Impact of COVID-19 on pediatric emergency fellowship training in Saudi Arabia.

OBJECTIVES: To assess the impact of the COVID-19 pandemic on the academic and clinical processes of pediatric emergency medicine (PEM) fellowship training held by the Saudi Commission for Health Specialties (SCHS). METHODS: A cross-sectional, nationwide, survey-based study was conducted between June and December 2020. PEM program directors as well as fellowship trainees were eligible. The collected data were under the following domains: (1) sociodemographic and work-related characteristics; (2) impact of the COVID-19 pandemic on patient flow and PEM procedures; (3) impact on emergency skills and competence; (4) impact on academic performance; and (5) attitudes toward PEM practice and potential solutions. Monthly reports of PEM visits and procedures were also collected from program directors. RESULTS: A total of 11 PEM program directors and 42 fellows responded. During the pandemic, the number of total ED visits decreased by 70.1%, ED inpatient admissions fell by 57.3%, and the number of intraosseous need insertion and lumbar puncture procedures fell by 76.7% and 62.3%, respectively; the temporal differences in the median frequencies were statistically significant. The pandemic has influenced the knowledge acquisition and leadership skills of one-third of program directors (36.4% and 27.3%, respectively) and the skills and competence of fellows (31.0%). The majority of directors and fellows showed that online classes/webinars were useful (100% and 95.2%, respectively), and there was no need to extend the current fellowship training to compensate for learning deficits (62.7% and 78.6%, respectively). The importance of dedicated modalities to fill in the training gap increased by 62.5% of program directors and 35.7% of fellows. CONCLUSION: The COVID-19 pandemic had significant effects on clinical procedures and academic activities in the PEM fellowship program. The impact was consistently perceived across PEM program directors and fellows. Technology-driven solutions are warranted to mitigate the expected learning and clinical deficits due to reduced clinical exposure.

Analysis of Emergency Department Use by Non-Urgent Patients and Their Visit Characteristics at an Academic Center.

Objective: We studied the extent and reasons for non-urgent emergency department (ED) visits in a single university hospital, their predictors, and patient outcomes to propose solutions suitable for Middle Eastern healthcare systems. Design: We conducted a retrospective review of electronic medical records, including all non- and less-urgent ED visits with complete triage records (levels 4 and 5 triage based on the Canadian Triage and Acuity Scale (CTAS) over one year. The data on patient demographics, visit characteristics, and patient disposition were analyzed using SPSS software. Setting: The study was conducted in the ED at King Abdullah Bin Abdul-Aziz University Hospital (KAAUH), a Saudi university hospital located within the campus of Princess Nourah Bint Abdulrahman University. Participants: A chart review was carried out for 18,880 patients with CTAS 4 or 5 visiting the KAAUH ED between July 2020 and July 2021. Additionally, a total of "11,857" patients with missing triage acuity or CTAS levels 1, 2, or 3 were excluded from the study. Results: The majority (61.4%) of the 30,737 ED visits were less-urgent or non-urgent. The most common reasons for non-urgent visits were routine examination/investigation (40.9%), medication refilling (14.6%), and upper respiratory tract infection/symptoms (9.9%). Most visits (73.4%) were during weekdays and resulted in the prescription of medication (94.2%), laboratory tests (62.8%), sick leaves (4.7%), radiology examinations (3.6%), and a visit to primary healthcare clinics (family medicine) within a week of the emergency visit (3.6%). Conclusion: Less- and non-urgent ED visits often did not need any further follow-ups or admission and represented a burden better managed by a primary healthcare center. Policymakers should mitigate unnecessary ED visits through public awareness, establish clear regulations for ED visits, improve the quality of care in primary healthcare centers, facilitate booking for outpatient department appointments, and regulate the systems of payment coverage/insurance and referral by other organizations.

Testing for anosmia and ageusia in patients presenting to the emergency department with suspected coronavirus disease 2019 in Saudi Arabia.

