Multimodal learning for emergency department triage implementation: experiences from Papua New Guinea during the COVID-19 pandemic.

Background: Triage implementation in resource-limited emergency departments (EDs) has traditionally relied on intensive in-person training. This study sought to evaluate the impact of a novel digital-based learning strategy focused on the Interagency Integrated Triage Tool, a three-tier triage instrument recommended by the World Health Organization. Methods: A mixed methods study utilising pre-post intervention methods was conducted in two EDs in Papua New Guinea. The primary outcome was the mean change in knowledge before and after completion of a voluntary, multimodal training program, primarily delivered through a digital learning platform accessible via smartphone. Secondary outcomes included the change in confidence to perform selected clinical tasks, and acceptability of the learning methods. Findings: Among 136 eligible ED staff, 91 (66.9%) completed the digital learning program. The mean knowledge score on the post-training exam was 87.5% (SD 10.4), a mean increase of 12.9% (95% CI 10.7-15.1%, p < 0.0001) from the pre-training exam. There were statistically significant improvements in confidence for 13 of 15 clinical tasks, including undertaking a triage assessment and identifying an unwell patient.In an evaluation survey, 100% of 30 respondents agreed or strongly agreed the online learning platform was easy to access, use and navigate, and that the digital teaching methods were appropriate for their learning needs. In qualitative feedback, respondents reported that limited internet access and a lack of dedicated training time were barriers to participation. Interpretation: The use of digital learning to support triage implementation in resource-limited EDs is feasible and effective when accompanied by in-person mentoring. Adequate internet access is an essential pre-requisite. Funding: Development of the Kumul Helt Skul learning platform was undertaken as part of the Clinical Support Program (Phase II), facilitated by Johnstaff International Development on behalf of the Australian Government Department of Foreign Affairs and Trade through the PNG-Australia Partnership. RM is supported by a National Health and Medical Research Council Postgraduate Scholarship and a Monash Graduate Excellence Scholarship, while PC is supported by a Medical Research Future Fund Practitioner Fellowship. Funders had no role in study design, results analysis or manuscript preparation.

"When all else fails you have to come to the emergency department": Overarching lessons about emergency care resilience from frontline clinicians in Pacific Island countries and territories during the COVID-19 pandemic.

The COVID-19 pandemic continues to test health systems resilience worldwide. Low- and middle-income country (LMIC) health care systems have considerable experience in disasters and disease outbreaks. Lessons from the preparedness and responses to COVID-19 in LMICs may be valuable to other countries.This policy paper synthesises findings from a multiphase qualitative research project, conducted during the pandemic to document experiences of Pacific Island Country and Territory (PICT) frontline clinicians and emergency care (EC) stakeholders. Thematic analysis and synthesis of enablers related to each of the Pacific EC systems building blocks identified key factors contributing to strengthened EC systems.Effective health system responses to the COVID-19 pandemic occurred when frontline clinicians and 'decision makers' collaborated with respect and open communication, overcoming healthcare workers' fear and discontent. PICT EC clinicians demonstrated natural leadership and strengthened local EC systems, supporting essential healthcare. Despite resource limitations, PICT cultural strengths of relational connection and innovation ensured health system resilience. COVID-19 significantly disrupted services, with long-tail impacts on non-communicable disease and other health burdens.Lessons learned in responding to COVID-19 can be applied to ongoing health system strengthening initiatives. Optimal systems improvement and sustainability requires EC leaders' involvement in current decision-making as well as future planning. Search strategy and selection criteria: Search strategy and selection criteria We searched PubMed, Google Scholar, Ovid, WHO resources, Pacific and grey literature using search terms 'emergency care', 'acute/critical care', 'health care workers', 'emergency care systems/health systems', 'health system building blocks', 'COVID-19', 'pandemic/surge event/disease outbreaks' 'Low- and Middle-Income Countries', 'Pacific Islands/region' and related terms. Only English-language articles were included. Funding: Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Copyright of the original work on which this publication is based belongs to WHO. The authors have been given permission to publish this manuscript. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of WHO. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant. RM is supported by a National Health and Medical Research Council (NHMRC) Postgraduate Scholarship and a Monash Graduate Excellence Scholarship. GOR is supported by a NHMRC Early Career Research Fellowship. CEB is supported by a University of Queensland Development Research Fellowship. None of these funders played any role in study design, results analysis or manuscript preparation.

