CO-aVoID: coronavirus outbreak affecting variability of presentations to a local emergency department.

BACKGROUND: The impact of the COVID-19 pandemic on public health, specifically on patients presenting to the emergency department (ED) with non-COVID-related diseases, remains largely undocumented. OBJECTIVE: This study explored how overall rates of presentations to the emergency department were impacted immediately after the declaration of the COVID-19 pandemic, and specifically how key presenting symptoms representing emergency, standard and low-acuity conditions were impacted. METHODS: A sequential modified Delphi survey and cross-sectional analysis of administrative census data from a tertiary care center in New Brunswick, Canada, were performed. Details of ED presentations for emergency, standard and low-acuity conditions from February 1 to April 30, 2020, were compared to data from previous years. RESULTS: There was a significant decrease in the number of patients visiting the ED with emergency, standard and low-acuity complaints immediately after March 13, 2020, compared to 2019. The proportion of females and males remained similar, with a median age of 48 years in 2020 and 44 years in 2019. Total presentation patterns to the ED (registrations, admissions to hospital and left without being seen numbers) decreased, compared to previous years. CONCLUSIONS: We report a predictable decrease in patient visits to the ED with minor, non-life-threatening conditions during a pandemic. However, we also report a decrease in presentations for emergency and standard conditions. Improved messaging highlighting the need to seek help for "true" emergencies, while providing non-ED options for minor, non-life-threatening conditions, may be helpful under normal circumstances and during future pandemics.

RéSUMé: CONTEXTE: L'impact de la pandémie COVID-19 sur la santé publique, en particulier sur les patients se présentant aux services d'urgence (SU) avec des maladies non liées à la COVID, demeure en grande partie non documenté. OBJECTIF: Cette étude a exploré la façon dont les taux globaux de présentations au service des urgences ont été touchés immédiatement après la déclaration de la pandémie de COVID-19, et plus particulièrement la façon dont les principaux symptômes représentant des conditions d'urgence, standard et de faible acuité ont été touchés. MéTHODES: Une enquête Delphi séquentielle modifiée et une analyse transversale des données du recensement administratif provenant d'un centre de soins tertiaires du Nouveau-Brunswick, au Canada, ont été réalisées. Les détails des présentations du SU pour les conditions d'urgence, standard et de faible acuité du 1er février au 30 avril 2020 ont été comparés aux données des années précédentes. RéSULTATS: Il y a eu une diminution significative du nombre de patients se rendant au service d'urgence avec des plaintes d'urgence, standard et de faible gravité immédiatement après le 13 mars 2020, par rapport à 2019. La proportion de femmes et d'hommes est demeurée semblable, avec un âge médian de 48 ans en 2020 et de 44 ans en 2019. Le nombre total de modèles de présentation à l'urgence (inscriptions, admissions à l'hôpital et nombre laissé sans être vu) a diminué par rapport aux années précédentes. CONCLUSIONS: Nous faisons état d'une diminution prévisible des visites de patients aux urgences pour des affections mineures qui ne mettent pas leur vie en danger pendant une pandémie. Toutefois, nous signalons également une diminution des présentations pour les situations d'urgence et les conditions normales. Des messages améliorés soulignant la nécessité de demander de l'aide pour les urgences « réelles ¼, tout en offrant des options non urgentes pour des conditions mineures et qui ne mettent pas la vie en danger peuvent être utiles dans des circonstances normales et lors de futures pandémies.

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.

Does Point of Care Ultrasound Improve Resuscitation Markers in Undifferentiated Hypotension? An International Randomized Controlled Trial From The Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Series.

Introduction Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for patients with undifferentiated hypotension, yet there is a paucity of evidence for any outcome benefit. We undertook an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key clinical outcomes. Here we report on resuscitation markers.  Methods Adult patients presenting to six emergency departments (ED) in Canada and South Africa with undifferentiated hypotension (systolic blood pressure (SBP) <100mmHg or a Shock Index >1.0) were randomized to receive a PoCUS protocol or standard care (control). Reported physiological markers include shock index (SI), and modified early warning score (MEWS), with biochemical markers including venous bicarbonate and lactate, at baseline and four hours.  Results A total of 273 patients were enrolled, with data collected for 270. Baseline characteristics were similar for each group. Improvements in mean values for each marker during initial treatment were similar between groups: Shock Index; mean reduction in Control 0.39, 95% CI 0.34 to 0.44 vs. PoCUS 0.33, 0.29 to 0.38; MEWS, mean reduction in Control 2.56, 2.22 to 2.89 vs. PoCUS 2.91, 2.49 to 3.32; Bicarbonate, mean reduction in Control 2.71 mmol/L, 2.12 to 3.30 mmol/L vs. PoCUS 2.30 mmol/L, 1.75 to 2.84 mmol/L, and venous lactate, mean reduction in Control 1.39 mmol/L, 0.93 to 1.85 mmol/L vs. PoCUS 1.31 mmol/L, 0.88 to 1.74 mmol/L. Conclusion We found no meaningful difference in physiological and biochemical resuscitation markers with or without the use of a PoCUS protocol in the resuscitation of undifferentiated hypotensive ED patients. We are unable to exclude improvements in individual patients or in specific shock types.

Just the Facts: Point-of-care ultrasound in the management of shoulder dislocations.

A 59-year-old man presents with left shoulder pain after falling while playing with his dog at the park. He drove himself to the emergency department (ED). He reports 5/10 pain and has reduced range of motion of the shoulder. His shoulder looks normal on exam and is not squared off. You wonder if he might have a posterior shoulder dislocation.

Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators.

STUDY OBJECTIVE: Point-of-care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED). There is little published evidence for any mortality benefit. We compare the effect of a point-of-care ultrasonography protocol versus standard care without point-of-care ultrasonography for survival and clinical outcomes. METHODS: This international, multicenter, randomized controlled trial recruited from 6 centers in North America and South Africa and included selected hypotensive patients (systolic blood pressure <100 mm Hg or shock index >1) randomized to early point-of-care ultrasonography plus standard care versus standard care without point-of-care ultrasonography. Diagnoses were recorded at 0 and 60 minutes. The primary outcome measure was survival to 30 days or hospital discharge. Secondary outcome measures included initial treatment and investigations, admissions, and length of stay. RESULTS: Follow-up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. We found no important differences between groups for the primary outcome of survival (point-of-care ultrasonography group 104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%; 95% binomial confidence interval [CI] -10.2% to 11.0%), survival in North America (point-of-care ultrasonography group 76 of 89 patients versus standard care 72 of 88 patients; difference 3.6%; CI -8.1% to 15.3%), and survival in South Africa (point-of-care ultrasonography group 28 of 47 patients versus standard care 30 of 46 patients; difference 5.6%; CI -15.2% to 26.0%). There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay. CONCLUSION: To our knowledge, this is the first randomized controlled trial to compare point-of-care ultrasonography to standard care without point-of-care ultrasonography in undifferentiated hypotensive ED patients. We did not find any benefits for survival, length of stay, rates of CT scanning, inotrope use, or fluid administration. The addition of a point-of-care ultrasonography protocol to standard care may not translate into a survival benefit in this group.