Comparing methods to classify admitted patients with SARS-CoV-2 as admitted for COVID-19 versus with incidental SARS-CoV-2: A cohort study.

INTRODUCTION: Not all patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection develop symptomatic coronavirus disease 2019 (COVID-19), making it challenging to assess the burden of COVID-19-related hospitalizations and mortality. We aimed to determine the proportion, resource utilization, and outcomes of SARS-CoV-2 positive patients admitted for COVID-19, and assess the impact of using the Center for Disease Control's (CDC) discharge diagnosis-based algorithm and the Massachusetts state department's drug administration-based classification system on identifying admissions for COVID-19. METHODS: In this retrospective cohort study, we enrolled consecutive SARS-CoV-2 positive patients admitted to one of five hospitals in British Columbia between December 19, 2021 and May 31,2022. We completed medical record reviews, and classified hospitalizations as being primarily for COVID-19 or with incidental SARS-CoV-2 infection. We applied the CDC algorithm and the Massachusetts classification to estimate the difference in hospital days, intensive care unit (ICU) days and in-hospital mortality and calculated sensitivity and specificity. RESULTS: Of 42,505 Emergency Department patients, 1,651 were admitted and tested positive for SARS-CoV-2, with 858 (52.0%, 95% CI 49.6-54.4) admitted for COVID-19. Patients hospitalized for COVID-19 required ICU admission (14.0% versus 8.2%, p<0.001) and died (12.6% versus 6.4%, p<0.001) more frequently compared with patients with incidental SARS-CoV-2. Compared to case classification by clinicians, the CDC algorithm had a sensitivity of 82.9% (711/858, 95% CI 80.3%, 85.4%) and specificity of 98.1% (778/793, 95% CI 97.2%, 99.1%) for COVID-19-related admissions and underestimated COVID-19 attributable hospital days. The Massachusetts classification had a sensitivity of 60.5% (519/858, 95% CI 57.2%, 63.8%) and specificity of 78.6% (623/793, 95% CI 75.7%, 81.4%) for COVID-19-related admissions, underestimating total number of hospital and ICU bed days while overestimating COVID-19-related intubations, ICU admissions, and deaths. CONCLUSION: Half of SARS-CoV-2 hospitalizations were for COVID-19 during the Omicron wave. The CDC algorithm was more specific and sensitive than the Massachusetts classification, but underestimated the burden of COVID-19 admissions. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04702945.

Diagnostic yield of screening for SARS-CoV-2 among patients admitted to hospital for alternate diagnoses: an observational cohort study.

OBJECTIVES: To determine the diagnostic yield of screening patients for SARS-CoV-2 who were admitted with a diagnosis unrelated to COVID-19 and to identify risk factors for positive tests. DESIGN: Cohort from the Canadian COVID-19 Emergency Department Rapid Response Network registry. SETTING: 30 acute care hospitals across Canada. PARTICIPANTS: Patients hospitalised for non-COVID-19-related diagnoses who were tested for SARS-CoV-2 between 1 March and 29 December 2020. MAIN OUTCOME: Positive nucleic acid amplification test for SARS-CoV-2. OUTCOME MEASURE: Diagnostic yield. RESULTS: We enrolled 15 690 consecutive eligible adults who were admitted to hospital without clinically suspected COVID-19. Among these patients, 122 tested positive for COVID-19, resulting in a diagnostic yield of 0.8% (95% CI 0.64% to 0.92%). Factors associated with a positive test included presence of fever, being a healthcare worker, having a positive household contact or institutional exposure, and living in an area with higher 7-day average incident COVID-19 cases. CONCLUSIONS: Universal screening of hospitalised patients for COVID-19 across two pandemic waves had a low diagnostic yield and should be informed by individual-level risk assessment in addition to regional COVID-19 prevalence. TRIAL REGISTRATION NUMBER: NCT04702945.

Development of the Canadian COVID-19 Emergency Department Rapid Response Network population-based registry: a methodology study.

BACKGROUND: Emergency physicians lack high-quality evidence for many diagnostic and treatment decisions made for patients with suspected or confirmed coronavirus disease 2019 (COVID-19). Our objective is to describe the methods used to collect and ensure the data quality of a multicentre registry of patients presenting to the emergency department with suspected or confirmed COVID-19. METHODS: This methodology study describes a population-based registry that has been enrolling consecutive patients presenting to the emergency department with suspected or confirmed COVID-19 since Mar. 1, 2020. Most data are collected from retrospective chart review. Phone follow-up with patients at 30 days captures the World Health Organization clinical improvement scale and contextual, social and cultural variables. Phone follow-up also captures patient-reported quality of life using the Veterans Rand 12-Item Health Survey at 30 days, 60 days, 6 months and 12 months. Fifty participating emergency departments from 8 provinces in Canada currently enrol patients into the registry. INTERPRETATION: Data from the registry of the Canadian COVID-19 Emergency Department Rapid Response Network will be used to derive and validate clinical decision rules to inform clinical decision-making, describe the natural history of the disease, evaluate COVID-19 diagnostic tests and establish the real-world effectiveness of treatments and vaccines, including in populations that are excluded or underrepresented in clinical trials. This registry has the potential to generate scientific evidence to inform our pandemic response, and to serve as a model for the rapid implementation of population-based data collection protocols for future public health emergencies. TRIAL REGISTRATION: Clinicaltrials.gov, no. NCT04702945.