Lessons from the frontline: Leadership and governance experiences in the COVID-19 pandemic response across the Pacific region.

Background: Universal access to safe, effective emergency care (EC) during the COVID-19 pandemic has illustrated its centrality to healthcare systems. The 'Leadership and Governance' building block provides policy, accountability and stewardship to health systems, and is essential to determining effectiveness of pandemic response. This study aimed to explore the experience of leadership and governance during the COVID-19 pandemic from frontline clinicians and stakeholders across the Pacific region. Methods: Australian and Pacific researchers collaborated to conduct this large, qualitative research project in three phases between March 2020 and July 2021. Data was gathered from 116 Pacific regional participants through online support forums, in-depth interviews and focus groups. A phenomenological approach shaped inductive and deductive data analysis, within a previously identified Pacific EC systems building block framework. Findings: Politics profoundly influenced pandemic response effectiveness, even at the clinical coalface. Experienced clinicians spoke authoritatively to decision-makers; focusing on safety, quality and service duty. Rapid adaptability, past surge event experience, team-focus and systems-thinking enabled EC leadership. Transparent communication, collaboration, mutual respect and trust created unity between frontline clinicians and 'top-level' administrators. Pacific cultural assets of relationship-building and community cohesion strengthened responses. Interpretation: Effective governance occurs when political, administrative and clinical actors work collaboratively in relationships characterised by trust, transparency, altruism and evidence. Trained, supported EC leadership will enhance frontline service provision, health security preparedness and future Universal Health Coverage goals. Funding: Epidemic Ethics/World Health Organization (WHO), Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Lessons from the frontline: Documenting the experiences of Pacific emergency care clinicians responding to the COVID-19 pandemic.

Low- and middle-income countries (LMICs) across the Pacific region have been severely impacted by the COVID-19 pandemic, and emergency care (EC) clinicians have been on the frontline of response efforts. Their responsibilities have extended from triage and clinical management of patients with COVID-19 to health system leadership and coordination. This has exposed EC clinicians to a range of ethical and operational challenges.This paper describes the context and methodology of a rapid, collaborative, qualitative research project that explored the experiences of EC clinicians in Pacific LMICs during the COVID-19 pandemic. The study was conducted in three phases, with data obtained from online regional EC support forums, key informant interviews and focus group discussions. A phenomenological approach was adopted, incorporating a hybrid inductive and deductive thematic analysis. Research findings, reported in other manuscripts in this collection, will inform multi-sectoral efforts to improve health system preparedness for future public health emergencies. Funding: Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z (Phases 1 and 2A) and an Australasian College for Emergency Medicine Foundation International Development Fund Grant.

Lessons from the frontline: Documenting the pandemic emergency care experience from the Pacific region - Infrastructure and equipment.

Background: The COVID-19 pandemic highlighted challenges for all health systems worldwide. This research aimed to explore the impact of COVID-19 across the Pacific especially with regards to emergency care (EC) and clinicians' preparations and responses. Methods: A collaboration of Australia and Pacific researchers conducted prospective qualitative research over 18 months of the pandemic. In this three phase study data were gathered from Emergency Clinicians and stakeholders through online support forums, in-depth interviews and focus groups. A phenomenological methodological approach was employed to explore the lived experience of participants. This paper discusses the findings of the study regarding the EC building block of 'Infrastructure and Equipment.' Findings: Pre-existing infrastructure and equipment were not sufficient to help control the pandemic. Adequate space and correct equipment were essential needs for Pacific Island emergency clinicians, with donations, procurement and local ingenuity required for suitable, sustainable supplies and facilities. Adequate personal protective equipment (PPE) conferred a sense of security and increased Health Care Workers willingness to attend to patients. Interpretation: Investing in adequate infrastructure and appropriate equipment is crucial for an effective response to the COVID-19 pandemic. The sustainability of such investments in the Pacific context is paramount for ongoing EC and preparation for future surge responses and disasters. Funding: Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

Lessons from the frontline: The value of emergency care processes and data to pandemic responses across the Pacific region.

