Intubation practices and outcomes for patients with suspected or confirmed COVID-19: a national observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN).

OBJECTIVE: Intubation practices changed during the COVID-19 pandemic to protect healthcare workers from transmission of disease. Our objectives were to describe intubation characteristics and outcomes for patients tested for SARS CoV-2 infection. We compared outcomes between patients testing SARS COV-2 positive with those testing negative. METHODS: We conducted a health records review using the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. We included consecutive eligible patients who presented to one of 47 EDs across Canada between March 1, 2020 and June 20, 2021, were tested for SARS-CoV-2 and intubated in the ED. The primary outcome was the proportion of patients experiencing a post-intubation adverse event during the ED stay. Secondary outcomes included first-pass success, intubation practices, and hospital mortality. We used descriptive statistics to summarize variables with subgroup differences examined using t tests, z tests, or chi-squared tests where appropriate with 95% CIs. RESULTS: Of 1720 patients with suspected COVID-19 who were intubated in the ED during the study period, 337 (19.6%) tested SARS-CoV-2 positive and 1383 (80.4%) SARS-CoV-2 negative. SARS-CoV-2 positive patients presented to hospital with lower oxygen levels than SARS-CoV-2 negative patients (mean pulse oximeter SaO2 86 vs 94%, p < 0.001). In total, 8.5% of patients experienced an adverse event post-intubation. More patients in the SARS-CoV-2 positive subgroup experienced post-intubation hypoxemia (4.5 vs 2.2%, p = 0.019). In-hospital mortality was greater for patients who experienced intubation-related adverse events (43.2 vs 33.2%, p = 0.018). There was no significant difference in adverse event-associated mortality by SARS-CoV-2 status. First-pass success was achieved in 92.4% of all intubations, with no difference by SARS-CoV-2 status. CONCLUSIONS: During the COVID-19 pandemic, we observed a low risk of adverse events associated with intubation, even though hypoxemia was common in patients with confirmed SARS-CoV-2. We observed high rates of first-pass success and low rates of inability to intubate. The limited number of adverse events precluded multivariate adjustments. Study findings should reassure emergency medicine practitioners that system modifications made to intubation processes in response to the COVID-19 pandemic do not appear to be associated with worse outcomes compared to pre-COVID-19 practices.

RéSUMé: OBJECTIF: Les pratiques d'intubation ont changé au cours de la pandémie de COVID-19 afin de protéger le personnel de santé contre la transmission de la maladie. Nos objectifs étaient de décrire les caractéristiques de l'intubation et les résultats pour les patients testés pour l'infection par le CoV-2 du SRAS. Nous avons comparé les résultats entre les patients testés positifs au SARS COV-2 et ceux testés négatifs. MéTHODES: Nous avons effectué un examen des dossiers de santé à l'aide du registre du Réseau canadien d'intervention rapide dans les services d'urgence pour la COVID-19 (RCIRSUC). Nous avons inclus les patients éligibles consécutifs qui se sont présentés à l'un des 47 services d'urgence du Canada entre le 1er mars 2020 et le 20 juin 2021, qui ont été testés pour le SRAS-CoV-2 et qui ont été intubés dans le service d'urgence. Le résultat principal était la proportion de patients ayant subi un événement indésirable après l'intubation pendant leur séjour aux urgences. Les critères de jugement secondaires comprenaient le succès du premier passage, les pratiques d'intubation et la mortalité hospitalière. Nous avons utilisé des statistiques descriptives pour résumer les variables avec des différences de sous-groupes examinées à l'aide de tests t, de tests z ou de tests du chi carré, le cas échéant, avec des IC à 95%. RéSULTATS: Sur les 1720 patients suspects de COVID-19 qui ont été intubés aux urgences pendant la période de l'étude, 337 (19,6%) ont été testés positifs au SARS-CoV-2 et 1383 (80,4%) négatifs au SARS-CoV-2. Les patients positifs au SRAS-CoV-2 se sont présentés à l'hôpital avec des niveaux d'oxygène inférieurs à ceux des patients négatifs pour le SRAS-CoV-2 (oxymètre de pouls moyen SaO2 86% contre 94%, p < 0,001). Au total, 8,5% des patients ont présenté un événement indésirable après l'intubation. Un plus grand nombre de patients du sous-groupe positif au SRAS-CoV-2 ont présenté une hypoxémie post-intubation (4,5% vs 2,2%, p = 0,019). La mortalité hospitalière était plus élevée chez les patients ayant subi des événements indésirables liés à l'intubation (43,2% vs 33,2%, p = 0,018). Il n'y avait pas de différence significative dans la mortalité associée aux événements indésirables selon le statut du SRAS-CoV-2. Le succès du premier passage a été obtenu dans 92,4% de toutes les intubations, sans différence selon le statut SARS-CoV-2 CONCLUSIONS: Pendant la pandémie de COVID-19, nous avons observé un faible risque d'événements indésirables associés à l'intubation, même si l'hypoxémie était fréquente chez les patients atteints de SRAS-CoV-2 confirmé. Nous avons observé des taux élevés de réussite du premier passage et des taux faibles d'incapacité à intuber. Le nombre limité d'événements indésirables a empêché les ajustements multivariés. Les résultats de l'étude devraient rassurer les praticiens de la médecine d'urgence que les modifications apportées aux processus d'intubation en réponse à la pandémie de COVID-19 ne semblent pas être associées à des résultats plus défavorables que les pratiques antérieures à la pandémie de COVID-19.

