Emergency Department Visits and Deaths from Cardiovascular Diseases at a Referral Center for Cardiology During the COVID-19 Pandemic

Abstract Background The COVID-19 pandemic has imposed measures of social distancing and, during this time, there has been an elevation in cardiovascular mortality rates and a decrease in the number of emergency visits. Objectives To assess and compare in-hospital mortality for cardiovascular diseases and emergency department visits during the COVID-19 pandemic and the same period in 2019. Methods Retrospective, single-center study that evaluated emergency visits and in-hospital deaths between March 16, 2020 and June 16, 2020, when the steepest fall in the number of emergency admissions for COVID-19 was registered. These data were compared with the emergency visits and in-hospital deaths between March 16 and June 16, 2019. We analyzed the total number of deaths, and cardiovascular deaths. The level of significance was set at p < 0.05. Results There was a 35% decrease in the number of emergency visits and an increase in the ratio of the number of deaths to the number of emergency visits in 2020. The increase in the ratio of the number of all-cause deaths to the number of emergency visits was 45.6% and the increase in the ratio of the number of cardiovascular deaths to the number of emergency visits was 62.1%. None of the patients who died in the study period in 2020 tested positive for COVID-19. Conclusion In-hospital mortality for cardiovascular diseases increased proportionally to the number of emergency visits during the COVID-19-imposed social distancing compared with the same period in 2019. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

Development and evaluation of a virtual reality training for emergency treatment of shortness of breath based on frameworks for serious games.

Background: Virtual reality (VR) can offer an innovative approach to providing training in emergency situations, especially in times of COVID-19. There is no risk of infection, and the procedure is scalable and resource-efficient. Nevertheless, the challenges and problems that can arise in the development of VR training are often unclear or underestimated. As an example, we present the evaluation of the feasibility of development of a VR training session for the treatment of dyspnoea. This is based on frameworks for serious games, and provides lessons learned. We evaluate the VR training session with respect to usability, satisfaction, as well as perceived effectiveness and workload of participants. Methods: The VR training was developed using the established framework (Steps 1-4) for serious games of Verschueren et al. and Nicholson's RECIPE elements for meaningful gamification. Primary validation (Step 4) was performed at the University of Bern, Switzerland, in a pilot study without control group, with a convenience sample of medical students (n=16) and established measurement tools. Results: The theoretical frameworks permitted guided development of the VR training session. Validation gave a median System Usability Scale of 80 (IQR 77.5-85); for the User Satisfaction Evaluation Questionnaire, the median score was 27 (IQR 26-28). After the VR training, there was a significant gain in the participants' confidence in treating a dyspnoeic patient (median pre-training 2 (IQR 2-3) vs. post-training 3 (IQR 3-3), p=0.016).Lessons learned include the need for involving medical experts, medical educators and technical experts at an equivalent level during the entire development process. Peer-teaching guidance for VR training was feasible. Conclusion: The proposed frameworks can be valuable tools to guide the development and validation of scientifically founded VR training. The new VR training session is easy and satisfying to use and is effective - and is almost without motion sickness.

Editorial - The NHS urgent and emergency care crisis: how much worse could it get?

NHS urgent and emergency care is under intolerable strain. This strain is increasingly causing harm to patients. Timely and high-quality patient care is often not being delivered due to overcrowding driven by workforce and capacity constraints. This drives low staff morale perpetuating burn out and high absence levels which currently dominate. Whilst COVID19 has accentuated and arguably expedited the crisis; the spiral of decline in urgent and emergency care has been decade long and unless urgent action is taken, we may not yet have reached its nadir.

Impact of Coronavirus Disease 2019 Pandemic on Cardiac Arrest and Emergency Care.

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.

A qualitative study on overdose response in the era of COVID-19 and beyond: how to spot someone so they never have to use alone.

