Heatstroke-related ambulance dispatch risk before and during COVID-19 pandemic: Subgroup analysis by age, severity, and incident place.

BACKGROUND: In summer 2020 under the COVID-19 pandemic, the Ministry of Health, Labour and Welfare has made public warnings that specific preventive measures such as maskwearing and stay-at-home orders, may increase heatstroke risk. In our previous work, we found a lower risk of heatstroke-related ambulance dispatches (HSAD) during the COVID-19 period, however, it is uncertain whether similar risk reductions can be observed in different vulnerable subgroups. This study aimed to determine the HSAD risk during the COVID-19 pandemic by age, severity, and incident place subgroups. METHOD: A summer-specific (June-September), time-series analysis was performed, using daily HSAD and meteorological data from 47 Japanese prefectures from 2017 to 2020. A two-stage analysis was applied to determine the association between HSAD and COVID-19 pandemic, adjusting for maximum temperature, humidity, seasonality, and relevant temporal adjustments. A generalized linear model was utilized in the first stage to estimate the prefecture-specific effect estimates. Thereafter, a fixed effect meta-analysis in the second stage was implemented to pool the first stage estimates. Subsequently, subgroup analysis via an interaction by age, severity, and incident place was used to analyze the HSAD risk among subgroups. RESULTS: A total of 274,031 HSAD cases was recorded across 47 Japanese prefectures. The average total number of HSAD in the pre-COVID-19 period was 69,721, meanwhile, the COVID-19 period was 64,869. Highest reductions in the risks was particularly observed in the young category (ratio of relative risk (RRR) = 0.54, 95% Confidential Interval (CI): 0.51, 0.57) compared to the elderly category. Whereas highest increment in the risks were observed in severe/death (RRR = 1.25, 95% CI: 1.13, 1.37) compared to the mild category. CONCLUSION: COVID-19 situation exhibited a non-uniform change in the HSAD risk for all subgroups, with the magnitude of the risks varying by age, severity, and incident place.

Paediatric NHS 111 Clinical Assessment Services pilot: an observational study.

OBJECTIVE: To determine the feasibility and impact of having paediatric clinicians working in the Clinical Assessment Services (CAS) within NHS 111, a national telephone advice service. DESIGN: Observational study. SETTING: Six NHS 111 providers across England with CAS where volunteer paediatric clinicians (doctors and advanced nurse practitioners (ANPs)) worked between May and December 2020. A data reporting framework was used to compare the outcomes of calls taken by paediatric vs non-paediatric clinicians. PATIENTS: Under 16-year-olds prompting calls to NHS 111 over the study period. MAIN OUTCOME MEASURES: The disposition (final outcome of calls) taken by paediatric versus non-paediatric clinicians, paediatric clinicians' and patient experience. RESULTS: 70 paediatric clinicians (66 doctors and 4 ANPs) worked flexible shifts in six NHS 111 providers' CAS over the study period: 2535 calls for under 16-year-olds were taken by paediatric clinicians and 137 008 by non-paediatric clinicians. Overall, disposition rates differed significantly between the calls taken by paediatric versus (vs) non-paediatric clinicians: 69% vs 43% were advised on self-care only, 13% vs 18% to attend emergency departments (EDs), 13% vs 29% to attend primary care, 1% vs 4% to receive an urgent ambulance call out and 4% vs 6% referred to another health service, respectively. When compared with recent (all age) national whole data sets, the feedback from calls taken by paediatricians noted a greater proportion of patients/carers reporting that their problem was fully resolved (92% vs 27%). CONCLUSIONS: Introducing paediatric specialists into NHS 111 CAS is likely to increase self-care dispositions, and reduce onward referrals to primary care, ED and ambulances. Future work will evaluate the impact of a national paediatric clinical assessment service to which specific case types are streamed.

COVID-19 pandemic modifies temperature and heat-related illness ambulance transport association in Japan: a nationwide observational study.

