Maintaining Prehospital Intubation Success with COVID-19 Personal Protective Precautions.

BACKGROUND: Tracheal intubation is a high-risk intervention for exposure to airborne infective pathogens, including the novel coronavirus disease 2019 (COVID-19). During the recent pandemic, personal protective equipment (PPE) was essential to protect staff during intubation but is recognized to make the practical conduct of anesthesia and intubation more difficult. In the early phase of the coronavirus pandemic, some simple alterations were made to the emergency anesthesia standard operating procedure (SOP) of a prehospital critical care service to attempt to maintain high intubation success rates despite the challenges posed by wearing PPE. This retrospective observational cohort study aims to compare first-pass intubation success rates before and after the introduction of PPE and an altered SOP. METHODOLOGY: A retrospective observational cohort study was conducted from January 1, 2019 through August 30, 2021. The retrospective analysis used prospectively collected data using prehospital electronic patient records. Anonymized data were held in Excel (v16.54) and analyzed using IBM SPSS Statistics (v28). Patient inclusion criteria were those of all ages who received a primary tracheal intubation attempt outside the hospital by critical care teams. March 27, 2020 was the date from which the SOP changed to mandatory COVID-19 SOP including Level 3 PPE - this date is used to separate the cohort groups. RESULTS: Data were analyzed from 1,266 patients who received primary intubations by the service. The overall first-pass intubation success rate was 89.7% and the overall intubation success rate was 99.9%. There was no statistically significant difference in first-pass success rate between the two groups: 90.3% in the pre-COVID-19 group (n = 546) and 89.3% in the COVID-19 group (n = 720); Pearson chi-square 0.329; P = .566. In addition, there was no statistical difference in overall intubation success rate between groups: 99.8% in the pre-COVID-19 group and 100.0% in the COVID-19 group; Pearson chi-square 1.32; P = .251.Non-drug-assisted intubations were more than twice as likely to require multiple attempts in both the pre-COVID-19 group (n = 546; OR = 2.15; 95% CI, 1.19-3.90; P = .01) and in the COVID-19 group (n = 720; OR = 2.5; 95% CI, 1.5-4.1; P = <.001). CONCLUSION: This study presents simple changes to a prehospital intubation SOP in response to COVID-19 which included mandatory use of PPE, the first intubator always being the most experienced clinician, and routine first use of video laryngoscopy (VL). These changes allowed protection of the clinical team while successfully maintaining the first-pass and overall success rates for prehospital tracheal intubation.

The effect of the COVID-19 pandemic on major trauma presentations and patient outcomes in English hospitals