OBJECTIVE: This study investigated the role of objective olfactory dysfunction (OD) and gustatory dysfunction (GD) testing among patients with suspected coronavirus disease 2019 (COVID-19) who presented with respiratory symptoms. METHODS: A prospective, blinded, observational study was conducted in the emergency units of two tertiary hospitals. Participants were asked to identify scents in the pocket smell test (PST) and flavors in four different solutions in the gustatory dysfunction test (GDT). We assessed the level of agreement between objective findings and self-reported symptoms. We evaluated the diagnostic accuracy of chemosensory dysfunction for diagnosing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. RESULTS: Of 250 participants, 74 (29.6%) were SARS-CoV-2-positive. There was slight agreement between self-reported symptoms and objective findings (kappa = 0.13 and 0.10 for OD and GD, respectively). OD assessed by the PST was independently associated with COVID-19 (adjusted odds ratio = 1.89, 95% confidence interval, 1.04-3.46). This association was stronger when OD was combined with objective GD, cough, and fever (adjusted odds ratio = 7.33, 95% confidence interval, 1.17-45.84). CONCLUSIONS: Neither the PST nor GDT alone are useful screening tools for COVID-19. However, a diagnostic scale based on objective OD, GD, fever, and cough may help triage patients with suspected COVID-19.

Exploring the Prevalence and Patterns of Use of Sleep Aids and Stimulants Among Emergency Physicians and EMS Providers in Saudi Arabia.

PURPOSE: This study explores the prevalence and patterns of the use of pharmacologic sleep aids and stimulants among Saudi Arabia's emergency physicians (EPs) and emergency medical services (EMS) providers. PATIENTS AND METHODS: We adopted a descriptive, cross-sectional design. To collect data on the types and frequencies of sleep aids and stimulants used, we distributed a semi-structured, anonymous, web-based questionnaire to registered EPs, paramedics, and emergency medicine technicians (EMTs) in the Saudi Commission for Health Specialties. An internal consistency analysis showed good reliability (Cronbach's alpha=0.667) of the questionnaire. A subscale analysis confirmed the results-alpha values were 0.720 and 0.618 for the use of sleep aids and stimulants, respectively. RESULTS: Males and females represented 81.8% and 18.2%, respectively, of the valid sample of 669 participants. Respondents aged 25-34, 35-44, and 45-55 years represented 51.9%, 32.7%, and 10.2% of the sample, respectively. Results showed that a majority of the respondents (67.1%) used stimulants. Caffeine was the most common stimulant; caffeine and energy drinks were used by 65.9% and 17.2% of the respondents, respectively. Caffeine, energy drinks, nicotine, and ephedrine were used by 65.9%, 17.2%, 18.5%, and 17.3% of the respondents, respectively. The respondents who used at least one sleeping aid and those using only one and two sleeping aids accounted for 36.6%, 15.6%, and 9.7%, respectively. The most common sleeping aids antihistamines and marijuana were used on most days by 13.4% and 13.3% of the respondents, respectively. The average monthly number of night shifts (P = 0.025) significantly influenced sleep aid use. Respondents working in night shifts for 3-5 months or more than 7 days were more likely to use sleeping aids. CONCLUSION: Future research should enhance health workers' knowledge of the efficacy and safety of these medications and guide strategies to organize and reduce night shift work.

Protective Boxes to Prevent Airborne Transmission of SARS-COV-2: Hospital-Based Experiences and a Narrative Literature Review.