BACKGROUND: During the COVID-19 pandemic, several illnesses were reduced. In Japan, heat-related illnesses were reduced by 22% compared to pre-pandemic period. However, it is uncertain as to what has led to this reduction. Here, we model the association of maximum temperature and heat-related illnesses in the 47 Japanese prefectures. We specifically examined how the exposure and lag associations varied before and during the pandemic. METHODS: We obtained the summer-specific, daily heat-related illness ambulance transport (HIAT), exposure variable (maximum temperature) and covariate data from relevant data sources. We utilized a stratified (pre-pandemic and pandemic), two-stage approach. In each stratified group, we estimated the 1) prefecture-level association using a quasi-Poisson regression coupled with a distributed lag non-linear model, which was 2) pooled using a random-effects meta-analysis. The difference between pooled pre-pandemic and pandemic associations was examined across the exposure and the lag dimensions. RESULTS: A total of 321,655 HIAT cases was recorded in Japan from 2016 to 2020. We found an overall reduction of heat-related risks for HIAT during the pandemic, with a wide range of reduction (10.85 to 57.47%) in the HIAT risk, across exposure levels ranging from 21.69 °C to 36.31 °C. On the contrary, we found an increment in the delayed heat-related risks during the pandemic at Lag 2 (16.33%; 95% CI: 1.00, 33.98%). CONCLUSION: This study provides evidence of the impact of COVID-19, particularly on the possible roles of physical interventions and behavioral changes, in modifying the temperature-health association. These findings would have implications on subsequent policies or heat-related warning strategies in light of ongoing or future pandemics.

Hubei's Core Response Policies in the Early Stage of COVID-19.

BACKGROUND: This study is aimed at confirming the effectiveness of nonpharmaceutical interventions during the COVID-19 outbreak in Hubei, China. METHODS: The data are all from the epidemic information released by the National Health Commission of the People's Republic of China and the Health Commission of Hubei Province. We used the multivariable linear regression by the SPSS 19.0 software: the cumulative number of confirmed cases, the cumulative number of cured cases, and the number of daily severe cases were taken as dependent variables, and the six policies, including the Joint Prevention and Control Mechanism of the State Council, lockdown Wuhan city, the first-level response to public health emergencies, the expansion of medical insurance coverage to suspected patients, mobile cabin hospitals, and counterpart assistance in Hubei province, were gradually entered into multiple linear regression models as independent variables. RESULTS: The factors influencing the cumulative number of diagnosed cases ranged from large to small: mobile cabin hospitals and the expansion of medical insurance coverage to suspected patients. The factors influencing the cumulative number of cured cases ranged from large to small: counterpart support medical teams in Hubei province and mobile cabin hospitals. The factors influencing the number of daily severe cases ranged from large to small: mobile cabin hospitals and the expansion of medical insurance coverage to suspected patients. CONCLUSION: The mobile cabin hospital is a major reason for the successfully defeating COVID-19 in China. As COVID-19 pandemic spreads globally, the mobile cabin hospital is a successful experience in formulating policies to defeat COVID-19 for other countries in the outbreak phase.

[COVID-Guide: an app for covid-19 triage and self-assessment.] / COVID-Guide: una app per il triage e l'autovalutazione della covid-19.

INTRODUCTION: The unprecedented covid-19 pandemic has shown the weaknesses of health systems and opened new spaces for e-health and telemedicine. Recent literature states that chatbots, if implemented effectively, could be useful tools for quickly sharing information, promoting healthy behaviors, and helping reduce the psychological burden of isolation. The aim of this project is to develop and test a secure and reliable computerized decision support system (CDSS) in web-app and evaluate its use, usability and its outputs in a pre-specified way. METHODS: A multidisciplinary team was recruited to plan and design, based on the SMASS medical CDSS, the scenarios of the COVID-Guide web-app, a self-triage system for patients with suspected covid-19. The output data for the period May-September 2020 from Germany were analyzed. RESULTS: During the period under review, the total number of consultations in Germany was 96,012. 3,415 (3.56%) consultations indicated the need for immediate evaluation, by activating the emergency service (calling an ambulance) - 1,942, equal to 2.02% - or by advising the patient to go to hospital - 1,743, equal to 1.54%. CONCLUSIONS: Data seems to show good usability and a consistent number of consultations carried out. Regular use of COVID-Guide could help collect epidemiological data on the spread of (suspected) covid-19 cases, easily and quickly available in all countries where the tool will be used. Using the SSDC could help reduce the load on operators. Furthermore, the use of anonymous and geolocatable clinical data together with the generation of alerts and indicators produced by COVID-Guide could become a useful tool for epidemiological surveillance in the future phases of the pandemic (Telemedical Syndromic Surveillance).

