An immune-protein score combining TRAIL, IP-10 and CRP for predicting severe COVID-19 disease.

COVID-19 patients are oftentimes over- or under-treated due to a deficit in predictive management tools. This study reports derivation of an algorithm that integrates the host levels of TRAIL, IP-10, and CRP into a single numeric score that is an early indicator of severe outcome for COVID-19 patients and can identify patients at-risk to deteriorate. 394 COVID-19 patients were eligible; 29% meeting a severe outcome (intensive care unit admission/non-invasive or invasive ventilation/death). The score's area under the receiver operating characteristic curve (AUC) was 0.86, superior to IL-6 (AUC 0.77; p = 0.033) and CRP (AUC 0.78; p < 0.001). Likelihood of severe outcome increased significantly (p < 0.001) with higher scores. The score differentiated severe patients who further deteriorated from those who improved (p = 0.004) and projected 14-day survival probabilities (p < 0.001). The score accurately predicted COVID-19 patients at-risk for severe outcome, and therefore has potential to facilitate timely care escalation and de-escalation and appropriate resource allocation.

Utility of COVID-19 antigen testing in the emergency department.

BACKGROUND: The BinaxNOW coronavirus disease 2019 (COVID-19) Ag Card test (Abbott Diagnostics Scarborough, Inc.) is a lateral flow immunochromatographic point-of-care test for the qualitative detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleocapsid protein antigen. It provides results from nasal swabs in 15 minutes. Our purpose was to determine its sensitivity and specificity for a COVID-19 diagnosis. METHODS: Eligible patients had symptoms of COVID-19 or suspected exposure. After consent, 2 nasal swabs were collected; 1 was tested using the Abbott RealTime SARS-CoV-2 (ie, the gold standard polymerase chain reaction test) and the second run on the BinaxNOW point of care platform by emergency department staff. RESULTS: From July 20 to October 28, 2020, 767 patients were enrolled, of which 735 had evaluable samples. Their mean (SD) age was 46.8 (16.6) years, and 422 (57.4%) were women. A total of 623 (84.8%) patients had COVID-19 symptoms, most commonly shortness of breath (n = 404; 55.0%), cough (n = 314; 42.7%), and fever (n = 253; 34.4%). Although 460 (62.6%) had symptoms ≤7 days, the mean (SD) time since symptom onset was 8.1 (14.0) days. Positive tests occurred in 173 (23.5%) and 141 (19.2%) with the gold standard versus BinaxNOW test, respectively. Those with symptoms >2 weeks had a positive test rate roughly half of those with earlier presentations. In patients with symptoms ≤7 days, the sensitivity, specificity, and negative and positive predictive values for the BinaxNOW test were 84.6%, 98.5%, 94.9%, and 95.2%, respectively. CONCLUSIONS: The BinaxNOW point-of-care test has good sensitivity and excellent specificity for the detection of COVID-19. We recommend using the BinasNOW for patients with symptoms up to 2 weeks.

Mental Health of Emergency Department Healthcare Workers During COVID-19 in Brooklyn, New York

Background. Maintaining good mental health among Emergency Department healthcare workers (ED HCW) is paramount to well-functioning healthcare. We measured mental health and COVID-19 symptoms in ED HCW at a COVID-19 epicenter. Methods. A cross-sectional, convenience sample of adult (≥18 years) ED HCW in Brooklyn, New York, USA, who were employed at ≥50% of a full-time effort, was surveyed September–December, 2020 with reference period March-May 2020. An anonymous email-distributed survey assessed gender, age, race, healthcare worker status (clinical versus non-clinical), SARS-CoV-2 testing, number of people to talk to, COVID-19-related home problems, mental health care interruption during COVID-19, loneliness, and survey date. Outcomes included symptoms of depression, psychological distress, perceived stress, post-traumatic stress disorder (PTSD), anxiety, and resilience measured using validated scales. Results. Of 774 HCW, 247 (31.9%) responded (mean age 38.2±10.8 years;59.4% White;52.5% men;80.1% clinical;61.6% SARS-CoV-2 tested). Average mental health scores were significantly higher among clinical vs non-clinical HCW (P’s<0.0001–0.019). The proportion reporting a clinically-relevant psychological distress symptom burden was higher among clinical vs non-clinical HCW (35.8% vs 13.8%, p=0.019);and suggested for depression (53.9% clinical vs 35.7% non-clinical, p=0.072);perceived stress (63.6% clinical vs 44.8% non-clinical, p=0.053);and PTSD (18.2% clinical vs 3.6% non-clinical, p=0.064). Compared to non-clinical staff, Medical Doctors and Doctors of Osteopathy reported 4.8-fold higher multivariable-adjusted odds of clinically-relevant perceived stress (95%CI 1.8–12.9, p=0.002);Emergency Medical Technicians reported 15.5-fold higher multivariable-adjusted odds of clinically-relevant PTSD (95%CI 1.6–150.4, p=0.018). Increasing age, number of COVID-19-related home problems and people to talk to, loneliness and mental health care interruption were adversely associated with mental health;being male and SARS-CoV-2 testing were beneficial. Conclusions. COVID-19-related mental health burden was high among ED HCW in Brooklyn. Mental health support services are essential for ED HCW.