BACKGROUND: Spotting is an informal practice among people who use drugs (PWUD) where they witness other people using drugs and respond if an overdose occurs. During COVID-19 restrictions, remote spotting (e.g., using a telephone, video call, and/or a social media app) emerged to address physical distancing requirements and reduced access to harm reduction and/or sexually transmitted blood borne infection (STBBI's) prevention services. We explored spotting implementation issues from the perspectives of spotters and spottees. METHODS: Research assistants with lived/living expertise of drug use used personal networks and word of mouth to recruit PWUD from Ontario and Nova Scotia who provided or used informal spotting. All participants completed a semi-structured, audio-recorded telephone interview about spotting service design, benefits, challenges, and recommendations. Recordings were transcribed and thematic analysis was used. RESULTS: We interviewed 20 individuals between 08/2020-11/2020 who were involved in informal spotting. Spotting was provided on various platforms (e.g., telephone, video calls, and through texts) and locations (e.g. home, car), offered connection and community support, and addressed barriers to the use of supervised consumption sites (e.g., location, stigma, confidentiality, safety, availability, COVID-19 related closures). Spotting calls often began with setting an overdose response plan (i.e., when and who to call). Many participants noted that, due to the criminalization of drug use and fear of arrest, they preferred that roommates/friends/family members be called instead of emergency services in case of an overdose. Both spotters and spottees raised concerns about the timeliness of overdose response, particularly in remote and rural settings. CONCLUSION: Spotting is a novel addition to, but not replacement for, existing harm reduction services. To optimize overdose/COVID-19/STBBI's prevention services, additional supports (e.g., changes to Good Samaritan Laws) are needed. The criminalization of drug use may limit uptake of formal spotting services.

Editorial - Virtual wards: A key concept that requires careful evaluation to ensure success in the real world.

Urgent and emergency care services remain under huge pressures with concerns regarding overcrowding, delays in patient care and exhausted staff with increasing unsustainable workforce pressures. Short term mitigation measures are needed alongside the imperative need to ensure long-term innovative and sustainable measures to ensure that the NHS can deliver high quality acute and emergency care.

Health emergencies and interoceptive sensibility modulate the perception of non-evidence-based drug use: Findings from the COVID-19 outbreak.

Scientific evidence plays an important role in the therapeutic decision-making process. What happens when physicians are forced to make therapeutic decisions under uncertainty? The absence of scientific guidelines at the beginning of a pandemic due to an unknown virus, such as COVID-19, could influence the perceived legitimacy of the application of non-evidence-based therapeutic approaches. This paper reports on a test of this hypothesis, in which we administered an ad hoc questionnaire to a sample of 64 Italian physicians during the first wave of the COVID-19 pandemic in Italy (April 2020). The questionnaire statements regarding the legitimacy of off-label or experimental drugs were framed according to three different scenarios (Normality, Emergency and COVID-19). Furthermore, as the perception of internal bodily sensations (i.e., interoception) modulates the decision-making process, we tested participants' interoceptive sensibility using the Multidimensional Assessment of Interoceptive Awareness (MAIA). The results showed that participants were more inclined to legitimate non-evidence-based therapeutic approaches in the COVID-19 and Emergency scenarios than the Normality scenario. We also found that scores on the MAIA Trusting subscale positively predicted this difference. Our findings demonstrate that uncertain medical scenarios, involving a dramatic increase in patient volume and acuity, can increase risk-taking in therapeutic decision-making. Furthermore, individual characteristics of health care providers, such as interoceptive ability, should be taken into account when constructing models to prevent the breakdown of healthcare systems in cases of severe emergency.

Peripheral intravenous cannulation decision-making in emergency settings: a qualitative descriptive study.

