Comparison of Early and Late Intubation in COVID-19 and Its Effect on Mortality.

BACKGROUND: Best practices for management of COVID-19 patients with acute respiratory failure continue to evolve. Initial debate existed over whether patients should be intubated in the emergency department or trialed on noninvasive methods prior to intubation outside the emergency department. OBJECTIVES: To determine whether emergency department intubations in COVID-19 affect mortality. METHODS: We conducted a retrospective observational chart review of patients who had a confirmed positive COVID-19 test and required endotracheal intubation during their hospital course between 1 March 2020 and 1 June 2020. Patients were divided into two groups based on location of intubation: early intubation in the emergency department or late intubation performed outside the emergency department. Clinical and demographic information was collected including comorbid medical conditions, qSOFA score, and patient mortality. RESULTS: Of the 131 COVID-19-positive patients requiring intubation, 30 (22.9%) patients were intubated in the emergency department. No statistically significant difference existed in age, gender, ethnicity, or smoking status between the two groups at baseline. Patients in the early intubation cohort had a greater number of existing comorbidities (2.5, p = 0.06) and a higher median qSOFA score (3, p ≤ 0.001). Patients managed with early intubation had a statistically significant higher mortality rate (19/30, 63.3%) compared to the late intubation group (42/101, 41.6%). CONCLUSION: COVID-19 patients intubated in the emergency department had a higher qSOFA score and a greater number of pre-existing comorbidities. All-cause mortality in COVID-19 was greater in patients intubated in the emergency department compared to patients intubated outside the emergency department.

Predicting 30 - Day outcomes in emergency department patients discharged with COVID-19.

INTRODUCTION: Determining disposition for COVID-19 patients can be difficult for emergency medicine clinicians. Previous studies have demonstrated risk factors which predict severe infection and mortality however little is known about which risk factors are associated with failure of outpatient management and subsequent admission for COVID-19 patients. METHODS: We conducted a retrospective observational chart review of patients who had a confirmed positive COVID-19 test collected during an ED visit between March 1, 2020 and October 11, 2020. Patients were divided into two groups based on presence or absence of a subsequent 30-day hospitalization. Clinical and demographic information were collected including chief complaint, triage vital signs and comorbid medical conditions. RESULTS: 1038 patients were seen and discharged from a network ED with a positive SARS-CoV-2 PCR test. 94 patients (9.1%) were admitted to a hospital within 30 days of the index ED visit while 944 (90.9%) were not admitted to a network hospital within 30 days. Patients that were admitted were more likely to be older (aOR = 1.04 (95% CI 1.03-1.06)), hypoxic (aOR = 2.16 (95% CI 1.14-4.10)) and tachycardic (aOR = 2.13 (95% CI 1.34-3.38)) on initial ED presentation. Preexisting hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease and malignancy were all highly significant risk factors for 30-day hospital admission following initial ED discharge (p < 0.0001). CONCLUSION: Emergency Department providers should consider age, chief complaint, vital signs and comorbid medical conditions when determining disposition for patients diagnosed with COVID-19.

Failure Rates During Reuse of Disposable N95 Masks in Clinical Practice in the Emergency Department.

INTRODUCTION: The coronavirus 2019 pandemic caused a shortage of disposable N95 respirators, prompting healthcare entities to extend the use of these masks beyond their intended single-use manufacturer recommendation with a paucity of supporting research. METHODS: We performed a prospective cohort study of ED healthcare workers (HCW) ("subjects") required to use respirators at an academic, Level I trauma center. Subjects had been previously fit tested and assigned an appropriately sized N95 mask per hospital protocol. Per study protocol, subjects were fit tested periodically throughout their shifts and on multiple shifts over the eight-week study period. Data points collected included the age of the mask, subjective assessment of mask seal quality, and fit test results. We analyzed the data using Fisher's exact test, and calculated odds ratios (OR) to determine the failure rate of disposable N95 masks following reuse. RESULTS: A total of 130 HCWs underwent fit testing and 127 were included for analysis. Mask failure rate climbed after day 2 of use, with 33.3% of masks failing at day 3, 42.9% at day 4, and 50% at ≥ day 5. Categorizing the masks into those being used for two or fewer days vs those in use for three or more, failure was more common on day 3 of use or older compared to those in the first two days of use (41.8% vs 8.3%, P < 0.0001) with an OR of failure with an older mask of 7.9 (confidence interval [CI], 2.8-22.3). The healthcare workers' assessment of poor seal was 33.3% sensitive (CI, 18.6-51.9) and 95.7% specific (CI, 88.8-98.6) for fit test failure. CONCLUSION: Disposable N95 masks have significant failure rates following reuse in clinical practice. Healthcare personnel also performed poorly in assessing the integrity of the seal of their disposable respirators.

