Trends in Burn Injuries in Northern Israel During the COVID-19 Lockdown.

Coronavirus disease 2019 obliged many countries to apply lockdown policies to contain the spread of infection. The restrictions in Israel included limitations on movement, reduction of working capacity, and closure of the educational system. The present study focused on patients treated at a referral center for burns in northern Israel. Their goal was to investigate temporal variations in burn injuries during this period. Data were retrospectively extracted from the medical records of burn patients treated at our hospital between March 14, 2020 and April 20, 2020 (ie, the period of aggravated lockdown). Data from this period were compared with that from paralleling periods between 2017 and 2019. During the lockdown and paralleling periods, 178 patients were treated for burn injuries, of whom 44% were under 18. Although no restrictions were enforced during the virus outbreak period with regard to seeking medical care, we noticed a decrease in the number of patients admitted to the emergency room for all reasons. Of particular interest was a 66% decrease in the number of adult burn patients (P < .0001). Meanwhile, among the pediatric population, no significant decrease was observed. Nonetheless, subgroups with higher susceptibility to burn injuries included children aged 2 to 5 years (56.3% vs 23.8%, P = .016) and female patients from all pediatric age groups (57.1% vs 25%, P = .027). These findings may be explained by the presumably busier kitchen and dining areas during the lockdown. Overall, the study results can assist with building a stronger understanding of varying burn injuries and with developing educational and preventive strategies.

Pre-hospital care & interfacility transport of 385 COVID-19 emergency patients: an air ambulance perspective.

BACKGROUND: COVID-19, the pandemic caused by the severe acute respiratory syndrome coronavirus-2, is challenging healthcare systems worldwide. Little is known about problems faced by emergency medical services-particularly helicopter services-caring for suspected or confirmed COVID-19 patients. We aimed to describe the issues faced by air ambulance services in Europe as they transport potential COVID-19 patients. METHODS: Nine different HEMS providers in seven different countries across Europe were invited to share their experiences and to report their data regarding the care, transport, and safety measures in suspected or confirmed COVID-19 missions. Six air ambulance providers in six countries agreed and reported their data regarding development of special procedures and safety instructions in preparation for the COVID-19 pandemic. Four providers agreed to provide mission related data. Three hundred eighty-five COVID-19-related missions were analysed, including 119 primary transport missions and 266 interfacility transport missions. RESULTS: All providers had developed special procedures and safety instructions in preparation for COVID-19. Ground transport was the preferred mode of transport in primary missions, whereas air transport was preferred for interfacility transport. In some countries the transport of COVID-19 patients by regular air ambulance services was avoided. Patients in interfacility transport missions had a significantly higher median (range) NACA Score 4 (2-5) compared with 3 (1-7), needed significantly more medical interventions, were significantly younger (59.6 ± 16 vs 65 ± 21 years), and were significantly more often male (73% vs 60.5%). CONCLUSIONS: All participating air ambulance providers were prepared for COVID-19. Safe care and transport of suspected or confirmed COVID-19 patients is achievable. Most patients on primary missions were transported by ground. These patients were less sick than interfacility transport patients, for whom air transport was the preferred method.

Evaluation of Diagnostic and Triage Accuracy and Usability of a Symptom Checker in an Emergency Department: Observational Study.

