Impact of the COVID-19 pandemic on Canadian emergency medical system management of out-of-hospital cardiac arrest: A retrospective cohort study

AIM

We sought to describe the impact of the COVID-19 pandemic on the care provided by Canadian emergency medical system (EMS) clinicians to patients suffering out of hospital cardiac arrest (OHCA), and whether any observed changes persisted beyond the initial phase of the pandemic.

METHODS

We analysed cases of adult, non-traumatic, OHCA from the Canadian Resuscitation Outcome Consortium (CanROC) registry who were treated between January 27th, 2018, and December 31st, 2021. We used adjusted regression models and interrupted time series analysis to examine the impact of the COVID-19 pandemic (January 27th, 2020 - December 31st, 2021)on the care provided to patients with OHCA by EMS clinicians.

RESULTS

There were 12,947 cases of OHCA recorded in the CanROC registry in the pre-COVID-19 period and 17,488 during the COVID-19 period. We observed a reduction in the cumulative number of defibrillations provided by EMS (aRR 0.91, 95% CI 0.89 - 0.93, p < 0.01), a reduction in the odds of attempts at intubation (aOR 0.33, 95% CI 0.31 - 0.34, p < 0.01), higher rates of supraglottic airway use (aOR 1.23, 95% CI 1.16-1.30, p < 0.01), a reduction in vascular access (aOR for intravenous access 0.84, 95% CI 0.79 - 0.89, p < 0.01; aOR for intraosseous access 0.89, 95% CI 0.82 - 0.96, p < 0.01), a reduction in the odds of epinephrine administration (aOR 0.89, 95% CI 0.85 - 0.94, p < 0.01), and higher odds of resuscitation termination on scene (aOR 1.38, 95% CI 1.31 - 1.46, p < 0.01). Delays to initiation of chest compressions (2 min. vs. 3 min., p < 0.01), intubation (16 min. vs. 19 min., p = 0.01), and epinephrine administration (11 min. vs. 13 min., p < 0.01) were observed, whilst supraglottic airways were inserted earlier (11 min. vs. 10 min., p < 0.01).

CONCLUSION

The COVID-19 pandemic was associated with substantial changes in EMS management of OHCA. EMS leaders should consider these findings to optimise current OHCA management and prepare for future pandemics.

One-year survival after out-of- hospital cardiac arrest: Sex-based survival analysis in a Canadian population

Objective

We investigated sex differences in 1-year survival in a cohort of patients who survived out-of-hospital cardiac arrest (OHCA) to hospital discharge. We hypothesized that female sex is associated with higher 1-year posthospital discharge survival.

Methods

A retrospective analysis of linked data (2011-2017) from clinical databases in British Columbia (BC) was conducted. We used Kaplan-Meier curves, stratified by sex, to display survival up to 1-year, and the log-rank test to test for significant sex differences. This was followed by multivariable Cox proportional hazards analysis to investigate the association between sex and 1-year mortality. The multivariable analysis adjusted for variables known to be associated with survival, including variables related to OHCA characteristics, comorbidities, medical diagnoses, and in-hospital interventions.

Results

We included 1278 hospital-discharge survivors; 284 (22.2%) were female. Females had a lower proportion of OHCA occurring in public locations (25.7% vs. 44.0%, P < 0.001), a lower proportion with a shockable rhythm (57.7% vs. 77.4%, P < 0.001), and fewer hospital-based acute coronary diagnoses and interventions. One-year survival for females and males was 90.5% and 92.4%, respectively (log-rank P = 0.31). Unadjusted (hazard ratio [HR] males vs. females 0.80, 95% confidence interval [CI] 0.51-1.24, P = 0.31) and adjusted (HR males vs. females 1.14, 95% CI 0.72-1.81, P = 0.57) models did not detect differences in 1-year survival by sex.

Conclusion

Females have relatively unfavorable prehospital characteristics in OHCA and fewer hospital-based acute coronary diagnoses and interventions. However, among survivors to hospital discharge, we found no significant difference between males and females in 1-year survival, even after adjustment.