1427 Figure 2Interrupted time series analysis assessing the impact of COVID restrictions on likelihood of survival (red horizontal lines indicate introduction and relaxation of ‘lockdown’ measures)[Figure omitted. See PDF] 1427 Table 1Comparison of demographics ‘lockdown’ and pre-COVID periodsPeriodPeriod24Mar19 – 03Jul19 (comparator)24Mar20 – 03Jul20 (lockdown 1)Absolute change [percentage point change (95%CI)] p-value01Nov18 – 16May19 (comparator)01Nov20 – 16May21 (lockdown 1)Absolute change [percentage point change (95%CI)] p-valueTotal2224317510-4733 (-21%)p<0.0001‡41016382622754 (–6.7%)p<0.0001‡Age (years), Median (IQR)67.6 (46.5–83.1)70.9 (50.3–84.2)3.3 (2.4 to 4.2)p<0.000169.1 (48.7–83.6)73.1 (53.3–85.1)4 (3.5 to 4.2)<0.0001Age bands, n(%)Age< 1138 (0.6%)130 (0.7%)-8 [0.1(-0.04 to 0.030)] p=0.14 281 (0.7%)234 (0.6%)-47 [0.1 (-0.2 to 0.04)]p=0.1979Age <16942 (4.2%)674 (3.8%)-268 [-0.4 (-0.8 to 0]p=0.05311444 (3.5%)1218 (3.2%)-226 [-0.3(-0.6 to – 0.1)p=0.0084Age 16 – 649561 (43%)6974 (39.8%)-2587 [-3.2(-4.1 to -2.2)P<0.000117173 (41.9%)13980 (36.5%)-3193 [-5.3(-6 to -5)]p<0.0001Age 65 and over11740 (52.8%)9862 (56.3%)-1878 [3.5 (2.5 to 4.5)]p<0.000122399 (54.6%)23064 (60.3%)665 [5.7(5 to 6.3)]P<0.0001Age 85 and over4610 (20.7%)4047 (23.1%)-563 [2.4(1.6 to 3.2)]p<0.00018903 (21.7%)9731 (25.4%)828 [3.7 (3.1 to 4.3)]p<0.0001Male, n(%)12316 (55.4%)9512 (54.3%)-2804 [-1 (-2 to -0.6)]p=0.037322146 (54%)19769 (51.7%)-2377 [-2.3 (-3 to -1.6)]<0.0001CCI*, n(%)CCI 09359 (42.1%)6220 (35.5%)-3139 [ -6.5 (-7.5 to -5.6)] p<0.000116665 (40.6%)12806 (33.5%)-3859 [-7.1(-7.8 to -6.5)]p<0.0001CCI 1 – 58538 (38.4%)6896 (39.4%)-1642 [1 (0.3 to 2)]p=0.042615899 (38.8%)15667 (40.9%)-232 [2.2 (1.5 to 2.9)]p<0.0001CCI 6 – 103032 (13.6%)3061 (17.5%)29 [3.8 (3.2 to 4.6)]p<0.00015987 (14.6%)6863 (17.9%)876 [3.3(2.8 to 3.8)]p<0.0001CCI > 10927 (4.2%)1024 (5.8%)97 [1.7(1.2 to 2.1)]p<0.00011648 (4%)2410 (6.3%)762 [2.3(2 to 2.6)]p<0.0001Not recorded387 (1.7%)309 (1.8%)-88 [0.2 (-0.2 to 0.3)]p=0.8513817 (2%)516 (1.3%)-301 [-0.6(-0.8 to -0.5)]p<0.0001MOI**: RTC, n(%)Car occupant1247 (30.7%)551 (20.4%)-696 [-10.4(-12.4 to -8.2)]p<0.00012485 (35.2%)1551 (31.3%)-934 [-3.9(-5.6 to -2.2)]p<0.0001Pedestrian661 (16.3%)288 (10.6%)-373 [-5.6 (-7.2 to -4)]p<0.00011629 (23.1%)962 (19.4%)-667 [-3.7(-5.1 to -2.2)]p<0.0001Motorcycles1196 (29.4%)711 (26.3%)-485 [-3.2(-5.3 to -1)]p<0.00011524 (21.6%)976 (19.7%)-548[ -1.9(-3.3 to -0.4)]p<0.0001Cyclist912 (22.4%)1139 (42.1%)227 [19.6(17.4 to 21.9)]p<0.00011315 (18.6%)1396 (28.2%)81 [9.5(8 to 11.1)]p<0.0001Other11 (0.3%)<9 ()-10 [ -0.2(-0.4 to -0.06)p=0.025131 (0.4%)10 (0.2%)-21 [-0.23(-0.4 to -0.04)]p=0.0281MOI: Intentional, n(%)Intentional assault130 (0.6%)88 (0.5 )-42 [-0.08 (-0.2 to 0.06)]p=0.2724227 (0.6%)175 (0.5%)-52 [-0.1(-0.2 to 0.002)]P=0.0570Self harm276 (1.2%)284 (1.6%)8 [0.4 (0.1 to 0.6)]p=0.0014525 (1.3%)562 (1.5%)37 [0.2 (0.02 to 0.3)]p=0.0223NAI63 (0.3%)27 (0.2%)-36 [-0.1(-0.2 to -0.03)]p=0.007297 (0.2%)90 (0.2%)-7 [-0.001(-0.07 to 0.07)]p=0.9701Shooting34 (0.2%)40 (0.2%)6 [0.08(-0.01 to 0.2)]p=0.082680 (0.2%)56 (0.1%)-24 [ -0.05(-0.1 to 0.001)]p=0.0979Stabbing450 (2%)312 (1.8%)-138 [-0.2(-0.5 to 0.03)]p=0.0816791 (1.9%)589 (1.5%)-202 [-0.4 (-0.6 to -0.2)]p<0.0001Blows1174 (5.3%)647 (3.7%)-527 [-1.6(-1.9 to -1.2)]p<0.00012059 (5%)1299 (3.4%)-760 [-1.6(-1.9 to -1.3)]p<0.0001Unintentional, n(%)Falls>2m2055 (9.2%)1757 (10%)-298 [0.8(0.2 to 1.4)]P=0.00753740 (9,1%)3528 (9.2%)-212 [0.1(-0.3 to 0.5)]p=0.6181Falls<2m13384 (60.2%)11314 (64.6%)-2070 [4.4 (3.5 to 5.4)]p<0.000125505 (62.2%)26203 (65.8%)698 [6.3 (5.6 to 6.9)]p<0.0001Sport449 (2%)320 (1.8%)-129 [-0.2 (-0.5 to 0.01]p=0.1697615 (1.5%)489 (1.3%)-126 [-0.2 (-0.4 to -0.006)]p=0.0079GCS bands , n(%)Mild19609 (88.2%)15449 (88.2%)4160 [0.1 (-0.6 to 0.7)]p=0.826435831 (87.4%)34051 (89%)-1780 [1.6 (1.2 to 2.1)]p<0.0001Moderate689 (3.1%)625 (3.6%)-64 [0.5(0.1 to 0.8)]p=0.00901333 (3.2%)1127 (2.9%)-206 [-0.3 (-0.5 t -0.06)]p=0.0135Severe955 (4.3%)765 (4.4%)-190 [0.1 (-0.3 to 0.5)]p=0.71361886 (4.6%)1464 (3.8%)-422 [-0.8(-1 to -0.5)]p<0.0001Not recorded990 (4.5%)671 (3.8%)-319 [ -0.6(-1 to -0.2)]p=0.00221966 (4.8%)1620 (4.2%)-346 [-0.6(-0.8 to -0.3)]p=0.0002ISS***, median (IQR)9 (9–18)9 (9–18)09 (9–18)9 (9–17)0ISS bands, n(%)ISS 1 – 84545 (20.4%)3062 (17.5%)-1483 [-3 (-4 to -2)]p=<0.00018266 (20.2%)7838 (20.5%)-428 [0.3(-0.2 to 0.9)]p=0.2457ISS 9 – 159290 (41.8%)7728 (44.1%)-1562 [2.4(1.4 to 3.3)]p<0.000117207 (42%)16969 (44.3%)-233 [2.4(1.7 to 3.1)]p<0.0001ISS >158408 (37.8%)6720 (38.4%)-1688 [5.6(-0.4 to 1.5)]p=0.239115543 (37.9%)13455 (35.2%)-2088 [-2.7 (-3.4 to -2)]p<0.0001ISS >253995 (18%)3127 (17.9%)-868 [-0.1(-0.9 to 0.7 )]p=0.79217521 (18.3%)6201 (16.2%)-1320 [-2.1(-2.6 to -1.6)]p<0.0001Body regions, n(%)Head AIS 3+5911 (26.6%)4670 (26.7%)-1241 [0.1 (-0.8 to 1)]p=0.830111128 (27.1%)9629 (25.2%)-1499 [ -2(-2.6 to -1.3)]p<0.0001Face AIS 3+63 (0.3%)41 (0.2%)-22 [-0.05 (-0.1 to 0.05)]p=0.341699 (0.2%)69 (0.2%)-30 [-0.06 (-0.1 to 0)]p=0.0618Chest AIS 3+4787 (21.5%)3915 (22.4%)-872 [8.3 (0.2 to 1.6)]<0.04508515 (20.8%)8075 (21.1%)-440 [0.3 (-0.2 to 0.9)]p=0.2337Abdomen AIS 3+872 (3.9%)690 (3.9%)-182 [0.02 (-0.3 to 0.4)]p=0.91771465 (3.6%)1179 (3.1%)-286 [-0.5 (-0.7 to -0.2)]p=0.0001Spine AIS 3+1985 (8.9%)1561 (8.9%)-424 [-0.01(-0.6 to 0.5)]p=0.97443784 (9.2%)3459 (9%)-325 [-0.2(-0.6 to 0.2)]p=0.3654Pelvis AIS 3+758 (3.4%)600 (3.4%)-158 [0.02(-0.3 to 0.4)]p=0.91841501 (3.7%)1386 (3.6%)-115 [-0.04(-0.3 to 0.2)]p=0.7802Limb AIS 3+5707 (25.7%)4892 (27.9%)-815 [2.3 (1.4 to 3.2)]p<0.000110719 (26.1%)10122 (26.5%)-597 [0.3(-0.3 to 0.9)]p=0.3053Other AIS 3+217 (1%)199 (1.1%)-18 [0.2 (-0.04 to 0.3)]p=0.1176375 (0.9%)396 (1%)21 [0.1 (-0.01 to 0.2]p=0.0836Polytrauma1622 (7.3%)1350 (7.7%)-272 [0.4 (-0.1 to 0.9)]p=0.11602984 (7.3%)2429 (6.3%)-555 [-0.9(-1.2 to 0.6)]p<0.0001*CCI Charlson Comorbidity Index**MOI Mechanism of injury***ISS Injury Severity Score‡ chi square test for uniform distribution 1427 Table 2Comparison care pathways ‘lockdown’ and pre-COVID periodsPeriodPeriod24Mar19 – 03Jul19 (comparator)24Mar20 – 03Jul20 (lockdown 1)Absolute