BACKGROUND: Symptom checkers are clinical decision support apps for patients, used by tens of millions of people annually. They are designed to provide diagnostic and triage advice and assist users in seeking the appropriate level of care. Little evidence is available regarding their diagnostic and triage accuracy with direct use by patients for urgent conditions. OBJECTIVE: The aim of this study is to determine the diagnostic and triage accuracy and usability of a symptom checker in use by patients presenting to an emergency department (ED). METHODS: We recruited a convenience sample of English-speaking patients presenting for care in an urban ED. Each consenting patient used a leading symptom checker from Ada Health before the ED evaluation. Diagnostic accuracy was evaluated by comparing the symptom checker's diagnoses and those of 3 independent emergency physicians viewing the patient-entered symptom data, with the final diagnoses from the ED evaluation. The Ada diagnoses and triage were also critiqued by the independent physicians. The patients completed a usability survey based on the Technology Acceptance Model. RESULTS: A total of 40 (80%) of the 50 participants approached completed the symptom checker assessment and usability survey. Their mean age was 39.3 (SD 15.9; range 18-76) years, and they were 65% (26/40) female, 68% (27/40) White, 48% (19/40) Hispanic or Latino, and 13% (5/40) Black or African American. Some cases had missing data or a lack of a clear ED diagnosis; 75% (30/40) were included in the analysis of diagnosis, and 93% (37/40) for triage. The sensitivity for at least one of the final ED diagnoses by Ada (based on its top 5 diagnoses) was 70% (95% CI 54%-86%), close to the mean sensitivity for the 3 physicians (on their top 3 diagnoses) of 68.9%. The physicians rated the Ada triage decisions as 62% (23/37) fully agree and 24% (9/37) safe but too cautious. It was rated as unsafe and too risky in 22% (8/37) of cases by at least one physician, in 14% (5/37) of cases by at least two physicians, and in 5% (2/37) of cases by all 3 physicians. Usability was rated highly; participants agreed or strongly agreed with the 7 Technology Acceptance Model usability questions with a mean score of 84.6%, although "satisfaction" and "enjoyment" were rated low. CONCLUSIONS: This study provides preliminary evidence that a symptom checker can provide acceptable usability and diagnostic accuracy for patients with various urgent conditions. A total of 14% (5/37) of symptom checker triage recommendations were deemed unsafe and too risky by at least two physicians based on the symptoms recorded, similar to the results of studies on telephone and nurse triage. Larger studies are needed of diagnosis and triage performance with direct patient use in different clinical environments.

Impact of Prenatal SARS-CoV-2 Infection on Infant Emergency Department Visits and Hospitalization.

To better understand the impact of prenatal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on infants, this study sought to compare the risk of hospital visits and of postnatal SARS-CoV-2 infection between infants born to mothers with and without prenatal SARS-CoV-2 infection. In this retrospective observational cohort study of 6871 mothers and their infants, overall rates of emergency department (ED) visits and hospital admissions in the first 90 days of life were similar for infants born to mothers with and without prenatal SARS-CoV-2 infection. Infants born to negative mothers were more likely than infants of positive mothers to be hospitalized after ED visit (relative risk: 3.76; 95% confidence interval: 1.27-11.13, P = .003). Five infants tested positive; all were born to negative mothers, suggesting that maternal prenatal SARS-CoV-2 infection may protect infants from postnatal infection. The lower acuity ED visits for infants born to mothers with prenatal SARS-CoV-2 infection may reflect a heightened level of concern among these mothers.

Management of resources in a federal emergency hospital during the COVID-19 pandemic.

OBJECTIVE: To describe actions taken by the organizational management of an emergency service due to the COVID-19 pandemic, determined according to the prevalence of cases of infection by the coronavirus, severe acute respiratory syndrome, and flu-like illnesses. METHODS: Experience report based on a retrospective analysis of the attention for respiratory syndromes in the first semester of 2019 and 2020, in addition to an analysis of documents from the institutional protocols of a federal emergency service.Development: An increase in the number of attendances was observed, representing 7.25% and 19.4% of cases in 2019 and 2020, respectively. This was due to the creation of the Crisis Office, including a multidisciplinary team created to elaborate the plan of action, changes in the physical structure and in the work processes, and training sessions. FINAL CONSIDERATIONS: It became clear that the planning, coordination of actions based on the decisions of the Crisis Office, and the dissemination of reliable information, taking into consideration a focal point, were essential for the organization, management of the emergency service, and protection to the workers.

Impact of the COVID-19 pandemic on emergency department utilization patterns in South Korea: A retrospective observational study.

