Introduction
COVID-19 has and continues to transform the house of medicine and has had a significant impact on the field of Emergency Medicine (EM). There is not an aspect of EM from patient demographics and volume to emergency medicine services, clinical care, staffing, education, research, and safety and quality initiatives that the pandemic has not affected. During the height of the pandemic, Emergency Department (ED) volumes across the United States dropped by 50% and even by April 2021 volumes remained 20% below pre-COVID levels.1 The greatest reductions in volume have been in the pediatric population and minor illness and injury presentations.2 During the height of the pandemic there was a significant reduction in all types of ED patients including stroke and acute myocardial infarctions thereby leading to higher than normal prehospital deaths and higher acuity presentation volumes to the ED. Many of these changes are likely to permanently alter the role of EM in the healthcare system.
When COVID-19 began, the healthcare community underestimated its severity and responded using plans built for a Flu pandemic (US Department of Health and Human Services Pandemic Flu Plan/CDC Response Framework).3 Stockpiles of personal protective equipment (PPE) that were accumulated during the Ebola presentation, years before, were depleted or out of date. There was great difficulty purchasing PPE, and producers were hampered by disruptions in supply chains which created limited access of respirator masks and gowns. This made access to PPE for frontline workers very difficult and often individual groups and persons began to rely on a privatized access to PPE.
The healthcare community did not recognize or act on many aspects of COVID-19, including the role of asymptomatic spread, the mortality rate to high-risk patients, or the route of transmission, and thereby the appropriate PPE, to prevent contraction. Early in the pandemic the country was without adequate testing capabilities, contact tracing, and other public health interventions which lead to wide, fast spread of the disease. Initial guidance by the CDC was focused on droplet transmission of COVID-19 and in fact it was not until March of 2021 that the CDC recognized the risk of aerosol transmission. It was also not until March 2021 that the CDC revised its position and stated that fomites were a rare risk of transmission and deep cleaning was not necessary to ensure safety.4 For a year the concerns related to cleaning and ensuring safety created logistical delays for patients needing admission and at time even increased waiting times in the ED secondary to lack of available rooms.
Many EDs have reported significant increases in overdoses, alcohol-related illness, and psychiatric conditions including suicidal ideation, anxiety, and depression. Stress on ED personnel working with COVID patients led to burnout, staffing difficulties, posttraumatic stress disorder, anxiety, and depression. The closing of schools added to this burden for many healthcare workers trying to care for ED patients and their families. Witnessing the volume of deaths, and the impersonal nature of such events since family and friends were not allowed to visit or be present, further added to the mental strain on all of us.
In this chapter we aim to review the major key aspects of COVID-19 as well as specifically addressing its affects and developments on Emergency Medical Services (EMSs), Pediatrics, and our Obstetric populations.
Emergency Department Facilities and PPE
Most EDs have limited numbers of negative pressure rooms and designated areas for infectious disease. These areas in many facilities were rapidly overwhelmed, and EDs explored opportunities to add additional rooms, created negative pressure or positive pressure areas of departments, and, in some cases, were able to turn the entire ED into a negative pressure environment. Open bay bed designs created challenges to minimize the risk of transmission for COVID patients in the ED. As cases increased the entire ED in most facilities was considered a high-risk area and all patients were treated as potential COVID patients regardless of their presenting complaints. This was embraced as we learned of the numbers of asymptomatic COVID patients and the delay in symptoms despite active COVID infection.
The risk of exposure and lack of understanding of the transmission of the disease challenged all of us. There were severe shortages of PPE in many EDs. Concerns about transmission and frequently changing CDC recommendations forced us to adjust accordingly. Recommended N95 respirators were in such limited supply that they were rationed and used for up to a week. Subsequent studies have shown they degrade and should not be used for more than 2 to 3 days.5 Extending the use of N95 masks included sterilization with UV light systems which initially was thought to allow use for up to 30 days but subsequent studies have disproven this.6 Sterilization with hydrogen peroxide systems were given emergency use authorization (EUA) but later studies showed degradation of the integrity of masks and the EUA was rescinded a year later in May 2021.
Recommendations for “deep cleaning” of surfaces and rooms challenged the ED in many ways. Rooms required hours of cleaning by environmental services that were already strained with the challenges of cleaning inpatient rooms. ED rooms were not able to be efficiently utilized due to this slow turnover. This was exacerbated by prolonged holding of patients in the ED while waiting for inpatient rooms to be cleaned.
Intensive care units (ICUs) were overwhelmed and this forced EDs to provide prolonged ICU care for many patients being held in the ED waiting for inpatient rooms. ICUs were greatly expanded and in many institutions ED personnel were utilized to support this expansion. This was also true for non-ICU patients and hospitalist services. Multiple EDs utilized their clinicians to create inpatient teams for patients that were holding to assure they would receive adequate care.
Since we could not ensure a safe environment and provide appropriate PPE for all of our normal ED personnel and visitors, attempts were made to mitigate these issues. Visitation at most hospitals were restricted or eliminated. This created great challenges in communication with the patient’s family and friends. Telephones, IPad, internet, and many other technologic solutions were employed to help with these challenges.
Nonessential personnel were removed from the ED or performed their jobs remotely. Students were not allowed to rotate in the ED clinical areas. Secretaries and scribes were often able to perform their jobs remotely. Many consultants were reluctant to come to the ED which resulted in the expansion of the ED physicians’ authority and decision-making abilities. Routine and nonemergent consultations were greatly reduced. Consultants used telemedicine and technology to provide input by assessing patients remotely.