Association between location of out-of-hospital cardiac arrest, on-scene socioeconomic status, and accessibility to public automated defibrillators in two large metropolitan areas in Canada and France

AIM

To compare walking access times to automated external defibrillators (AEDs) between area-level quintiles of socioeconomic status (SES) in out-of-hospital cardiac arrest (OHCA) cases occurring in 2 major urban regions of Canada and France.

METHODS

This was an international, multicenter, retrospective cohort study of adult, non-traumatic OHCA cases in the metropolitan Vancouver (Canada) and Rhône County (France) regions that occurred between 2014 and 2018. We calculated area-level SES for each case, using quintiles of country-specific scores (Q5 = most deprived). We identified AED locations from local registries. The primary outcome was the simulated walking time from the OHCA location to the closest AED (continuous and dichotomized by a 3-minute 1-way threshold). We fit multivariate models to analyze the association between OHCA-to-AED walking time and outcomes (Q5 vs others).

RESULTS

A total of 6,187 and 3,239 cases were included from the Metro Vancouver and Rhône County areas, respectively. In Metro Vancouver Q5 areas (vs Q1-Q4), areas, AEDs were farther from (79 % over 400 m from case vs 67 %, p < 0.001) and required longer walking times to (97 % above 3 min vs 91 %, p < 0.001) cases. In Rhône Q5 areas, AEDs were closer than in other areas (43 % over 400 m from case vs 50 %, p = 0.01), yet similarly poorly accessible (85 % above 3 min vs 86 %, p = 0.79). In multivariate models, AED access time ≥ 3 min was associated with decreased odds of survival at hospital discharge in Metro Vancouver (odds ratio 0.41, 95 % CI [0.23-0.74], p = 0.003).

CONCLUSIONS

Accessibility of public AEDs was globally poor in Metro Vancouver and Rhône, and even poorer in Metro Vancouver's socioeconomically deprived areas.

Workplace violence against emergency health care workers: What Strategies do Workers use?

Background

Workplace violence by patients and bystanders against health care workers, is a major problem, for workers, organizations, patients, and society. It is estimated to affect up to 95% of health care workers. Emergency health care workers experience very high levels of workplace violence, with one study finding that paramedics had nearly triple the odds of experiencing physical and verbal violence.

Many interventions have been developed, ranging from zero-tolerance approaches to engaging with the violent perpetrator. Unfortunately, as a recent Cochrane review showed, there is no evidence that any of these interventions work in reducing or minimizing violence.

To design better interventions to prevent and minimize workplace violence, more information is needed on those strategies emergency health care workers currently use to prevent or minimize violence.

The objective of the study was to identify and discuss strategies used by prehospital emergency health care workers, in response to violence and aggression from patients and bystanders. Mapping the strategies used and their perceived usefulness will inform the development of tailored interventions to reduce the risk of serious harm to health care workers.

In this study the following research questions were addressed: (1) What strategies do prehospital emergency health care workers utilize against workplace violence from patients or bystanders? (2) What is their experience with these strategies?

Methods

Five focus groups with paramedics and dispatchers were held at different urban and rural locations in Canada. The focus group responses were transcribed verbatim and analyzed using thematic analysis.

Results

It became apparent that emergency healthcare workers use a variety of strategies when dealing with violent patients or bystanders. Most strategies, other than generic de-escalation techniques, reflect a reliance on the systems the workers work with and within.

Conclusion

The study results support the move away from focusing on the individual worker, who is the victim, to a systems-based approach to help reduce and minimize violence against health care workers. For this to be effective, system-based strategies need to be implemented and supported in healthcare organizations and legitimized through professional bodies, unions, public policies, and regulations.

Utilization and cost-effectiveness of school and community center AED deployment models in Canadian cities

BACKGROUND

The optimal locations and cost-effectiveness of placing automated external defibrillators(AEDs) for out-of-hospital cardiac arrest(OHCAs) in urban residential neighbourhoods are unclear.

METHODS

We used prospectively collected data from 2016 to 2018 from the British Columbia OHCA Registry to examine the utilization and cost-effectiveness of hypothetical AED deployment in municipalities with a population of over 100 000. We geo-plotted OHCA events using seven hypothetical deployment models where AEDs were placed at the exteriors of public schools and community centers and fetched by bystanders. We calculated the "radius of effectiveness" around each AED within which it could be retrieved and applied to an individual prior to EMS arrival, comparing automobile and pedestrian-based retrieval modes. For each deployment model, we estimated the number of OHCAs within the "radius of effectiveness".

