Acute effect of the COVID-19 pandemic on emergency transportation due to acute alcoholic intoxication: a retrospective observational study.

BACKGROUND: The COVID-19 pandemic has caused changes in people's drinking habits and the emergency management system for various diseases. However, no studies have investigated the pandemic's impact on emergency transportation for acute alcoholic intoxication. This study examines the effect of the pandemic on emergency transportation due to acute alcoholic intoxication in Kochi Prefecture, Japan, a region with high alcohol consumption. METHODS: A retrospective observational study was conducted using data of 180,747 patients from the Kochi-Iryo-Net database, Kochi Prefecture's emergency medical and wide-area disaster information system. Chi-squared tests and multiple logistic regression analyses were performed. The association between emergency transportation and alcoholic intoxication was examined. The differences between the number of transportations during the voluntary isolation period in Japan (March and April 2020) and the same period for 2016-2019 were measured. RESULTS: In 2020, emergency transportations due to acute alcoholic intoxication declined by 0.2%, compared with previous years. Emergency transportation due to acute alcoholic intoxication decreased significantly between March and April 2020, compared with the same period in 2016-2019, even after adjusting for confounding factors (adjusted odds ratio 0.67; 95% confidence interval 0.47-0.96). CONCLUSIONS: This study showed that lifestyle changes due to the COVID-19 pandemic affected the number of emergency transportations; in particular, those due to acute alcoholic intoxication decreased significantly.

Factors Associated With Voluntary Refusal of Emergency Medical System Transport for Emergency Care in Detroit During the Early Phase of the COVID-19 Pandemic.

Importance: Emergency department (ED) and emergency medical services (EMS) volumes decreased during the COVID-19 pandemic, but the amount attributable to voluntary refusal vs effects of the pandemic and public health restrictions is unknown. Objective: To examine the factors associated with EMS refusal in relation to COVID-19 cases, public health interventions, EMS responses, and prehospital deaths. Design, Setting, and Participants: A retrospective cohort study was conducted in Detroit, Michigan, from March 1 to June 30, 2020. Emergency medical services responses geocoded to Census tracts were analyzed by individuals' age, sex, date, and community resilience using the Centers for Disease Control and Prevention Social Vulnerability Index. Response counts were adjusted with Poisson regression, and odds of refusals and deaths were adjusted by logistic regression. Exposures: A COVID-19 outbreak characterized by a peak in local COVID-19 incidence and the strictest stay-at-home orders to date, followed by a nadir in incidence and broadly lifted restrictions. Main Outcomes and Measures: Multivariable-adjusted difference in 2020 vs 2019 responses by incidence rate and refusals or deaths by odds. The Social Vulnerability Index was used to capture community social determinants of health as a risk factor for death or refusal. The index contains 4 domain subscores; possible overall score is 0 to 15, with higher scores indicating greater vulnerability. Results: A total of 80 487 EMS responses with intended ED transport, 2059 prehospital deaths, and 16 064 refusals (62 636 completed EMS to ED transports) from 334 Census tracts were noted during the study period. Of the cohort analyzed, 38 621 were women (48%); mean (SD) age was 49.0 (21.4) years, and mean (SD) Social Vulnerability Index score was 9.6 (1.6). Tracts with the highest per-population EMS transport refusal rates were characterized by higher unemployment, minority race/ethnicity, single-parent households, poverty, disability, lack of vehicle access, and overall Social Vulnerability Index score (9.6 vs 9.0, P = .002). At peak COVID-19 incidence and maximal stay-at-home orders, there were higher total responses (adjusted incident rate ratio [aIRR], 1.07; 1.03-1.12), odds of deaths (adjusted odds ratio [aOR], 1.60; 95% CI, 1.20-2.12), and refusals (aOR, 2.33; 95% CI, 2.09-2.60) but fewer completed ED transports (aIRR, 0.82; 95% CI, 0.78-0.86). With public health restrictions lifted and the nadir of COVID-19 cases, responses (aIRR, 1.01; 0.97-1.05) and deaths (aOR, 1.07; 95% CI, 0.81-1.41) returned to 2019 baselines, but differences in refusals (aOR, 1.27; 95% CI, 1.14-1.41) and completed transports (aIRR, 0.95; 95% CI, 0.90-0.99) remained. Multivariable-adjusted 2020 refusal was associated with female sex (aOR, 2.71; 95% CI, 2.43-3.03 in 2020 at the peak; aOR 1.47; 95% CI, 1.32-1.64 at the nadir). Conclusions and Relevance: In this cohort study, EMS transport refusals increased with the COVID-19 outbreak's peak and remained elevated despite receding public health restrictions, COVID-19 incidence, total EMS responses, and prehospital deaths. Voluntary refusal was associated with decreased EMS transports to EDs, disproportionately so among women and vulnerable communities.