Work as a frontline clinician came with significant risk: healthcare workers were three times more likely to be infected with COVID-19 compared to the general public. This high infectivity rate was likely exacerbated by PPE shortages during the initial phases of the pandemic, with many healthcare workers either having inadequate PPE or being forced to reuse their equipment well beyond its intended use. Emergency providers and ICU critical care providers had the highest rate of COVID illness.7
COVID-19 and Emergency Department Expansion and Triage
As more COVID hotspots burned throughout the world and the manufacturing and supply chain of PPE, life-saving supplies, cleaning products, ventilators, and availability of hospital beds were stressed to a breaking point, it became essential to implement new triage systems to spread these scarce resources throughout the hospitals in these communities. Though overall ED volume was down across the world, there became an obvious need to find space to treat COVID positive and patients under investigation (PUIs) safely. A separation between PUI and Co-COVID (+) patients and “clean” patients allowed providers to wear continuous PPE and thereby decreased waste, as well as decreased exposure to patients that presented to the ED for non-COVID complaints. Screening questions initially focused on travel to endemic areas, exposure risk, and signs and symptoms of COVID. As the pandemic progressed and community spread became rampant, travel history, and exposure often became irrelevant and difficult to track. Even symptomology became unreliable, as it was determined by the CDC that the virus may take 2 weeks to present symptomatically. Thus, in addition to the prehospital telephone triage systems, to attempt to keep worried well patients at home, EDs revamped physical structures, triage operations, and even staffing models to continue providing care.
One of the most notorious COVID hotspots early in the COVID pandemic was New York City. New York Presbyterian Hospital–Weill Cornell Medical Center (NYP-WCMC), an urban academic level 1 trauma center, reconfigured both physical structures and their triage process to expand the number of adult COVID patients they could see on a daily basis. Like many other hospitals, NYP-WCMC utilized the precipitous drop-off in pediatric ED volume to reconfigure professional emergency management (PEM)-designated areas into adult COVID areas. Pediatric-designated resuscitation bays and negative pressure rooms were turned into treatment and holding areas for adult COVID patients awaiting beds. With this additional space and additional PEM providers available to staff them, a triage nurse would assign adult patients up to their 35th birthday to be evaluated by PEM providers in pediatric areas. Patients who were intoxicated, incarcerated, critically ill, or in respiratory failure were excluded and triaged to the adult ED to be evaluated by an adult ED provider. Pediatric patients continued to also be managed by these PEM providers.8
Many hospitals acted in a similar manner to divide their existing EDs into COVID spaces and “clean” areas and implemented triage processes to determine which patients would be seen in each area. The Sheba Medical Center in Tel Hashomer, Israel divided their existing ED into both an advanced Biologic ED and a regular non-COVID ED, and then created a novel triage system to determine which of the EDs a patient would be evaluated in.9 A professional triage nurse in full PPE would evaluate a patient at the door and directed patients to each ED section based on epidemiology, medical history, and clinical manifestations. The biologic ED was subdivided further based on the presence of symptomology and severity of illness. Many other institutions have devised similar severity of illness triage models (Fig. 14.1).110
Fig. 14.1 Patient flow within the hospitals from presentation through assessment to final disposition. Disposition based on risk factors and clinical presentation, Green (minor), yellow (moderate) and red (immediate) triage codes based on local emergency department triage protocol. Abbreviations. CXR, chest X-ray; BA bronchial aspirate; BAL, bronchoalveolar lavage; CT, computed tomography; ICU, intensive care unit.110
Hospitals without the physical space to subdivide into COVID EDs were forced to create temporary structures to accommodate this. These structures varied from army-style disaster tents to hospital cafeterias, and even covered parking garages. EDs utilized these facilities differently with some using them for triage, or as screening and testing facilities, or as additional treatment areas for less sick patients. In many cases, these areas were an integral part of a new extended triage process such as that developed in Israel. The Robert Wood Johnson Barnabas Hospital system in New Jersey utilized a series of tents at each individual hospital site to perform medical screening and evaluations on potential COVID patients. Patients that were extremely hypoxic, critically ill, or requiring admission were immediately transferred to internal COVID areas in the ED. Most were screened and discharged to quarantine with or without testing. Tents allowed faster movement of patients in and out of one-way screening areas with decreased wait times in a safe, climate-controlled area outside of the waiting rooms. All staff in the tent areas remained in full PPE and would be decontaminated with wipes upon leaving the tent. Wheelchairs and one stretcher were also available inside these tents in case a patient decompensated or needed to be moved into the main ED.
Vanderbilt University Medical Center in Nashville, Tennessee converted a covered parking garage into an additional treatment pod, called an “E-Pod,” where COVID patients were sent to have medical work-ups performed.10 In E-Pod, like a tent, COVID patients were most often tested and discharged to home, allowing decreased exposure to other patients and staff. Both examples required power, oxygen, and integration with the electronic medical record (EMR) to be developed for both charting and visibility of patients in these areas. Vanderbilt also developed an extended triage program prior to assigning patients to the E-Pod in an attempt to capture specific high-risk patients with chest pain, hypoxia, or tachypnea from presenting to that area (Fig. 14.2).10
Signs, Symptoms, and Testing
The signs and symptoms of COVID-19 varied widely on presentations to the ED from asymptomatic to mild headaches to severe respiratory failure and cardiac collapse. Since COVID-19 symptoms overlap with many other illnesses, it is important to have specific testing that is rapid and reliable for ED patients. This is also true because up to 40% of COVID patients are asymptomatic and all ED patients being admitted need to be screened.11 Early in the pandemic, the availability of testing was scarce and turnaround time for results was extensive. Therefore, the clinician’s judgement was relied upon to consider each patient as low risk or high risk for having the disease based upon their presentations and other diagnostics. Those at high risk were, and still, are termed patients under investigation (PUI) for COVID-19 and were placed on airborne and contact isolation, assumed to have and treated for the disease until definitive testing could be obtained (Table 14.1).
