How the COVID-19 Epidemic Affected Prehospital Emergency Medical Services in Tehran, Iran

INTRODUCTION

Coronavirus disease 2019 (COVID-19) has substantially impacted the healthcare delivery system in Tehran, Iran. The country's first confirmed positive test for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was on February 18, 2020. Since then, the number of cases has steadily increased in Iran and worldwide. Emergency medical services (EMS) quickly adapted its operations to accommodate a greater number of patients, and it worked to decrease the risk of COVID-19 spread among EMS personnel, given the disease's high transmissibility.

METHODS

We evaluated the chief complaint as well as the pattern and number of EMS calls and dispatches during the 28-day intervals before and after the February 18, 2020, COVID-19 outbreak in Iran.

RESULTS

EMS calls increased from 355,241 in the pre-outbreak period to 1,589,346 in the post-outbreak period, a 347% increase (p<0.001). EMS dispatches rose more modestly from 82,282 to 99,926, a 21% increase (p<0.001). The average time on telephone hold decreased from 10.6 ± 12.7 seconds pre-outbreak to 9.8 ± 11.8 seconds post-outbreak, a 7% decrease (p<0.001). The average length of call also decreased from 1.32 ± 1.42 minutes pre-outbreak to 1.06 ± 1.28 minutes post-outbreak, a 20% decrease (p<0.001). The highest number of daily dispatches occurred during the second and third weeks of the four-week post-outbreak period, peaking at 4557 dispatches/day. After the first reported case of SARS-CoV-2, there were significant increases in chief complaints of fever (211% increase, p<0.001) and respiratory symptoms (245% increase, p<0.001).

CONCLUSION

The number of EMS calls and dispatches in Tehran increased 347% and 20%, respectively, after the outbreak of COVID-19. Despite this, the time on hold for EMS response decreased. The Tehran EMS system accomplished this by increasing personnel hours, expanding call-center resources, and implementing COVID-19-specific training.

Accuracy of the pre-hospital triage tools (qSOFA, NEWS, and PRESEP) in predicting probable COVID-19 patients' outcomes transferred by Emergency Medical Services

BACKGROUND

This study aimed to evaluate the efficiency of pre-hospital triage tools including the qSOFA, NEWS, and PRESEP in determining the prognosis of probable COVID-19 patients.

METHODS

In this diagnostic accuracy study, all probable COVID-19 patients older than 16-year-old who were transferred to the hospital by the Tehran Emergency Medical Services (EMS) during the first month of the pandemic, entered to the study. The scores of qSOFA, NEWS, and PRESEP were calculated using data gathered while providing pre-hospital care. The primary outcome was death; and the secondary outcomes were ICU admission, length of stay in the ICU, and length of hospital stay.

RESULTS

The data of 557 individuals with the mean age of 56.93±18.31 were analyzed of whom 67.5% were males. The area under the ROC curve (AUC) of qSOFA, NEWS, and PRESEP for ICU admission was 0.553, 0.557, and 0.551, respectively. The AUC of qSOFA, NEWS, and PRESEP for death was 0.596, 0.566, and 0.604, respectively. The best obtained cut-off point for qSOFA was a score >0 (the sensitivity and specificity were 25.0 and 85.68%, respectively), for NEWS was a score >2 (the sensitivity and specificity were 83.61 and 32.67%, respectively), and for PRESEP was a score >1 (the sensitivity and specificity were 54.10 and 55.56%, respectively).

CONCLUSION

Based on the findings of the current study, it is likely that the available pre-hospital triage tools (qSOFA, NEWS, and PRESEP) do not have proper efficacy to predict death, ICU admission, and disease severity of COVID-19 patients.

The Geographical Distribution of Probable COVID-19 Patients Transferred by Tehran Emergency Medical Services; a Cross Sectional Study

INTRODUCTION

Mapping of COVID-19 infection in the city can help us know more about how the disease is distributed and spread. This study was conducted to investigate the geographical distribution of probable COVID-19 patients who were transferred to destination hospitals by emergency medical services (EMS) in the first wave of the epidemic, in Tehran, Iran.