ABSTRACT: The purpose of analyzing changes in the use of emergency departments (EDs) was to better understand how to use ED resources efficiently during infectious disease outbreaks.Our study was a retrospective observational study. We analyzed the patterns of visits of adult and pediatric patients to separate EDs during 2020 coronavirus disease 2019 (COVID-19) outbreak to know the changes in the ED utilization. We collected the patient's demographics and time of visit, patients' acuity level at triage, cause of visit, transportation used, disposition, symptom to visit time, length of stay, and top 10 most common complaints. We compared pediatric and adult EDs before and after COVID-19.The total number of patients who visited the EDs was 197,152 over 3 years. During the COVID-19 outbreak in 2020, the number of visits decreased significantly, especially the number of pediatric patients. The number of ED visits decreased in correlation with a surge in the number of confirmed COVID patients. The proportion of severe cases in pediatric emergency department (PED) visits increased, but there was no difference in adult emergency department. The number of hospitalized PED patients increased, and the number of hospitalized adult emergency department patients decreased. However, both types of ED patients increased in intensive care unit hospitalizations, proportion of deaths, and use of ambulances. The proportion of trauma patients in the PED increased significantly (P  < .001). The time from symptom onset to ED visit time was reduced for patients. The ED length of stay increased in adults, and decreased for pediatric patients.COVID-19 brought about many changes to ED utilization. A greater reduction in ED utilization occurred in pediatric patients compared to adult patients. Our study showed changes in the number and characteristics of patients visiting the ED during the COVID-19 period compared to 2018 and 2019.

A Global Survey of Emergency Department Responses to the COVID-19 Pandemic.

INTRODUCTION: Emergency departments (ED) globally are addressing the coronavirus disease 2019 (COVID-19) pandemic with varying degrees of success. We leveraged the 17-country, Emergency Medicine Education & Research by Global Experts (EMERGE) network and non-EMERGE ED contacts to understand ED emergency preparedness and practices globally when combating the COVID-19 pandemic. METHODS: We electronically surveyed EMERGE and non-EMERGE EDs from April 3-June 1, 2020 on ED capacity, pandemic preparedness plans, triage methods, staffing, supplies, and communication practices. The survey was available in English, Mandarin Chinese, and Spanish to optimize participation. We analyzed survey responses using descriptive statistics. RESULTS: 74/129 (57%) EDs from 28 countries in all six World Health Organization global regions responded. Most EDs were in Asia (49%), followed by North America (28%), and Europe (14%). Nearly all EDs (97%) developed and implemented protocols for screening, testing, and treating patients with suspected COVID-19 infections. Sixty percent responded that provider staffing/back-up plans were ineffective. Many sites (47/74, 64%) reported staff missing work due to possible illness with the highest provider proportion of COVID-19 exposures and infections among nurses. CONCLUSION: Despite having disaster plans in place, ED pandemic preparedness and response continue to be a challenge. Global emergency research networks are vital for generating and disseminating large-scale event data, which is particularly important during a pandemic.

The effect of the COVID-19 pandemic on non-COVID respiratory ED visits in Israel.

BACKGROUND: The COVID 19 pandemic has had a crucial effect on the patterns of disease and treatment in the healthcare system. This study examines the effect of the COVID-19 pandemic on respiratory ED visits and admissions broken down by age group and respiratory diagnostic category. METHODS: Data on non-COVID related ED visits and hospitalizations from the ED were obtained in a retrospective analysis for 29 acute care hospitals, covering 98% of ED beds in Israel, and analyzed by 5 age groups: under one-year-old, 1-17, 18-44, 45-74 and 75 and over. Diagnoses were classified into three categories: Upper respiratory tract infections (URTI), pneumonia, and COPD or asthma. Data were collected for the whole of 2020, and compared for each month to the average number of cases in the three pre-COVID years (2017-2019). RESULTS: In 2020 compared to 2017-2019, there was a decrease of 34% in non-COVID ED visits due to URTI, 40% for pneumonia and a 35% decrease for COPD and asthma. Reductions occurred in most age groups, but were most marked among infants under a year, during and following lockdowns, with an 80% reduction. Patients over 75 years old displayed a marked drop in URTI visits. Pediatric asthma visits fell during lockdowns, but spiked when restrictions were lifted, accompanied by a higher proportion admitted. The percent of admissions from the ED visits remained mostly stable for pneumonia; the percent of young adults admitted with URTI decreased significantly from March to October. CONCLUSIONS: Changing patterns of ED use were probably due to a combination of a reduced rate of viral diseases, availability of additional virtual services, and avoidance of exposure to the ED environment. Improved hygiene measures during peaks of respiratory infections could be implemented in future to reduce respiratory morbidity; and continued provision of remote health services may reduce overuse of ED services for mild cases.