Pale, ray, or blue-colored skin, lips, or nail beds, depending on skin tone | |
Directly testing for COVID was not widely available for several months in the early portions of the pandemic. Results were often delayed for more than a week which did not help in contact tracing or the management of patients in our hospitals. After several months, point of care (POC) polymerase chain reaction (PCR) testing for COVID became the standard but limits of tests and reagents meant that this was not readily available for most EDs for several months.12
Currently, there are point of care (POC) COVID PCR tests that can determine if there is an active infection by identifying the presence of COVID RNA in 15 to 20 minutes. These tests provide answers with acceptable sensitivity and specificity to be routinely used to help diagnose and appropriately place or disposition patients in the ED (Table 14.2).
Abbreviations: CI, confidence interval; NPV, negative predictive value; PPV, positive predictive value; RNA, ribonucleic acid; RT-PCR, reverse transcriptase polymerase chain reaction.
Other basic types of COVID tests less commonly ordered in EDs include viral antigen detection which also indicates active infection, and the detection of antibodies to the virus. Antibody tests provide evidence of prior infection with SARS-CoV-2 (Table 14.2). The CDC and FDA advise against the use of antibody tests for the diagnosis of acute infection.12 Antigen tests are less sensitive than RNA detection with a meta-analysis showing the average sensitivity as 56.2%.13,14
Laboratory diagnostics routinely ordered expanded to include signs of inflammatory response, coagulopathies, and organ failure. Studies routinely ordered included CBC, chemistry panel, liver enzymes, blood urea nitrogen (BUN), creatinine, troponin, d-dimer, fibrinogen, and C-reactive protein (CRP).
The findings associated with COVID infection included high or low white blood cells (WBCs), lymphocytosis, elevated creatinine, elevated liver enzymes, as well as elevated troponin, d-dimer, and CRP. Clinically, these findings increased the likelihood of active infection. Many of these tests also seemed associated with the severity of disease and in many hospitals help to direct treatment utilization of steroids and anticoagulation.
Chest X-ray findings for COVID were typically multifocal and ground-glass opacities and consolidations with peripheral and basal predominance. However, the diagnosis based off chest X-ray (CXR) was limited and found to only have a sensitivity of 69%.14,15
Computed tomography (CT) scanning also displayed bilateral and peripheral ground-glass and consolidative pulmonary opacities. They were more sensitive than CXR but the time, logistics, and risks of transmission to further personnel and patients all limited routine adoption of CT scan to confirm COVID illness. Additionally, early in the disease process (3–5 days) up to 56% of patients had no findings on CT scan.16 computed tomographic angiography (CATs) were routinely used to identify pulmonary emboli which occurred as a complication of COVID illness.
Ultrasound findings at the bedside showed B lines and added to the sensitivity of clinical assessment and CXR findings. US was frequently used by Emergency Physicians (EPs) to assist in the evaluation of patients. Combining US with clinical assessment showed improved sensitivity and negative predictive value 94.4% vs. 80.4% for PCR testing alone.17
Treatment
Early in the pandemic, there were no specific treatments available for patients who were diagnosed with COVID-19 infections. EM physicians provided supportive care and were given the responsibility of identifying which patients were safe to go home, which may decompensate, and which were sick enough to require hospitalization. One of the first methods used to identify which patients needed to be hospitalized was their oxygenation saturation. Patients with oxygen saturation levels of 92 to 94% on room air required supplemental oxygen and therefore were admitted to the hospital.18 As the number of patients meeting this criteria increased, many hospitals developed coordinated care systems to provide oxygen and pulse oximetry at home to decrease the number of patients requiring admission. These patients were followed closely with Telehealth or paramedicine. Another hurdle early on was that aerosolized viral particles via nebulizers, bilevel positive airway pressure (BIPAP), continuous positive airway pressure (CPAP), and noninvasive ventilation were thought to greatly increase the risk of transmission of COVID-19 to healthcare providers. Therefore, many EDs were not utilizing these means of oxygenation in patients who were high risk or confirmed cases of COVID-19. This led to many more patients being treated with mechanical ventilation and managed similar to acute respiratory distress syndrome (ARDS). As a result, there was an increased need for ICU beds, a shortage of ventilators, and intensivists. This management was also found to be associated with a higher mortality rate.19
As the pandemic continued and more and more data was collected and analyzed, it was found that the risks of aerosolization through methods of oxygenation such as nebulizers and BIPAP were exaggerated. As long as the patient care team wore appropriate PPE there was no increased risk of transmission of viral particles. Once the successfulness of PPE was demonstrated, strategies changed to try to avoid intubation in these patients and utilize other methods of oxygenation. Interventions such as supplemental oxygen, high flow oxygen, BIPAP, and proning, in conjunction with supportive care, were shown to have better outcomes.20 If tolerated, proning patients became routine as patients were better able to maintain oxygenation. In addition to avoiding aggressive, early intubation, aggressive fluid resuscitation was also associated with poorer outcomes. In terms of treating fever and the severe body aches commonly accompanying COVID-19 infection, nonsteroidal anti-inflammatory drugs (NSAIDs) were implicated early by the French Health Ministry and therefore avoided whenever possible. However, later research found that the use of NSAIDs did not result in worse outcomes. After adjusting for confounders, in-hospital mortality for patients who were taking NSAIDs prior to admission was no different from those who were not (matched OR 0.95, 95% CI 0.84–1.07).21 NSAID use was also not associated with critical care admission (matched OR 0.96, 95% CI 0.80–1.17) or noninvasive ventilation (matched OR 1.12, 95% CI 0.96–1.32).21
Disposition decisions evolved throughout the pandemic. Initially, many patients with suspected COVID were admitted for supportive care. As facilities were overwhelmed, physicians were forced to become more selective when determining who should be admitted for hospitalization. Risk factors for progression to severe disease were used to stratify these patients and included age, obesity, comorbidities, such as hypertension, coronary artery disease, diabetes mellitus, as well as lab abnormalities (Fig. 14.3). American College of Emergency Physicians (ACEP) developed an evidence-based tool to help assess the risk of developing severe disease in order to aid in this complex decision-making process.24 Once intravenous (IV) treatments became available, the decision to admit was also determined based on whether or not the patient met criteria for these IV therapies. These treatments included IV steroids, remdesevir, tocilizumab, as well as anticoagulation. The cornerstone of treatment of hospitalized COVID patients focused on maintaining oxygenation in the face of hyperinflammatory respiratory failure.23
Fig. 14.3 TPopulations at risk— modified from the American College of Emergency Physicians (ACEP) COVID-19 field guide.24
Fig. 14.4 The New Jersey Triage to Home Protocol. Put into place by waivers, this protocol allowed patients who met criteria to be triaged to home to convalesce instead of being transported to the Emergency Department in order to decrease exposure to Emergency Medical Service (EMS) providers and preserve limited resources when New Jersey was a hotspot for COVID-19.55–56
In the beginning of the pandemic, there was great uncertainty in regard to treatment modalities. Some of the medical community adhered to evidence-based strategies until studies could provide adequate information to direct treatment. Studies for treatments embraced adaptive study designs to accelerate information and guidance for clinicians. Other providers embraced treatment modalities that were based on the ever-evolving understanding of the pathophysiology of the disease process and extrapolation of possible treatments for critically ill patients. Despite numerous studies investigating potential treatments, there has not been a single agent or combination therapy that has been shown to be a cure for COVID-19. However, there continues to be incremental progress and an evolution of our understanding of the disease and how to treat it effectively. With the continued research and development of treatment strategies, it seems inevitable that we will be using newer, more effective agents and strategies over the next few years.