METHODS

This cross-sectional study was performed based on recorded missions during the first 3-month period of the pandemic in Tehran, Iran. All probable cases of COVID-19 who were transferred to the hospitals following contact with Tehran EMS during the study period were enrolled. Arc-GIS software was utilized to draw the distribution map of the contact places of the cases.

RESULTS

In this study, the data of 4018 patients were analyzed (60.9% male). The mean age of the patients was 54.1 ± 20.7 years; and the mean age of the patients had increased with time during the studied 3 months (p = 0.003). The average incidence rate of this disease in Tehran during the study period was 4.6 per 10,000 population. Generally, the lowest and highest raw frequencies of Tehran COVID-19 contamination were seen in municipal districts 21 and 4, respectively. The raw frequency of cases during the 3-month study period also showed that the highest number of cases in Tehran occurred in municipal districts 5 and 4, respectively.

CONCLUSION

In the present study, using geographic information systems (GIS), geographical distribution map of COVID-19 in Tehran, Iran, during the first 3 months of the pandemic was drawn.

The effect of prehospital telecardiology on the mortality and morbidity of ST-segment elevated myocardial infarction patients undergoing primary percutaneous coronary intervention: A cross-sectional study

OBJECTIVES

The sooner the primary percutaneous coronary intervention (PPCI) is performed, the better prognosis is expected in patients with acute myocardial infarction. The objective is to evaluate the effect of prehospital triage based on electrocardiogram (ECG) and telecardiology on the mortality and morbidity of ST-segment elevated myocardial infarction (STEMI) patients undergoing PPCI.

METHODS

This cross-sectional study was conducted based on the data extracted from the hospital information system (HIS) of one general hospital, which had the capability of performing PPCI 24 h a day, 7 days a week. All patients with STEMI who undergone PPCI during 1 year, transferred by emergency medical service (EMS) and their data were registered in the HIS were eligible. Besides the baseline characteristics, first medical contact (FMC)-to-balloon time was recorded. Morbidity based on predischarge left ventricular ejection fraction (LVEF) and mortality based on Global Registry of Acute Cardiac Events (GRACE) score were also recorded. Patients who were referred to the hospital by EMS with prehospital ECG and telecardiology were compared with those without prehospital ECG.

RESULTS

Totally, 298 patients with STEMI were enrolled, of whom 183 patients (61.4%) had prehospital ECG (telecardiology), and 115 patients (38.6%) had not. The means of predischarge LVEF of the patients in the first and the second groups were 40.7 ± 10.4 and 40.6 ± 11.2, respectively (P = 0.946). The mean of the probability of 6-month mortality based on GRACE score in the first group was significantly less than that of the second group (P = 0.004). Analyses of multivariable ordinal logistic regression showed that 6-month mortality severity risk in the second group was 1.5 times more than the first group (95% confidence interval 0.8-2.6), although this difference was not statistically significant (P = 0.199).

CONCLUSIONS

It is likely that prehospital telecardiology, with shortening FMC to balloon time result in reducing probability 6-month mortality in STEMI patients who undergone PPCI. However, the process of telecardiology had no effect on predischarge LVEF in the current study.

Antibody Rapid Test Results in Emergency Medical Services Personnel during COVID-19 Pandemic; a Cross Sectional study

INTRODUCTION

Like other infectious diseases, it is expected that COVID-19 will mostly end with the development of neutralizing antibody immunity. This study aimed to evaluate the value of COVID-19 antibody rapid test assessment in emergency medical services (EMS) personnel.

METHODS

This cross-sectional study was conducted in Tehran, Iran from 20th March until 20th May 2020. The results of chest computed tomography (CT) scan, and antibody rapid test were compared in EMS personnel with confirmed COVID-19, as well as symptomatic and asymptomatic ones who had exposure to a probable/confirmed COVID-19 teammate. In symptomatic or asymptomatic individuals who were only IgM-positive, chest CT scan or RT-PCR was recommended.