Derivation and validation of a clinical decision rule to risk-stratify COVID-19 patients discharged from the emergency department: The CCEDRRN COVID discharge score.

Objective: To risk-stratify COVID-19 patients being considered for discharge from the emergency department (ED). Methods: We conducted an observational study to derive and validate a clinical decision rule to identify COVID-19 patients at risk for hospital admission or death within 72 hours of ED discharge. We used data from 49 sites in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) between March 1, 2020, and September 8, 2021. We randomly assigned hospitals to derivation or validation and prespecified clinical variables as candidate predictors. We used logistic regression to develop the score in a derivation cohort and examined its performance in predicting short-term adverse outcomes in a validation cohort. Results: Of 15,305 eligible patient visits, 535 (3.6%) experienced the outcome. The score included age, sex, pregnancy status, temperature, arrival mode, respiratory rate, and respiratory distress. The area under the curve was 0.70 (95% confidence interval [CI] 0.68-0.73) in derivation and 0.71 (95% CI 0.68-0.73) in combined derivation and validation cohorts. Among those with a score of 3 or less, the risk for the primary outcome was 1.9% or less, and the sensitivity of using 3 as a rule-out score was 89.3% (95% CI 82.7-94.0). Among those with a score of ≥9, the risk for the primary outcome was as high as 12.2% and the specificity of using 9 as a rule-in score was 95.6% (95% CI 94.9-96.2). Conclusion: The CCEDRRN COVID discharge score can identify patients at risk of short-term adverse outcomes after ED discharge with variables that are readily available on patient arrival.

Prognostic association between d-dimer thresholds and 30-day pulmonary embolism diagnosis among emergency department patients with suspected SARS-CoV-2 infection: a Canadian COVID-19 Emergency Department Rapid Response Network study.