OBJECTIVES: Rates of unused ('idle') peripheral intravenous catheters (PIVCs) are high but can vary per setting. Understanding factors that influence the decision-making of doctors, nurses and paramedics in the emergency setting regarding PIVC insertion, and what factors may modify their decision is essential to identify opportunities to reduce unnecessary cannulations and improve patient-centred outcomes. This study aimed to understand factors associated with clinicians' decision-making on whether to insert or use a PIVC in the emergency care setting. DESIGN: A qualitative descriptive study using in-depth semistructured interviews and thematic analysis. SETTING: Gold Coast, Queensland, Australia, in a large tertiary level emergency department (ED) and local government ambulance service. PARTICIPANTS: Participants recruited were ED clinicians (doctors, nurses) and paramedics who regularly insert PIVCs. RESULTS: From the 15 clinicians interviewed 4 key themes: knowledge and experience, complicated and multifactorial, convenience, anticipated patient clinical course, and several subthemes emerged relating to clinician decision-making across all disciplines. The first two themes focused on decision-making to gather data and evidence, such as knowledge and experience, and decisions being complicated and multifactorial. The remaining two themes related to the actions clinicians took such as convenience and anticipated patient clinical course. CONCLUSION: The decision to insert a PIVC is more complicated than clinicians, administrators and policy-makers may realise. When explored, clinician decisions were multifaceted with many factors influencing the decision to insert a PIVC. In actual practice, clinicians routinely insert PIVCs in most patients as a learnt reflex with little cognitive input. When considering PIVC insertion, more time needs to be devoted to the awareness of: (1) decision-making in the context of the clinician's own experience, (2) cognitive biases and (3) patient-centred factors. Such awareness will support an appropriate risk assessment which will benefit the patient, clinician and healthcare system.

Pediatric Emergency Department Visits Before and During the COVID-19 Pandemic - United States, January 2019-January 2022.

Emergency departments (EDs) in the United States remain a frontline resource for pediatric health care emergencies during the COVID-19 pandemic; however, patterns of health-seeking behavior have changed during the pandemic (1,2). CDC examined changes in U.S. ED visit trends to assess the continued impact of the pandemic on visits among children and adolescents aged 0-17 years (pediatric ED visits). Compared with 2019, pediatric ED visits declined by 51% during 2020, 22% during 2021, and 23% during January 2022. Although visits for non-COVID-19 respiratory illnesses mostly declined, the proportion of visits for some respiratory conditions increased during January 2022 compared with 2019. Weekly number and proportion of ED visits increased for certain types of injuries (e.g., drug poisonings, self-harm, and firearm injuries) and some chronic diseases, with variation by pandemic year and age group. Visits related to behavioral concerns increased across pandemic years, particularly among older children and adolescents. Health care providers and families should remain vigilant for potential indirect impacts of the COVID-19 pandemic, including health conditions resulting from delayed care, and increasing emotional distress and behavioral health concerns among children and adolescents.

Pediatric Emergency Department Visits Associated with Mental Health Conditions Before and During the COVID-19 Pandemic - United States, January 2019-January 2022.

In 2021, a national emergency* for children's mental health was declared by several pediatric health organizations, and the U.S. Surgeon General released an advisory† on mental health among youths. These actions resulted from ongoing concerns about children's mental health in the United States, which was exacerbated by the COVID-19 pandemic (1,2). During March-October 2020, among all emergency department (ED) visits, the proportion of mental health-related visits increased by 24% among U.S. children aged 5-11 years and 31% among adolescents aged 12-17 years, compared with 2019 (2). CDC examined changes in U.S. pediatric ED visits for overall mental health conditions (MHCs) and ED visits associated with specific MHCs (depression; anxiety; disruptive behavioral and impulse-control disorders; attention-deficit/hyperactivity disorder; trauma and stressor-related disorders; bipolar disorders; eating disorders; tic disorders; and obsessive-compulsive disorders [OCD]) during 2019 through January 2022 among children and adolescents aged 0-17 years, overall and by sex and age. After declines in weekly visits associated with MHCs among those aged 0-17 years during 2020, weekly numbers of ED visits for MHCs overall and for specific MHCs varied by age and sex during 2021 and January 2022, when compared with corresponding weeks in 2019. Among adolescent females aged 12-17 years, weekly visits increased for two of nine MHCs during 2020 (eating disorders and tic disorders), for four of nine MHCs during 2021 (depression, eating disorders, tic disorders, and OCD), and for five of nine MHCs during January 2022 (anxiety, trauma and stressor-related disorders, eating disorders, tic disorders, and OCD), and overall MHC visits during January 2022, compared with 2019. Early identification and expanded evidence-based prevention and intervention strategies are critical to improving children's and adolescents' mental health (1-3), especially among adolescent females, who might have increased need.