The first attempts at treating patients with COVID-19 infection used existing antiviral therapies in hopes of reducing the severity of infection and in some cases lower risk of becoming infected. These antivirals included drugs such as hydroxychloroquine, ivermectin, colchicine, remdesivir, and a few others used in cancer treatment.26 There was never any strong evidence to support utilization of these drugs unless it was in a select patient population or very early in the course of the illness. However, even under those circumstances, it remained controversial and under further investigation. Remdesivir was approved in October 2020 under an EUA by the FDA. Remdesivir became and remains routinely used in hospitalized patients as it has demonstrated benefits in patients requiring supplemental oxygen, especially when used in conjunction with dexamethasone. It has not shown significant benefit in critically ill patients requiring mechanical ventilation or in mild disease.25
The hyperinflammatory respiratory failure caused by COVID-19 infection led to the investigation of many anti-inflammatory drugs. The most severely ill COVID-19 patients had progressive hyperinflammatory responses with cytokine storm. Dexamethasone and other steroid treatments were some of the first treatments to demonstrate a significant impact on outcome for patients with moderate-to-severe disease. Dexamethasone was the first treatment that showed significant clinical benefit in improving severity of illness and mortality in hospitalized patients requiring supplemental oxygen.25 The use of dexamethasone was widely adopted by EPs and is routinely administered in the ED. Dexamethasone is recommended in conjunction with remdesevir in patients requiring supplemental oxygenation. If remdesivir is unavailable at a facility, dexamethasone is recommended to be given alone. If dexamethasone is unavailable, other glucocorticoids may be used. The RECOVERY trial demonstrated that dexamethasone decreased mortality by 35% in patients requiring mechanical ventilation. Incidence of death was significantly lower for patients in the dexamethasone group who received mechanical ventilation versus those receiving usual care (29.3% vs. 41.4%, RR 0.64, 95% CI 0.51–0.81) and those receiving supplemental oxygen without mechanical ventilation (23.3% vs. 26.2%, RR 0.82, 95% CI 0.72–0.94).25 Mortality decreased for all hospitalized patients who were treated with dexamethasone.25 The use of these medications in the ED is determined at a local level and coordinated with physicians that will manage these patients once they are hospitalized. Some institutions have developed clinical pathways or guidelines to integrate care and determine which treatments will be initiated in the ED and which will be started by the admitting physicians.
In addition to corticosteroids, the national institutes of health (NIH) does recommend the use of other anti-inflammatory agents under certain conditions. Tocilizumab (Actrema), an IL-6 inhibitor, is an anti-inflammatory agent that is recommended for use in conjunction with dexamethasone in hospitalized patients showing rapid respiratory decompensation.25 However, it is rarely administered in the ED and should be coordinated with the admission team when its use is being considered. Tocilizumab should be avoided in immunocompromised patients. Other anti-inflammatory agents such as baricitinib, a JAK-inhibitor, were found to be beneficial when used in conjunction with remdesivir. The NIH recommends remdesivir be used in conjunction with baricitinib, if other corticosteroids cannot be used.26
Another approach initiated early on in the treatment of COVID-19 included passive immunization using neutralizing antibodies in convalescent serum. Convalescent plasma received an EUA from the FDA to treat hospitalized patients with COVID-19 infection. However, this approach was limited by availability and the difficulty in determining the appropriate concentration of neutralizing antibodies. Clinicians were rarely able to determine if the plasma available had a high enough titer with adequate antibodies to be effective against the disease. When there were adequate antibodies, effectiveness was demonstrated; however, it appeared to be more effective when it was administered to patients earlier in the disease process. The EUA was narrowed in February to specify the use of only high-titer plasma. The development of monoclonal antibodies allowed for much higher doses of effective antibodies to be used, and therefore convalescent serum is rarely used anymore. The NIH guidelines recommend against the use of convalescent plasma for hospitalized patients without impaired immunity, who are mechanically ventilated.26 These guidelines also recommend against the use of high-titer plasma for hospitalized, nonvented patients, unless they are enrolled in a clinical trial.26 The NIH states that there is insufficient data to recommend for or against the treatment with convalescent plasma in patients with impaired immunity. The NIH also states there is insufficient evidence to make recommendations regarding the use of plasma in nonhospitalized patients.28
Monoclonal antibodies are administered intravenously and recommended in patients with mild-to-moderate disease with risk factors for progression to severe disease or at high risk for the development of complications from COVID-19. Monoclonal antibodies effectively block the replication cycle of COVID-19 and are most effective early in the course of infection when viral particles are replicating, during the first 10 days of symptoms. The BLAZE-1 trial showed an 87% reduction in hospitalization or death when selected patients at high risk for disease progression were given bamlanivimab.29 Initially, the FDA gave an EUA for the use of bamlanivimab for outpatients with mild-to-moderate illness who did not require supplemental oxygen or hospitalization. The development of SARS-CoV-2 variants decreased the efficacy of using a single monoclonal antibody and increased the risks of further mutations. On April 16, 2021, the FDA removed the EUA for single antibody use, but continues to recommend the use of bamlanivimab in combination with a second antibody such as etesevimab, which was given an EUA in February 2021.30 The FDA also recommends the combination of casirivimab and imdevimab (REGEN-COV), which was given an EUA in November 2020. A study showed that REGEN-COV provided 72% protection against symptomatic infections in the first week and 93% protection in the following weeks. In patients who had moderate disease, REGEN-COV was shown to help clear the infection faster. Patients with symptomatic COVID-19 recovered in 1 week as compared to 3 weeks in patients who did not receive this antibody combination.31 In the study, none of the patients who received REGEN-COV were hospitalized over the course of 29 days. Adverse events were reported in 29% of patients receiving the placebo and in 20% of patients who received the actual treatment.31 There are other monoclonal antibodies and combinations of antibodies under development. In June 2021, the FDA authorized the monoclonal antibody, sotrovimab, for emergency use. In terms of administering monoclonal antibodies, most EDs try to identify patients that qualify for treatment and coordinate care with an outpatient infusion center. However, some EDs administer treatments in the ED or in observation areas and then discharge patients home. The patients are identified if they meet certain criteria based on age and comorbidities, do not require supplemental oxygen, and are stable to be discharged home after administration. RWJBarnabas Health instituted one such system in their EDs utilizing specific criteria.