Decision Making and Interventions During Interfacility Transport of High-Acuity Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

OBJECTIVE: There are limited data regarding the typical characteristics of coronavirus disease 2019 (COVID-19) patients requiring interfacility transport or the clinical capabilities of the out-of-hospital transport clinicians required to provide safe transport. The objective of this study is to provide epidemiologic data and highlight the clinical skill set and decision making needed to transport critically ill COVID-19 patients. METHODS: A retrospective chart review of persons under investigation for COVID-19 transported during the first 6 months of the pandemic by Johns Hopkins Lifeline was performed. Patients who required interfacility transport and tested positive for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction assay were included in the analysis. RESULTS: Sixty-eight patients (25.4%) required vasopressor support, 35 patients (13.1%) were pharmacologically paralyzed, 15 (5.60%) were prone, and 1 (0.75%) received an inhaled pulmonary vasodilator. At least 1 ventilator setting change occurred for 59 patients (22.0%), and ventilation mode was changed for 11 patients (4.10%) during transport. CONCLUSION: The safe transport of critically ill patients with COVID-19 requires experience with vasopressors, paralytic medications, inhaled vasodilators, prone positioning, and ventilator management. The frequency of initiated critical interventions and ventilator adjustments underscores the tenuous nature of these patients and highlights the importance of transport clinician reassessment, critical thinking, and decision making.

Use of Helicopter Emergency Medical Services in the Transport of Patients With Known or Suspected Coronavirus Disease 2019.

OBJECTIVE: Limited information exists regarding the response of helicopter emergency medical services (HEMS) programs to patients with known or suspected coronavirus disease 2019 (COVID-19). The purpose of this study was to determine changes in flight operations during the early stages of the pandemic. METHODS: A survey of the American College of Emergency Physicians Air Medical Section was conducted between May 13, 2020, and August 1, 2020. COVID-19 prevalence was defined as high versus low based on cases > 2,500 or ≤ 2,500. RESULTS: Of the 48 respondents, the majority (89.6%) reported that their patient guidelines had changed because of COVID-19; 89.6% of programs reported transporting COVID-19-positive patients, whereas 91.5% reported transporting persons under investigation. The majority of respondents reported additional training in COVID-19 airway management (79.2%) and personal protective equipment use (93.6%). Permitted aerosol-generating procedures included bilevel positive airway pressure (40.4%) and high-flow nasal oxygen (66.0%). No difference in guideline changes, positive COVID-19/persons under investigation transport restrictions, or permitted aerosol-generating procedures were noted between high- and low-prevalence settings. CONCLUSION: COVID-19 has resulted in changes to HEMS guidelines regardless of local disease prevalence. The pandemic has persisted sufficiently long that data regarding the effectiveness of guideline changes should be analyzed. In the absence of definitive data, national best practices should be developed to guide COVID-19 HEMS transport.

Pre-hospital assistance by ambulance in the context of coronavirus infections.