Pandemic hospitals and reorganizing emergency departments

Emergency departments have always been the first point of contact for hospitals in many situations, including man-made and natural disasters. The first places where patients with symptoms of COVID-19 were met in health institutions were also emergency departments. Emergency departments play an important role in diagnosing the disease and isolating patients (by hospitalization if necessary). The process, which starts with the triage of outpatients admitted to the emergency department and brought by ambulance, continues as isolation of the patients in appropriate areas including physical evaluation, management of laboratory and scanning processes and, if necessary, providing cardiopulmonary resuscitation with airway support. Afterwards, patients can be treated as an outpatient, or hospitalized, or treated at the intensive care unit in line with their preliminary diagnosis and clinical conditions. Disruptions that may occur in one or more of these stages can lead to crowds and lengthy queues in the emergency department by prolonging the follow-up period of the patients. One of the strengths of Turkey at this point is that emergency departments are accustomed to the heavy patient load. The experiences gained from these conditions have facilitated the organization of pre-hospital emergency medical services, pandemic hospitals, and their emergency departments. In this organization, the main goal should be to provide uninterrupted and high-quality patient care through personnel training, personal protection measures, and the creation of physical conditions. Turkey's emergency departments are accustomed to managing the intensive patient flow, as they work at full capacity during normal times. Thanks to the experiences of emergency healthcare workers, health service was provided without any patient being turned away from the door of the emergency departments during the COVID-19 pandemic. In this review, we aimed to present the organization of pandemic hospitals and emergency departments during the COVID-19 pandemic. We made a schematic representation of the architectural areas through the emergency department of Ankara City Hospital, which has a bed capacity of 4200 with 256 beds in emergency department.

Pandemic Preparedness.

Pandemic preparedness is a key function of any health care facility. Activities pertaining to pandemic preparedness should be developed and maintained within a broader emergency management plan. The use of a Hospital Incident Command System can centralize coordination of the response and facilitate internal and external communication. This review addresses several components of pandemic preparedness, including incident management, health care personnel safety, strategies to support ongoing clinical activities, and organizational communication during a pandemic. Preparations addressing potential ethical challenges and the psychological impact associated with pandemic response are also reviewed.

COVID 19: are South African junior doctors prepared for critical care management outside the intensive care unit?

INTRODUCTION: the coronavirus disease 2019 (COVID-19) pandemic has negatively impacted countries across the globe. Infected individuals will seek aid at various health care facilities. Many patients will recover without requiring specialised treatment. A significant percentage of infected individuals will need critical care management, which will begin in the emergency department, generally staffed by junior doctors. Junior doctors will need to stabilize, triage and manage these patients prior to referral to specialized units. Above and beyond the usual occupational demands that accompany junior doctors in state facilities, this pandemic will thrust further responsibility on them. The objectives were to describe crisis preparedness of junior doctors in the areas of triage decision-making and critical care management, outside the intensive care unit. METHODS: this is a descriptive, cross-sectional study, utilizing a web-based survey. Junior doctors in South Africa, being doctors in year one or year two of internship and community service, were invited to participate anonymously via various social media platforms. Results: a total of 210 junior doctors across South Africa answered the survey. Junior doctors expressed confidence with knowledge of intubation drugs, to perform intubation and cardiopulmonary arrest resuscitation without supervision. Only 13.3% of respondents expressed comfort with setting and adjusting ventilator settings independently. 57% of participants expressed discomfort with making critical care triage decisions. Ninety-three percent (93%) of participants expressed benefit from a telemedicine intervention. CONCLUSION: junior doctors in South Africa indicate that they are prepared to initiate management of the critically ill patient outside the intensive care unit but remain uncertain in their ability to provide ongoing critical care management. The COVID-19 pandemic has highlighted the need to prepare junior doctors with the ability to manage critical care triage and management in emergency rooms. Leveraging of the workforce in South Africa may be potentiated by telemedicine interventions.

