key: cord-0759063-nvudywc1
authors: Cho, Jae Wan; Jung, Haewon; Lee, Mi Jin; Lee, Sang Hun; Lee, Suk Hee; Mun, You Ho; Chung, Han-sol; Kim, Yang Hun; Kim, Gyun Moo; Park, Sin-youl; Jeon, Jae Cheon; Kim, Changho
title: Preparedness of personal protective equipment and implementation of new CPR strategies for patients with out-of-hospital cardiac arrest in the COVID-19 era
date: 2020-06-25
journal: Resuscitation plus
DOI: 10.1016/j.resplu.2020.100015
sha: 378c9bf5f71c07723ee1db069aec484c303f3a1c
doc_id: 759063
cord_uid: nvudywc1

Abstract Background In February and March 2020, healthcare providers and citizens in Daegu, South Korea, experienced the onslaught of a large-scale community epidemic of COVID-19. This had a profound impact on patients who experienced out-of-hospital cardiac arrest (OHCA). Methods We conducted a retrospective observational study of 171 OHCA patients based on the multicenter WinCOVID registry. Demographic and clinical characteristics, overall survival, COVID-19 related data, as well as personal protective equipment (PPE) and resuscitation techniques used during the COVID-19 outbreak were evaluated and compared with outcomes from a 2018 historical cohort (n=158). Results Among the interventions, high-level PPE was introduced and standard cardiopulmonary resuscitation was changed to chest compressions using mechanical devices. All OHCA patients were treated as confirmed or suspicious for COVID-19 regardless of symptoms. Furthermore, complete or partial closures of emergency centers and the number of medical personnel requiring self-isolation decreased in response to the introduction of isolated resuscitation units. However, the adjusted odds ratio and 95% confidence intervals for survival discharge and favorable neurologic outcome were 0.51 (0.25–0.97) and 0.45 (0.21–1.07) compared with those in the 2018 historical cohort. Conclusions Responses to the COVID-19 pandemic included changes to current PPE strategies and introduction of isolated resuscitation units; the latter intervention reduced the number of unexpected closures and quarantines of emergency resources early on during the COVID-19 outbreak. Given the possibility of future outbreaks, we need to have revised resuscitation strategies and the capacity to commandeer emergency resources for OHCA patients.

Healthcare workers who perform cardiopulmonary resuscitation (CPR) are vulnerable to dangerous 52 infectious diseases spread by aerosols or respiratory droplets. [1] [2] [3] [4] The current COVID-19 pandemic has 53 highlighted issues associated with safety of team members during CPR. 5 Guidance from the Centers 54 for Disease Control and Prevention (CDC), 6, 7 the American Heart Association (AHA), 8 Healthcare providers may be unable to distinguish between confirmed/suspected patients, 62 asymptomatic carriers of COVID-19 and those who remain uninfected in an acute setting. For OHCA 63 events, it is clinically impossible to determine the risk of infection before performing immediate CPR. 64 Moreover, given that infection with SARS-CoV-2 is associated with few pathognomonic cases in 2018. Daegu includes two regional EMCs, four local EMCs and 19 emergency facilities or 104 clinics. Of note, there are six EMCs where advanced life support, post-cardiac arrest care and 105 cardiovascular intervention are available. Patients who were aged 18 years or older with OHCA of 106 presumed medical aetiology and who used the EMS system in Daegu were included in our study. 107 Patients who did not undergo resuscitative attempts and cases in which cardiac arrest occurred in a 108 primary care clinic or long-term care hospital were excluded from the analysis. From the observation 109 period of February 17, 2020 to March 31, 2020, a total of 189 adult OHCAs occurred in the 110 community; five were untreated because they were dead on arrival and 13 cases were excluded ( Fig.   111 1), and thereby 171 cases were included in the final analysis dataset of this study.

This was a before-and-after observational cohort study to examine the changes in the characteristics We investigated the demographics, including sex, age, medical history; CPR-related 119 prehospital factors such as the presence of a witness, CPR by a bystander, location of the arrest, and 120 initial electrocardiographic rhythms that were obtained before hospital arrival; EMS resuscitation care, 121 including prehospital AED or defibrillation, intravenous adrenaline administration and invasive 122 airway interventions; and CPR-related time variables, such as the response time interval (time from 123 call to arrival of the ambulance at the scene) and scene time interval (time from arrival of the 124 ambulance at the scene to departure from the scene), which were obtained as basic epidemiologic and recorded as hospital-level variables. 17 technique, the location of the resuscitation room, the length of stay in the ED after CPR, post- The primary outcomes were descriptive analyses of the clinical outcomes as well as the changes in 142 CPR strategies used to treat cardiac arrest patients during the outbreak period. Secondary outcomes 143 included before-and-after comparative analyses focusing on the outbreak period and the analogous however, we applied various strategies that were tailored for each hospital. Fig. 2 reveals an overview 180 of the changes in the resuscitation techniques that were introduced in stages. In Phase I, there was no 181 provision for back-up equipment that would prevent the rapid increase of confirmed or suspected 182 COVID-19 patients, and no provisions had been made for vacancies due to the need for self-isolation 183 by medical staff in order to prevent the spread of infectious diseases in hospitals. As such, we 184 experienced closing of EDs for 48 h or more. In Phase II, the PPE levels increased as adequate levels 185 of protective equipment were supplied (Table 2) , although 26% of EDs were still performing CPR in 186 the resuscitation room inside the hospital area. Temporary ED shutdowns continued during this period.