Prospective Evaluation of Point-of-Care Ultrasound at a Remote, Multi-Day Music Festival.

IntroductionPoint-of-Care Ultrasound (POCUS) has become an important diagnostic tool for hospital-based clinicians. This study assesses the role of POCUS at Pemberton Music Festival 2016 (Pemberton, British Columbia [BC], Canada), a remote mass gathering where physicians face limited resources, complex disposition decisions, and a dynamic clinical environment. OBJECTIVES: This study prospectively evaluated the impact of POCUS on patient diagnosis, management, and disposition based on the self-report of the study physicians. The authors hypothesized that having ultrasound available for use would aid in diagnostic and management decisions and would reduce the need to transfer patients off-site to other health care facilities, reducing impact on the acute health services in the host community. METHODS: A handheld ultrasound was available for use by physicians in the main medical tent. All participating physicians self-reported their training and comfort using POCUS. After each POCUS scan, physicians completed a survey and recorded the indication for use, scans performed, and impact on patient diagnosis, management, and disposition. RESULTS: In total, POCUS was used on 28 of the 686 patients treated in the main medical tent; POCUS was reported to narrow the differential diagnosis in 64% of cases and altered the working diagnosis in 21% of cases. Its use changed the management plan in 39% of patients. Its use was reported to reduce the burden on broader health care resource utilization in 46% of cases and prevented ambulance transport off-site in 32% of cases (nine cases in total). This corresponded to an absolute risk reduction of 1.3% for the percentage of patients transferred to hospital (PPTH; relative risk reduction of 53%). CONCLUSION: Physicians reported that POCUS improved the diagnosis, management, and disposition of select patients at a remote, multi-day music festival. Also, POCUS reduced ambulance transfers off-site and reduced the perceived burden on broader health care utilization. PragerR, SedgwickC, LundA, KimD, HoB, StachuraM, GutmanS. Prospective evaluation of point-of-care ultrasound at a remote, multi-day music festival. Prehosp Disaster Med. 2018;33(5):484-489.

Evaluation of a point-of-care ultrasound scan list in a resource-limited emergency centre in Addis Ababa Ethiopia.

INTRODUCTION: Emergency centres (EC) in low- and middle-income countries often have limited diagnostic imaging capabilities. Point-of-care ultrasound (POCUS) is used in high-income countries to diagnose and guide treatment of life-threatening conditions. This study aims to identify high impact POCUS scans most relevant to practice in an Ethiopian EC. METHODS: A prospective observational study where patients presenting to Tikur Anbessa Specialized Hospital EC in Addis Ababa were eligible for inclusion. Physicians referred patients with a clinical indication for POCUS from a pre-determined 15-scan list. Scans were performed and interpreted, at the bedside, by qualified emergency physicians with POCUS training. RESULTS: A convenience sample of 118 patients with clinical indications for POCUS was enrolled. The mean age was 35 years and 42% were female. In total, 338 scans were performed for 145 indications in 118 patients. The most common scans performed were pericardial (n = 78; 23%), abdominal free fluid (n = 73; 22%), pleural effusion/haemothorax (n = 51; 15%), inferior vena cava (n = 43; 13%), pneumothorax (n = 38; 11%), and global cardiac activity (n = 25; 7%). One hundred and twelve (95%) POCUS scans provided clinically useful information. In 53 (45%) patients, ultrasound findings changed patient management plans by altering the working diagnosis (n = 32; 27%), resulting in a new treatment intervention (n = 28; 24%), resulting in a procedure/surgical intervention (n = 17; 14%) leading to consultation with a specialist (n = 16; 14%), and/or changing a disposition decision (n = 9; 8%). DISCUSSION: In this urban, low-resource, academic EC in Ethiopia, POCUS provided clinically relevant information for patient management, particularly for polytrauma, undifferentiated shock and undifferentiated dyspnea. Results have subsequently been used to develop a locally relevant emergency department ultrasound curriculum for Ethiopia's first emergency medicine residency program.

A comparison of the supraclavicular and infraclavicular views for imaging the subclavian vein with ultrasound.

INTRODUCTION: Ultrasound guidance for central line placement in the subclavian vein (SCV) is more efficient and safer than landmark-based technique. The supraclavicular (SC) approach is an alternative to the infraclavicular (IC) approach, but the research is sparse. The objective was to determine which approach provides the best view. METHODS: This was a prospective anatomical survey of voluntary normovolemic patients. Four experienced emergency physicians and 1 resident scanned the right and left SCVs from SC and IC approaches. They assigned a score for the views obtained on a 5-point Likert scale. RESULTS: Ninety-eight patients were enrolled. Mean Likert scores for the 4 views were: right SC, 4.06 (95% confidence interval [CI], 0.22); right IC, 3.07 (95% CI, 0.25); left SC, 3.82 (95% CI, 0.23); left IC, 3.12 (95% CI, 0.25). When combining data from right and left, the mean score for the SC view was significantly higher than the mean score for the IC view: 3.94 (95% CI, 0.16) vs 3.10 (95% CI, 0.18). The following ratings were obtained: right SC view was good or excellent in 71.5%; left SC view was good or excellent in 66.3%; right IC view was good or excellent in 37.8%; and left IC view was good or excellent in 38.8%. CONCLUSION: The SC approach allows for a better view of the SCV on ultrasound than the IC approach. Future research should determine if this translates to a greater success rate when placing central lines in the SCV.