Patient compliance with NHS 111 advice: Analysis of adult call and ED attendance data 2013-2017.

The NHS 111 telephone advice and triage service is a vital part of the management of urgent and emergency care (UEC) services in England. Demand for NHS 111 advice has increased since its introduction in 2013, and the service is of particular importance in light of the current pandemic and resulting increased demand for emergency care. Currently, little is known about the effectiveness of NHS 111 in terms of the appropriateness of the advice given, or about the compliance of patients with that advice. We aimed to address this issue by analysing a large linked routine dataset of all NHS 111 calls (n = 3,631,069) and subsequent emergency department (ED) attendances made in the Yorkshire & Humber region from March 2013-March 2017. We found that many patients do not comply with advice, with 11% (n = 289,748) of patients attending ED when they are advised to self-care or seek primary care. We also found that a considerable number of these patients are further classed as urgent (88%, n = 255,931) and a substantial minority (37%, 106,207) are subsequently admitted to hospital. Further, many patients who are sent an ambulance or told to attend ED are classed as non-urgent upon attending ED (9%, n = 42,372). This research suggests that the level at which NHS 111 is currently triaging results in many hundreds of thousands of mis-triaged cases annually. Additionally, patients frequently do not comply with the advice they receive. This has implications for understanding the accuracy and efficiency of triaging systems.

Incidence of emergency calls and out-of-hospital cardiac arrest deaths during the COVID-19 pandemic: findings from a cross-sectional study in a UK ambulance service.

BACKGROUND: In response to the COVID-19 pandemic, a national lockdown was introduced on 23 March 2020. In the following weeks, emergency departments in the UK reported a reduction in attendances. We aimed to explore the incidence of emergency calls across North East England, as well as the number of out-of-hospital cardiac arrest (OHCA) deaths. METHODS: Data were collected for all patients who contacted North East Ambulance Service between 4 March 2019-2 June 2019 and 2 March 2020-31 May 2020 suffering stroke, ST elevation myocardial infarction, allergy, asthma, chronic obstructive pulmonary disease, falls, intoxication, seizure, sepsis, acute coronary syndrome and OHCA. RESULTS: There were a reduction in incidence of calls, excluding OHCA, resulting in ambulance activation during the pandemic compared with same period in 2019, 16 743 versus 19 639, respectively (-14.74%). The decline in calls was partially reversed by the end of May 2020. Incidence of OHCA at the time of the national lockdown had increased by 13.79% with a peak increase of 73.56% in the second week in April 2020. OHCA deaths peaked in the first 2 weeks in April 2020, 95.65% and 90.07%, respectively, but by the end May 2020, incidence of OHCA and OHCA deaths had returned to prelockdown levels. CONCLUSION: Incidence of emergency calls were reduced during the pandemic compared with 2019. There was a rise in incidence of OHCA and OHCA deaths during the same period; however, these changes appear transient. Further research is required to understand patient behaviour towards seeking help during the pandemic and the long-term consequences of not doing so.

Pre-hospital assistance by ambulance in the context of coronavirus infections.