RESULTS

We included 4017 OHCAs from ten urban municipalities. The estimated radius of effectiveness around each AED was 625 m for automobile and 240m for pedestrian retrieval. With AEDs placed outside each school and community center, 2567(64%) and 605(15%) of OHCAs fell within the radii of effectiveness for automobile and pedestrian retrieval, respectively. For each AED, there was an average of 1.20-2.66 and 0.25-0.61 in-range OHCAs per year for automobile retrieval and pedestrian retrieval, respectively, depending on the deployment model. All of our proposed surpassed the cost-effectiveness threshold of 0.125 OHCA/AED/year provided >5.3-11.6% in-range AEDs were brought-to-scene.

CONCLUSIONS

The systematic deployment of AEDs at schools and community centers in urban neighbourhoods may result in increased application and be a cost-effective public health intervention.

Collaborative Heart Attack Management Program (CHAMP): use of prehospital thrombolytics to improve timeliness of STEMI management in British Columbia

Coronary artery disease is the second leading cause of death in Canada. Time to treatment in ST-elevation myocardial infarction (STEMI) is directly related to morbidity and mortality. Thrombolysis is the primary treatment for STEMI in many regions of Canada because of prolonged transport times to percutaneous coronary intervention-capable centres. To reduce time from first medical contact (FMC) to thrombolysis, some emergency medical services (EMS) systems have implemented prehospital thrombolysis (PHT). PHT is not a novel concept and has a strong evidence base showing reduced mortality.

Here, we describe a quality improvement initiative to decrease time from FMC to thrombolysis using PHT and aim to describe our methods and challenges during implementation. We used a quality improvement framework to collaborate with hospitals, EMS, cardiology, emergency medicine and other stakeholders during implementation. We trained advanced care paramedics to administer thrombolysis in STEMI with remote cardiologist support and aimed to achieve a guideline-recommended median FMC to needle time of <30 min in 80% of patients.

Overall, we reduced our median FMC to needle time by 70%. Our baseline patients undergoing in-hospital thrombolysis had a median time of 84 min (IQR 62–116 min), while patients after implementation of PHT had a median time of 25 min (IQR 23–39 min). Patients treated within the guideline-recommended time from FMC to needle of <30 min increased from 0% at baseline to 61% with PHT. Return on investment analysis showed $2.80 saved in acute care costs for every $1.00 spent on the intervention.

While we did not achieve our goal of 80% compliance with FMC to needle time of <30 min, our results show that the intervention substantially reduced the FMC to needle time and overall cost. We plan to continue with ongoing implementation of PHT through expansion to other communities in our province.

PP41 British columbia emergency health services assess, see treat and refer palliative clinical pathway

Background/Research Objectives

Paramedic services have experienced a steadily increasing demand from palliative patients accessing 911 during times of acute crisis, and not wishing subsequent conveyance to ED. Early data indicates that many of these patients are NOT already connected to palliative care teams.

To address this demand and to connect patients to care, BCEHS introduced the Assess, See, Treat and Refer (ASTAR)-Palliative Clinical Pathway. Objectives are to reduce patient conveyance to ED, reduce hospitalizations and improve patient care through referral after non-conveyance.

Intervention

Paramedic activation of the ASTaR Palliative Clinical Pathway results in referral of non-conveyed palliative patients to local Home and Community Care teams and BCEHS paramedics. The referral occurs within 1-6 hours of paramedic contact and follow up occurs over the next 24-48 hours by telephone. This referral action provides safe, effective, patient-centred care for non-conveyed patients, and also fills a gap for connecting patients to local palliative care teams.

Impact

A retrospective case review of 183 cases was conducted. Symptom improvement was achieved in 70% of cases, the ED non-conveyance rate was 19%, and the time on task when palliative patients were treated at home and not conveyed was 37% less (52 minutes) than if palliative patients were transported (82 minutes). All 183 patients were connected to either the local home and community care team or BCEHS Rural Advanced Care Community Paramedics (RACCP).