A Novel 29-Messenger RNA Host-Response Assay From Whole Blood Accurately Identifies Bacterial and Viral Infections in Patients Presenting to the Emergency Department With Suspected Infections: A Prospective Observational Study.

OBJECTIVES: The rapid diagnosis of acute infections and sepsis remains a serious challenge. As a result of limitations in current diagnostics, guidelines recommend early antimicrobials for suspected sepsis patients to improve outcomes at a cost to antimicrobial stewardship. We aimed to develop and prospectively validate a new, 29-messenger RNA blood-based host-response classifier Inflammatix Bacterial Viral Non-Infected version 2 (IMX-BVN-2) to determine the likelihood of bacterial and viral infections. DESIGN: Prospective observational study. SETTING: Emergency Department, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Germany. PATIENTS: Three hundred twelve adult patients presenting to the emergency department with suspected acute infections or sepsis with at least one vital sign change. INTERVENTIONS: None (observational study only). MEASUREMENTS AND MAIN RESULTS: Gene expression levels from extracted whole blood RNA was quantified on a NanoString nCounter SPRINT (NanoString Technologies, Seattle, WA). Two predicted probability scores for the presence of bacterial and viral infection were calculated using the IMX-BVN-2 neural network classifier, which was trained on an independent development set. The IMX-BVN-2 bacterial score showed an area under the receiver operating curve for adjudicated bacterial versus ruled out bacterial infection of 0.90 (95% CI, 0.85-0.95) compared with 0.89 (95% CI, 0.84-0.94) for procalcitonin with procalcitonin being used in the adjudication. The IMX-BVN-2 viral score area under the receiver operating curve for adjudicated versus ruled out viral infection was 0.83 (95% CI, 0.77-0.89). CONCLUSIONS: IMX-BVN-2 demonstrated accuracy for detecting both viral infections and bacterial infections. This shows the potential of host-response tests as a novel and practical approach for determining the causes of infections, which could improve patient outcomes while upholding antimicrobial stewardship.

Sepsis Alerts in Emergency Departments: A Systematic Review of Accuracy and Quality Measure Impact.

INTRODUCTION: For early detection of sepsis, automated systems within the electronic health record have evolved to alert emergency department (ED) personnel to the possibility of sepsis, and in some cases link them to suggested care pathways. We conducted a systematic review of automated sepsis-alert detection systems in the ED. METHODS: We searched multiple health literature databases from the earliest available dates to August 2018. Articles were screened based on abstract, again via manuscript, and further narrowed with set inclusion criteria: 1) adult patients in the ED diagnosed with sepsis, severe sepsis, or septic shock; 2) an electronic system that alerts a healthcare provider of sepsis in real or near-real time; and 3) measures of diagnostic accuracy or quality of sepsis alerts. The final, detailed review was guided by QUADAS-2 and GRADE criteria. We tracked all articles using an online tool (Covidence), and the review was registered with PROSPERO registry of reviews. A two-author consensus was reached at the article choice stage and final review stage. Due to the variation in alert criteria and methods of sepsis diagnosis confirmation, the data were not combined for meta-analysis. RESULTS: We screened 693 articles by title and abstract and 20 by full text; we then selected 10 for the study. The articles were published between 2009-2018. Two studies had algorithm-based alert systems, while eight had rule-based alert systems. All systems used different criteria based on systemic inflammatory response syndrome (SIRS) to define sepsis. Sensitivities ranged from 10-100%, specificities from 78-99%, and positive predictive value from 5.8-54%. Negative predictive value was consistently high at 99-100%. Studies showed some evidence for improved process-of-care markers, including improved time to antibiotics. Length of stay improved in two studies. One low quality study showed improved mortality. CONCLUSION: The limited evidence available suggests that sepsis alerts in the ED setting can be set to high sensitivity. No high-quality studies showed a difference in mortality, but evidence exists for improvements in process of care. Significant further work is needed to understand the consequences of alert fatigue and sensitivity set points.