OBJECTIVE: To reflect on the safe care exercised by the pre-hospital care team by emergency ambulance in times of coronavirus infection. METHOD: A reflection and description of how to provide safe care to the patient and the professional during pre-hospital care in times of coronavirus infection. RESULTS: To ensure the health of all those involved in the care, health professionals who work in pre-hospital care by emergency ambulance should use the recommended Personal Protective Equipment (PPE), such as the use of surgical masks and N95, N99, N100, PFF2 or PFF3, the use of an apron or overall, goggles and face shield, gloves and a hat. The entire team must receive training and demonstrate the ability to use PPE correctly and safely. FINAL CONSIDERATIONS: The professional working in the pre-hospital care by ambulance is exposed to a series of occupational risks that need to be discussed and minimized through professional training.

An assessment of treatment, transport, and refusal incidence in a National EMS's routine work during COVID-19.

BACKGROUND: COVID-19 created lifestyle changes, and induced a fear of contagion affecting people's decisions regarding seeking medical assistance. Concern surrounding contagion and the pandemic has been found to affect the number and type of medical emergencies to which Emergency Medical Services (EMS) have responded. AIM: To identify, categorize, and analyze Magen David Adom (MDA), Israel's national EMS, pre-hospital activities including patients' refusal to hospital transport, during the COVID-19 pandemic crises. METHODS: A comparative before and after design study of MDA incidents during March/April 2019 and March/April 2020. Medical type, frequency, demographic, location, and transport refusal proportions and outcomes were analyzed. RESULTS: A decrease of 2.6% in the total volume of incidents was observed during March and April 2020 compared with the equivalent period in 2019. This contrasted with the retrospective trend of annually increase observed through 2016-2019. Medical categories showing increase in 2020 were infectious disease, cardiac arrest, psychiatric, and labor and deliveries, with out-of-hospital deliveries increasing by 14%. Decreases in 2020 were seen in neurology and trauma, with trauma incidents occurring at home showing an 8.6% increase. Patients' refusal to transport rose from 13.4% in 2019 to 19.9% in 2020. Cases of refusals followed by death within 8 days were more prevalent in 2020. CONCLUSION: EMS must be prepared for changes in patients' behavior due to COVID concerns. Targeting populations at risk for refraining or refusing hospital transport and implementing diverse models of EMS, especially during pandemic times, will allow EMS to assist patients safely, either by reducing truly unnecessary ED visits minimizing contagion or by increasing hospital transports for patients in urgent or emergent conditions.

Effects of the COVID-19 pandemic on reperfusion therapy for acute ischemic stroke patients in Huizhou City, China.

BACKGROUND AND PURPOSE: The COVID-19 pandemic has impacted the reperfusion therapy for acute ischemic stroke (AIS) patients. Huizhou City utilized its experience with the SARS and MERS breakouts to establish a reperfusion treatment program for AIS patients. METHOD: This is a retrospective study on 8 certified stroke hospitals in Huizhou City from January 2020 to May 2020. We analyzed the number of AIS patients with reperfusion therapy, stroke type (anterior/posterior circulation stroke), modes of transport to hospital, NIHSS score, onset to door time (ODT), door to needle time (DNT), and door to puncture time (DPT). The analysis was compared with baseline data from the same time period in 2019. RESULT: In 2020, the number of AIS patients receiving reperfusion therapy decreased (315 vs. 377), NIHSS score increased [8 (4, 15) vs. 7 [ (1, 2)], P = 0.024], ODT increased [126 (67.5, 210.0) vs. 120.0 (64.0, 179.0), P = 0.032], and DNT decreased [40 (32.5, 55) vs. 48 (36, 59), P = 0.003]. DPT did not change. Seventy percent of AIS patients indicated self-visit as their main mode of transport to the hospital. In both periods, mild stroke patients were more likely to self-visit than utilize emergency systems [2019: 152 (57.6%) vs. 20 (45.6%), P = 0.034; 2020: 123 (56.9%) vs. 5 (14.7%), P < 0.001]. The NIHSS score for self-visiting patients was lower for patients who utilized the ambulance system in both years [self-visit: 6.00 (3.00, 12.00), ambulance: 14.00 (9.00, 19.00), P < 0.001]. The volume of reperfusion patients was lower in 2020; however, the decrease was only significant (P = 0.028) in February 2020. CONCLUSION: During the COVID-19 pandemic in 2020, the number of AIS patients receiving reperfusion therapy significantly decreased when compared to the same period in 2019. The patients' condition increased severity, ODT increased, and the DNT decreased. DPT was not significant for self-visiting and ambulance patients. Moderate to severe stroke patients were more likely to utilize ambulance services.

