Impact of a COVID-19 code blue protocol on resuscitation care and CPR quality during in-hospital cardiac arrest.

OBJECTIVE: We sought to evaluate the impact of a COVID-19 Code Blue policy on in-hospital cardiac arrest (IHCA) processes of care, cardiopulmonary resuscitation (CPR) quality metrics, and survival to hospital discharge. METHODS: We completed a health record review of consecutive IHCA for which resuscitation was attempted. We report Utstein outcomes and CPR quality metrics 33 months before (July,2017-March,2020) and after (April,2020-December,2022) the implementation of a COVID-19 Code Blue policy requiring all team members to don personal protective equipment including gown, gloves, mask, and eye protection for all IHCA. RESULTS: There were 800 IHCA with the following characteristics (Before n = 396; After n = 404): mean age 66, 62.9% male, 81.3% witnessed, 31.3% in the emergency department, 25.6% cardiac cause, and initial shockable rhythm in 16.7%. Among all 404 patients screened for COVID-19, 25 of 288 available test results before IHCA occurred were positive. Comparing the before and after periods: there were relevant time delays (min:sec) in start of chest compressions (0:17vs.0:37;p = 0.005), team arrival (0:43vs.1:21;p = 0.002), 1st rhythm analysis (1:15vs.3:16;p < 0.0001), 1st epinephrine (3:44vs.4:34;p = 0.02), and airway insertion (8:38vs. 10:18;p = 0.02). Resuscitation duration was similar (18:28vs.19:35;p = 0.34). Exception of peri-shock pause which appeared longer (0:06vs.0:14;p = 0.07), chest compression fraction, rate and depth were identical and good. Factors independently associated with survival were age (adjOR 0.98;p < 0.001), male sex (adjOR 1.51;p = 0.048), witnessed (adjOR 2.35;p = 0.02), shockable rhythm (adjOR 3.31;p < 0.0001), hospital location (p = 0.0002), and COVID-19 period (adjOR 0.68;p = 0.052). CONCLUSIONS: The COVID-19 Code Blue policy was associated with delayed processes of care but similarly good CPR quality. The COVID-19 period appeared associated with decreased survival.

A Randomized Double-Blind Placebo-Control Feasibility Trial of Immunoglobulin Treatment for Prevention of Recurrent Acute Exacerbations of COPD.

BACKGROUND: Observational studies suggest that immunoglobulin treatment may reduce the frequency of acute exacerbations of COPD (AECOPD). OBJECTIVE: To inform the design of a future randomised control trial (RCT) of intravenous immunoglobulin (IVIG) treatment efficacy for AECOPD prevention. METHODS: A pilot RCT was conducted. We recruited patients with COPD hospitalized for AECOPD, or from ambulatory clinics with one severe, or two moderate AECOPD in the previous year regardless of their serum IgG level. Patients were allocated in a 1:1 ratio with balanced randomisation to monthly IVIG or normal saline for 1 year. The primary outcome was feasibility defined as pre-specified accrual, adherence, and follow-up rates. Secondary outcomes included safety, tolerance, AECOPD rates, time to first AECOPD, quality of life, and healthcare costs. RESULTS: Seventy patients were randomized (37 female; mean age 67.7; mean FEV1 35.1%). Recruitment averaged 4.5±0.9 patients per month (range 0-8), 34 (49%) adhered to at least 80% of planned treatments, and four (5.7%) were lost to follow-up. There were 35 serious adverse events including seven deaths and one thromboembolism. None was related to IVIG. There were 56 and 48 moderate and severe AECOPD in the IVIG vs control groups. In patients with at least 80% treatment adherence, median time to first moderate or severe AECOPD was 275 vs 114 days, favoring the IVIG group (HR 0.76, 95% CI 0.3-1.92). CONCLUSION: The study met feasibility criteria for recruitment and retention, but adherence was low. A trend toward more robust treatment efficacy in adherent patients supports further study, but future trials must address treatment adherence. TRIAL REGISTRATION NUMBER: NCT0290038, registered 24 February 2016, https://clinicaltrials.gov/ct2/show/NCT02690038 and NCT03018652, registered January 12, 2017, https://clinicaltrials.gov/ct2/show/NCT03018652.

Development and Implementation of a Diabetic Ketoacidosis Protocol for Adults With Type 1 and Type 2 Diabetes at a Tertiary Care Multicampus Hospital.

