The scandals of covid-19

Where clinicians once believed "there is no harm trying,” they realise that CPR offers little benefit to patients but brings significant risk to staff as they wait for the protective equipment that was promised in the UK and globally (doi:10.1136/bmj.m1423;doi:10.1136/bmj.m1367). Adding to the scandals of unpreparedness and lack of personal protective equipment is the scandal of testing. Germany's relatively low case fatality rate is helped by an "early and high level of testing” (doi:10.1136/bmj.m1395).

Initiating advance care planning in New South Wales general practices using a structured conversation guide

There is variation in ACP terminology and legislation of ACDs between different jurisdictions within Australia.4 General practice is the ideal setting for ACP discussions, and evidence supports patient preference for initiation of ACP while they are still healthy in the community.5-7 The Royal Australian College of General Practitioners (RACGP) recommends that general practitioners (GPs) discuss ACP as part of routine care for older patients during the annual 75 years and over health assessment.8 The COVID-19 pandemic highlighted the need for GPs to have these conversations, and there have been calls for ACP to be an integral part of pandemic health planning responses.9 Evaluating the prevalence of ACP conversations is difficult, with most studies focusing on the more tangible assessment of ACD completion. Some barriers to GPs initiating ACP include difficulties in defining the right moment to discuss the topic, a perceived lack of knowledge in the ACP process and concern regarding the potential time-consuming nature of ACP discussions.11'12 Strategies to increase initiation of ACP in general practice have focused on workshops and communication skills training for GPs and general practice nurses (GPNs), which are time and resource intensive.13-15 Some studies have shown that discussion guides and question prompt lists can improve the frequency of ACP discussions with patients, but these have been limited to palliative care settings.16-18 Most doctors believe it is their responsibility to initiate these discussions but struggle with timing.19 More evidence is needed to understand how to help GPs facilitate these conversations in a way that is acceptable and meaningful for older patients and their families. [...]it's the family that's really going to make the decision. [Female GP, FG 1.1] Some GPs preferred to focus on clinical decisions such as cardiopulmonary resuscitation (CPR) as the main subject of the conversation, while others preferred to broaden the discussion to general healthcare goals.

Cardio pulmonary resuscitation (CPR) in the frail and multimorbid;outcomes before and during the COVID pandemic

IntroductionSARS-COV2 placed greater emphasis on identifying frail or comorbid patients early and limiting treatment where appropriate. Resuscitation guidelines changed as cardiopulmonary resuscitation (CPR) was classified an aerosol generating procedure (AGP). We assessed the impact of these changes in our tertiary centre focusing on frail and/or comorbid patients.MethodsRetrospective analysis of prospectively collected data from contemporaneous clinical and electronic records for all patients with a recorded cardiac arrest between June 2020 and June 2021. Data collected on features of the cardiac arrest, clinical frailty scale (CFS), Charlson comorbidity index (CCI), survival at discharge, 30 days and 12 months. The comparator was our previously published cohort between April 2017 to March 2018.Results62 patients studied compared to 113 in 2017–18. 20 patients survived to discharge, 30 days and 1 year. This 32.2% survival rate is higher than the 23.8% observed in 2017–18 but not statistically significant (p=0.235). Rates of ROSC similar in both studies (61.3% v 60.2% p=0.960). Median CFS was significantly lower (3.4 v 4.2, p=0.006) as was median CCI (4.1 v 5.7, p001 more patients received CPR in the cardiology department (64.5% v 38.9% p=‘0.002).'ConclusionThere was a dramatic reduction in cardiac arrest events on medical and surgical wards with little change in arrests within the cardiology department. The improvement in survival rate observed in this study is multifactorial but likely includes a less frail and comorbid population and a higher proportion of cardiac arrests in a shockable rhythm. CPR outcomes improved due to better patient selection. No evidence to show COVID ALS guidelines affect outcomes.

Impact of Personal Protective Equipment on the Quality of Chest Compressions in Prehospital Care: A Prospective Randomized Crossover Study

Introduction:The use of personal protective equipment (PPE) in prehospital emergency care has significantly increased since the onset of the coronavirus disease 2019 (COVID-19) pandemic. Several studies investigating the potential effects of PPE use by Emergency Medical Service providers on the quality of chest compressions during resuscitation have been inconclusive.Study Objectives:This study aimed to determine whether the use of PPE affects the quality of chest compressions or influences select physiological biomarkers that are associated with stress.Methods:This was a prospective randomized, quasi-experimental crossover study with 35 Emergency Medical Service providers who performed 20 minutes of chest compressions on a manikin. Two iterations were completed in a randomized order: (1) without PPE and (2) with PPE consisting of Tyvek, goggles, KN95 mask, and nitrile gloves. The rate and depth of chest compressions were measured. Salivary cortisol, lactate, end-tidal carbon dioxide (EtCO2), and body temperature were measured before and after each set of chest compressions.Results:There were no differences in the quality of chest compressions (rate and depth) between the two groups (P >.05). After performing chest compressions, the group with PPE did not have elevated levels of cortisol, lactate, or EtCO2 when compared to the group without PPE, but did have a higher body temperature (P <.001).Conclusion:The use of PPE during resuscitation did not lower the quality of chest compressions, nor did it lead to higher stress-associated biomarker levels, with the exception of body temperature.

