Advertisement

Suboptimal rates of return of spontaneous circulation with prehospital CPR in the COVID-19 era

      The COVID-19 pandemic – caused by the virus SARS-COV-2 – has significantly taxed all levels of the modern healthcare system.

      The World Health Organization. Coronavirus disease (COVID-19) pandemic. N.d.

      The virulence of SARS-COV-2 has led to substantial increases in the usage of personal protective equipment – including masks, gowns, face shields, and gloves – in a variety of healthcare settings.
      • Cook T.M.
      Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic—a narrative review.
      Cardiopulmonary resuscitation (CPR) is one of the most important and lifesaving interventions performed by healthcare providers of all levels, and favorable outcomes are heavily contingent on proper form and performance based on published standards.
      • Gallagher E.J.
      • Lombardi G.
      • Gennis P.
      Effectiveness of bystander cardiopulmonary resuscitation and survival following out-of-hospital cardiac arrest.
      It has been suggested that PPE hinders adequate CPR performance,
      • Shin D.M.
      • Chung J.H.
      • Kim S.Y.
      • Hong E.J.
      • Kim K.Y.
      • Han Y.T.
      A study on the motion analysis of CPR on EMT who wearing PPE.
      and there is also a hypothesized hesitation towards performing CPR – which is considered an aerosol-generating procedure and carries an increased risk of virus transmission – out of fear that it could lead to the infection of providers.
      • Mahase E.
      • Kmietowicz Z.
      COVID-19: doctors are told not to perform CPR on patients in cardiac arrest.
      To understand if the pandemic has affected prehospital cardiac arrest care in the United States, the National Emergency Medical Services Information System (NEMSIS) database, a database containing millions of EMS activations, was analyzed. Inclusion criteria were cardiac arrest calls involving either ventricular fibrillation (VF) or ventricular tachycardia (VT) where providers documented whether or not a return of spontaneous circulation (ROSC) was achieved. These calls for the month of April in 2017, 2018, 2019, and 2020 were isolated; April 2020 was chosen to represent the pandemic because it contained a significant number of COVID-related healthcare activations and was projected to be the peak of COVID-related health outcomes in many communities.

      The World Health Organization. Coronavirus disease (COVID-19) pandemic. N.d.

      There was a total of 3232 cardiac arrests that fit the inclusion criteria: 2736 occurred during non-pandemic time periods (April 2017, 2018, 2019), and 496 occurred during the COVID-19 pandemic (April 2020). During both pandemic and non-pandemic time periods, the overwhelming majority of arrests involved VF, while a minority of cases involved VT (81–84% VF & 16–19% VT). During non-pandemic periods, rates of ROSC achievement were consistently around 47% each year. Interestingly, during April 2020 – when the pandemic was in effect – rates of ROSC achievement decreased to 42.95% (p < 0.05; Fig. 1).
      Fig. 1
      Fig. 1Shows the percentages of cases where a return of spontaneous circulation (ROSC) was achieved for the months of April 2017, April 2018, April 2019, and April 2020. During non-pandemic times, EMS crews were able to consistently achieve ROSC in roughly 47% of cases, whereas, during the COVID-19 pandemic (April 2020), EMS crews were able to achieve ROSC in just 42.9% of cases.
      Considering the significant decrease in the rate of ROSC achievement, these results likely indicate that either CPR quality has decreased or patients are somehow responding less favorably to the current conventions of resuscitation. Decreased CPR quality could be due to prehospital providers’ hesitation to provide adequate CPR out of fear of contracting COVID-19 or hindrances due to the presence of personal protective equipment. Less favorable responses to CPR from patients in the prehospital environment could also be due to sicker patients being recipients of EMS care in a pandemic situation or patients activating EMS later than they normally would out of fear. Given how vital CPR quality is to improving ROSC, our data show that there is an urgent need to reassess how best to perform the safest and most effective resuscitation by EMS first responders in the field, particularly during the COVID-19 and subsequent pandemics.

      Funding

      None.

      Conflicts of interest

      None.

      Acknowledgement

      The author acknowledges Mr. Jonathan Osters and Professor Keith Ruskin who helped with the manuscript.

      References

      1. The World Health Organization. Coronavirus disease (COVID-19) pandemic. N.d.

        • Cook T.M.
        Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic—a narrative review.
        Anaesthesia. 2020; 75: 920-927
        • Gallagher E.J.
        • Lombardi G.
        • Gennis P.
        Effectiveness of bystander cardiopulmonary resuscitation and survival following out-of-hospital cardiac arrest.
        JAMA. 1995; 274: 1922-1925
        • Shin D.M.
        • Chung J.H.
        • Kim S.Y.
        • Hong E.J.
        • Kim K.Y.
        • Han Y.T.
        A study on the motion analysis of CPR on EMT who wearing PPE.
        J Korean Soc Saf. 2015; 30: 74-79
        • Mahase E.
        • Kmietowicz Z.
        COVID-19: doctors are told not to perform CPR on patients in cardiac arrest.
        BMJ. 2020; 368: m1282