In Phase III, all emergency centers (except one introduced independent sector in ED) performed 188 resuscitation outside the main hospital area in order to avoid the need for future shutdowns. During 189 this period, there were no complete shutdowns of any of the EDs, and only temporary resuscitation 190 unit closures occurred for periods of 18 h only. Fortunately, we experienced no direct infection of 191 healthcare personnel during any of the resuscitation events that occurred during the study period.

During the observation period, the data from a total of 189 patients with EMS-treated adult OHCA 194 were analyzed, with 171 patients who were treated at the six EMCs. The short-term survival outcomes, 195 including ROSC and survival to discharge rates were 22.8% and 4.7%, respectively (Table 1 ). The 196 survival prognosis based on each initial ECG rhythm is shown in Fig. 1 . 197 Survival outcomes during the COVID-19 outbreak were significantly decreased compared to 198 the same period in 2018 (Fig. 3) . After adjustment for patient-and community-associated variables, 199 the adjusted OR and 95% CI for survival to discharge and favourable neurologic outcomes were 0.51 200 (0.25-0.97) and 0.45 (0.21-1.07), respectively, compared with the 2018 historical patient cohort.

During the COVID-19 epidemic outbreak, we changed the procedure for standard CPR as performed 204 on patients who experience OHCA. As we needed to maintain a high suspicion of infectivity, the level 205 of PPE used was raised for those participating in CPR. The most important implementation strategy 206 was the introduction of an isolated resuscitation unit within an area that was separated from the ED.

As a result of this intervention, frequent ED closure as observed in the early stages of the epidemic 208 was dramatically reduced. However, the survival outcomes deteriorated during the COVID-19 209 outbreak.

The interim CPR guidelines published by the AHA and ERC as well as the KCDC that were during CPR were based on results obtained during the SARS and MERS epidemics. 4, 19, 20 It is also 218 critical to recognise that there is a very high rate of asymptomatic carriers of SARS-CoV-2 24, 25 ; the 219 rate of virus transmission has far exceeded that of previous virus pathogens and has already spread 220 worldwide. 26 Accordingly, we urgently needed to make changes to the level of protective equipment 221 and standard CPR strategies used during resuscitation events.

As we progressed to Phase III, it was necessary to set up an isolated resuscitation unit that 223 functioned independently of the existing space in the hospital in order to reduce ED closures.

Currently, ED regulations in Korea are designated by the Emergency Medical Service Act. 27 Almost 225 resuscitation areas are located inside the ED, at a site near to the entrance for easy ambulance access. 226 We were quite dismayed to find that, until the isolated areas were available, some OHCA patients 227 were unable to enter the resuscitation room inside the ED and inside the hospital to protect the ED.

We realised that there was a significant knowledge gap with respect to our desire to provide high-230 quality CPR and likewise our concerns regarding preventing of in-hospital contamination by COVID-231 19. Finally, five EMCs (all except one independent sector in ED), became capable of operating a 232 resuscitation room with a mobile intensive care unit or a negative pressure isolation unit. Over the 233 course of 2 weeks, independent isolated CPR areas specialised for individual hospitals were set up; 234 this became a decisive factor in our efforts to reduce or eliminate ED shutdowns after treatment of 235 patients who present as OHCA.

With respect to our additional findings, we determined whether the COVID-19 epidemic 237 crisis had an impact on survival of OHCA patients using a before-and-after analysis. We note that 238 survival after OHCA during the epidemic period was lower than in 2018 While our findings indicate 239 that increasing the level of PPE and performing CPR in an independent unit ultimately prevented the 240 loss of emergency medical resources during early phase of COVID-19 outbreak, we do note the 241 significantly lower overall survival during the epidemic period. Additional research is needed in order 242 to generate a better understanding of this outcome. Although this low survival rate may be a direct 243 effect of COVID-19 infection itself, we also need to consider the possibilities of significant delays in 244 EMS transfer time in the prehospital setting or at the scene of the primary event. We were unable to 245 describe the reasons behind differential survival and the potential negative impact of our interventions 246 with respect to the performance of high-quality CPR; the pandemic has most likely changed the risk-247 benefit balance for CPR. 5 9, 10 248 Our study has some limitations. First, it is difficult to generalize our findings because each 249 country, community and hospital maintains different resources. Second, during the study period, only 250 one medical physician was infected at an emergency centre during a physical examination; however, 251 he was not providing CPR. As such, the new and enhanced PPE strategy can be viewed as excessive 252 by some communities or by individual regions or countries. However, given the current global 253 epidemic, we recognise that CPR involves emergency procedures associated with a high risk of infection and typically no information regarding a given patient's COVID-19 status. Furthermore, 255 upon identifying a patient as SARS-CoV-2-positive, EDs are often forced to close for extended 256 periods of time. Third, the observation period of this study was 2 months; as such, the impact on long-257 term survival outcomes, which are among the most important for OHCA research, have not been fully 258 considered. We will continue to conduct further studies on this subject, including those focused on 259 long-term outcomes. As a final point, the lower survival rate may be due to a lower quality of 

Expert recommendations for tracheal

occurrence of the postmortem reverse transcription polymerase chain reaction (RT-PCR) COVID-19 test in out-of-hospital cardiac arrest patients.

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☒The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: none