Out-of-Hospital Cardiac Arrest during the COVID-19 Pandemic: A Systematic Review.

Objective: Out-of-hospital cardiac arrest (OHCA) is a prominent cause of death worldwide. As indicated by the high proportion of COVID-19 suspicion or diagnosis among patients who had OHCA, this issue could have resulted in multiple fatalities from coronavirus disease 2019 (COVID-19) occurring at home and being counted as OHCA. Methods: We used the MeSH term "heart arrest" as well as non-MeSH terms "out-of-hospital cardiac arrest, sudden cardiac death, OHCA, cardiac arrest, coronavirus pandemic, COVID-19, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)." We conducted a literature search using these search keywords in the Science Direct and PubMed databases and Google Scholar until 25 April 2022. Results: A systematic review of observational studies revealed OHCA and mortality rates increased considerably during the COVID-19 pandemic compared to the same period of the previous year. A temporary two-fold rise in OHCA incidence was detected along with a drop in survival. During the pandemic, the community's response to OHCA changed, with fewer bystander cardiopulmonary resuscitations (CPRs), longer emergency medical service (EMS) response times, and worse OHCA survival rates. Conclusions: This study's limitations include a lack of a centralised data-gathering method and OHCA registry system. If the chain of survival is maintained and effective emergency ambulance services with a qualified emergency medical team are given, the outcome for OHCA survivors can be improved even more.

The effects of the introduction of two new paediatric HDU cubicles

AimsThe presence of paediatric High dependency Unit (pHDU) within the Paediatric emergency department (PED) provides more efficient patient care service.In our emergency department (ED), we previously had 1 resus bay within the adult resus, there was no intermediate High dependency Unit (HDU). We converted 2 cubicles within the PED into pHDU. The changes made to the cubicles were in line with national HDU requirements including cardiac monitor, oxygen, Resus trolley and bed at the centre of the room.We set out to identify the impact of the new pHDU on the use of the resus Bay and to assess its use against the guidelines. We also surveyed acceptability among staff.MethodsThis is a retrospective study;we assessed the electronic notes of patients who presented to the Resus during the winter months of 2018/2019 and compared to those who presented during the winter months of 2019/2020.A questionnaire was used to collect feedback from staff who worked during these two winter periods.Results70 patients presented to the Resus during the winter months of 2018/2019 while 126 patients presented to Resus during 2019/2020 winter months. The increase can be explained by the increase in the total number that presented to PED during this period.350/691(50.6%) of children admitted to the pHDU in 2020 were done following the guideline.Of 41 the staff surveyed 40 were either extremely likely or likely to use the new pHDU.ConclusionIt was easy to convert the normal cubicle into a pHDU. The pHDU cubicles can also be stepped up to Resus, this was done during the Covid peak period. Majority of patients arriving as blue calls to our Resus are now stepped down to the PHDU. Most of our patients now spend less time in Resus.The staff preferred pHDU over resus as this is better for patient care in the contest of the design of the department, this was ascertained in a focus group with 22 MDT staff 2 years later showing increased satisfaction in using pHDU instead of resus for patients.Patient’s experience will be audited in our follow-up study.

Innovative Tele-Instruction Approach Impacts Basic Life Support Performance: A Non-inferiority Trial.

Background: Sustaining Basic Life Support (BLS) training during the COVID-19 pandemic bears substantial challenges. The limited availability of highly qualified instructors and tight economic conditions complicates the delivery of these life-saving trainings. Consequently, innovative and resource-efficient approaches are needed to minimize or eliminate contagion while maintaining high training standards and managing learner anxiety related to infection risk. Methods: In a non-inferiority trial 346 first-year medical, dentistry, and physiotherapy students underwent BLS training at AIXTRA-Competence Center for Training and Patient Safety at the University Hospital RWTH Aachen. Our objectives were (1) to examine whether peer feedback BLS training supported by tele-instructors matches the learning performance of standard instructor-guided BLS training for laypersons; and (2) to minimize infection risk during BLS training. Therefore, in a parallel group design, we compared arm (1) Standard Instructor Feedback (SIF) BLS training (Historical control group of 2019) with arm (2) a Tele-Instructor Supported Peer-Feedback (TPF) BLS training (Intervention group of 2020). Both study arms were based on Peyton's 4-step approach. Before and after each training session, objective data for BLS performance (compression depth and rate) were recorded using a resuscitation manikin. We also assessed overall BLS performance via standardized instructor evaluation and student self-reports of confidence via questionnaire. Non-inferiority margins for the outcome parameters and sample size calculation were based on previous studies with SIF. Two-sided 95% confidence intervals were employed to determine significance of non-inferiority. Results: The results confirmed non-inferiority of TPF to SIF for all tested outcome parameters. A follow-up after 2 weeks found no confirmed COVID-19 infections among the participants. Conclusion: Tele-instructor supported peer feedback is a powerful alternative to in-person instructor feedback on BLS skills during a pandemic, where infection risk needs to be minimized while maximizing the quality of BLS skill learning. Trial registration: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00025199, Trial ID: DRKS00025199.