OBJECTIVE: The primary objective was to quantify the prognostic association between various D-dimer thresholds and 30-day PE diagnosis among emergency department (ED) patients with suspected SARS-CoV-2 infection. METHODS: This was a retrospective study of patients enrolled in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) registry from March 1, 2020 to July 2, 2021. We included consecutive adults (≥ 18 years) presenting to 49 EDs with chest pain, shortness of breath, hypoxia, syncope, presyncope, or hemoptysis who were tested for both SARS-CoV-2 and D-dimer at index ED visit. The primary outcome measure was the sensitivity, specificity, and negative predictive value of D-dimer test thresholds for the outcome of 30-day PE diagnosis. RESULTS: Among 10,837 patients included in our study, 404 (3.7%) were diagnosed with PE at 30-days. A standard D-Dimer threshold of 500 ng/mL had a sensitivity of 97.8% (95% confidence interval [CI] 95.8-99.0%), specificity of 40.9% (95% CI 39.9-41.8%), and negative predictive value of 99.8% (95% CI 99.6-99.9%). An age-adjusted D-dimer threshold had a sensitivity of 96.0% (95% CI 93.6-97.7%), specificity of 48.5% (95% CI 47.5-49.4%), and negative predictive value of 99.7% (95% CI 99.5-99.8%). D-dimer testing had slightly lower prognostic performance among SARS-CoV-2 positive compared to SARS-CoV-2 negative patients in predicting 30-day PE diagnosis. CONCLUSIONS: Among ED patients with suspected SARS-CoV-2, the standard 500 ng/mL and age-adjusted D-dimer thresholds were comparable for the prediction of PE at 30-days. The prognostic performance of D-dimer was lower among SARS-CoV-2 positive patients. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04702945.

RéSUMé: OBJECTIF: L'objectif principal était de quantifier l'association pronostique entre différents seuils de D-dimères et le diagnostic d'EP à 30 jours chez les patients des services d'urgence suspectés d'être infectés par le SRAS-CoV-2. MéTHODES: Il s'agissait d'une étude rétrospective des patients inscrits au registre du réseau canadien de réponse rapide aux urgences COVID-19 (CCEDRRN) du 1er mars 2020 au 2 juillet 2021. Nous avons inclus des adultes consécutifs (>18 ans) se présentant dans 49 services d'urgence pour une douleur thoracique, un essoufflement, une hypoxie, une syncope, une présyncope ou une hémoptysie et qui ont été testés à la fois pour le SRAS-CoV-2 et les D-dimères lors de la visite de référence aux urgences. Le principal critère d'évaluation était la sensibilité, la spécificité et la valeur prédictive négative des seuils du test des D-dimères pour le diagnostic de l'EP à 30 jours. RéSULTATS: Parmi les 10 837 patients inclus dans notre étude, 404 (3,7 %) ont reçu un diagnostic d'EP à 30 jours. Un seuil standard de D-Dimer de 500 ng/mL avait une sensibilité de 97,8 % (intervalle de confiance [IC] à 95 % 95,8-99,0 %), une spécificité de 40,9 % (IC à 95 % 39,9-41,8 %) et une valeur prédictive négative de 99,8 % (IC à 95 % 99,6-99,9 %). Un seuil de D-dimères ajusté à l'âge avait une sensibilité de 96,0% (IC à 95 % 93,6-97,7 %), une spécificité de 48,5% (IC à 95 % 47,5-49,4 %) et une valeur prédictive négative de 99,7 % (IC à 95 % 99,5-99,8 %). Le test des D-dimères avait une performance pronostique légèrement inférieure chez les patients positifs pour le SRAS-CoV-2 par rapport aux patients négatifs pour le SRAS-CoV-2 en ce qui concerne la prédiction du diagnostic d'EP à 30 jours. CONCLUSIONS: Chez les patients des urgences suspectés d'être atteints du SRAS-CoV-2, les seuils standard de 500 ng/ml et les seuils de D-dimères ajustés à l'âge étaient comparables pour la prédiction de l'EP à 30 jours. La performance pronostique des D-dimères était plus faible chez les patients positifs pour le SRAS-CoV-2. ENREGISTREMENT DE L'ESSAI: Clinicaltrials.gov, NCT04702945.

Diagnostic yield of screening for SARS-CoV-2 among patients admitted to hospital for alternate diagnoses: an observational cohort study.