Background: Emergency care (EC) addresses the needs of patients with acute illness and injury, and has fulfilled a critical function during the COVID-19 pandemic. 'Processes' (e.g. triage) and 'data' (e.g. surveillance) have been nominated as essential building blocks for EC systems. This qualitative research sought to explore the impact of the pandemic on EC clinicians across the Pacific region, including the contribution of EC building blocks to effective responses. Methods: The study was conducted in three phases, with data obtained from online support forums, key informant interviews and focus group discussions. There were 116 participants from more than 14 Pacific Island Countries and Territories. A phenomenological approach was adopted, incorporating inductive and deductive methods. The deductive thematic analysis utilised previously identified building blocks for Pacific EC. This paper summarises findings for the building blocks of 'processes' and 'data'. Findings: Establishing triage and screening capacity, aimed at assessing urgency and transmission risk respectively, were priorities for EC clinicians. Enablers included support from senior hospital leaders, previous disaster experience and consistent guidelines. The introduction of efficient patient flow processes, such as streaming, proved valuable to emergency departments, and checklists and simulation were useful implementation strategies. Some response measures impacted negatively on non-COVID patients, and proactive approaches were required to maintain 'business as usual'. The pandemic also highlighted the value of surveillance and performance data. Interpretation: Developing effective processes for triage, screening and streaming, among other areas, was critical to an effective EC response. Beyond the pandemic, strengthening processes and data management capacity will build resilience in EC systems. Funding: Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

Lessons from the frontline: The COVID-19 pandemic emergency care experience from a human resource perspective in the Pacific region.

Background: This study explores emergency care (EC) and other frontline healthcare worker (HCW) experiences responding to the COVID-19 pandemic in the Pacific region. The crisis has reinforced the crucial role well-trained, resourced, and supported EC providers play in supporting vital health systems and services in all global regions not only during 'business as usual' periods, but in times of tremendous stress and surge. Methods: Qualitative data were collected from EC providers and relevant stakeholders in three research phases in 2020 and 2021. Data on the World Health Organization's (WHO) Human Resources Building Block, adapted for the Pacific EC context, was thematically analysed. Key findings were further analysed to identify enablers and barriers to effective EC pandemic management. Findings: 116 participants from across the Pacific region participated in this study. Five themes emerged: (1) EC providers performed multiple pandemic roles; (2) Importance of authorities' valuing frontline HCWs; (3) HCW mental health and exhaustion; (4) HCW tension managing stigma, personal/professional expectations, and chronic health needs; and (5) Building health and human resource capacity. Interpretation: This study significantly contributes to the limited scientific literature on HCW experiences responding to COVID-19 across the Pacific. Recommendations arising out of this research align with consensus priorities and standards that were identified pre-pandemic by health stakeholders across the Pacific for enhancing EC system development. With limited HCWs available for many Pacific nations, it is imperative the dignity and welfare of local HCWs is genuinely prioritised. Funding: Epidemic Ethics/WHO, Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Emergency department triage and COVID-19: Performance of the Interagency Integrated Triage Tool during a pandemic surge in Papua New Guinea.

OBJECTIVE: To determine the sensitivity of the Interagency Integrated Triage Tool to identify severe and critical illness among adult patients with COVID-19. METHODS: A retrospective observational study conducted at Port Moresby General Hospital ED during a three-month Delta surge. RESULTS: Among 387 eligible patients with COVID-19, 63 were diagnosed with severe or critical illness. Forty-seven were allocated a high acuity triage category, equating to a sensitivity of 74.6% (95% CI 62.1-84.7) and a negative predictive value of 92.7% (95% CI 88.4-95.8). CONCLUSION: In a resource-constrained context, the tool demonstrated reasonable sensitivity to detect severe and critical COVID-19, comparable with its reported performance for other urgent conditions.

Behavioural drivers influencing emergency department attendance in Victoria during the 2020 COVID-19 pandemic: A mixed methods investigation.

