Point-of-care ultrasound (PoCUS) in the early diagnosis of novel coronavirus 2019 disease (COVID-19) in a first-level emergency department during a SARS-CoV-2 outbreak in Italy: a real-life analysis.

In December 2019, the severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) spread worldwide, challenging emergency departments (EDs) with the need of rapid diagnosis for appropriate allocation in dedicated setting. Many authors highlighted the role of lung ultrasound (LUS) in management of the novel coronavirus disease 2019 (COVID-19). The study aims to analyze the performance of LUS in the early identification of COVID-19 patients in ED during a SARS-CoV-2 outbreak. We prospectively collected consecutive adult patients admitted to a first-level ED in Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation Florence with history or symptoms suggestive for COVID-19 that underwent LUS during the ED management. LUS findings were categorized in 6 discrete main etiological patterns. "A", "Cardiogenic B" and "Typical C" patterns were referred as non-COVID-19-suggestive, while "Atypical" B or C patterns, "Multiple Consolidations" pattern and "ARDS" pattern were referred as COVID-19-suggestive. The primary outcome was the diagnosis of SARS-CoV-2 infection. From 12 March to 12 May 2020, 360 patients were enrolled. COVID-19 suggestive LUS findings were significantly associated with final COVID-19 diagnosis (86% in COVID-19 vs 29% in non-COVID-19, p < 0.001). The presence in ED of at least one in positive swab OR a COVID-19-suggestive LUS showed a sensitivity of 97% and a negative predictive value (NPV) of 98%. In patients with known SARS-CoV-2 exposition in the last 14 days, a COVID-19-suggestive pattern at LUS had a positive predictive value (PPV) of 97% for COVID-19 diagnosis. Point-of-care ultrasound (PoCUS) is a valuable tool for diagnostic stratification during COVID-19 outbreaks. LUS can help physicians in identifying false-negative RT-PCR, improving its diagnostic sensitivity in ED.

The presentations/physician ratio predicts door-to-physician time but not global length of stay in the emergency department: an Italian multicenter study during the SARS-CoV-2 pandemic.

To investigate the effects of the dramatic reduction in presentations to Italian Emergency Departments (EDs) on the main indicators of ED performance during the SARS-CoV-2 pandemic. From February to June 2020 we retrospectively measured the number of daily presentations normalized for the number of emergency physicians on duty (presentations/physician ratio), door-to-physician and door-to-final disposition (length-of-stay) times of seven EDs in the central area of Tuscany. Using the multivariate regression analysis we investigated the relationship between the aforesaid variables and patient-level (triage codes, age, admissions) or hospital-level factors (number of physician on duty, working surface area, academic vs. community hospital). We analyzed data from 105,271 patients. Over ten consecutive 14-day periods, the number of presentations dropped from 18,239 to 6132 (- 67%) and the proportion of patients visited in less than 60 min rose from 56 to 86%. The proportion of patients with a length-of-stay under 4 h decreased from 59 to 52%. The presentations/physician ratio was inversely related to the proportion of patients with a door-to-physician time under 60 min (slope - 2.91, 95% CI - 4.23 to - 1.59, R2 = 0.39). The proportion of patients with high-priority codes but not the presentations/physician ratio, was inversely related to the proportion of patients with a length-of-stay under 4 h (slope - 0.40, 95% CI - 0.24 to - 0.27, R2 = 0.36). The variability of door-to-physician time and global length-of-stay are predicted by different factors. For appropriate benchmarking among EDs, the use of performance indicators should consider specific, hospital-level and patient-level factors.

A qualification course in an international emergency medicine intervention.

BACKGROUND: The Tuscan Emergency Medicine Initiative is a comprehensive training program for physicians designed to create a lasting infrastructure for training in emergency medicine (EM) in a region of Italy. A "Train-the-Trainers" model was utilized to prepare physicians who were working in the emergency department (ED) to become the teachers of EM, and a master's program was created to train the next generation of emergency physicians as well as to put in place a structure into which residency training in EM will be placed. This model has been used in other projects as well; however, the dilemma of what to do with physicians who are already in practice remained an unsolved problem. OBJECTIVES: We wished to create a qualification course in EM for this important group of physicians. METHODS: Didactic lectures, workshops, simulations, and clinical rotations were utilized to standardize current emergency care delivery in the region's EDs. RESULTS: Between 2005 and 2008, 488 physicians completed the program. CONCLUSIONS: We propose this model as a way of training and including the physicians caught in the transition to specialty training in any area developing the specialty of EM.

Intubation practice patterns in Tuscan emergency departments.

INTRODUCTION: Intubation is one of the most important life-saving procedures performed by emergency physicians (EPs). There is variation in practice when different countries are compared. METHODS: A written questionnaire on intubation practices was administered to a group of Italian doctors practicing in Tuscany during the examination period of a year-long course in emergency medicine. RESULTS: The survey was administered to 153 participants. Of these, 143 (93.4%) returned a complete survey. In the sub-group of physicians who work in the emergency department (ED), 73.6% report intubating patients. Of those that intubate patients, 92.3% use some sort of sedation, and 49.3% use paralytics. While direct visualization of the cords for intubation and auscultation of breath sounds after intubation are almost universal (97% and 100%, respectively), only 11.9% use colorimetric CO2 detectors for confirmation of intubation. After intubation 58.2% commonly place a nasogastric tube and 50.7% obtain a post intubation chest radiograph. CONCLUSIONS: Practice patterns in the USA and Tuscany are different. RSI and post-intubation radiographs are the standard of care in EDs in the USA. This is not the case in Tuscany.

Difficult airway management.

Airway management is unequivocally the most important responsibility of the emergency physician. No matter how prepared for the task, no matter what technologies are utilized, there will be cases that are difficult. The most important part of success in the management of a difficult airway is preparation. When the patient is encountered, it is too late to check whether appropriate equipment is available, whether a rescue plan has been in place, and what alternative strategies are available for an immediate response. The following article will review the principles of airway management with an emphasis upon preparation, strategies for preventing or avoiding difficulties, and recommended technical details that hopefully will encourage the reader to be more prepared and technically skillful in practice.