Changes of practice on out of hospital cardiopulmonary arrest during the COVID-19 pandemic: a cross-sectional survey of SOS-KANTO 2017 study

BACKGROUND

New coronavirus disease (COVID-19) spread rapidly and its high mortality intimidated people across the whole world [1, 2]. Within areas suffered from the pandemic, the incidence of out-of-hospital cardiac arrest (OHCA) increased, and both the return of spontaneous circulation and survival rates decreased dramatically [3–5]. However, factors that affected OHCA outcomes have not been cleared yet. Not only the viruses but also an impact and change on the practice provided by healthcare providers could affect survival outcomes of OHCA patients during the pandemic [6]. The pre- and in-hospital care for OHCA patients might be suboptimal due to concerns on transmission of COVID-19 during cardiopulmonary resuscitation (CPR) [7]. In other words, imposed restrictions on healthcare practice in precaution of the virus exposure might influence the practice in OHCA care [8]. There might be important changes in the overall performance of emergency medical service (EMS). For instance, effects on overall time of pre-hospital care due to an increment of EMS work load within a local area, and delays in treatments due to the requirement of earlier intubation/supraglottic airway to reduce aerosols [9].

The American Heart Association and other academic associations formulated an interim guideline for basic and advanced life support in April 2020 [10] .

The interim guidance recommended to balance a practice between the need for urgent care for COVID-19 patients and the protection of healthcare providers from infections. For example, the guidelines suggested to limit the number of rescuers and early intubation with high efficiency particle arresting filters. Limiting the number of rescuers may hinder high quality CPR due to the lack of a manpower. Moreover, if EMS cannot perform intubation/supraglottic airway with high efficiency particle arresting filters, chest compression may be interrupted until the intubation. However, little is known about a practice change of OHCA care in pre- and in-hospital CPR protocol during the pandemic [11]. The aim of our study is to survey changes in practice of OHCA care. The survey was intended to know whether participating institutions implemented any changes that could limit the quality of resuscitation such as an interruption of chest compression by balancing the risks of cross-infections to health care providers.

METHODS

This study was based on a questionnaire survey conducted in the SOS-KANTO 2017 facilities, organizing the Japanese Association for Acute Medicine of KANTO, (JAAM-KANTO) between September 2019 and March 2021. It adhered to the principles of the Declaration of Helsinki and was approved by the relevant institutional review boards of all 42 institutions. JAAM-KANTO conducted the SOS-KANTO study, a multi-center collaborative study, to answer clinically relevant questions in order to improve the emergency medical service for OHCA. Since 2002 [12, 13], the study team regularly performed prospective observational studies with per-registered research hypotheses. After the Association decided to conduct the latest study, SOS-KANTO 2017, and began recruiting OHCA patients, Japan was hit by the COVID-19 pandemic. A questionnaire survey was performed because there was an urgent need for investigation of the changes in actual clinical practice during and after the pandemic as it was not expected.

In Japan, the EMS personnel performs CPR according to the Japanese CPR guidelines in consensus with the International Liaison Committee on Resuscitation Guidelines and the American Heart Association Guidelines. EMS crews are certified to provide intravenous access, defibrillators, and supraglottic airway devices to the patients with cardiac arrest and some specially trained technicians can administer medications and place an endotracheal intubation tube. Most participating hospitals account for the medical control to EMS in each local area and the EMS crews follow the policy and CPR protocol provided by these medical control systems.

Questionnaire Content and Definitions

The survey covered the following three topics: 1) differences in each institution’s CPR protocol, 2) the timing of initiation of the new CPR protocol, and 3) the airway management protocol of the emergency medical services and each institution’s infection prevention management (Table 1). The survey was 3-page long and covering the above 3 topics with 7 questionnaires.