RESULTS

A total of 243 EMS personnel with the mean age of 36.14±8.70 (range 21 to 59) years took part in this study (87.7% were males). Most of the participants (73.3%) had history of exposure. One hundred sixty-three EMS personnel were tested using either RT-PCR test or chest CT-scan or both, and 78 (47.9%) of them had at least one positive result. Among the participants who had undergone chest CT-scan and/or RT-PCR test (n=163), 78 had positive chest CT-scan and/or RT-PCR test; of these, 18 individuals had negative results for IgM and IgG. The rate of positive IgM and IgG in participants with positive chest CT-scan was 1.6 or 1.3 times more than those with negative chest CT-scan, respectively (p < 0.05). The percentage of positive results for both IgM and IgG in participants having positive RT-PCR test was 1.7 times more than those having negative RT-PCR test (p < 0.05).

CONCLUSION

Rapid antibody test could help in diagnosis of COVID-19 in asymptomatic or symptomatic EMS personnel who did not undergo RT-PCR test or the test was reported as negative. However, its sensitivity could be enhanced through use along with other diagnostic methods.

Changes in COVID-19 IgM and IgG antibodies in emergency medical technicians (EMTs)

INTRODUCTION

Serologic testing can provide a safe and fast approach for assessing SARS-CoV-2 antibodies. These tests can be utilized as a complementary method in diagnosis and patients' follow-up, and can also be helpful in epidemiological studies. This study aimed to describe temporal changes in the incidence of COVID-19 IgM and IgG antibodies in emergency medical technicians (EMTs) within a specified time period.

METHODS

All EMTs working for Tehran Emergency Medical Service (EMS) center during May to September 2020 were eligible for this study. Those EMTs who were suspected/probable/confirmed cases of COVID-19, based on WHO defined criteria and were willing to participate, entered the study. The EMTs underwent serology testing four weeks after the occurrence of exposure (in suspected cases) or onset of their symptoms (in probable/confirmed cases). Cases were further confirmed by RT-PCR and/or lung CT, and antibody testing was performed for the second and third time with 12-week intervals. Finger-stick blood sampling was utilized for the specimen collection in three different phases. Samples were then analyzed by a commercial immunochromatography-based kit for qualitative measurement of serum IgM and IgG antibodies against the COVID-19 S-protein antigen.

RESULTS

Two hundred eighty-four participants met the inclusion criteria; their mean age was 35.9 (SD = 7.6) years and consisted of 244 (85.9%) males. COVID-19 was confirmed in 169 out of 284 participants. Subsequently, 142 and 122 participants were included in phases 2 and 3 of the study, respectively. The number of seronegative patients exceeded seropositive ones in all three phases. At baseline, 162 (57%) patients were seronegative, 27 (9.5%) were only positive for IgG, 3 (1.1%) were only positive for IgM, and 92 (32.4%) were positive for both antibodies; Seventy-eight (54.9%) were seronegative, and 31 (21.8%) were positive for both antibodies in the second phase; These values were 85 (69.6%) and 8 (6.6%) for the third phase, respectively. Among the people who were positive IgG in the first phase (80 people), 56.3% were still positive in the second phase and 27.5% in both subsequent phases.

CONCLUSION

The results of our study show that there is a significant reduction in COVID-19 antibody seropositivity over time.

Comparing the prehospital NEWS with in-hospital ESI in predicting 30-day severe outcomes in emergency patients

BACKGROUND

In Iran, the emergency departments (EDs) have largely adopted the emergency severity index (ESI) to prioritize the emergency patients, however emergency medical services (EMS) mainly triage the patients based on the paramedics' gestalt. The National Early Warning Score (NEWS) is a recommended prehospital triage in the UK. We aimed to compare prehospital NEWS and ED ESI for predicting severe outcomes in emergency patients.

