Cardiopulmonary resuscitation protocol changes during the COVID-19 pandemic: a cross- sectional survey of SOS-KANTO 2017 study

doi:10.21203/rs.3.rs-3130802/v1

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Cardiopulmonary resuscitation protocol changes during the COVID-19 pandemic: a cross- sectional survey of SOS-KANTO 2017 study

https://doi.org/10.21203/rs.3.rs-3130802/v1

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The international guidelines recommend that rescuers balance the urgent needs of care for COVID-19 patients and the protection of healthcare providers from cross-infections. However, little is known about a change in CPR protocol during the Pandemic. The aim of our study is to survey the protocol change and know whether any institution implemented adversely affecting changes in resuscitation. This was a cross-sectional survey study investigating changes in CPR protocol between the pre- COVID-19 pandemic and pandemic period. Online questionnaires were distributed to 41 institutions that participated in the SOS-KANTO 2017 study in January 2021. The survey covered the following three topics: 1) differences in each institution’s cardiopulmonary resuscitation (CPR) protocol; 2) timing of initiation of the new CPR protocol; and 3) airway and infection management protocol of emergency medical services (EMS) and each institution. Of the institutions, 90% implemented protocol changes by April 2020 and 100% by October 2020. However, we found variations in these changes, particularly those regarding airway management; a total of 75% of the institutions answered that they did not modify or change their methods of airway management. Around of the institutions might not have implemented enough strategies to reduce exposure to the COVID-19 virus as recommended by the guidelines as of January 2021. Overall, based on the results of our survey, resuscitation protocols for all participating institutions have been revised, but few has changed protocols to detrimental to OHCA. On the other hand, emergency services showed variation in airway management, with 75% not modifying or changing airway managements.

Health sciences/Cardiology

Health sciences/Medical research

In 2019, a new coronavirus disease (COVID-19) spread globally. Its rapid spread intimidated the population across the globe. It was declared a pandemic by the World Health Organization (WHO) in 2020.¹ COVID-19 was initially often progressive, and the patients sometimes had complications like acute respiratory failure, acute myocardial infarction, and pulmonary embolism due to their hyperinflammatory status and hypercoagulability, leading to high mortality.² Within the pandemic areas, the incidence of out-of-hospital cardiac arrest (OHCA) increased, and both the return of spontaneous circulation (ROSC) and survival rates decreased dramatically.^3–5 However, the factors affecting OHCA outcomes were not clear. It was considered that not only the pathophysiology of the disease but also its impact on the pre- and in-hospital resuscitation system could lead to worse survival outcomes from OHCA.⁶

The American Heart Association (AHA) and other academic associations formulated an interim guideline for basic and advanced life support in April 2020.⁷ At the same time, the Japanese government released emergent public health orders and restrictions. The interim guidance recommended a balance between the need for urgent care for COVID-19 patients and the protection of healthcare providers from infections.⁷ More specifically, the guidelines suggested limiting the number of rescuers and early intubation with high efficiency particle arresting (HEPA) filters. These guidelines were recommended for rescuers to reduce their exposure to COVID-19 by decreasing the risk of aerosol generation. Thus, the in-hospital care for OHCA patients may be limited due to the pandemic, which causes concerns regarding cross-infections between patients and healthcare providers.

However, little is known about a change in CPR protocol during the Pandemic. The aim of our study is to survey the protocol change and know whether any institution implemented adversely affecting changes in resuscitation such as an interruption of CPR by balancing the risks of cross-infections to health care providers. We hypothesized that the COVID-19 pandemic might affect the CPR protocol.

The Japanese Association of Acute Medicine in Kanto conducted a multi-center prospective cohort study, the Survey of Survivors after Cardiac Arrest in the Kanto Area (SOS-KANTO) 2017, during the COVID-19 pandemic. A questionnaire survey was conducted to clarify the changes in actual clinical practice during the pre- COVID-19 pandemic and pandemic period. Here, we report the results of the surveys completed by healthcare providers who treated OHCA patients during the COVID-19 pandemic in the SOS-KANTO 2017 study.

This study was based on a questionnaire survey conducted in the SOS-KANTO 2017 facilities. It adhered to the principles of the Declaration of Helsinki and was approved by the relevant institutional review boards of all 41 institutions. Our analysis did not include any personal identifying information; therefore, the requirement for informed consent was waived (Ethical Review Board of Kimitsu Chuo Hospital, Approval Number 440).

SOS-KANTO study and questionnaire subject

In 2002, the Kanto Regional Association of the Japanese Association for Acute Medicine conducted the SOS-KANTO study, a multi-center collaborative study, to understand and contribute to establishing an emergency medical care system for OHCA patients. ⁸ In 2012, a similar registry, SOS-KANTO 2012, was conducted. ^9–16And a new registry was planned in 2017 as SOS-KANTO 2017. The patient data collection period was from September 2019 to March 2021, with 9909 cases from 41 centers.