OBJECTIVE: To reflect on the safe care exercised by the pre-hospital care team by emergency ambulance in times of coronavirus infection. METHOD: A reflection and description of how to provide safe care to the patient and the professional during pre-hospital care in times of coronavirus infection. RESULTS: To ensure the health of all those involved in the care, health professionals who work in pre-hospital care by emergency ambulance should use the recommended Personal Protective Equipment (PPE), such as the use of surgical masks and N95, N99, N100, PFF2 or PFF3, the use of an apron or overall, goggles and face shield, gloves and a hat. The entire team must receive training and demonstrate the ability to use PPE correctly and safely. FINAL CONSIDERATIONS: The professional working in the pre-hospital care by ambulance is exposed to a series of occupational risks that need to be discussed and minimized through professional training.

Higher clinical acuity and 7-day hospital mortality in non-COVID-19 acute medical admissions: prospective observational study.

OBJECTIVES: To understand the effect of COVID-19 lockdown measures on severity of illness and mortality in non-COVID-19 acute medical admissions. DESIGN: A prospective observational study. SETTING: 3 large acute medical receiving units in NHS Lothian, Scotland. PARTICIPANTS: Non-COVID-19 acute admissions (n=1682) were examined over the first 31 days after the implementation of the COVID-19 lockdown policy in the UK on 23 March 2019. Patients admitted over a matched interval in the previous 5 years were used as a comparator cohort (n=14 954). MAIN OUTCOME MEASURES: Patient demography, biochemical markers of clinical acuity and 7-day hospital inpatient mortality. RESULTS: Non-COVID-19 acute medical admissions reduced by 44.9% across all three sites in comparison with the mean of the preceding 5 years (p<0.001). Patients arriving during this period were more likely to be male, of younger age and to arrive by emergency ambulance transport. Non-COVID-19 admissions during lockdown had a greater incidence of acute kidney injury, lactic acidaemia and an increased risk of hospital death within 7 days (4.2% vs 2.5%), which persisted after adjustment for confounders (OR 1.87, 95% CI 1.43 to 2.41, p<0.001). CONCLUSIONS: These data demonstrate a significant reduction in non-COVID-19 acute medical admissions during the early weeks of lockdown. Patients admitted during this period were of higher clinical acuity with a higher incidence of early inpatient mortality.

Effects of the COVID-19 pandemic on reperfusion therapy for acute ischemic stroke patients in Huizhou City, China.

BACKGROUND AND PURPOSE: The COVID-19 pandemic has impacted the reperfusion therapy for acute ischemic stroke (AIS) patients. Huizhou City utilized its experience with the SARS and MERS breakouts to establish a reperfusion treatment program for AIS patients. METHOD: This is a retrospective study on 8 certified stroke hospitals in Huizhou City from January 2020 to May 2020. We analyzed the number of AIS patients with reperfusion therapy, stroke type (anterior/posterior circulation stroke), modes of transport to hospital, NIHSS score, onset to door time (ODT), door to needle time (DNT), and door to puncture time (DPT). The analysis was compared with baseline data from the same time period in 2019. RESULT: In 2020, the number of AIS patients receiving reperfusion therapy decreased (315 vs. 377), NIHSS score increased [8 (4, 15) vs. 7 [ (1, 2)], P = 0.024], ODT increased [126 (67.5, 210.0) vs. 120.0 (64.0, 179.0), P = 0.032], and DNT decreased [40 (32.5, 55) vs. 48 (36, 59), P = 0.003]. DPT did not change. Seventy percent of AIS patients indicated self-visit as their main mode of transport to the hospital. In both periods, mild stroke patients were more likely to self-visit than utilize emergency systems [2019: 152 (57.6%) vs. 20 (45.6%), P = 0.034; 2020: 123 (56.9%) vs. 5 (14.7%), P < 0.001]. The NIHSS score for self-visiting patients was lower for patients who utilized the ambulance system in both years [self-visit: 6.00 (3.00, 12.00), ambulance: 14.00 (9.00, 19.00), P < 0.001]. The volume of reperfusion patients was lower in 2020; however, the decrease was only significant (P = 0.028) in February 2020. CONCLUSION: During the COVID-19 pandemic in 2020, the number of AIS patients receiving reperfusion therapy significantly decreased when compared to the same period in 2019. The patients' condition increased severity, ODT increased, and the DNT decreased. DPT was not significant for self-visiting and ambulance patients. Moderate to severe stroke patients were more likely to utilize ambulance services.