METHODS

An observational study was conducted in a university-affiliated ED between January and April 2021. Adult patients who arrived in the ED by EMS were included. EMS providers calculated the patients' NEWS upon arriving on the scene using an Android NEWS application. In the ED, triage nurses utilized the ESI algorithm to prioritize patients with higher clinical risk. Then, Research nurses recorded patients' 30-day severe outcomes (death or ICU admission). Finally, The prognostic properties of ESI and NEWS were evaluated.

RESULTS

One thousand forty-eight cases were included in the final analysis, of which 29 (2.7%) patients experienced severe outcomes. The difference between the prehospital NEWS and ED ESI in predicting severe outcomes was not statistically significant (AUC = 0.825, 95% CI: 0.74-0.91 and 0.897, 95% CI, 0.83-0.95, for prehospital NEWS and ESI, respectively).

CONCLUSION

Our findings indicated that prehospital NEWS compares favorably with ED ESI in predicting 30-day severe outcomes in emergency patients.

Out-of-hospital cardiac arrest diagnosis by emergency medical dispatchers; a diagnostic accuracy study

IntroductionThis study was conducted to assess the diagnostic accuracy of out-of-hospital cardiac arrest (OHCA) made by emergency medical dispatchers (EMDs) in Tehran, Iran.MethodsPatients more than 18 years of age who were suspected of having an OHCA by EMDs or emergency medical service (EMS) technicians at the patient’s bedside were eligible for inclusion in the study. The initial diagnosis, results of primary assessment and monitoring, and the final outcome of the mission (gold standard) were all recorded. Related archived audios were extracted from the system and listened to by the researcher (MM). Other required data were extracted from EMS mission forms and recorded in a pre-prepared checklist. After statistical analysis the accuracy was calculated.ResultsA total of 4732 patients were included (mean age 68.1 ± 19.7 years) of which 2830 (59.8%) were men. These cases reported by 173 EMDs that the EMDs mean age was 27.7±3.7 years, and they were all women. Cardiac arrest prevalence based on final diagnosis (gold standard) was 37.4% (95% CI: 36.0–38.8). Sensitivity and specificity of OHCA diagnosis by EMDs was 78.6% and 92.4%, respectively. Positive predictive value, negative predictive value and accuracy were 86.1% (95% CI: 84.5–87.6), 87.8% (95% CI: 86.8–88.8) and 87.3% (95% CI: 86.3–88.2), respectively. The sensitivity of diagnosis increased with increasing EMD’s work experience and also increasing the number of reported OHCA cases.ConclusionBased on the results, accuracy of OHCA diagnosis by EMDs was almost 87%. It is likely that more experienced EMDs or those with more experience diagnosing OHCA are better at recognising OHCA.

Efficacy of rescue blanket versus conventional blanket in terms of preventing accidental hypothermia during patient transfer by emergency medical service: a randomized clinical trial

Objective: This study aimed to compare the efficacy of rescue blankets with conventional blankets in terms of preventing hypothermia in the pre-hospital setting. Methods: In this randomized clinical trial, patients older than 18 years old with Cold Discomfort Scale (CDS) > 2, and those who were transferred to the emergency department (ED) by emergency medical service entered the study. Patients were randomly divided into two groups based on the type of transfer. In this regard, one group was transferred with rescue blankets and the other group was transferred with conventional blankets. The tympanic temperature in patients and CDS were recorded before the use of blanket (primary) and at the time of arrival in the ED (secondary). Results: Finally, 161 patients with the mean age of 45.31±19.8 years were included (63.4% were male). Totally, 88 cases (54.7%) were transferred with rescue blankets and 73 cases (45.3%) with conventional blankets. The mean of the primary tympanic temperatures in the rescue and conventional blanket groups were 36.20±0.84°C and 36.34±0.65°C, respectively (P=0.23). The mean of the primary CDS in rescue and conventional blanket groups were 6.55±1.95 and 5.89±2.29, respectively (P=0.05). Also, the mean of the secondary tympanic temperatures in the rescue and conventional blanket groups were 36.59±0.47°C and 36.76±0.48 °C, respectively (P=0.03). Besides, the mean of the secondary CDS in the rescue and conventional blanket groups were 2.64±2.80 and 2.41±1.29, respectively (P=0.48). Conclusion: According to the results, there is no significant difference in the tympanic temperature and CDS of the patients transferred with the rescue blanket compared with the conventional blanket.