OBJECTIVE: Occupational safety in healthcare settings is an integral part of treating COVID-19. A growing body of evidence suggests that the inhalation of both respiratory droplets (>5 µm) and tiny aerosols (<5 µm) is a possible route of virus transmission. Recently, innovative barrier enclosures (aerosol boxes) have been designed to cover patients' heads while allowing the implementation of airway management procedures through fitted holes. The initial design has undergone a series of modifications to improve staff safety, operators' ergonomics, and the efficacy of airway procedures. METHODS: We reviewed the literature concerning different box modifications and provided an insight into our experience of using the box. Aerosol boxes have garnered the attention of clinicians who are frequently exposed to aerosols while performing aerosol-generating medical procedures, particularly endotracheal intubation. Current evidence comes from simulation-based studies rather than real-life clinical investigations. RESULTS: The reports indicated that the box has significantly reduced the diffusion of aerosols into the room; however, the operators have experienced difficulties in the maneuverability of airway devices. CONCLUSION: Aerosol boxes should be used for patients necessitating simple elective intubations after healthcare providers are adequately trained. Customized designs can be further made based on clinicians' experiences.

Premenarchal Adolescent Female Ovarian Torsion: A Case of Delayed Diagnosis.

BACKGROUND Ovarian torsion is a rare surgical emergency in premenarchal girls. Early diagnosis and surgical detorsion are required to restore blood flow and limit tissue damage. CASE REPORT Here, we present a case of ovarian torsion and appendicitis in an 11-year-old premenarchal girl who presented to our emergency room with a 4-day history of right iliac fossa pain, limping, and fever. Upon initial evaluation in our hospital, her vital signs were stable and clinical examination revealed abdominal guarding and right lower quadrant rebound tenderness with positive Rovsing's sign. Abdominal ultrasound and computed tomography scans showed adnexal cysts and torsion, an inflamed appendix, and free fluid in the abdomen. Intraoperative findings included a twisted gangrenous ovary and an edematous appendix. The patient underwent emergency laparoscopic oophorectomy and appendectomy. CONCLUSIONS This case demonstrates that reactive appendicitis can occur secondary to inflammation of adjacent structures such as the ovary.

A Push-to-Talk Application as an Inter-Professional Communication Tool in an Emergency Department During the COVID-19 Pandemic.

OBJECTIVE: To assess the effects of using a smartphone-based push-to-talk (PTT) application on communication, safety, and clinical performance of emergency department (ED) workers during the COVID-19 outbreak. DESIGN: An observational, cross-sectional study. SETTING: ED in an academic medical center. PARTICIPANTS: All ED staff members, including physicians (consultants, specialists, residents, and interns), nurses, emergency medical services staff, technicians (X-ray), and administration employees. INTERVENTIONS: Eligible participants (n=128) were invited to fill out an online questionnaire 30 days after using a PTT application for sharing instant voice messages during the COVID-19 outbreak. MAIN OUTCOME MEASURES: Self-reported data related to communication, implementation of personal protective measures, and clinical performance at the ED were collected and analyzed on a 5-item Likert scale (from 5 [strongly agree] to 1 [strongly disagree]). Also, the proportions of favorable responses (agree or strongly agree) were calculated. RESULTS: Responses of 119 participants (51.3% females, 58.8% nurses, and 34.5% physicians; 90.4% received at least one notification per day) were analyzed. The participants had favorable responses regarding all domains of communication (between 63.0% and 81.5%), taking precautionary infection control measures (between 49.6% and 79.0%), and performance (between 55.5% and 72.3%). Receiving fake and annoying alerts and application breakdowns were the lowest perceived limitations (between 12.5% and 21.0%). CONCLUSION: The assessed PTT application can be generalized to other departments and hospitals dealing with patients with COVID-19 to optimize staff safety and institutional preparedness.

EMS operation in a female restricted university, Saudi prospective.

This paper was written to explain the process and steps and to describe the experience with building a women-only operated collegiate emergency medical service (EMS) system in the largest women-only university in the world. To the best of the authors' knowledge, the EMS system described in this report is the first collegiate EMS system in the Gulf region. The concept of the collegiate EMS system at the university, the factors that mandated the creation of this system, the process steps, the challenges faced, and, finally, the reported outcome have been evaluated. The women-only campus conferred unique challenges and additional pressure during the planning and implementation stages of this project; our system had helped in decreasing response time to medical emergency, provided back up support during mass gathering events in the university, and helped in decreasing the load on other national EMS services.