COVID-19 disease has shown to be a hypercoagulable state and the associated thrombosis in hospitalized patients includes deep venous vein thrombosis (DVT), pulmonary embolus (PE), acute myocardial infarction (AMI), stroke, and more unusual blood clots. Many EPs consider initiating anticoagulation for high-risk hospitalized COVID-19 patients. The NIH recommends prophylactic anticoagulation for all hospitalized, nonpregnant, adult patients.26 Some trials have shown that full anticoagulation does not improve clinical outcomes and mortality in ICU patients and those on mechanical ventilation without evidence of acute thromboembolic disease, leading to bleeding events and inferior outcomes.32 However, other studies have associated systemic anticoagulation with heparin with better outcomes. There remains controversy over the use of full anticoagulation versus prophylaxis for hospitalized patients.33 Many EPs administer lovenox in the ED for high-risk patients. Choosing full anticoagulation versus prophylaxis is usually coordinated with the admitting physicians. NIH recommends against anticoagulation in the outpatient setting.26 The development of platelet-laden clots in the microcirculation of patients infected with COVID-19 has led some clinicians to recommend aspirin therapy in the outpatient setting. One study by Chow showed that patients treated with aspirin were less likely to need mechanical ventilation (35.7% vs. 48.4%) and ICU admission (38.8% vs. 41%) than patients who did not receive aspirin.34 Furthermore, after multivariable adjustment for nine confounding variables, aspirin was independently associated with a reduced risk of mechanical ventilation, ICU admission, and in-hospital mortality. The use of aspirin should depend on a clinical decision made by EPs based on a risk versus benefit analysis. The NIH has not made any recommendations regarding this yet.
EPs frequently have to decide what outpatient treatment, if any, they would recommend in patients with mild-to-moderate COVID-19 infection. Given the lack of strong evidence, some physicians are uncomfortable with making such recommendations. When recommendations are made, it should be part of the standard shared decision-making that physicians use when there is significant uncertainty. Most physicians also incorporate the current practices of their medical community and attempt to coordinate care with patients’ primary care physicians. Hydroxychloroquine was one of the first drugs that was being considered for treatment early on in the pandemic. The FDA granted an EUA in March 2020, but rescinded it in June following studies that showed no benefit. The RECOVERY trial showed that the use of hydroxychloroquine did not reduce mortality in hospitalized patients.37 Another clinical trial in the NEJM found that hydroxychloroquine with or without azithromycin did not improve outcomes for hospitalized patients with mild to moderate COVID-19 infection after 15 days.111 A retrospective cohort study demonstrated improved survival rates among patients treated with hydroxychloroquine, but the study did not account for confounding variables including ICU admission differences and dexamethasone use.36 Many of the negative clinical trials enrolled hospitalized patients later in the course of disease when an antiviral therapy would not be expected to be effective. There have been prospective trials that have shown benefit if used very early on in the course of the disease and when used at the appropriate dose. Both the WHO and the NIH recommend against the use of hydroxychloroquine, with or without azithromycin. It is rarely prescribed by EPs. Ivermectin is an antiparasitic drug that inhibits SARS-CoV-2 replication cell cultures. However, according to the NIH, achieving the plasma concentrations necessary to achieve antiviral efficacy against the virus may require doses much higher than the dose approved for use in humans.26 The NIH changed its recommendation from “against” use in COVID-19 to there is “insufficient data” to recommend for or against use in January 2021. Ivermectin has been used as an antiviral early in the disease process and when there has been COVID-19 exposures in many areas of the world.26,35 There is emerging evidence of its efficacy when used in this manner. It is occasionally prescribed by EPs.35
Vitamins and supplements have been used in the treatment of COVID-19 infection with the rationale of providing supportive and therapeutic levels to support a patient’s immune system. This included vitamin C, D, and other agents such as zinc, which were associated with improved outcomes. There are several ongoing clinical trials evaluating the efficacy of vitamin C (ascorbic acid) in COVID-19; however, the NIH currently states that there is insufficient data to recommend for or against its use.26 The NIH also states that there is insufficient data to recommend for or against the use of vitamin D in COVID-19. In regards to zinc, the NIH states that there is insufficient data to recommend for or against its use, and it also recommends against supplementation above the recommended dietary allowed for prevention of COVID-19, except if in a clinical trial.26
Other drugs of various classes have been considered in the outpatient treatment of COVID-19. Protease inhibitors such as lopinavir/ritonavir and other HIV protease inhibitors are not recommended by the NIH as clinical trials have not shown benefit. These drugs were studied in both the RECOVERY trial and the WHO Solidarity Trial and did not demonstrate efficacy in either.36–38 As of April 2021, the NIH recommends against the use of colchicine in the treatment of COVID-19. However, the COLCORONA trial showed improved outcomes in patients with mild illness who were treated with colchicine.39 Fluvoxamine, an selective serotonin reuptake inhibitor (SSRI), has gained some attention based on two recent studies that showed lower clinical deterioration and hospitalization in patients who were treated with it.40 One of the studies was a small, randomized controlled trial of 152 patients, published in the Journal of the American Medical Association, which showed that none of the patients taking fluvoxamine reached the primary end point of clinical deterioration compared with 8.3% of those on the placebo, and only one patient required hospitalization as compared to five patients in the placebo group.40 In a pragmatic British trial, budesonide, an inhaled corticosteroid, showed to shorten the duration of illness in patients at risk for severe disease as well as diminish rates of hospitalization or death in the outpatient setting. The NIH is yet to weigh in on this therapy.41
Ultimately, like many aspects of COVID, treatment has been variable and uncertain (Table 14.3). As clinical trials continue, treatment plans that are effective will be developed.
