including mortality, hospital length of stay, intensive care unit length of stay, sepsis diagnosis on admission, Clostridioides difficile infection rates, fluid bolus utilization, anti-MRSA antibiotic utilization rates, and anti-Pseudomonal antibiotic utilization rates were not found to be significantly different.ConclusionsSepsis alerts called in the field via EMS may decrease time to antibiotics and increase the likelihood of antibiotic administration occurring within 60 min of arrival when compared to those called in the ED.     

Acute complex appendicitis during the COVID-19 epidemic: A single-institution retrospective analysis based on real-world data

ObjectivesTo investigate the influence of Coronavirus Disease 2019 on incidence of acute complex appendicitis and management of acute appendicitis.MethodsPatients undergoing acute appendicitis surgery in a single center during the COVID-19 epidemic from January to September 2020 and patients from January to September 2019 were taken as the epidemic group and control group respectively. The clinical characteristics and surgical pathological information were compared between the two groups. The primary outcome measure was complex appendicitis.ResultsA total of 235 patients were included in the study, containing 106 in the epidemic group and 129 in the control group. The patients in the epidemic group had a significantly longer interval from the onset of symptoms to registration (37.92 h vs 24.57 h, P = 0.028), from registration to admission (18.69 h vs 8.04 h, P < 0.001), and from admission to surgery (7.23 h vs 6.52 h, P = 0.016). The epidemic group had a higher incidence of suppurative appendicitis (86.8% vs 76.0%, P = 0.036) and a higher incidence of complex appendicitis (35.8% vs 19.4%, P = 0.005).ConclusionHigher incidence of acute complex appendicitis seemed to occur during COVID-19 outbreak.