Use of In Situ Simulation to Improve Emergency Department Readiness for the COVID-19 Pandemic.

INTRODUCTION: During the world-wide coronavirus disease 2019 (COVID-19) outbreak, there is an urgent need to rapidly increase the readiness of hospitals. Emergency departments (EDs) are at high risk of facing unusual situations and need to prepare extensively in order to minimize risks to health care providers (HCPs) and patients. In situ simulation is a well-known method used in training to detect system gaps that could threaten safety. STUDY OBJECTIVES: One objective is to identify gaps, test hospital systems, and inform necessary modifications to the standard processes required by patients with COVID-19 presenting at the hospital. The other objective is to improve ED staff confidence in managing such patients, and to increase their skills in basic and advanced airway management and proper personal protective equipment (PPE) techniques. METHODS: This is a quasi-experimental study in which 20 unannounced mock codes were carried out in ED resuscitation and isolation rooms. A checklist was designed, validated, and used to evaluate team performances in three areas: donning, basic and advanced airway skills, and doffing. A pre- and post-intervention survey was used to evaluate staff members' perceived knowledge of ED procedures related to COVID-19 and their airway management skills. RESULTS: A total of 20 mock codes were conducted in the ED. Overall, 16 issues that posed potential harm to staff or patients were identified and prioritized for immediate resolution. Approximately 57.4% of HCPs felt comfortable dealing with suspected/confirmed, unstable COVID-19 cases after mock codes, compared with 33.3% beforehand (P = .033). Of ED HCPs, 44.4% felt comfortable performing airway procedures for suspected/confirmed COVID-19 cases after mock codes compared with 29.6% beforehand. Performance of different skills was observed to be variable following the 20 mock codes. Skills with improved performance included: request of chest x-ray after intubation (88.0%), intubation done by the most experienced ED physician (84.5%), and correct sequence and procedure of PPE (79.0%). CONCLUSION: Mock codes identified significant defects, most of which were easily fixed. They included critical equipment availability, transporting beds that were too large to fit through doors, and location of biohazard bins. Repeated mock codes improved ED staff confidence in dealing with patients, in addition to performance of certain skills. In situ simulation proves to be an effective method for increasing the readiness of the ED to address the COVID-19 pandemic and other infection outbreaks.

A randomized controlled trial of mist in the acute treatment of moderate croup.

OBJECTIVE: To determine whether the use of mist improves clinical symptoms in children presenting to the emergency department (ED) with moderate croup. METHODS: Children 3 months to 6 years of age were eligible for the study if they presented to the ED with moderate croup. Moderate croup was defined as a croup score of 2-7. The patients were randomly assigned to receive either mist (humidified oxygen) via mist stick or no mist. The patients had croup scores measured at baseline and every 30 minutes for up to two hours. At these intervals the following parameters were also measured: heart rate, respiratory rate, oxygen saturation, and patient comfort score. The patients were treated until the croup score was less than 2 or until two hours had elapsed. All patients initially received a dose of oral dexamethasone (0.6 mg/kg). Other treatments, such as racemic epinephrine or inhaled budesonide, were given at the discretion of the treating physician. The research assistants were unaware of the assigned treatments. RESULTS: There were 71 patients enrolled in the study; 35 received mist and 36 received no mist. The two treatment groups had similar characteristics at baseline. The median baseline croup score was 4 in both groups. The outcomes were measured as the change from baseline at 30, 60, 90, and 120 minutes. The change in the croup score from baseline in the mist group was not statistically different from the croup score change in the group that did not receive mist (p = 0.39). There was also no significant difference in improvement of oxygen saturation, heart rate, or respiratory rate at any of the assessment times. There was no adverse effect from the mist therapy. CONCLUSIONS: Mist therapy is not effective in improving clinical symptoms in children presenting to the ED with moderate croup.