The COVID-19 pandemic occurred during the SOS-KANTO 2017 study period. Thus, the current questionnaire survey was conducted as part of a facility survey during the SOS-KANTO 2017 study period. This survey was completed by the participating facility directors either by mail or via an Internet survey system in January 2021.

Questionnaire content and definitions

The survey covered the following three topics: 1) differences in each institution’s cardiopulmonary resuscitation (CPR) protocol, 2) the timing of initiation of the new CPR protocol, and 3) the airway management protocol of the emergency medical services (EMS) and each institution’s infection prevention management (Table 1).

The Japanese government declared a state of emergency in April 2020; therefore, we defined the pandemic period as the period from September 2019 to March 2020 and the post-pandemic period from April 2020 to March 2021. No statistical analysis was performed for this survey; however, descriptive findings have been provided.

Table.1	Questionnaire and its results: The survey was consisted of 7 questions to research investigating changes between pre- COVID-19 pandemic and pandemic period post-pandemic care.
Question No	Questions	Survey Responses
1	Has the protocol for treating cardiac arrest patients at your facility changed compared to that of the previous years since the declaration of the state of emergency in April 2020?
1	・Yes ・No	41/41 0/41	(100.0%) (0.0%)
2	If "yes" to question 1, when did that happen?
2	・April 2020 emergency declaration or earlier ・From July-September 2020, “the second wave” ・After October 2020, “the third wave” ・After October 2020, “the third wave”	37/41 3/41 1/41 0/41	(90.2%) (7.3%) (2.4%) (0.0%)
3	Have pre-hospital airway management practices changed in comparison to those in the pre-pandemic period, as of January 2021?
3	・No change, we continued the pre-existing protocol ・We mandated intubation to our crews if a case had indication ・We suggested intubation or supraglottic airways to our crews ・We recommended bag-valve-mask ventilation with a tight mask-face seal	31/41 5/41 4/41 1/41	(75.6% ) (12.2%) (9.8%) (2.4%)
4	What is the method of transfer from the ambulance to the emergency room, as of January 2021?
4 − 1	If not already intubated by emergency personnel at the scene
4 − 1	・As in the past, the EMS team ventilates the patient with an emergency bag valve mask, moves the patient to the ER with chest compressions, and then intubates the patient in the ER. ・The patient wears a surgical mask and is moved to the ER with chest compressions, and then intubated. ・Interrupt chest compressions, transfer to ER, then resume chest compressions after tracheal intubation at ER ・After tracheal intubation in the ambulance, the patient is moved to the ER while performing chest compressions	22/41 12/41 5/41 2/41	(53.7%) (29.3%) (12.2%) (4.9%)
4 − 2	If the patient is using a supraglottic device with a HEPA filter by the emergency personnel
	・Ventilate the patient with an airway device and move to the ER while performing chest compressions. ・Interrupt chest compressions, transfer to ER, and resume chest compressions after tracheal intubation in ER ・Move to the ER with chest compressions after switching to tracheal intubation in the ambulance ・Others	22/41 5/41 3/41 3/41	(53.7%) (12.2%) (7.3%) (7.3%)
4 − 3	If the patient is using a supraglottic device without HEPA filter by the emergency personnel
	・Ventilate the patient without a HEPA filter attached to the airway device, perform chest compressions, and transfer to the ER. ・Ventilate the patient with a HEPA filter attached to the airway device, perform chest compressions, and transfer the patient to the ER. ・Interrupt chest compressions, transfer to ER, resume chest compressions after tracheal intubation in ER. ・Switch to an endotracheal tube in the ambulance, attach a HEPA filter, and then move to the ER with chest compressions. ・Others	17/41 14/41 5/41 2/41 3/41	(41.5%) (34.1%) (12.2%) (4.9%) (7.3%)
4–4	If the patient is intubated with a HEPA filter by emergency medical personnel
	・Transfer to ER with ventilation and chest compressions as before ・Transfer to ER without chest compressions ・Others	39/41 1/41 1/41	(95/1%) (2.4%) (2.4%)
4–5	If the patient is intubated without a HEPA filter by emergency medical personnel
	・Transfer to the ER with ventilation and chest compressions with a HEPA filter attached to the endotracheal tube ・Transfer to ER with ventilation and chest compressions without using a HEPA filter to the endotracheal tube ・Transfer to ER without chest compressions ・Others	22/41 15/41 2/41 2/41	(53.7%) (36.6%) (4.9%) (4.9%)
5	As of 2021 Jan, which of the following the describes your institutional infectious management?
	・PPE with N95 mask, goggles/face shield etc. ・PPE with surgical mask, goggles/face shield etc. ・No rule	34/41 3/41 2/41	(82.9%) (7.3%) (4.9%)
6	As of 2021 Jan, which of the following intubation equipment did you mostly use?
	・McGRATHTM ・Video laryngoscopy ・MacIntosh laryngoscope blades ・Others ・No rule	22/41 6/41 3/41 2/41 8/41	(53.7%) (14.6%) (7.3%) (4.9%) (19.5%)
7	As of 2021 Jan, did your institution limit the number of people who could participate in resuscitation?
	・Yes ・No	21/41 20/41	(51.2%) (48.8%)

