Management of the COVID-19 Pandemic: Analysis of the Perception of Professionals of Emergency Medical Systems in Spain after the First Wave.

OBJECTIVE: The objective of this study was to identify the perceived problems by medical and nursing professionals that have arisen in the Spanish Emergency Medical Services (EMS) as a consequence of the first wave of the severe acute respiratory syndrome-coronavirus-2/SARS-CoV-2 pandemic, as well as the measures or solutions adopted to manage those problems and improve response. METHOD: This was a cross-sectional study of quantitative and qualitative methodology ("mixed methods") using a self-administered questionnaire in 23 key informants of EMS of Spain selected by purposeful sampling, followed by the statistical analysis of both types of variables and an integration of the results in the discussion. RESULTS: Common problems had been identified in many EMS, as well as similar solutions in some of them. Among the former, the following had been found: lack of leadership and support from managers, initial shortage of personal protective equipment (PPE), lack of participation in decision making, initial lack of clinical protocols, and slowness and/or lack of adaptability of the system, among others. Among the solutions adopted: reinforcement of emergency call centers, development of specific coronavirus disease 2019 (COVID-19) telephone lines and new resources, personal effort of professionals, new functions of EMS, support to other structures, and reinforcement of the role of nursing. CONCLUSION: The general perception among the respondents was that there was a lack of support and communication with health care managers and that the staff expertise was not used by policy makers to make decisions adapted to reality, also expressing the need to improve the capacity for analysis of the EMS response. Few respondents reported good overall satisfaction with their EMS response. The EMS adopted different types of measures to adapt to the COVID-19 pandemic.

Effect of EARLY administration of DEXamethasone in patients with COVID-19 pneumonia without acute hypoxemic respiratory failure and risk of development of acute respiratory distress syndrome (EARLY-DEX COVID-19): study protocol for a randomized controlled trial.

BACKGROUND: Corticosteroids are one of the few drugs that have shown a reduction in mortality in coronavirus disease 2019 (COVID-19). In the RECOVERY trial, the use of dexamethasone reduced 28-day mortality compared to standard care in hospitalized patients with suspected or confirmed COVID-19 requiring supplemental oxygen or invasive mechanical ventilation. Evidence has shown that 30% of COVID-19 patients with mild symptoms at presentation will progress to acute respiratory distress syndrome (ARDS), particularly patients in whom laboratory inflammatory biomarkers associated with COVID-19 disease progression are detected. We postulated that dexamethasone treatment in hospitalized patients with COVID-19 pneumonia without additional oxygen requirements and at risk of progressing to severe disease might lead to a decrease in the development of ARDS and thereby reduce death. METHODS/DESIGN: This is a multicenter, randomized, controlled, parallel, open-label trial testing dexamethasone in 252 adult patients with COVID-19 pneumonia who do not require supplementary oxygen on admission but are at risk factors for the development of ARDS. Risk for the development of ARDS is defined as levels of lactate dehydrogenase > 245 U/L, C-reactive protein > 100 mg/L, and lymphocyte count of < 0.80 × 109/L. Eligible patients will be randomly assigned to receive either dexamethasone or standard of care. Patients in the dexamethasone group will receive a dose of 6 mg once daily during 7 days. The primary outcome is a composite of the development of moderate or more severe ARDS and all-cause mortality during the 30-day period following enrolment. DISCUSSION: If our hypothesis is correct, the results of this study will provide additional insights into the management and progression of this specific subpopulation of patients with COVID-19 pneumonia without additional oxygen requirements and at risk of progressing to severe disease. TRIAL REGISTRATION: ClinicalTrials.gov NCT04836780. Registered on 8 April 2021 as EARLY-DEX COVID-19.

Effect of corticosteroids in patients with COVID-19 early stage pneumonia and risk of disease progression: An uncharted territory.

Corticosteroids are one of the few drugs that have shown a reduction in mortality in coronavirus disease 2019 (COVID-19). In the RECOVERY trial, the use of dexamethasone reduced 28-day mortality compared to standard care in hospitalized patients with suspected or confirmed COVID-19 requiring supplemental oxygen or invasive mechanical ventilation. No benefit in patients not requiring respiratory support at randomization was observed. However, we believe that the use of corticosteroids in patients with COVID-19 pneumonia might not be subject to a decision based solely on oxygen needs. Evidence has shown that 30% of COVID-19 patients in its initial phases will progress to acute respiratory distress syndrome, particularly patients in whom laboratory inflammatory biomarkers associated with COVID-19 disease progression are detected. We postulated that corticosteroids in patients with COVID-19 in its initial phases and risk of progressing to severe disease might lead to a decrease in the development of acute respiratory distress syndrome, and thereby reduce death.

Antiplatelet therapy and outcome in COVID-19: the Health Outcome Predictive Evaluation Registry.

BACKGROUND: Standard therapy for COVID-19 is continuously evolving. Autopsy studies showed high prevalence of platelet-fibrin-rich microthrombi in several organs. The aim of the study was therefore to evaluate the safety and efficacy of antiplatelet therapy (APT) in hospitalised patients with COVID-19 and its impact on survival. METHODS: 7824 consecutive patients with COVID-19 were enrolled in a multicentre international prospective registry (Health Outcome Predictive Evaluation-COVID-19 Registry). Clinical data and in-hospital complications were recorded. Data on APT, including aspirin and other antiplatelet drugs, were obtained for each patient. RESULTS: During hospitalisation, 730 (9%) patients received single APT (93%, n=680) or dual APT (7%, n=50). Patients treated with APT were older (74±12 years vs 63±17 years, p<0.01), more frequently male (68% vs 57%, p<0.01) and had higher prevalence of diabetes (39% vs 16%, p<0.01). Patients treated with APT showed no differences in terms of in-hospital mortality (18% vs 19%, p=0.64), need for invasive ventilation (8.7% vs 8.5%, p=0.88), embolic events (2.9% vs 2.5% p=0.34) and bleeding (2.1% vs 2.4%, p=0.43), but had shorter duration of mechanical ventilation (8±5 days vs 11±7 days, p=0.01); however, when comparing patients with APT versus no APT and no anticoagulation therapy, APT was associated with lower mortality rates (log-rank p<0.01, relative risk 0.79, 95% CI 0.70 to 0.94). On multivariable analysis, in-hospital APT was associated with lower mortality risk (relative risk 0.39, 95% CI 0.32 to 0.48, p<0.01). CONCLUSIONS: APT during hospitalisation for COVID-19 could be associated with lower mortality risk and shorter duration of mechanical ventilation, without increased risk of bleeding. TRIAL REGISTRATION NUMBER: NCT04334291.