Dental Emergency Admissions in Emergency Oral Health Care Centers during COVID-19 Pandemic in Buenos Aires, Argentina.

This study aimed to describe patients' demographic characteristics and treatment delivered in private and public dental emergency clinics and to compare them with a pre-pandemic period. A retrospective cross-sectional study was carried out on patients attending the University Dental Hospital of the University of Buenos Aires and on one private dental clinic, situated in Buenos Aires, between March and June of 2019 and 2020. The sample considered all the patients' medical records of those requiring emergency dental treatment at these centers during that period. We systematize the treatments required and delivered by the emergency providers into categories. In 2019, 36,071 patients were treated at the university dental hospital and the private clinic. In 2020, 7485 patients received emergency treatment, showing a fivefold reduction. During a pre-pandemic period, in 2019, both oral care centers provided 44,894 treatments, around three times the treatments provided in 2020 during the same period. We have found significant differences in the age groups of people who required emergency treatment in the pandemic period compared to the pre-pandemic period. During the pandemic period, the most represented types of treatment were radiographic exams (3061) and tooth extractions (2583). Conversely, during the pre-pandemic period, the most frequent treatments were radiographic examinations (16,649) and general consultations (10,591). The percentages of all types of treatments differ significantly between the two years except for pediatric consultations and prosthetics emergencies. As the pandemic is still an ongoing sanitary problem, urgent dental care patterns should be considered.

Patients' perspective on emergency treatment of ophthalmologic diseases during the first phase of SARS-CoV2 pandemic in a tertiary referral center in Germany - the COVID-DETOUR questionnaire study.

BACKGROUND: During the first wave of the COVID-19 pandemic, the need of treatment of urgent ophthalmological diseases and the possible risk of a SARS-CoV-2 infection had to be weighed against each other. In this questionnaire study, we aimed to analyze potential barriers and patients' health beliefs during and after the lockdown early 2020 in a tertiary referral center in Kiel, Germany. METHODS: Patients admitted for the treatment of urgent ophthalmic diseases between March 1st, 2020, and June 3rd, 2020, were asked to participate in a questionnaire study. After informed consent was obtained, patients were interviewed using a standardized questionnaire which addressed aspects of their medical history, their health beliefs concerning the COVID-19 pandemic and barriers on their way to the treatment center. The study group was subdivided into two subgroups, depending on the occurrence of their symptoms, before and after the lockdown was ended on April 20th, 2020. RESULTS: Ninety-three patients were included, 43 in subgroup A (before April 20th) and 50 in subgroup B (April 20th or later). Retinal disorders were the most common causes for admission (approximately 60%).. Only 8 patients (8.6%) experienced a delay between their decision to visit a doctor until the actual examination. Every fourth patient was afraid of a COVID-19 infection, and expected a higher likelihood for an infection at the hospital. Patients with comorbidities tended to be more likely to be afraid of an infection (correlation coefficient 0.183, p = 0.0785) and were significantly more likely to be concerned about problems with organizing follow-up care (corr. Coefficient 0.222, p = 0.0328). Higher age was negatively correlated with fear of infection (corr. Coefficient - 0.218, p-value 0.034). CONCLUSION: In this questionnaire study, only a minority of patients indicated a delay in treatment, regardless of whether symptoms occurred before or after the lockdown before April 20th, 2020. While patients with comorbidities were more concerned about infection and problems during follow-up care, patients of higher age - who have a higher mortality - were less afraid. Protection of high-risk groups should be prioritized during the SARS-CoV-2 pandemic. TRIAL REGISTRATION: The study was registered as DRKS00021630 at the DRKS (Deutsches Register Klinischer Studien) before the conduction of the study on May 5th, 2020.