Change01Nov18 – 16May19 (comparator)01Nov20 – 16May21 (lockdown 2)Absolute Change1st Hospital MTC9908 (44.5%)7376 (42.1%)-2532 [-2.4 (-3.4 to -1.4)]p<0.000118099 (44.1%)15928 (41.6%)-2171 [-2.5 (-3.2 to -1.8)]p<0.0001Treated at MTC11176 (50.2%)8256 (47.2%)-2920 [-3 (-4 to -2)]p<0.000120395 (49.7%)17852 (46.7%)-2543[-3 (-4 to -2.4)]p<0.0001Consultant ED8140 (36.6%)5562 (31.8%)-2578 [-4.8(-5.8 to -3.9)]p<0.000114779 (36%)12577 (32.9%)-2202 [-3.2 (-3.8 to -2.5)]p<0.0001CT within 1 hr5062 (31.9%)3992 (30.9%)-1070 [-0.9(-2 to 0.1)]p=0.09449203 (31.6%)7776 (27.1%)-1427 [-4(-5 to -3.7)]p<0.0001Whole body CT3348 (15.1%)3210 (18.3%)-138 [3 (2 to 4)]p<0.00016040 (14.7%)64 7 (16.8%)377 [2 (1.5 to 2.5)]p<0.0001ICU stay3092 (13.9%)2208 (12.6%)-884 [-1.3(-1.9 to -0.6) ]p=0.00025591 (13.6%)3850 (10.1%)-1741 [-3.6(-4 to -3)]p<0.0001Mortality*1417 (7.1%)1316 (8.3%)-101 [1.2 (0.6 to 1.7)]p<0.00012916 (7.9%)2858 (8.1%)-58 [0.2 (-0.1 to 0.6)] p=0.2040Discharge destination, n(%)Home (own)13800 (62%)10484 (59.9%)-3316 [-2(-3.1 to -1.2)]p<0.000124961 (60.9%)23368 (61.1%)-1593 [-0.7 (-1.4 to -0.05)]p=0.0340Home (relative/carer)473 (2.1%)372 (2.1%)-101 [0 (-0.3 to 0.3)]p=0.9890974 (2.4%)852 (2.2%)-122 [-0.1(-0.4 to 0.06)]p=0.1653Mortuary*1501 (6.7%)1323 (7.6%)-178 [0.8(0.3 to 1.3)]p=0.00193086 (7.5%)2977 (7.8%)-109 [0.1 (-0.3 to 0.5)]p=0.5113No fixed abode75 (0.3%)47 (0.3%)-28 (-37.3%)107 (0.3%)87 (0.2%)-20 (-18.7%)Not Known87 (0.4%)39 (0.2%)-48 (-55.2%)101 (0.2%)95 (0.2%)-6 (-5.9%)Nursing Home1190 (5.3%)1063 (6.1%)-127 [0.7(0.3 to 1.2)]p=0.00202448 (6%)2231 (5.8%)-217 [-0.2(-0.6 to 0.1)]p=0.1620Other Acute hospital2425 (10.9%)1736 (9.9%)-689 [-0.1(-1.6 to -0.4)]p=0.00144346 (10.6%)3313 (8.7%)-1033 [-0.1(-0.5 to 0.2)]p=0.4115Other institution526 (2.4%)516 (2.9%)-10 [0.6 (0.3 to 0.9)]p=0.0003980 (2.4%)870 (2.3%)-110 [-0.1 (-0.3 to 0.1)]p=0.2817Rehabilitation2077 (9.3%)1871 (10.7%)-206 [1.3(0.7 t 1.9)]p<0.00013851 (9.4%)4274 (11.2%)423 [ 1.7(1.3 to 2.2)]p<0.0001Social care63 (0.3%)50 (0.3%)-13 [0 (-0.1 to 0.1)]p=0.9657121 (0.3%)103 (0.3%)-18 [-0.2(-0.1 to 0.5)]p=0.4939*These totals do not correspond as mortality includes deaths in the community and is censored at 30 daysResults and ConclusionThe first ‘lockdown’ had a larger associated reduction in total trauma volume (-21%) compared to the pre-COVID period than the second ‘lockdown’ (-6.7%). Trauma volume increased for those 65 and over (3%) and 85 and over (9.3%) during the second ‘lockdown’.There was a reduction in likelihood of survival (-1.71;95% CI:-2.76 to -0.66) associated with the immediate introduction of the first ‘lockdown’. However, this was followed by a trend of improving survival (0.25;95% CI: 0.14 to 0.35) and likelihood of survival returned to pre-pandemic levels by the end of the first ‘lockdown’ period.Future research is needed understand the initial reduction in likelihood of survival after major trauma observed with the implementation of the first ‘lockdown’ to prevent this occurring if measures re-introduced.