The questionnaire was completed by all 41 institutions (including 22 university hospitals) that participated in the current SOS-KANTO 2017 study. Twelve hospitals were located in the Tokyo Prefecture, 12 in the Chiba Prefecture, 5 in the Saitama Prefecture, 3 in the Gunma Prefecture and Kanagawa, and 5 in other prefectures.

All institutions changed their resuscitation protocols, including both the pre- and in-hospital management (Table 1). Among those, 90% of the institutions implemented these changes by April 2020, and this number reached 100% by October 2020. Approximately 75% of the institutions did not modify or change their methods of airway management. Moreover, for both post-intubation and mask-ventilation airways, more than half of the institutions did not use HEPA filters during or after emergency room (ER) transport. Five institutions (12%) interrupted CPR during transportation. Most institutions mandated personal protective equipment (PPE) use with face masks in the ER.

Most institutions used McGRATH™ or video laryngoscopes to reduce aerosol contamination; however, only 7% used Macintosh laryngoscopes. Most instructions mandated PPE use with face masks in the ER. Approximately half of the institutions reduced the number of rescuers for CPR.

Our report revealed that all institutions agreed with changes in resuscitation protocols, including pre- and in-hospital management. Of the surveyed institutions, 90% implemented these changes by April 2020, and this number raised to 100% by October 2020, when Japan encountered “the third wave” in the number of COVID-19 patients.

However, in this multicenter survey, only 22% of the 41 institutions followed the AHA guidelines regarding "early intubation or supraglottic airways." Moreover, for both post-intubation and mask-ventilation airways, more than half of the institutions did not use HEPA filters during or after ER transport.

We found that 75% of the emergency medical services, for which the study institutions are responsible in its Medical Control, did not modify or change airway management. Early in the pandemic, it might not mean whether the emergency medical services believed or did not believe the recommended airway managements that could be detrimental to cardiopulmonary resuscitation. And it might be simply because the recommendations were not well distributed at the beginning of the pandemic, or because of the inadequate supply of HEPA filters to the fire departments.

A total of five institutions (12%) halted CPR during transportation and resumed CPR after intubation in the ER due to concerns regarding cross-infections. It was also highlighted that more than half of the institutions reduced the number of rescuers for CPR. But the effects of these changes on patient outcomes are not elucidated.

There are several limitations of this study. First, the participating hospitals were not randomly selected, but were held at a voluntary, announced facility within the emergency hospitals organizing the Kanto Region of Japanese Association of Acute Care Medicine. For this reason, this study may not reflect the overall population at the Kanto region. However, since the participating facilities are widely distributed, it might not cause biases towards a specific region. Second, the study lacks the information how the pandemic affected the fire departments. Life-saving procedures provided by emergency medical services have a significant impact on the patient outcomes and are important information to be taken into account. Therefore, the resuscitation methods such as the airway management, which is prescribed by medical control facilities, were included in our study. And we investigated how medical personal from each facility took over a patient from emergency medical service personnel. However, effects of the pandemic on the fire department protocol were not intended to be studied in our current work. Finally, this survey focused on the early pandemic stage, and it is unclear whether the protocols at each facility and emergency medical service activities change or not until the end of this pandemic.

In summary, based on the results of our survey, resuscitation protocols for all participating institutions have been revised, but few has changed protocols to detrimental to OHCA. On the other hand, emergency services showed variation in airway management, with 75% not modifying or changing airway managements. The effects of these changes on patient outcomes are not elucidated in the current study.

We are currently analyzing the individual patient data compared to those of the 1^st and 2^nd SOS-KANTO studies. The results are highlighted in terms of differences with or without the pandemic.

Data availability

The dataset generated during the current survey will be available from the corresponding author upon reasonable request.

Ethics Statement

Before study initiation, all collaborating hospitals obtained individual local institutional review board approval for conducting research on human subjects. This study was approved by the Institutional Review Board of Kimitsu Chuo Hospital (approval number: 440). The requirement for informed consent was waived due to the anonymous nature of the data used.