Persistent/late complications of COVID-19 in affected emergency medical technicians; a case series and brief literature review

Background:

The present study aimed to assess the prevalence of persistent/late complications after recovery from the acute phase of COVID-19 in emergency medical technicians (EMTs).

Methods:

This is a cross-sectional case-series study performed during the last quarter of 2020 in Tehran, Iran. All EMTs who had been diagnosed with COVID-19 were eligible. The researcher contacted the EMTs via telephone to determine any complications following their recovery. Those who suffered from any complication were referred to an internal specialist physician for a detailed history and physical examination. Based on the physician’s opinion, some paraclinical or clinical evaluations were requested to be performed.

Results:

Four hundred thirty-one confirmed cases and two deaths due to this disease were registered among the Tehran EMS center’s EMTs during the study period. Two hundred thirty-eight EMTs were contacted, and 22.7% of them had at least one persistent/late complication following recovery of the acute phase of COVID-19; of whom, 28 EMTs were visited by an internist and completed the tests. The final participants mentioned seventy-five persistent/late complications. Only one EMT had a residual lesion among those who underwent lung CT scans. There were also some pathological findings in the echocardiographic examination and spirometry.

Conclusion:

Our study showed that persistent/late-onset complications could likely accompany by COVID-19.

The Role of Pre-Hospital Telecardiology in Reducing the Coronary Reperfusion Time; a Brief Report

INTRODUCTION

Telecardiology is defined as using telecommunication for remote treatment of cardiac patients. This study aimed to assess the role of pre-hospital triage via telecardiology on coronary reperfusion time of patients with ST segment elevation myocardial infarction (STEMI).

METHODS

This cross-sectional study was conducted from September, 2015 to January, 2018 in six academic referral hospitals, Tehran, Iran. Studied patients were divided into two groups of percutaneous coronary intervention (PCI) following telecardiology or PCI following emergency department (ED) diagnosis of STEMI and time to reperfusion was compared between them.

RESULTS

1205 patients with the mean age of 58.99 ± 12.33 (19-95) years entered the study (82.7% male). 841 (69.8%) cases were transferred directly to the Cath-Lab following telecardiology and 364 (30.2%) cases were first admitted to the ED. There was no significant difference between the groups regarding mean age (p = 0.082) and gender (p = 0.882) of participants. Symptom-to-device interval time in patients who underwent PCI following telecardiology was significantly lower (p < 0.001); however, the difference was not significant in the first medical contact (FMC)-to-device interval time (p = 0.268).

CONCLUSIONS

It is likely that the use of telecardiology in pre-hospital triage plays an important role in reducing time to PCI for patients with STEMI.

A report on the experience of using ultrasound by emergency medical technicians in dealing with trauma patients in pre-hospital setting: a pilot study