The pragmatic use of industrial elastomeric facemasks in health care practice during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has forced health care workers to explore alternative personal protective equipment (PPE) strategies due to traditional product shortages in the setting of increased global demand. Some physicians have chosen to use elastomeric face masks (EFMs), traditionally used in non-healthcare industries. METHODS: We performed a prospective cohort study of Emergency Medicine (EM) physicians working at a Level 1 Trauma Center who chose to use self-supplied EFMs for PPE. All subjects used commercial EFMs with disposable filters (N95, P95, or P100). All subjects chose their mask size independently with no input from employee health regarding appropriate fit. Per study protocol, subjects were fit tested periodically during clinical shifts over the course of the 6-week study period. All investigators performing fit testing underwent OSHA qualitative fit testing training. Data collected included mask/filters age, subjective assessment of mask seal quality, and fit test results. The data were analyzed using descriptive statistics. RESULTS: 105 fit tests were performed on physicians wearing EFMs over the course of 49 shifts. Physicians felt their fit was adequate for all tests performed. There were no fit test failures in any subjects. CONCLUSIONS: EFMs have an extremely low failure rate. Physicians are able to assess the adequacy of fit and accurately choose EFM size.

The efficacy of continuous use disposable N95 masks in clinical practice in the emergency department.

During the SARS-CoV-2 pandemic, many emergency departments (EDs) initiated continuous use of N95 disposable respirators (N95s) rather than discarding them after each use to conserve respirators. This study investigates the efficacy of wearing disposable N95s continuously during clinical work. METHODS: This is a prospective cohort study of ED staff required to wear N95s continuously throughout their shifts. Subjects were doctors, nurses, and technicians who were previously fitted for their assigned N95 by employee health. Subjects were fit tested periodically throughout their shifts. Investigators filled out a questionnaire for each subject noting the hours of continuous N95 wear. Data were analyzed using descriptive statistics. RESULTS: One hundred thirteen N95s were evaluated, with 23 failures at first testing. These were not retested. Twenty-seven N95s passed at the start of a shift and did not have repeat testing during the course of the shift. These were excluded from further analysis. Seventeen N95s passed testing after several hours of continuous wear, but only had a single fit test done partway or at the end of a shift. These were assumed to have passed if tested at shift start, and were assigned as "passes" for continuous use. Forty-six N95s had an initial pass and were evaluated for continuous use, of which 6 subsequently failed later in the shift, giving a fail rate with continuous use of 9.5%. CONCLUSION: Continuous use of disposable N95s throughout an ED shift is reasonable during a PPE shortage if wearers are assured of fit at the start of their shift.

Effect of Fingolimod on Platelet Count Among Multiple Sclerosis Patients.

BACKGROUND: While many studies have previously focused on fingolimod's effect on immune cells, the effect it has on circulating and local central nervous system platelets (Plts) has not yet been investigated. This study will elucidate what effects fingolimod treatment has on multiple sclerosis (MS) patients' plasma Plt levels. In addition, it will propose possible reasoning for these effects and suggest further investigation into this topic. METHODS: This quasi-experimental study used patients from the Isfahan Multiple Sclerosis Society to produce a subject pool of 80 patients, including 14 patients who ceased fingolimod use due to complications. The patients had their blood analyzed to determine Plt levels both 1-month prior to fingolimod treatment and 1-month after fingolimod treatment had been started. RESULTS: The mean level of Plts before initiation of fingolimod therapy (Plt1) among these MS patients was 256.53 ± 66.26. After 1-month of fingolimod treatment, the Plt level yielded an average of 229.96 ± 49.67 (Plt2). This number is significantly lower than the average Plt count before treatment (P < 0.01). CONCLUSIONS: MS patients taking oral fingolimod treatment may be at risk for side-effects caused by low Plt levels. This may not be a factor for patients with higher or normal Plt levels. However, a patient with naturally low Plt levels may experience a drop below the normal level and be at risk for excessive bleeding. In addition to these possible harmful side-effects, the decreased Plt population may pose positive effects for MS patients.