Recommended for patients with mild-to-moderate disease with high risk of clinical progression | |||
Recommended in conjunction with remdesivir in patients requiring supplemental oxygen; other glucocorticoids may be used if dexamethasone is unavailable; may be given alone if remdesivir not available | Recommended in conjunction with remdesivir in patients requiring supplemental oxygen; other glucocorticoids may be used if dexamethasone is unavailable; may be given alone if remdesivir not available | ||
Recommended in patients requiring supplemental oxygen; recommended to be given in conjunction with dexamethasone in patients requiring increasing amounts of oxygen | Recommended in patients requiring supplemental oxygen; recommended to be given in conjunction with dexamethasone in patients requiring increasing amounts of oxygen | ||
Recommended in conjunction with dexamethasone for rapidly decompensating patients | |||
Recommended in conjunction with remdesivir when corticosteroids cannot be used and patient’s supplemental oxygen requirements are increasing | Recommended in conjunction with remdesivir when corticosteroids cannot be used and patient’s supplemental oxygen requirements are increasing |
Vaccinations
The development of several effective vaccinations and the treatment of enough of the population have greatly reduced the number of COVID patients presenting to EDs. It has also made the ED a much safer environment for healthcare workers and other patients. In the short term, it appears that all of the vaccinations have a high safety profile. We have, however, become familiar with some of the complications of COVID vaccinations including allergic reactions, postvaccination symptoms, and unusual coagulopathies, including central venous occlusion. The healthcare system and government have worked to immunize as many people as possible and a few EDs have even participated in distributing vaccinations, especially aimed at vulnerable populations. Many of our personnel have volunteered at vaccination distribution centers and have contributed to the campaign to vaccinate patients.
COVID-19 and Emergency Medical Services and Prehospital Care
Like many other specialties in the House of Medicine, Emergency Medical Services (EMS) and Prehospital Care was greatly affected by the COVID-19 pandemic. EMS, the frontline of the frontline, saw huge changes and played a vital role in combating the COVID-19 pandemic in all parts of the world. Not only will we discuss the changes that the COVID-19 pandemic had on EMS and Prehospital Care, but we will also discuss how these changes affected the mental health and well-being of the professionals who served in these roles.
In the United States, a large portion of the data on types of emergency responses can be obtained through the National Emergency Medical Services Information System (NEMSIS) database. Several studies queried this database to make conclusions on how the types and volumes of prehospital emergencies changed in response to the declaration of the COVID-19 pandemic.
Since little had been studied on EMS call type and volume during a pandemic prior to 2020, Lerner performed a 3-year retrospective cohort analysis of NEMSIS data to quantify the general trends in EMS incidents as well as the incidence in prehospital death. The National Syndromic Surveillance Program found that from the 11th to 14th week of the year 2020, ED visits across the United States dropped from 2.5 million to 1.2 million, and anecdotally, acuity sharply increased. In places where COVID was rampant at the time (New York, New Jersey, and Puerto Rico), volumes still dropped from 223,489 to 144,249 with an increase in acuity.43 This information, combined with preliminary media reports that out-of-hospital cardiac arrest rates at the time were soaring, painted a dismal scene. It appeared that the most critically ill were avoiding emergency medical care due to the “stay at home” order or fear of exposure to the virus in an ambulance or in the hospital. Furthermore, this combination could indicate that COVID was much more prevalent in the community, resulting in an increased number of deaths faster than cases could be reported due to lack of testing availability.