Equal incidence of COVID-19 among homeless and non-homeless ED patients when controlling for confounders.

INTRODUCTION: The World Health Organization (WHO) declared severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) a pandemic in March 2020. Theoretically, homeless patients could have disproportionately worse outcomes from COVID-19, but little research has corroborated this claim. This study aimed to examine the demographics and incidence of COVID-19 in homeless vs non-homeless emergency department (ED) patients. METHODS: This is a retrospective study of all patients seen in the University of Louisville Hospital Emergency Department (ULH ED) from March 2019 to December 2020, excluding January and February 2020. Data was collected from the Kentucky Homeless Management Information System (HMIS) and ULH electronic health records. RESULTS: A total of 51,532 unique patients had 87,869 visits during the study period. There was a 18.1% decrease in homeless patient visits over the time period, which was similar to the decrease in non-homeless patient visits (19.2%). In the total population, 9471 individuals had known COVID-19 testing results, with a total of 610 positive (6.4% positivity rate). Of the 712 homeless ED patients, 39 tested positive (5.5% positivity rate). After adjusting for age, gender identity, race, and insurance, there was no statistically significant difference in test positivity between homeless and non-homeless patients, OR 1.23 (0.88, 1.73). Homeless patients were less likely to be admitted to either the intensive care unit (ICU) or hospital (OR = 0.55, 95% CI: OR 0.51, 0.60) as they were more likely to be discharged (OR = 1.65, 95% CI: 1.52, 1.79). CONCLUSION: Previous literature has indicated that higher disease burden, lack of access to social distancing, and poor hygiene would increase the risk of homeless individuals contracting COVID-19 and experiencing serious morbidity. However, this study found that homelessness was not an independent risk factor for COVID-19 infection.

Impact of the COVID-19 pandemic on workplace violence at an academic emergency department.

STUDY OBJECTIVES: COVID-19 brought unique challenges; however, it remains unclear what effect the pandemic had on violence in healthcare. The objective of this study was to identify the impact of the pandemic on workplace violence at an academic emergency department (ED). METHODS: This mixed-methods study involved a prospective descriptive survey study and electronic medical record review. Within our hospital referral region (HRR), the first COVID-19 case was documented on 3/11/2020 and cases peaked in mid-November 2020. We compared the monthly HRR COVID-19 case rate per 100,000 people to the rate of violent incidents per 1000 ED visits. Multidisciplinary ED staff were surveyed both pre/early-pandemic (April 2020) and mid/late-pandemic (December 2020) regarding workplace violence experienced over the prior 6-months. The study was deemed exempt by the Mayo Clinic Institutional Review Board. RESULTS: There was a positive association between the monthly HRR COVID-19 case rate and rate of violent ED incidents (r = 0.24). Violent incidents increased overall during the pandemic (2.53 incidents per 1000 visits) compared to the 3 months prior (1.13 incidents per 1000 visits, p < .001), as well as compared to the previous year (1.24 incidents per 1000 patient visits, p < .001). Survey respondents indicated a higher incidence of assault during the pandemic, compared to before (p = .019). DISCUSSION: Incidents of workplace violence at our ED increased during the pandemic and there was a positive association of these incidents with the COVID-19 case rate. Our findings indicate health systems should prioritize employee safety during future pandemics.