Decreased severity of disease during the first global omicron variant covid-19 outbreak in a large hospital in tshwane, south africa.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) first reported in Wuhan, China in December 2019 is a global pandemic that is threatening the health and wellbeing of people worldwide. To date there have been more than 274 million reported cases and 5.3 million deaths. The Omicron variant first documented in the City of Tshwane, Gauteng Province, South Africa on 9 November 2021 led to exponential increases in cases and a sharp rise in hospital admissions. The clinical profile of patients admitted at a large hospital in Tshwane is compared with previous waves. METHODS: 466 hospital COVID-19 admissions since 14 November 2021 were compared to 3962 admissions since 4 May 2020, prior to the Omicron outbreak. Ninety-eight patient records at peak bed occupancy during the outbreak were reviewed for primary indication for admission, clinical severity, oxygen supplementation level, vaccination and prior COVID-19 infection. Provincial and city-wide daily cases and reported deaths, hospital admissions and excess deaths data were sourced from the National Institute for Communicable Diseases, the National Department of Health and the South African Medical Research Council. RESULTS: For the Omicron and previous waves, deaths and ICU admissions were 4.5% vs 21.3% (p<0.00001), and 1% vs 4.3% (p<0.00001) respectively; length of stay was 4.0 days vs 8.8 days; and mean age was 39 years vs 49,8 years. Admissions in the Omicron wave peaked and declined rapidly with peak bed occupancy at 51% of the highest previous peak during the Delta wave. Sixty two (63%) patients in COVID-19 wards had incidental COVID-19 following a positive SARS-CoV-2 PCR test . Only one third (36) had COVID-19 pneumonia, of which 72% had mild to moderate disease. The remaining 28% required high care or ICU admission. Fewer than half (45%) of patients in COVID-19 wards required oxygen supplementation compared to 99.5% in the first wave. The death rate in the face of an exponential increase in cases during the Omicron wave at the city and provincial levels shows a decoupling of cases and deaths compared to previous waves, corroborating the clinical findings of decreased severity of disease seen in patients admitted to the Steve Biko Academic Hospital. CONCLUSION: There was decreased severity of COVID-19 disease in the Omicron-driven fourth wave in the City of Tshwane, its first global epicentre.

Initial prehospital Rapid Emergency Medicine Score (REMS) to predict outcomes for COVID-19 patients.

OBJECTIVE: The Rapid Emergency Medicine Score (REMS) has not been widely studied for use in predicting outcomes of COVID-19 patients encountered in the prehospital setting. This study aimed to determine whether the first prehospital REMS could predict emergency department and hospital dispositions for COVID-19 patients transported by emergency medical services. METHODS: This retrospective study used linked prehospital and hospital records from the ESO Data Collaborative for all 911-initiated transports of patients with hospital COVID-19 diagnoses from July 1 to December 31, 2020. We calculated REMS with the first recorded prehospital values for each component. We calculated area under the receiver operating curve (AUROC) for emergency department (ED) mortality, ED discharge, hospital mortality, and hospital length of stay (LOS). We determined optimal REMS cut-points using test characteristic curves. RESULTS: Among 13,830 included COVID-19 patients, median REMS was 6 (interquartile range [IQR]: 5-9). ED mortality was <1% (n = 80). REMS ≥9 predicted ED death (AUROC 0.79). One-quarter of patients (n = 3,419) were discharged from the ED with an optimal REMS cut-point of ≤5 (AUROC 0.72). Eighteen percent (n = 1,742) of admitted patients died. REMS ≥8 optimally predicted hospital mortality (AUROC 0.72). Median hospital LOS was 8.3 days (IQR: 4.1-14.8 days). REMS ≥7 predicted hospitalizations ≥3 days (AUROC 0.62). CONCLUSION: Initial prehospital REMS was modestly predictive of ED and hospital dispositions for patients with COVID-19. Prediction was stronger for outcomes more proximate to the first set of emergency medical services (EMS) vital signs. These findings highlight the potential value of first prehospital REMS for risk stratification of individual patients and system surveillance for resource planning related to COVID-19.

Approaches to screening for hyperglycaemia in pregnant women during and after the COVID-19 pandemic.