Impact of COVID-19 on healthcare activity in NSW, Australia.

OBJECTIVE: COVID-19 has left no healthcare system untouched. In New South Wales (NSW), the most populous state in Australia, COVID-19 case numbers have to date been relatively low. However, that does not mean the state's healthcare system has been unaffected. Preparations to create sufficient capacity to accommodate a COVID-19 surge resulted in widespread deferment of scheduled medical procedures and appointments. Patterns of healthcare-seeking behaviour changed, with a reluctance to visit healthcare settings. The aim of this study was to quantify the changes in activity seen in the NSW health system in the first half of 2020. METHODS: Healthcare data were drawn from multiple sources, including primary care, ambulance, emergency departments and inpatient settings. Volumes of healthcare activity in 2020, overall, by urgency of cases and by reasons for care were compared with the figures for the same period in 2019. Changes in the modality of care provision were also examined. RESULTS: In March to June 2020, compared with the same period in 2019, primary care face-to-face consultations decreased by 22.1%, breast screening activity by 51.5%, ambulance incidents by 7.2%, emergency department visits by 13.9%, public hospital inpatient episodes by 14.3%, and public hospital planned surgical activity by 32.6%. CONCLUSION: There were substantial declines in a wide range of healthcare activities across the NSW health system between March and June 2020 due to the impact of the COVID-19 pandemic. Although activity levels were recovering by September 2020, they had not yet returned to 'normal'. The implications of these changes - and the indirect impact of COVID-19 - require further study.

[Nomadism of patients treated by radiotherapy in Île-de-France: Does our health system have as much money to waste?] / Nomadisme des patients traités par radiothérapie en Île-de-France : notre système de santé a-t-il autant d'argent à gaspiller ?

PURPOSE: Human, material, and financial resources being limited, the organization of the care system must allow an efficient allocation of resources. The management of cancers leads to specific and repetitive care for which the reimbursement of transport costs represents a high cost. We carried out an analysis of the additional transport costs, linked to the care of patients in Île-de-France, in a center other than the radiotherapy center closest to their home. MATERIALS AND METHODS: Using data from the Île-de-France Regional Health Agency, we have created a model evaluating the additional cost linked to transport generated by the care of a radiotherapy patient far from his home. In order to take into account the uncertainties linked to the hypotheses made in the development of the model, we carried out deterministic and probabilistic sensitivity analyzes. RESULTS: In the base case, the additional annual cost related to transport was 841,176 euros in Île-de-France. The probabilistic sensitivity analysis reports a total annual additional cost of 2,817,481 euros. CONCLUSION: Our results are similar to a report from the General Inspectorate of Social Affairs published in July 2011, which then pointed to an additional cost of between 4 and 6 million euros annually. The long-term care of cancer patients from their homes contributes to a deterioration in the quality of life linked to travel times, a delay in the care of potential treatment complications, and the spread of infectious diseases, such as COVID-19, and bacteria resistant to antibiotics.

Collateral damage: Hidden impact of the COVID-19 pandemic on the out-of-hospital cardiac arrest system-of-care.