Objective: The current study was performed to provide real-time bedside ultrasonography for emergency medical technicians (EMTs) and assess the advantages and disadvantages of its application in dealing with trauma patients in pre-hospital setting from their viewpoints. Methods: This semi-experimental study was conducted in Tehran, Iran. Twenty EMTs were selected purposefully and underwent a training program. Thereafter, they were asked to perform extended focused assessment with sonography in trauma (eFAST) using a handheld ultrasound device on trauma patients, and also filled a questionnaire prepared (in four components including C1: coherence, C2: cognitive participation, C3: collective action, and C4: reflexive monitoring) based on the normalization process theory (NPT). Results: All 20 participants were men and their average age was 37.8 years (SD = 4.7). For C1, the median total score was 10.5 out of a score of 4-20; For C2, the median score was 6 out of 3-15; For C3, the median total score was 18 out of a score of 6-30; and for C4, the median total score was 11 out of a score of 5-25. Conclusion: Overall, it seems that EMTs welcomed using ultrasonography in dealing with trauma patients in pre-hospital setting. Although they thought that it might somewhat lead to an increase in their workload; but they believed that sufficient training was not provided for them yet. The EMTs were uncertain about the viewpoints of the patients and did not know how it could affect patients’ outcome.

The General Public Awareness of Emergency Conditions and the Services Provided by Emergency Medical Services

Objective

Considering the growing use of emergency medical services (EMS), we evaluated the level of public awareness of emergency situations in Iran.

Methods

This cross-sectional study was conducted from August 2021 to January 2023 on Iranian residents in Tehran, who were older than 18 years old. The participants were directed to a URL for an online survey link and asked to select their preferred options for the predetermined scenarios. We divided the participants into three groups: abuse, misuse, and non-use. At least 12 correct answers were required to qualify as acceptable knowledge and practice responses (KP score). Then, the relationship between participants' baseline characteristics and their level of awareness was investigated.

Results

Totally, 3864 people participated in the study, of whom 50.5% were men. The participants' ages ranged from 18 to 90 years old, with a mean age of 40.01±11.30 years. In general, the rate of abuse, misuse, and not-use in at least one scenario was 74.5%, 64%, and 70.4%, respectively. The results of the multivariable regression analysis indicated that female sex (OR=1.29), a higher education level (OR=3.36), a higher income level (OR=1.64), and Turkish ethnicity (OR=1.20) were significantly associated with the correct KP score.

Conclusion

The degree of inappropriate utilization of EMS services in Iran was significant. We found that the proper knowledge regarding the appropriate use of EMS was significantly associated with the participant's level of education, academic field, job, and income.

Persistent/Late-Onset Complications of COVID-19 in General Population: A Cross-Sectional Study in Tehran, Iran

Background

After recovery from acute phase of the COVID-19, some patients suffer from persistent/late-onset complications. The main objective of this study was to investigate the prevalence of such complications in a large scale of COVID-19 patients in Tehran, Iran.

Methods

In this cross-sectional study, those patients who called Tehran emergency medical services center and were visited by the emergency medical technicians from 20 March 2020 until 21 September 2020 and diagnosed as a confirmed COVID-19 case were enrolled. The minimum required sample size was estimated 385 cases, and they were selected randomly. The patients were interviewed by phone at least 4 weeks since initiation of their symptoms. Using a pre-prepared checklist, made by an expert panel who were involved in management of COVID-19 patients, data were collected on the types and duration of the complications, clinical information, and factors which could interfere with developing the complications. All analyses were performed using STATA 16 software. The association of the prevalence of each complication with independent factor was assessed using Chi-square test (or Fisher's exact test) for categorical variable, and the mean difference of numerical variables in the two groups (with and without complication) was assessed using independent t-test. Statistical significance was accepted at P value<0.05.

Results

Four-hundred forty-seven patients participated in the study. Among our total population, 345 (77.2%) patients experienced at least one of the persistent/late-onset complications. Cardiopulmonary and then skin-related symptom categories were reported in 179 (40.0%) and 173 (38.7%) patients, respectively, and were the most prevalent persistent/late-onset complications. The associations of long term persistent/late-onset complications with older ages (P=0.04), female (P<0.001), psychological stress (P=0.01), and inadequate rest after illness (P<0.001) were significant.

Conclusion

The findings of this study indicate that a significant number of patients will experience persistent/late-onset complications, both physically and mentally, after recovering from acute phase of COVID-19. Thus, physicians should have adequate resources and support to care for the patients to help them cope with the condition.