PCRs between October 2–8, 2021 and May 18–24, 2021 were studied to simulate responses during flu seasons from 2017 to 2020. Results showed that overall the numbers of EMS activations from 2019 to 2020 increased from the 2017–2018 year.42 Beginning in the 10th week of 2020 (March 2–8), however, there was a sharp decrease in 9-1-1 EMS call activations compared to previous years. The weekly call volume decreased by approximately 26.1% at this time. In addition, at the 11th week (March 9–15, 2020) scene deaths nearly doubled from 1.49 to 2.77%. Conversely, EMS calls for trauma patients dropped from 18.43 to 15.27% from week 10 to week 13.42 These findings support the hypothesis that individuals during this time did not access the EMS system as frequently as they have in the past, and that those who did access the EMS system did not do so in a timely manner.3 Similar trends were noted in other countries such as Portugal and Italy, indicating that the number of prehospital cardiac arrests were increasing, but were not fully explained by COVID-positive tests alone.42–45
A similar NEMSIS study focused on the above critical patients with emergent time-sensitive cardiovascular complaints. The database was queried for cardiac rhythms suggestive of STEMI, cardiac calls, out-of-hospital cardiac arrest (ventricular tachycardia/ventricular fibrillation), asystole, and stroke alerts during the time period of January 2020 to April 2020.46 Overall, the EMS call volume decreased by 21.95% at this time. Cardiac calls, ST-segment elevation myocardial infarction (STEMI) alerts, and stroke alerts decreased significantly during this time at a higher rate than call volume did. Interestingly, EMS responses in the United States for VT/VF initially decreased from January to March but increased from March to April by 3.04% and responses for asystole increased by 27.34%.46 This trend was not noted seasonally in years prior. This supports the conclusion from the previous study that during the time of the initial “stay at home” quarantine order, individuals with acute cardiovascular conditions accessed the EMS and healthcare system less frequently, presumably from fear of exposure to COVID-19. This combined with the possibility of a pathophysiological effect on the body as a result of COVID-19 infection resulted in higher incidences of on-scene death and less favorable outcomes.46
Prior to the COVID-19 pandemic, the United States suffered from an opioid epidemic. Since 1999, 841,000 people have died from a drug overdose. In 2019, 70,630 drug overdose deaths occurred in the United States. The age-adjusted rate of overdose deaths increased by over 4% during the pandemic.47–48 Social isolation during quarantine during the COVID-19 pandemic seemed to affect not only the decision to seek timely healthcare, but also the mental health of our nation. In addition to this, those suffering from opioid use disorder may have had increased strain on their well-being due to economic distress and disruption of treatment with many opioid recovery and mental health services unavailable.
Multiple studies of EMS call volume during the COVID-19 pandemic observed an increase in both opioid overdoses and cardiac arrests from overdoses.44–48 One study was performed to determine the number of EMS responses for opioid overdoses in the 52 days before and after the initial COVID-19 state of emergency declaration in Kentucky between January 14, 2020 and April 26, 2020. There was a 17% increase in the number of EMS opioid overdose runs with transportation to an ED, and a 71% increase in overall runs with refused transportation.48
Most concerning was an increase in runs for suspected opioid overdoses, with deaths at the scene increasing by 50% during the postdeclaration period.49
The mental health of the first responders facing this increased burden of death and disease while putting their own lives at risk to interface with the public should not be ignored. Researchers out of Turkey conducted a two-part voluntary survey to determine the anxiety level of frontline EMS workers.49 After completing one part of the survey for sociodemographic information, EMS professionals completed the State Anxiety Inventory, a 20-question validated tool. Results showed that anxiety scores were significantly elevated in females and those with family members at high risk of COVID-19 infection at home. They also found that the majority of those who had family members at risk were not living in their homes and were most worried about transmitting COVID to their family.49
As EM physicians became the default experts to the COVID-19 response inside of the hospital, EMS physicians took on the unique role of coordinating community response efforts and integrating public health interests with healthcare and government stakeholders. National agencies across the country helped to support EMS physicians accomplish these goals. The National Association of EMS Physicians (NAEMSP), as well as the ACEPs all created a simple online repository of COVID-19 resources including protocols, data, and how to navigate national CARES Act relief programs that EMS physicians could easily access. NAEMSP hosted multiple virtual Town Hall meetings on ZOOM to bring cutting edge resources and data to EMS physicians in real time. ACEP also helped EMS physicians by creating Amazon Business accounts for members to have access to ordering PPE for field physicians and field staff that were in short supply. Specifically, EMS physicians took on roles of occupational health experts, EMS system resource managers, clinical practice modifications, public health response experts, and advocates.4, 50, 52
EMS physicians and EMS medical directors have always played an important role in occupational health ensuring fitness for duty and proper PPE. However, occupational health took on a primary role during the COVID-19 pandemic to keep the frontline of the frontline safe. In Seattle, a retrospective cohort investigation of laboratory positive COVID-19 patients from February 14, 2020 to March 26, 2020 showed that by instituting a program to EMS operations that identified high-risk patients and a PPE program, including masks, eye protection, gown, and gloves (MEGG), decreased documented exposures from 94 to 6%. Furthermore, less than 0.5% of EMS providers experienced a COVID-19 illness within 14 days of treating a COVID-19 positive patient. Of those that tested positive, none were directly linked to a known exposure while in full MEGG.51 EMS medical directors spent many hours developing safety protocols, including educational programs on hand-washing, decontamination, and preventing occupational exposures. As news outlets and social media continued to sensationalize COVID-19 and as information changed daily, EMS physicians played an important role in deciphering fact from fiction and distilling evolving medical knowledge and guidelines down to concise recommendations that all levels of EMS providers can implement and follow.