OBJECTIVE: To identify behavioural drivers and barriers that may have contributed to changes in ED attendance during the first 10 months of the coronavirus disease 2019 (COVID-19) pandemic in Victoria. METHODS: We conducted a mixed methods analysis of patients who attended one of eight participating EDs between 1 November 2019 and 31 December 2020. A random sample of patients were chosen after their visit and invited to participate in an online survey assessing behavioural drivers and barriers to attendance. The study timespan was divided into four periods based on local and world events to assess changes in attitudes and behaviours over this period. RESULTS: A total of 5600 patients were invited to complete the survey and 606 (11%) submitted sufficient information for analysis. There were significant differences in participants' attitudes towards healthcare and EDs, levels of concern about contracting and spreading COVID-19 and the influence of mask wearing. Patients expressed more concern about the safety of an ED during the largest outbreak of COVID-19 infections than they did pre-COVID, but this difference was not sustained once community infection numbers dropped. General concerns about hospital attendance were higher after COVID than they were pre-COVID. A total of 27% of patients specifically stated that they had delayed their ED attendance. CONCLUSION: Patients expressed increased concerns around attending ED during the first 10 months of the 2020 COVID-19 pandemic and frequently cited COVID-19 as a reason for delaying their presentation. These factors would be amenable to mitigation via focussed public health messaging.

Preparing for reopening: An emergency care perspective.

Australia is rapidly moving towards 'living with COVID-19', with relaxation of some public health measures. The number of severe cases of COVID-19 may be mitigated by vaccination, but 'living with COVID-19' will be associated with higher number of patients seeking emergency care. This impending impact on the emergency care system requires recognition, monitoring and co-ordinated management. Current challenges include a lack of emergency care monitoring systems, staff shortages and patient flow processes that are quickly overwhelmed by large numbers, particularly in a system already operating at capacity. Effective monitoring systems are required for health systems to proactively detect and respond to stresses. Additional solutions include public health messaging and clinical innovation to facilitate care of the right patient in the right place at the right time. Optimising staff numbers and morale, and efficient patient flow, are integral steps to increasing capacity within the emergency care system.

Outcomes for emergency department patients with suspected and confirmed COVID-19: An analysis of the Australian experience in 2020 (COVED-5).

OBJECTIVE: The aim of the present study was to describe the characteristics and outcomes of patients presenting to Australian EDs with suspected and confirmed COVID-19 during 2020, and to determine the predictors of in-hospital death for SARS-CoV-2 positive patients. METHODS: This analysis from the COVED Project presents data from 12 sites across four Australian states for the period from 1 April to 30 November 2020. All adult patients who met local criteria for suspected COVID-19 and underwent testing for SARS-CoV-2 in the ED were eligible for inclusion. Study outcomes were mechanical ventilation and in-hospital mortality. RESULTS: Among 24 405 eligible ED presentations over the whole study period, 423 tested positive for SARS-CoV-2. During the 'second wave' from 1 July to 30 September 2020, 26 (6%) of 406 SARS-CoV-2 patients received invasive mechanical ventilation, compared to 175 (2%) of the 9024 SARS-CoV-2 negative patients (odds ratio [OR] 3.5; 95% confidence interval [CI] 2.3-5.2, P < 0.001), and 41 (10%) SARS-CoV-2 positive patients died in hospital compared to 312 (3%) SARS-CoV-2 negative patients (OR 3.2; 95% CI 2.2-4.4, P = 0.001). For SARS-CoV-2 positive patients, the strongest independent predictors of hospital death were age (OR 1.1; 95% CI 1.1-1.1, P < 0.001), higher triage category (OR 3.5; 95% CI 1.3-9.4, P = 0.012), obesity (OR 4.2; 95% CI 1.2-14.3, P = 0.024) and receiving immunosuppressive treatment (OR 8.2; 95% CI 1.8-36.7, P = 0.006). CONCLUSIONS: ED patients who tested positive for SARS-CoV-2 had higher odds of mechanical ventilation and death in hospital. The strongest predictors of death were age, a higher triage category, obesity and receiving immunosuppressive treatment.

COVID-19 and emergency care for adults experiencing homelessness.

Homeless individuals face many barriers to accessing healthcare, and EDs are often their primary entry point to the healthcare system. The COVID-19 pandemic has the potential to exacerbate existing social inequities and health disparities, including barriers to accessing social services and healthcare. Addressing the complex social and chronic health issues associated with homelessness can be challenging within the acute care environment. This perspective reflects upon the delivery of emergency healthcare to patients experiencing homelessness, and highlights strategies for optimising health outcomes during and beyond the pandemic.