Table 1 Questionnaire and its results

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?
	Yes	42/42 (100.0%)
	No	0/42 (0.0%)
2	If “yes” to question 1, when did that happen?
	April 2020 emergency declaration or earlier	37/42 (88.1%)
	From July–September 2020, “the second wave”	3/42 (7.1%)
	After October 2020, “the third wave”	2/42 (4.8%)
	After October 2020, “the third wave”	0/42 (0.0%)
3	Have pre-hospital airway management practices changed in comparison to those in the pre-pandemic period, as of January 2021?
	No change, we continued the pre-existing protocol	32/42 (76.2%)
	We mandated intubation to our crews if a case had indication	5/42 (11.9%)
	We suggested intubation or supraglottic airways to our crews	4/42 (9.5%)
	We recommended bag-valve-mask ventilation with a tight mask-face seal	1/42 (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
	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.	22/42 (52.4%)
	The patient wears a surgical mask and is moved to the ER with chest compressions, and then intubated.	12/42 (28.6%)
	Interrupt chest compressions, transfer to ER, then resume chest compressions after tracheal intubation at ER	6/42 (14.3%)
	After tracheal intubation in the ambulance, the patient is moved to the ER while performing chest compressions	2/42 (4.8%)
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.	31/42 (73.8%)
	Interrupt chest compressions, transfer to ER, and resume chest compressions after tracheal intubation in ER	5/42 (11.9%)
	Move to the ER with chest compressions after switching to tracheal intubation in the ambulance	3/42 (7.1%)
	Others	3/42 (7.1%)
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.	17/42 (40.5%)
	Ventilate the patient with a HEPA filter attached to the airway device, perform chest compressions, and transfer the patient to the ER.	15/42 (35.7%)
	Interrupt chest compressions, transfer to ER, resume chest compressions after tracheal intubation in ER.	5/42 (11.9%)
	Switch to an endotracheal tube in the ambulance, attach a HEPA filter, and then move to the ER with chest compressions.	2/42 (4.8%)
	Others	3/42 (7.1%)
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	40/42 (95.2%)
	Transfer to ER without chest compressions	1/42 (2.4%)
	Others	1/42 (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	23/42 (54.8%)
	Transfer to ER with ventilation and chest compressions without using a HEPA filter to the endotracheal tube	15/42 (35.7%)
	Transfer to ER without chest compressions	2/42 (4.8%)
	Others	2/42 (4.8%)
5	As of 2021 Jan, which of the following the describes your institutional infectious management?
	PPE with N95 mask, goggles/face shield etc.	34/42 (81.0%)
	PPE with surgical mask, goggles/face shield etc.	6/42 (14.3%)
	No rule	2/42 (4.8%)
6	As of 2021 Jan, which of the following intubation equipment did you mostly use?
	McGRATHTM	23/42 (54.8%)
	Video laryngoscopy	6/42 (14.3%)
	MacIntosh laryngoscope blades	3/42 (7.1%)
	Others	2/42 (4.8%)
	No rule	8/42 (19.0%)
7	As of 2021 Jan, did your institution limit the number of people who could participate in resuscitation?
	Yes	21/42 (50.0%)
	No	21/42 (50.0%)

The survey was consisted of 7 questions to research investigating changes between pre- COVID-19 pandemic and pandemic period post-pandemic care.

EMS: emergency medical services ER: emergency room HEPA: high efficiency particle arresting PPE: personal protective equipment

The Japanese government declared a state of emergency in April 2020; therefore, we defined the pre-pandemic as the period from September 2019 to March 2020 and the pandemic period from April 2020 to March 2021. The questionnaires for the current survey was distributed in February 2021. Answers were collected and the survey was completed by January 2022 via mail or an Internet survey system. The participants were asked about the situation as of January 1st, 2021. No statistical analysis was performed for this survey; however, descriptive findings have been provided.

RESULTS

The questionnaire was completed by all 42 institutions (including 22 university hospitals) that participated in the current SOS-KANTO 2017 study. Thirteen 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 6 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 high efficiency particle arresting filters during or after emergency room (ER) transport. Five institutions (12%) interrupted CPR during transportation. Most institutions mandated personal protective equipment use with face masks in the ER.

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

DISCUSSION

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.

Although the AHA interim guideline [7] declared a potential benefit of early intubation to prevent a spread of the viruses, our survey revealed that only 22% of 42 hospitals followed this recommendation. Additionally, for both post-intubation and mask- ventilation airways, more than half of the hospitals did not implement high efficiency particle arresting filters during or after transporting patients to the hospitals.

We found that 75% of EMS, 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 not the recommended airway managements. 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 particle arresting filters to the EMS.

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, each hospital voluntarily participated in the study. Although the announcement was made broadly to the emergency hospitals organizing JAAM-KANTO, this might cause a sampling bias and our study subjects might not reflect the overall population at local or nation. However, since the participating facilities were widely distributed within the region, it might minimize the bias. Second, the main objective of this study was to investigate the impact of the pandemic on the CPR protocols for OHCA. The questionnaire items were focused on whether respiratory management and chest compressions were interfered by the concerns about the virus exposure to health care providers. But we did not implement any measures to eliminate biases by such as shuffling or randomization method. In addition, these results were not validated with individual cases and it was not possible to determine whether individuals were actually affected by the changes that health care providers made. This is one of the study limitations and our study could not measure the overall impact of pandemic on CPR qualities or patient outcomes.

However, we consider our study results are still valuable as this is the unique record of what changes were made during the early pandemic in the Kanto region, one of the biggest metropolitan areas. Third, effects of the pandemic on the EMS protocol were not intended to be studied in our current work. However, life-saving procedures provided by EMS personnel have a significant impact on the patient outcomes and are important information to be taken into account. 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.

CONCLUSION

In summary, based on the results of our survey, resuscitation protocols for all participating institutions have been revised. However, few facilities applied a protocol change that was considered lowering the quality of resuscitation in OHCA. On the other hand, emergency medical 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.

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

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