AIM: Out-of-hospital cardiac arrest (OHCA) during COVID-19 has been reported by countries with high case numbers and overwhelmed healthcare services. Imposed restrictions and treatment precautions may have also influenced OHCA processes-of-care. We investigated the impact of the COVID-19 pandemic period on incidence, characteristics, and survival from OHCA in Victoria, Australia. METHODS: Using data from the Victorian Ambulance Cardiac Arrest Registry, we compared 380 adult OHCA patients who received resuscitation between 16th March 2020 and 12th May 2020, with 1218 cases occurring during the same dates in 2017-2019. No OHCA patients were COVID-19 positive. Arrest incidence, characteristics and survival rates were compared. Regression analysis was performed to understand the independent effect of the pandemic period on survival. RESULTS: Incidence of OHCA did not differ during the pandemic period. However, initiation of resuscitation by Emergency Medical Services (EMS) significantly decreased (46.9% versus 40.6%, p = 0.001). Arrests in public locations decreased in the pandemic period (20.8% versus 10.0%; p < 0.001), as did initial shocks by public access defibrillation/first-responders (p = 0.037). EMS caseload decreased during the pandemic period, however, delays to key interventions (time-to-first defibrillation, time-to-first epinephrine) significantly increased. Survival-to-discharge decreased by 50% during the pandemic period (11.7% versus 6.1%; p = 0.002). Survivors per million person-years dropped in 2020, resulting in 35 excess deaths per million person-years. On adjusted analysis, the pandemic period remained associated with a 50% reduction in survival-to-discharge. CONCLUSION: The COVID-19 pandemic period did not influence OHCA incidence but appears to have disrupted the system-of-care in Australia. However, this could not completely explain reductions in survival.

SARS-CoV-2 pandemic and epilepsy: The impact on emergency department attendances for seizures.

INTRODUCTION: The risk of acquiring SARS-CoV-2 in a hospital setting and the need of reorganizing the Emergency Departments (EDs) to cope with infected patients have led to a reduction of ED attendances for non-infectious acute conditions and to a different management of chronic disorders. METHODS: We performed a retrospective study evaluating the frequency and features of ED attendances for seizures during the lockdown period (March 10th-April 30th 2020) in the University Hospital of Trieste, Italy. We studied the possible pandemic impact on the way patients with seizures sought for medical assistance by comparing the lockdown period to a matched period in 2019 and to a period of identical length preceding the lockdown (January 18th-March 9th 2020). RESULTS: A striking decrease in total ED attendances was observed during lockdown (4664) compared to the matched control (10424) and to the pre-lockdown (9522) periods. A similar reduction, although to a lesser extent, was detected for seizure attendances to the ED: there were 37 during lockdown and 63 and 44 respectively during the two other periods. Intriguingly, during the lockdown a higher number of patients attended the ED with first seizures (p = 0.013), and more EEGs (p = 0.008) and CT brain scans (p = 0.018) were performed; there was a trend towards more frequent transport to the ED by ambulance (p = 0.061) in the lockdown period. CONCLUSIONS: Our data suggest that the pandemic has affected the way patients with seizures access the Health Care System.

Simulation-based training and assessment of mobile pre-hospital SARS-CoV-2 diagnostic teams in Styria, Austria.

The World Health Organization has declared coronavirus disease 2019 (COVID-19) a pandemic. Polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the diagnostic gold standard of COVID-19. We have developed a simulation-based training program for mobile prehospital diagnostic teams in the province of Styria, Austria, and performed a prospective observational study on its applicability and effectivity.The 1-day curriculum uses theoretical instruction, technical skills training, and simulator-based algorithm training to teach and train prehospital patient identification and communication, donning the personal protective equipment, collection of naso-/oropharyngeal swabs for SARS-CoV-2 polymerase chain reaction testing, doffing the personal protective equipment, and sample logistics. Trainings were conducted at the SIM CAMPUS simulation hospital, Eisenerz, using high-fidelity patient simulation. To ensure achievement of predefined learning outcomes, participants had to undergo a final simulator-based objective structured clinical examination.In March 2020, 45 emergency medical assistants and 1 physician of the Austrian Red Cross participated on a voluntary basis. Forty-five of the 46 participants (97.8%) completed the curriculum successfully, with mean objective structured clinical examination ratings of 98.6%.Using several proven educational concepts, we have successfully drafted and implemented a training program for mobile prehospital SARS-CoV-2 diagnostic teams. Based on simulation-based objective structured examinations, it has prepared participants effectively for preclinical duties.