Lessons Learned

Palliative patients frequently call 911 for help during acute crisis events and many of these patients do not wish conveyance to ED. The introduction of the ASTaR palliative clinical pathway provided safety netting and referral to appropriate care teams.

Multi-centre implementation of an Educational program to improve the Cardiac Arrest diagnostic accuracy of ambulance Telecommunicators and survival outcomes for sudden cardiac arrest victims: the EduCATe study design and methodology

Background

Sudden cardiac death remains a leading cause of mortality in Canada, resulting in more than 35,000 deaths annually. Most cardiac arrest victims collapse in their own home (85% of the time) and 50% are witnessed by a family member or bystander. Survivors have a quality of life similar to the general population, but the overall survival rate for out-of-hospital cardiac arrest (OHCA) rarely exceeds 8%. Victims are almost four times more likely to survive when receiving bystander CPR, but bystander CPR rates have remained low in Canada over the past decade, not exceeding 15–25% until recently. Telecommunication-assisted CPR instructions have been shown to significantly increase bystander CPR rates, but agonal breathing may be misinterpreted as a sign of life by 9–1-1 callers and telecommunicators, and is responsible for as much as 50% of missed OHCA diagnoses.

We sought to improve the ability and speed with which ambulance telecommunicators can recognize OHCA over the phone, initiate timely CPR instructions, and improve survival.

Methods

In this multi-center national study, we will implement and evaluate an educational program developed for ambulance telecommunicators using a multiple baseline interrupted time-series design. We will compare outcomes 12 months before and after the implementation of a 20-min theory-based educational video addressing barriers to recognition of OHCA while in the presence of agonal breathing. Participating Canadian sites demonstrated prior ability to collect standardized data on OHCA. Data will be collected from eligible 9–1-1 recordings, paramedic documentation and hospital medical records. Eligible cases will include suspected or confirmed OHCA of presumed cardiac origin in patients of any age with attempted resuscitation.

Discussion

The ability of telecommunication-assisted CPR instructions to improve bystander CPR and survival rates for OHCA victims is undeniable. The ability of telecommunicators to recognize OHCA over the phone is unequivocally impeded by relative lack of training on agonal breathing, and reluctance to initiate CPR instructions when in doubt. Our pilot data suggests the potential impact of this project will be to increase absolute OHCA recognition and bystander CPR rates by at least 10%, and absolute out-of-hospital cardiac arrest survival by 5% or more.

Trial registration

Prospectively registered on March 28, 2019 at ClinicalTrials.gov identifier: NCT03894059.

Canadian paramedic experience with intramuscular ketamine for extreme agitation: A quality improvement initiative

BackgroundThere are no published reports in Canada examining paramedic use of ketamine for highly agitated patients or excited delirium syndrome. We employed a Plan, Do, Study, Act (PDSA) quality improvement approach to evaluate the safety and effectiveness of advanced care paramedic administered intramuscular (IM) ketamine for patients with extreme agitation in the out-of-hospital setting.MethodsData were prospectively collected from July 2018 to January 2019 when advanced care paramedics with specific training administered IM ketamine as an alternative to midazolam. Paramedics used a clinical audit form to document the ketamine dose, patient response on the Richmond Agitation Sedation Scale (RASS) at time intervals, adverse effects, and any airway management interventions they performed. ResultsThirty-three patients received either 4 mg/kg or 5 mg/kg of ketamine. Combining data for both doses, the median change in RASS score at 5 minutes post-ketamine was 3 (range 0 to 8) and statistically significant for each dose. There were seven cases (21%) with reported adverse effects including SpO2 <90% (3/7), hypersalivation (3/7), trismus or teeth grinding (2/7), muscular rigidity (1/7) and laryngospasm (1/7). Statistical analysis confirmed that the incidence of adverse events was not dose dependent. Basic airway management was performed in one-third of all cases.ConclusionWe piloted the implementation of ketamine for sedation in our paramedic system by employing a PDSA cycle. Ketamine 5 mg/kg IM provided effective control of acutely agitated patients with adequate sedation at 5 minutes post-delivery. Any adverse events that occurred as a result of IM ketamine were readily managed with basic airway management interventions.