CovidStats: Development and Implementation of a Daily COVID-19 Clinical Dashboard in an Urban Teaching Hospital.

BACKGROUND AND OBJECTIVES: Dashboards have been utilized in health care to improve quality and patient care. The purpose of our project was to create a concise, timely, and accurate dashboard for administrative and clinical leadership during the COVID-19 pandemic. METHODS: Two authors collaborated to identify 14 metrics and design a comprehensive dashboard (CovidStats, CS) using Microsoft Excel. The dashboard was updated daily and distributed to leadership between December 2020 and April 2021. The utility of this quality measure was assessed by survey of hospital leadership. RESULTS: The 14 metrics included were as follows: (1) elective surgery census threshold; (2) daily COVID admissions; (3) daily COVID discharges; (4) net COVID admissions; (5) ED (emergency department) bed holds; (6) COVID ED bed holds; (7) hospital census; (8) percent COVID census; (9) active COVID census; (10) COVID ICU (intensive care unit); (11) MICU (medical ICU) census; (12) ventilators in use; (13) high-flow oxygen devices in use; and (14) weekly hospital census. The leadership response survey revealed unanimous approval for CS, with a mean rating of 4.9 ± 0.3 (rated 1-5). CONCLUSIONS: Effective clinical dashboards can be created using affordable basic computer software. Implementation of the CS dashboard conveyed relevant and timely information, which influenced the decision making of hospital leadership during the COVID-19 pandemic.

Alternatives to Opioids for Acute Pain Management in the Emergency Department

* Since the opioid crisis is still present, if not worse, it is important for emergency physicians to avoid the use of opioids whenever possible. * Many alternatives exist. Nitrous oxide provides short-term analgesia and can be used in children as young as 1 year of age. * Sub-dissociative doses of ketamine can be used for acute pain relief. Slow infusion decreases the psychoperceptual effects commonly seen with ketamine. It may be of some use even in chronic pain. * Intravenous lidocaine had been recommended for acute pain, particularly due to renal colic. However, more recent studies suggest it is inferior to ketorolac. * The use of ultrasound-guided regional anesthesia has been increasing and has been shown to be of value in acute trauma, central line placement, renal colic, zoster, and chest tube placement.

In-hospital cardiac arrest in patients with coronavirus 2019.

BACKGROUND: Coronavirus Disease 2019 (COVID-19) has caused over 1 200 000 deaths worldwide as of November 2020. However, little is known about the clinical outcomes among hospitalized patients with active COVID-19 after in-hospital cardiac arrest (IHCA). AIM: We aimed to characterize outcomes from IHCA in patients with COVID-19 and to identify patient- and hospital-level variables associated with 30-day survival. METHODS: We conducted a multicentre retrospective cohort study across 11 academic medical centres in the U.S. Adult patients who received cardiopulmonary resuscitation and/or defibrillation for IHCA between March 1, 2020 and May 31, 2020 who had a documented positive test for Severe Acute Respiratory Syndrome Coronavirus 2 were included. The primary outcome was 30-day survival after IHCA. RESULTS: There were 260 IHCAs among COVID-19 patients during the study period. The median age was 69 years (interquartile range 60-77), 71.5% were male, 49.6% were White, 16.9% were Black, and 16.2% were Hispanic. The most common presenting rhythms were pulseless electrical activity (45.0%) and asystole (44.6%). ROSC occurred in 58 patients (22.3%), 31 (11.9%) survived to hospital discharge, and 32 (12.3%) survived to 30 days. Rates of ROSC and 30-day survival in the two hospitals with the highest volume of IHCA over the study period compared to the remaining hospitals were considerably lower (10.8% vs. 64.3% and 5.9% vs. 35.7% respectively, p < 0.001 for both). CONCLUSIONS: We found rates of ROSC and 30-day survival of 22.3% and 12.3% respectively. There were large variations in centre-level outcomes, which may explain the poor survival in prior studies.