OBJECTIVES: To determine the diagnostic yield of screening patients for SARS-CoV-2 who were admitted with a diagnosis unrelated to COVID-19 and to identify risk factors for positive tests. DESIGN: Cohort from the Canadian COVID-19 Emergency Department Rapid Response Network registry. SETTING: 30 acute care hospitals across Canada. PARTICIPANTS: Patients hospitalised for non-COVID-19-related diagnoses who were tested for SARS-CoV-2 between 1 March and 29 December 2020. MAIN OUTCOME: Positive nucleic acid amplification test for SARS-CoV-2. OUTCOME MEASURE: Diagnostic yield. RESULTS: We enrolled 15 690 consecutive eligible adults who were admitted to hospital without clinically suspected COVID-19. Among these patients, 122 tested positive for COVID-19, resulting in a diagnostic yield of 0.8% (95% CI 0.64% to 0.92%). Factors associated with a positive test included presence of fever, being a healthcare worker, having a positive household contact or institutional exposure, and living in an area with higher 7-day average incident COVID-19 cases. CONCLUSIONS: Universal screening of hospitalised patients for COVID-19 across two pandemic waves had a low diagnostic yield and should be informed by individual-level risk assessment in addition to regional COVID-19 prevalence. TRIAL REGISTRATION NUMBER: NCT04702945.

Oxygen Therapy and Risk of Infection for Health Care Workers Caring for Patients With Viral Severe Acute Respiratory Infection: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: To synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection. Health care workers face significant risk of infection when treating patients with a viral severe acute respiratory infection. To ensure health care worker safety and limit nosocomial transmission of such infection, it is crucial to synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to April 1, 2020, for studies describing the risk of infection associated with the modalities of oxygen therapy used for patients with severe acute respiratory infection. The study selection, data extraction, and quality assessment were performed by independent reviewers. The primary outcome measure was the infection of health care workers with a severe acute respiratory infection. Random-effect models were used to synthesize the extracted data. RESULTS: Of 22,123 citations, 50 studies were eligible for qualitative synthesis and 16 for meta-analysis. Globally, the quality of the included studies provided a very low certainty of evidence. Being exposed or performing an intubation (odds ratio 6.48; 95% confidence interval 2.90 to 14.44), bag-valve-mask ventilation (odds ratio 2.70; 95% confidence interval 1.31 to 5.36), and noninvasive ventilation (odds ratio 3.96; 95% confidence interval 2.12 to 7.40) were associated with an increased risk of infection. All modalities of oxygen therapy generate air dispersion. CONCLUSION: Most modalities of oxygen therapy are associated with an increased risk of infection and none have been demonstrated as safe. The lowest flow of oxygen should be used to maintain an adequate oxygen saturation for patients with severe acute respiratory infection, and manipulation of oxygen delivery equipment should be minimized.

Development of the Canadian COVID-19 Emergency Department Rapid Response Network population-based registry: a methodology study.

BACKGROUND: Emergency physicians lack high-quality evidence for many diagnostic and treatment decisions made for patients with suspected or confirmed coronavirus disease 2019 (COVID-19). Our objective is to describe the methods used to collect and ensure the data quality of a multicentre registry of patients presenting to the emergency department with suspected or confirmed COVID-19. METHODS: This methodology study describes a population-based registry that has been enrolling consecutive patients presenting to the emergency department with suspected or confirmed COVID-19 since Mar. 1, 2020. Most data are collected from retrospective chart review. Phone follow-up with patients at 30 days captures the World Health Organization clinical improvement scale and contextual, social and cultural variables. Phone follow-up also captures patient-reported quality of life using the Veterans Rand 12-Item Health Survey at 30 days, 60 days, 6 months and 12 months. Fifty participating emergency departments from 8 provinces in Canada currently enrol patients into the registry. INTERPRETATION: Data from the registry of the Canadian COVID-19 Emergency Department Rapid Response Network will be used to derive and validate clinical decision rules to inform clinical decision-making, describe the natural history of the disease, evaluate COVID-19 diagnostic tests and establish the real-world effectiveness of treatments and vaccines, including in populations that are excluded or underrepresented in clinical trials. This registry has the potential to generate scientific evidence to inform our pandemic response, and to serve as a model for the rapid implementation of population-based data collection protocols for future public health emergencies. TRIAL REGISTRATION: Clinicaltrials.gov, no. NCT04702945.