Conflict of Interest Statement

All members that participated in the current study are the member of Japanese Association for Acute Medicine of Kanto. We declare that we have no financial conflict of interest.

Acknowledgments

Not applicable

SOS-KANTO 2017 Steering Council

Tokyo Women's Medical University (Munekazu Takeda), Kimitsu Chuo Hospital (Nobuya Kitamura), Chiba University Hospital (Taka-aki Nakada), The University of Tokyo (Hideo Yasunaga , Shotaro Aso), Nippon Medical School Musashikosugi Hospital (Takashi Tagami), Chiba Kaihin Municipal Hospital (Yosuke Honma, Yosihisa Tateishi), Nippon Medical School Hospital (Tomoko Ogasawara), Keio University Hospital (Kei Hayashida), Tokyo Bay Urayasu/Ichikawa Medical Center (Hiraku Funakoshi), Juntendo University Nerima Hospital (Tomohisa Nomura), Tokyo Dental College Ichikawa General Hospital (Masaru Suzuki), Tokyo Metropolitan Bokutoh Hospital (Kazuhiro Sugiyama), Nihon University Hosapital (Atsushi Sakurai)

SOS-KANTO 2017 Study Group

Tokai University School of Medicine (Yoshihide Nakagawa); St.Marianna University School of Medicine, Yokohama Seibu Hospital (Minoru Yoshida); Saitama Medical Center Department of Emergency Medicine(ER) (Masaki Hisamura); Kawasaki Municipal Hospital Emergency and Critical Care Center (Kunio Kanao); Japanese Red Cross Maebashi Hospital (Jun Maruyama); Juntendo University Urayasu Hospital (Tadashi Ishihara); Tokyo Women’s Medical University Hospital (Munekazu Takeda); Kimitsu Chuo Hospital (Nobuya Kitamura); Chiba University Graduate School of Medicine (Taku Oshima); Dokkyo Medical University Saitama Medical Center (Daisuke Sugimoto); National Disaster Medical Center (Mayuko Kaneko); Nihon University Hospital (Atsushi Sakurai); Nippon Medical School Tamanagayama Hospital (Chie Tanaka); Tokyo Women’s Medical University Yachiyo Medical Center (Tomohito Sadahiro); Japanese Red Cross Medical Center (Yuta Moroe); National Hospital Organization Mito Medical Center (Yusuke Tsutsumi); Tokyo Metropolitan Tama Medical Center (Tomohide Koyama); Gunma University Graduate School of Medicine (Kazunori Fukushima MD); Saitama Red Cross Hospital (Kazuya Kiyota); Tokyo Metropolitan Bokutoh Hospital (Kazuhiro Sugiyama); Keio University Hospital (Ryo Yamamoto); Teikyo University School of Medicine (Ryuichi Nishi); National Center for Global Health and Medicine Hospital (Makiko Yamamoto); Medical Hospital of Tokyo Medical and Dental University (Naoshi Urushibata); Juntendo University Nerima Hospital (Hiroki Takami); Nihon University Itabashi Hospital (Nami Sawada); National Center for Child Health and Development (Shima Ohnishi); Chiba Aoba Municipal Hospital (Shunsuke Otani); Matsudo City Hospital (Masayuki Yagi); Japanese Red Cross Narita Hospital (Yoshihisa Tateishi); Tokyo Bay Urayasu/Ichikawa Medical Center (Yosuke Honma); OTA Memorial Hospital (Kazuki Akieda); Tokyo Dental College Ichikawa General Hospital (Masaru Suzuki) ; Tokyo The Jikei University Kashiwa Hospital (Izumu Hasegawa); Jichi Medical University Saitama Medical Center (Masahiro Kashiura MD); IUHW Narita Hospital (Ryuhei Igeta); University of Tsukuba Hospital (Yasuaki Koyama MD); Seirei Hamamatsu General Hospital (Takahiro Atsumi); Seirei Mikatagahra General Hospital (Go Makishi); Eastern Chiba Medical Center (Tomoaki Hashida ); Nagoya University Hospital (Yuma Yasuda) (http://www.jaam- kanto.jp/sos_kanto/sos_kanto2017_contributors.html)

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No competing interests reported.

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Cardiopulmonary resuscitation protocol changes during the COVID-19 pandemic: a cross- sectional survey of SOS-KANTO 2017 study

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Abstract

INTRODUCTION

MATERIALS AND METHODS

SOS-KANTO study and questionnaire subject

Questionnaire content and definitions

RESULTS

DISCUSSION

Declarations

References

Additional Declarations

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