EMS resource managers, medical directors, and EMS physicians implemented processes to identify the likelihood of COVID exposure for first responders from the time an emergency call was made to 9-1-1 and PSAP (Public Service Answering Point) centers. This was accomplished in agencies across the country by screening questions to determine whether the patient was a PUI for COVID. This allowed responding crews to make informed decisions on PPE and the type or units of personnel responding. In addition, it was a resource to the community to allow for retrospective case tracking and exposure identification. EMS physicians had to ensure situational awareness during responses via specific dispatch protocols. In some cases, this meant drastically altering response configuration and even adjusting community standards of care when call volume overwhelmed available EMS units. Liaisons with local healthcare institutions such as group homes, nursing facilities, as well as transport destinations, such as ED directors, were crucial to determine COVID hotspots in the community and to ensure that the final destinations had the capability to care for these patients once they arrived at the hospital.50, 52
As clinical guidance from the Centers for Disease Control and Prevention (CDC) rapidly changed for EMS and fire services, EMS physicians were tasked with implementing new infection control practices and PPE protocols to protect personnel and patients alike. Some of these policies included drastic changes from standards of care and decontamination between patients. Prior to COVID, standard PPE for a cardiac arrest requiring chest compressions and intubation would include only gloves and perhaps a surgical mask with a splash shield for the provider managing the patient’s airway. This evolved into full gown or jumpsuit with an N95/P100 respirator, face shield, or Powered Air Purifying Respirator (PAPR) for aerosolizing procedures such as chest compressions or intubation.50–52
In New York state and other areas where cases and acuity overwhelmed EMS demand and availability of PPE for rescuers, clinical practice morphed from standard care to triage Crisis Standards of Care.53 In April 2020, the AMA released guidance on Crisis Standards of Care which stated that physicians have the responsibility to evaluate the risks of providing care to individual patients versus the need to be available to provide care in the future in public health emergencies. Furthermore, the AMA stated that when CPR is unlikely to provide the intended clinical benefit, and participating in resuscitation significantly increases already higher than usual risk for healthcare professionals, it may be ethically justifiable to withhold Cardio pulmonary resuscitation (CPR) without the patient’s consent.54 Translated to EMS, this meant that when responding to an out-of-hospital cardiac arrest (OHCA), CPR could be withheld or discontinued en route to the hospital by paramedics by Termination of Resuscitation Efforts (TRE). Though many EMS agencies have already been doing this for years, many more EMS agencies began to pronounce cardiac arrest patients in the field in asystole, or when efforts were deemed futile by protocols, or via Online Medical Control (OLMC), where a physician directly provides orders for paramedics to execute in the field.
Other states, such as New Jersey, adjusted both their resources and clinical practice through the use of waivers and executive orders where the standards of care and clinical practice of EMS rests in state law. As the pandemic progressed, PPE and personnel were scarce secondary to illness, exposure, and/or quarantine. This prompted many important waivers to state law to compensate for the shortage in EMS workers and included allowing any licensed emergency medical technician (EMT) or paramedic from other states to practice in the state of New Jersey.55–56 The configuration of response units was also waivered, from initially mandating 9-1-1 paramedic units to have two paramedics to a one paramedic one EMT model. The state of New Jersey also allowed expired EMTs and paramedics to re-enter the work force to expand the labor pool. A third waiver involved the “Triage to Home” protocol, which allowed paramedics to follow a stepwise path in order to refuse transport to the ED if COVID patients met certain criteria and could safely be treated at home to quarantine and convalesce (Fig. 14.4). Though several EMS agencies adopted this protocol, rarely did patients qualify to be triaged to home.55
In addition to 9-1-1 EMS units being affected, clinical practices of interfacility transport SCTU (Specialty Care Transport Units) changed as well. Interfacility transports across the country were often delayed due to the decreased availability of specialty care for nonemergent surgical procedures and treatments as well as bed availability due to the high volume of COVID patients admitted to the hospital for oxygen and ventilator support. In many areas of the country, where COVID volume was extremely heavy, many inpatient units, beds, and even cafeterias and parking lots were converted to COVID units and ICUs. Furthermore, due to the decreased volume of patients seeking care for illnesses in the ED for routine time-sensitive emergencies such as strokes, STEMI, and pediatric and adult surgical emergencies such as appendicitis, bowel perforations, and ovarian and testicular torsions, the volume of these potential emergent transfer cases decreased significantly. New protocols were put in place to determine the safety of moving one patient from one facility to another. If specific services were available and the patient was accepted for transfer, patients faced the new requirement of securing COVID testing prior to transport. This not only determined whether an appropriate bed was available at the receiving facility to avoid accidental exposure and infection but also ensured a proper unit could respond with appropriate PPE and decontamination services. In many locations, a shortage of available COVID tests made it extremely difficult if not impossible to secure a timely, emergent transfer. When testing was first available, it could take days and often involved a courier process to specialty state or county run labs at first. As more testing became available and finally, rapid testing became widespread, the logistics of transferring patients became easier.
Across the country and the world, EMS agencies developed new protocols, processes, and functions in the interest of Public Health as COVID spread to their communities through the use of community paramedicine. Community paramedicine is a fairly new and evolving concept that allows paramedics and EMTs to operate in expanded roles by assisting with public health and primary healthcare and preventive services to underserved populations in the community. The goals are to improve access to care and to avoid duplicating existing services.57
Outside of China, one of the first and largest major COVID-19 outbreaks occurred in Milan, Italy. The EMS system of the Lombardy region, where Milan is located, was the first to respond to emergency calls. The system not only handled calls for symptomatic patients but also developed protocols to adopt containment measures, and address population concerns. The Lombardy region Public-Safety Answering Point (PSAP), which typically functioned to serve the EMS systems of the area, now took on the new role of becoming COVID information call centers.58–59 The Metropolitan EMS system of Milan in this area formed a COVID-19 Response Team, made up of ten healthcare professionals and two technicians that were active around the clock. The COVID-19 Response Team developed a procedural algorithm for COVID-19 detection and community needs based on call intake to their PSAP Center (Fig. 14.5).58–59 PSAPs provided counseling to the “worried well” callers who did not meet screening criteria and were very unlikely to have COVID-19. Next, call takers would triage those symptomatic or likely infected callers to determine the appropriate prehospital response. Callers assessed the clinical conditions of those who screened positive. For those with severe respiratory or life-threatening symptoms, an ambulance was dispatched to the caller for transport. If the caller could safely quarantine at home with only mild symptoms, the caller was ordered to quarantine at home and a public health officer visited the caller’s domicile for testing. Finally, the COVID-19 Response Team handled issues as they arose regarding patient flow and transport to different facilities and would also facilitate transfers between facilities as hospitals became more crowded. Creating a COVID-19 team in their EMS system allowed Milan to track cases and outcomes of COVID-19 as well as appropriately direct care to prevent overburdening their healthcare system.58