Impact of the coronavirus disease 2019 outbreak on the transportation of patients requiring emergency care.

The first confirmed community transmission of coronavirus disease 2019 in Daegu Metropolitan City, South Korea, occurred on February 18, 2020. In the following 70-day period, approximately 6000 new cases occurred, severely impacting the medical service system. This study investigated the crisis-impact on the local emergency transport system.Emergency medical service activity reports were retrospectively reviewed to determine patient demographics and initial vital signs. Delay in reaching the patient, transporting the patient to the hospital, and returning to the fire station were assessed and categorized based on patients' initial vital signs. The study period was divided into 4 groups (1/1-2/18, 2/19-3/3, 3/4-3/31, and 4/1-04/30) and intergroup differences were analyzed.When compared to Period 1, the time-difference between the request to attend a scene and arrival at the scene was delayed in Periods 2, 3, and 4 by 4 minute 58 s, 3  minute 24 seconds, and 2 minute 20 seconds, respectively; that between arriving at the scene and at the hospital was delayed by 7  minute 43 seconds, 6 minutes 59 seconds, and 4 minutes 30 seconds, respectively; and that between arriving at the hospital and returning to the fire station was delayed by 29  minute 3 second, 25  minute 55 second, and 18  minute 44 second, respectively. In Period 2, for patients with symptoms of severe illness when compared to patients lacking such symptoms, the time-difference between the request to attend the scene and arrival at a hospital and between arrival at the hospital and returning to the fire station were 6 to 23 minute and 12 to 48 minute longer, respectively. Most of the delays impacted patients with a fever. In terms of condition, the statistical effect size for delay in transport time was from large to small: fever, hypoxia, abnormal respiratory rate, respiratory symptom, and hypotension.Outbreaks of infectious disease cause a paradoxical state in emergency medical transport systems, inducing delays in the transport of severely ill patients. Therefore, maintenance and improvement of the medical service system for both patients with infectious disease and those with other severe illnesses is required.

[Nomadism of patients treated by radiotherapy in Île-de-France: Does our health system have as much money to waste?] / Nomadisme des patients traités par radiothérapie en Île-de-France : notre système de santé a-t-il autant d'argent à gaspiller ?

PURPOSE: Human, material, and financial resources being limited, the organization of the care system must allow an efficient allocation of resources. The management of cancers leads to specific and repetitive care for which the reimbursement of transport costs represents a high cost. We carried out an analysis of the additional transport costs, linked to the care of patients in Île-de-France, in a center other than the radiotherapy center closest to their home. MATERIALS AND METHODS: Using data from the Île-de-France Regional Health Agency, we have created a model evaluating the additional cost linked to transport generated by the care of a radiotherapy patient far from his home. In order to take into account the uncertainties linked to the hypotheses made in the development of the model, we carried out deterministic and probabilistic sensitivity analyzes. RESULTS: In the base case, the additional annual cost related to transport was 841,176 euros in Île-de-France. The probabilistic sensitivity analysis reports a total annual additional cost of 2,817,481 euros. CONCLUSION: Our results are similar to a report from the General Inspectorate of Social Affairs published in July 2011, which then pointed to an additional cost of between 4 and 6 million euros annually. The long-term care of cancer patients from their homes contributes to a deterioration in the quality of life linked to travel times, a delay in the care of potential treatment complications, and the spread of infectious diseases, such as COVID-19, and bacteria resistant to antibiotics.