Two Case Reports of Life-Threatening Croup Caused by the SARS-CoV-2 Omicron BA.2 Variant in Pediatric Patients.

Croup is a common upper airway infection characterized by a barking cough, stridor, and hoarseness. It is usually caused by viral infection. A small number of croup caused by coronavirus disease 2019 (COVID-19) has been reported in children before the omicron variant surge. Previously reported cases indicated that croup caused by COVID-19 can be treated in the same manner as those with other viral causes. We describe two cases (9-month-old girl and 11-month-old boy) of previously healthy infants who presented with a barking cough and chest retraction and required endotracheal intubation and cardiopulmonary resuscitation. Despite receiving dexamethasone and nebulized racemic epinephrine (NRE) treatment for croup in the emergency department, these patients still developed acute respiratory failure. Reverse transcription polymerase chain reaction (RT-PCR) of nasopharyngeal samples revealed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) omicron BA.2 variant (Stealth omicron) and no other common respiratory viral pathogens. Both patients were treated with mechanical ventilation, dexamethasone, and NRE in the pediatric intensive care unit. The duration of intubation was 112 hours and 80 hours, respectively. Both patients were discharged without complications. To the best of our knowledge, this is the first report of life-threatening croup produced by the omicron BA.2 variant and confirmed by RT-PCR. We suggest that this SARS-CoV-2 variant may cause severe croup that may not improve with conventional treatment, even in children without underlying diseases.

Impact of COVID-19 on Basic Life Support Training Among Medical Students: An Experimental Study

Aims and objectives: Sudden cardiac death (SCD) is the most common cause of mortality worldwide. Bystander cardiopulmonary resuscitation (CPR) improves the victim's outcome, especially when the response time for advanced life support is prolonged. We performed a study to estimate the difference in knowledge among first-year medical students after basic life support (BLS) training (part of their foundation course) before and during the novel COVID-19 pandemic.Materials and methods: We recruited first-year medical college students (batch of 2019-20: pre-COVID group - P and batch of 2020-21: COVID-19 era group - C) who were undergoing BLS training for the first time and consented to this study. Since the training was delayed and affected by COVID-19 for the batch of 2020-21, their training duration was shorter with more usage of audiovisual aids. The difference in the change in knowledge (by a questionnaire with 10 questions of one mark each) after training by the two methods was analysed. Analysis of variance, Wilcoxon signed-rank test, Mann-Whitney U test, and chi-square tests was used as applicable to compare the groups, and p-value <0.05 was considered significant. The results are analysed by IBM SPSS version 20.0 software (SPSS Inc, Chicago, IL, USA).Results: The median (inter-quartile range) marks in group P (89 students) in the pre-test was 3 (4-2) and in the post-test was 6 (7-5) (out of 10). The corresponding marks in group C (112 students) in the pre-test were 3 (4-2) and in post-test was 7 (8-6). The knowledge improvement in group C was more with all the three changes being significant (p=0.0001). In group C, females had more improvement than males (p=0.0001).Conclusion: We found a significant increase in the improvement of the knowledge after the BLS training in group C compared to group P. In group C, the improvement was better in females (59% increase in mean marks versus 22% in males).

Comparison of Augmented Reality-assisted and Instructor-assisted Cardiopulmonary Resuscitation: A Simulated Randomized Controlled Pilot Trial.

Background: A trained lay rescuer is the most important determinant of survival from sudden cardiac arrest. Augmented Reality (AR) device may represent a powerful instrument for CPR assistance and self-training especially during the COVID-19 pandemic. Methods: A prospective, parallel, 1:1 pilot randomized clinical trial was designed. An AR CPR app was developed and 28 participants were randomly allocated into AR-assisted group and instructor-assisted group. Acceptability, usability, and mean per minute/per cycle chest compression depth, rate and accuracy were measured. Results: The mean scores for acceptability and usability were all rated good in each group. Comparing real-time AR-assisted CPR to instructor-assisted CPR, the mean difference of compression depth was 0.18 (95% CI: -0.18-0.53) cm and rate was -1.58 (95% CI: -6.11-2.95) min-1. Comparing AR self-training to instructor training, the AR group was not significantly different between two groups regarding both compression depth, rate and accuracy (p > .05). Conclusion: We found that the AR CPR app was an acceptable and usable tool both in real-time-assisted CPR and self-training CPR.