A new microcannula for injections in rat brains without disturbing social interactions

A new cannula system is presented that allows intracerebral microinjections of neuroactive substances in freely moving rats in a social environment. By connecting a microcannula to a freely rotating stainless steel spring, small (0.2 microliter) injections can be made without disturbing the ongoing social interaction. This microinjection system can be used for instantaneous injections, but can also be used for microinfusions during a considerable longer period of time.

[Continuous inflation of a leaking cuff of an intubation tube]

Perforation of the cuff of the endotracheal tube peroperatively is a very serious problem, especially when it occurs in a patient prone on an orthopaedic table. This is even more dramatic when the patient is not breathing spontaneously and he cannot be turned over to be reintubated. Given the unusual character of this situation, an apparatus has been designed to keep the cuff inflated permanently. It was a circuit consisting of a manual pressure valve, flexible tubing, a peripheral catheter and the cuff supply tube. The gas used was medical air at 3 bar pressure. This method proved perfectly safe and efficient, the operation having continued without reintubation.

[Zona after spinal anesthesia: coincidence or consequence?]

A case is reported of a herpes zoster infection occurring a few days after spinal anaesthesia in a man with severe cardiac disease who had undergone transurethral endoscopic resection of a prostatic epithelioma. The question as to whether there was a relationship between the two events had to be asked, all the more so as the rash seemed to be centered on the puncture wound. Others factors involved may have been the effect of anaesthesia on the body's defence mechanisms, the use of prophylactic antibiotics and the neoplasm.

[Hemorrhagic delivery in a full-term abdominal pregnancy with a live infant]

This is a new case report of a primary abdominal pregnancy with a full-term live baby in a 26 yr old women. The diagnosis was only made at laparotomy. The premature placental separation was followed by massive haemorrhage. Over a period of five days, the patient required a transfusion of 139 blood units and nine surgical explorations before control of the bleeding site could be obtained. Control of the haemorrhage could only be obtained with massive transfusions of fresh platelets and biological monitoring of coagulation by specialized laboratories. This case confirmed the diagnostic difficulties and the need to leave the placenta in situ until control of bleeding sites can be obtained.

[Determination of methylmethacrylate in expired gases after hip prosthesis cementing]

Total hip replacement using methylmethacrylate can induce early intraoperative hypoxaemia caused, according to some authors, by alveolar gas dilution by acrylic monomer vapour. In order to test this hypothesis, expired monomer was measured in ten patients undergoing total hip replacement carried out under narconeuroleptanalgesia. Methylmethacrylate was collected by adsorption on activated charcoal and measured by gas chromatography. The quality of expired monomer was 25 +/- 10 micrograms after cotyloid sealing. It is of 264 +/- 396 micrograms after femoral sealing; the most important excretion took place in the first three minutes, and its total duration may exceed 18 min. A simple calculation showed quite convincingly that the volume of expired monomer vapour was not sufficient to explain the hypoxaemia: impaired arterial oxygenation associated with the use of methylmethacrylate is not due to a dilution technique.

[Surgery and the acquired inhibitor of factor VIII coagulant]

A case is reported of an 80 year old woman with old sarcoidosis and acquired factor VIIIc inhibitor undergoing orthopaedic surgery. This was successfully carried out after she had been given a total of 48,420 units of factor VIII concentrate: there were no haemorrhagic complications. The main pathological states in which acquired factor VIIIc inhibitor may be found are related: principal treatments available nowadays are discussed: immunosuppressors, human factor VIII, animal factor VIII, prothrombin complex concentrate, plasma exchange.

[Potentiation of a vitamin K antagonist by a pefloxacin-rifampicin combination]

The combination of a new quinolone, pefloxacin, with rifampicin seemed of interest in the treatment of staphylococcal osteitis. Interactions of a coumarin anticoagulant (acenocoumarol) and several antibiotics were well known, mostly resulting in a decrease of the anticoagulant activity. A new interaction of this anticoagulant drug with the pefloxacin-rifampicin combination is described which gave an increase in the anticoagulant activity.