Epidemiology and clinical features of emergency department patients with suspected and confirmed COVID-19: A multisite report from the COVID-19 Emergency Department Quality Improvement Project for July 2020 (COVED-3).

OBJECTIVE: The aim of the present study was to describe the epidemiology and clinical features of patients presenting to the ED with suspected and confirmed COVID-19. METHODS: The COVID-19 ED (COVED) Project is an ongoing prospective cohort study in Australian EDs. This analysis presents data from eight sites across Victoria and Tasmania for July 2020 (during Australia's 'second wave'). All adult patients who met criteria for 'suspected COVID-19' and underwent testing for SARS-CoV-2 in the ED were eligible for inclusion. Study outcomes included a positive SARS-CoV-2 test result and mechanical ventilation. RESULTS: In the period 1 July to 31 July 2020, there were 30 378 presentations to the participating EDs and 2917 (9.6%; 95% confidence interval 9.3-9.9) underwent testing for SARS-CoV-2. Of these, 50 (2%) patients returned a positive result. Among positive cases, two (4%) received mechanical ventilation during their hospital admission compared to 45 (2%) of the SARS-CoV-2 negative patients (odds ratio 1.7, 95% confidence interval 0.4-7.3; P = 0.47). Two (4%) SARS-CoV-2 positive patients died in hospital compared to 46 (2%) of the SARS-CoV-2 negative patients (odds ratio 1.7, 95% confidence interval 0.4-7.1; P = 0.49). Strong clinical predictors of a positive SARS-CoV-2 result included self-reported fever, non-smoking status, bilateral infiltrates on chest X-ray and absence of a leucocytosis on first ED blood tests (P < 0.05). CONCLUSION: In this prospective multi-site study from July 2020, a substantial proportion of ED patients required SARS-CoV-2 testing, isolation and enhanced infection prevention and control precautions. Presence of SARS-CoV-2 on nasopharyngeal swab was not associated with death or mechanical ventilation.

Presentations of stroke and acute myocardial infarction in the first 28 days following the introduction of State of Emergency restrictions for COVID-19.

OBJECTIVES: To determine if Victorian State of Emergency (SOE) measures to combat COVID-19 were associated with delayed presentations or management of acute stroke and acute myocardial infarction (AMI). METHODS: This was a retrospective, pre- and post-implementation study using data from an adult, tertiary cardiology and neurosciences centre with 24-h capacity for endovascular procedures. All primary presentations with acute stroke or AMI during the first 28 days of stage 2 and stage 3 SOE restrictions (26 March to 23 April 2020) were compared to an equivalent period without restrictions (26 March to 23 April 2019). The primary outcome variable was time from onset of symptoms to ED presentation. RESULTS: There were 52 (1.6% of all ED presentations) patients who met inclusion criteria during the SOE period and 57 (1.0%) patients in the comparator period. Patients were equally matched for demographics, disease severity and prior history of stroke or AMI. Median time from symptom onset to presentation was 227 (93-1183) min during the SOE period and 342 (119-1220) min during the comparator period (P = 0.24). Among eligible patients with ischaemic stroke or ST-elevation AMI, median time to primary reperfusion intervention was 65 (37-78) min during SOE and 44 (39-60) min in the comparator period (P = 0.54). There were no differences in mortality at hospital discharge (9.6% vs 10.5%) and hospital length of stay (5.4 vs 4.3 days). CONCLUSIONS: In the first 28 days, SOE measures to combat COVID-19 were not associated with delays in presentation or life-saving interventions for patients with acute stroke and AMI.

Impact of patient isolation on emergency department length of stay: A retrospective cohort study using the Registry for Emergency Care.