OBJECTIVES: Diabetic ketoacidosis (DKA) is associated with significant morbidity and mortality. Using standardized protocols for DKA management improves outcomes and is recommended in Diabetes Canada's clinical practice guidelines. Audits of DKA care at our institution revealed inconsistent management. We developed, piloted and evaluated a standardized DKA protocol adapted into preprinted order sets for use in the emergency department and the acute monitoring area. METHODS: The protocol was developed by an expert committee on the basis of Diabetes Canada's clinical practice guidelines, a literature review and an environmental survey. A before-and-after analysis was used. Uptake of the DKA protocol and clinical outcomes were monitored through statistical process control. RESULTS: Patients admitted postprotocol (n=55, mean age 37.9 years [SD 17.5 years], 62% male, 85% type 1 diabetes) were compared to those admitted preprotocol (n=55, mean age 43.3 years [SD 17.5 years], 53% male, 67.2% type 1 diabetes). Postimplementation, 87% of patients were managed according to the protocol. Postprotocol ordering of appropriate laboratory investigations increased, appropriate intravenous (IV) fluid resuscitation improved, continuation of IV insulin until anion gap closure increased, mean time to anion gap closure decreased and mean length of stay was reduced. Of those surveyed, 85% of nurses and 74% of physicians felt that the protocol improved patient care, and 75% of patients rated their DKA management as being satisfactory. CONCLUSIONS: Successful implementation of a standardized preprinted protocol for DKA management significantly improved best practices for DKA management and was valued by treating clinicians.

Impact of emergency department surge and end of shift on patient workup and treatment prior to referral to internal medicine: a health records review.

BACKGROUND: The goal of this study was to determine if ED surge and end-of-shift assessment of patients affect the extent of diagnostic tests, therapeutic interventions and accuracy of diagnosis prior to referral to internal medicine. METHODS: This study was a health records review of consecutive patients referred to the internal medicine service with an ED diagnosis of heart failure, chronic obstructive pulmonary disease (COPD) or sepsis starting 1 December 2013 until 100 cases for each condition had been obtained. We developed a scoring system in consultation with emergency and internal medicine physicians to uniformly assess the completeness of treatments and investigations performed. These scores, expressed as percentage of possible points, were compared at high and low surge levels and at middle and end of shift at time of patient referral. End of shift was defined as 7:30-8:30, 15:30-16:30 and 23:30-00:30 as our shift changes occur at 8:00, 16:00 and 24:00. Rate of admission, diversion to other services and diagnosis disagreements were also assessed. RESULTS: We included 308 patients (101 heart failure, 101 COPD, 106 sepsis) with a mean age of 74.7. Comparing middle of shift to end of shift, the mean scores were 91.9% versus 91.8% (difference 0.1% (95% CI -2.4 to 3.0)) for investigations and 73.0% versus 70.4% (difference 2.6% (95% CI -1.8 to 7.4)) for treatments. Comparing low to high surge times, the mean scores were 92.1% versus 91.7% (difference 0.4% (95% CI -1.2 to 2.4)) for investigations and 71.4% versus 73.6% (difference -2.2% (95% CI -5.6 to 1.3)) for treatments. We found low rates of diversion to alternate services (8.9% heart failure, 0% COPD, 6.6% sepsis) and low rates of diagnosis disagreement (4.0% heart failure, 10.9% COPD, 8.5% sepsis). CONCLUSIONS: We found no evidence that surge levels and end of shift impact the extent of investigations and treatments provided to patients diagnosed in the ED with heart failure, COPD or sepsis and referred to internal medicine.

Identifying patients with post-discharge care problems using an interactive voice response system.

INTRODUCTION: Adverse events (AEs) are poor outcomes caused by medical care. They occur in 20% of medical patients following hospital discharge. We designed an interactive voice response system (IVRS) with the intent of identifying patients who might be experiencing an AE following discharge or were at risk of developing one. OBJECTIVES: We determined the proportion of post-discharge patients requiring an intervention after identifying potential problems using the IVRS, the relationship between IVRS responses and AE occurrence, and patients' opinions of the IVRS call. METHODS: We studied patients discharged from the general medical service of an academic hospital. The IVRS called patients 2 days post-discharge and asked three questions to determine the need for nurse follow-up. We contacted patients 30 days later to elicit AE status and perceptions of the IVRS. RESULTS: Our cohort consisted of 270 elderly patients [median 64 years (IQR 50-76)] with multiple co-morbidities. Responses to the IVRS identified 57 patients (21%, 95% CI 17%-27%) for follow-up. When contacted by a nurse, 25 patients (9%, 95% CI 6%-13%) actually required an intervention. At 30-day follow-up, AEs occurred in 33 patients (12%, 95% CI 8%-17%). Only three AEs (9%) were identified by the IVRS; the remainder occurred before or after the IVRS call. Patients remembering the IVRS call found it easy to use (97%), and a minority would prefer a person to call (8%). CONCLUSION: An IVRS-based method of monitoring was acceptable to patients and identified a significant proportion requiring changes in management. However, the method identified only a minority of AEs. To have a significant improvement in care, this method will need to be combined with other interventions.