AIM: To evaluate the diagnostic and prognostic performance of alternative diagnostic strategies to oral glucose tolerance tests, including random plasma glucose, fasting plasma glucose and HbA1c , during the COVID-19 pandemic. METHODS: Retrospective service data (Cambridge, UK; 17 736 consecutive singleton pregnancies, 2004-2008; 826 consecutive gestational diabetes pregnancies, 2014-2019) and 361 women with ≥1 gestational diabetes risk factor (OPHELIA prospective observational study, UK) were included. Pregnancy outcomes included gestational diabetes (National Institute of Health and Clinical Excellence or International Association of Diabetes and Pregnancy Study Groups criteria), diabetes in pregnancy (WHO criteria), Caesarean section, large-for-gestational age infant, neonatal hypoglycaemia and neonatal intensive care unit admission. Receiver-operating characteristic curves and unadjusted logistic regression were used to compare random plasma glucose, fasting plasma glucose and HbA1c performance. RESULTS: Gestational diabetes diagnosis was significantly associated with random plasma glucose at 12 weeks [area under the receiver-operating characteristic curve for both criteria 0.81 (95% CI 0.79-0.83)], fasting plasma glucose [National Institute of Health and Clinical Excellence: area under the receiver-operating characteristic curve 0.75 (95% CI 0.65-0.85); International Association of Diabetes and Pregnancy Study Groups: area under the receiver-operating characteristic curve 0.92 (95% CI 0.85-0.98)] and HbA1c at 28 weeks' gestation [National Institute of Health and Clinical Excellence: 0.83 (95% CI 0.75-0.90); International Association of Diabetes and Pregnancy Study Groups: 0.84 (95% CI 0.77-0.91)]. Each measure predicts some, but not all, pregnancy outcomes studied. At 12 weeks, ~5% of women would be identified using random plasma glucose ≥8.5 mmol/l (sensitivity 42%; specificity 96%) and at 28 weeks using HbA1c ≥39 mmol/mol (sensitivity 26%; specificity 96%) or fasting plasma glucose ≥5.2-5.4 mmol/l (sensitivity 18-41%; specificity 97-98%). CONCLUSIONS: Random plasma glucose at 12 weeks, and fasting plasma glucose or HbA1c at 28 weeks identify women with hyperglycaemia at risk of suboptimal pregnancy outcomes. These opportunistic laboratory tests perform adequately for risk stratification when oral glucose tolerance testing is not available.

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

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. METHODS: This case series evaluated electronic patient care records from EMS agencies participating in a large national bi-directional data exchange. All records for 9-1-1 responses between March 1 and April 19, 2020, resulting in transport to a hospital, with at least one ICD-10 outcome returned via the data exchange were included. Hospital ICD-10 codes used to determine COVID-19 diagnoses included B97.2, B97.21, B97.29, B34.2, and U07.1. COVID-19 EMS suspicion was defined as a documented EMS primary or secondary impression of COVID-19, or indication of COVID-19 suspicion in the prehospital free-text narrative. Comparisons were stratified by COVID-19 hospital diagnosis and COVID-19 EMS suspicion. Descriptive and comparative statistics are presented. RESULTS: There were 84,540 EMS patient records with linked hospital ICD-10 codes included. Of those, 814 (1%) patients had a COVID-19 hospital diagnosis. Overall, COVID-19 EMS suspicion was documented for 3,204 (4%) patients. A COVID-19 EMS suspicion was documented for 636 (78%) of hospital diagnosed COVID-19 patients. Those with COVID-19 hospital diagnoses were more likely to present with tachycardia, tachypnea, hypoxia, and fever during the EMS encounter. EMS responses for patients diagnosed with COVID-19 were also more likely to originate from a skilled nursing/assisted living facility. EMS PPE (eye protection, mask, or gown) use was more frequently documented on records of patients who had hospital diagnosed COVID-19. CONCLUSION: In this large sample of prehospital encounters, EMS COVID-19 suspicion demonstrated sensitivity of 78% and positive predictive value of 20% compared with hospital ICD-10 codes. These data indicate that EMS suspicion alone is insufficient to determine appropriate utilization of PPE.