OBJECTIVE: The number of patients with suspected COVID-19 presenting to Australian EDs continues to impose a burden on healthcare services. Isolation is an important aspect of infection prevention and control, but has been associated with undesirable consequences among hospital inpatients. The aim of the present study was to determine if isolation is associated with an increased length of stay (LOS) in the ED. METHODS: The Registry for Emergency Care Project is a prospective cohort study with a series of nested sub-studies. The present study was a retrospective analysis of adult patients allocated an Australasian Triage Scale category of 1 or 2 who presented to a tertiary ED between 18 and 31 May 2020. The primary outcome was ED LOS. Regression methods were used to determine the independent association between ED isolation and LOS. RESULTS: There were 447 patients who met inclusion criteria, of which 123 (28%) were managed in isolation. The median (interquartile range) ED LOS was 259 (210-377) min for the isolation group and 204 (126-297) min for the non-isolation group, a difference in median ED LOS of 55 min (P < 0.001). Isolation was independently associated with a 23% increase in ED LOS (P = 0.002) and doubled the odds of an ED stay of more than 4 h (adjusted odds ratio 2.2 [1.4-3.4], P = 0.001). CONCLUSION: Consistent with the anecdotal experience of Australian ED clinicians, the present study demonstrated an increased ED LOS for patients managed in isolation. Enhanced infection prevention and control precautions will be required during and beyond the current pandemic, creating significant ongoing challenges for emergency care systems.

Impact of COVID-19 State of Emergency restrictions on presentations to two Victorian emergency departments.

OBJECTIVE: To determine if COVID-19 State of Emergency (SOE) restrictions were associated with a reduction in presentations to two urban EDs in Melbourne, Victoria. METHODS: This retrospective observational study included adult patients presenting to The Alfred and Sandringham Hospital EDs during the first month of stage 2 and 3 SOE restrictions (26 March-25 April 2020). Patients transferred from other hospitals or diagnosed with COVID-19 were excluded. The primary outcome was the average number of presentations per day. Secondary outcomes included the average daily number of presentations for pre-specified subgroups defined by triage category and diagnosis. The independent impact of SOE restrictions, adjusted for underlying trends in attendance, was determined using negative binomial regression and reported as an incident rate ratio (IRR) with a 95% confidence interval (CI). RESULTS: Average daily attendance during the exposure period was 174.7. In the absence of SOE restrictions, 278.8 presentations per day were predicted, a reduction of 37.3% (IRR 0.63, 95% CI 0.59-0.67). Attendance was lower than anticipated for all triage categories (especially category 5 [IRR 0.51, 95% CI 0.44-0.59]) and diagnostic groups (including circulatory problems [IRR 0.62, 95% CI 0.50-0.76] and injury [IRR 0.58, 95% CI 0.53-0.63]). There were fewer than predicted presentations for several sentinel diagnoses, including gastroenteritis (IRR 0.27, 95% CI 0.17-0.42) and renal colic (IRR 0.55, 95% CI 0.33-0.92). CONCLUSIONS: SOE restrictions were associated with a significant reduction in ED presentations across a range of triage categories and diagnoses. Public health messaging should emphasise the importance of timely ED attendance for acute illness and injury.

Management of adult cardiac arrest in the COVID-19 era: consensus statement from the Australasian College for Emergency Medicine.

INTRODUCTION: The global pandemic of coronavirus disease 2019 (COVID-19) has caused significant worldwide disruption. Although Australia and New Zealand have not been affected as much as some other countries, resuscitation may still pose a risk to health care workers and necessitates a change to our traditional approach. This consensus statement for adult cardiac arrest in the setting of COVID-19 has been produced by the Australasian College for Emergency Medicine (ACEM) and aligns with national and international recommendations. MAIN RECOMMENDATIONS: In a setting of low community transmission, most cardiac arrests are not due to COVID-19. Early defibrillation saves lives and is not considered an aerosol generating procedure. Compression-only cardiopulmonary resuscitation is thought to be a low risk procedure and can be safely initiated with the patient's mouth and nose covered. All other resuscitative procedures are considered aerosol generating and require the use of airborne personal protective equipment (PPE). It is important to balance the appropriateness of resuscitation against the risk of infection. Methods to reduce nosocomial transmission of COVID-19 include a physical barrier such as a towel or mask over the patient's mouth and nose, appropriate use of PPE, minimising the staff involved in resuscitation, and use of mechanical chest compression devices when available. If COVID-19 significantly affects hospital resource availability, the ethics of resource allocation must be considered. CHANGES IN MANAGEMENT: The changes outlined in this document require a significant adaptation for many doctors, nurses and paramedics. It is critically important that all health care workers have regular PPE and advanced life support training, are able to access in situ simulation sessions, and receive extensive debriefing after actual resuscitations. This will ensure safe, timely and effective management of the patients with cardiac arrest in the COVID-19 era.