The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland’s (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care.

The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation.

Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide.

The C4 has played an integral role in the State of Maryland’s pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.

Hyperkalemia (HK) is common and potentially a life-threatening condition. If untreated, HK can progress to ventricular arrhythmia and cardiac arrest. Early treatment reduces mortality in HK. This study evaluates a novel protocol for identification and empiric management of presumed HK in the prehospital setting.

This was a retrospective, observational chart review of a single, large, suburban Emergency Medical Services (EMS) system. Patients treated for presumed HK, with both a clinical concern for HK and electrocardiogram (ECG) changes consistent with HK, from February 2018 through February 2021 were eligible for inclusion. Patients were excluded if found to be in cardiac arrest on EMS arrival. Empiric treatment of HK included administration of calcium, sodium bicarbonate, and albuterol. Post-treatment, patients were placed on cardiac monitoring and adverse events recorded enroute to receiving hospital. Protocol compliance was assessed by two independent reviewers. Serum potassium (K) level was obtained from hospital medical records.

A total of 582 patients were treated for HK, of which 533 patients were excluded due to cardiac arrest prior to EMS arrival. The remaining 48 patients included in the analysis had a mean age of 56 (SD = 20) years and were 60.4% (n = 29) male with 77.1% (n = 37) Caucasian, 10.4% (n = 5) African American, and 12.5% (n = 6) Hispanic. Initial blood draw at the receiving facilities showed K >5.0mEq/L in 22 (45.8%), K of 3.5-5.0mEq/L in 23 (47.9%), and K <3.5mEq/L in three patients (6.3%). Independent review of the EMS ECG found the presence of hyperkalemic-related change in 43 (89.6%) cases, and five (10.4%) patients did not meet criteria for treatment due to lack of either appropriate ECG findings or clinical suspicion. No episodes of unstable tachyarrhythmia or cardiac arrest occurred during EMS treatment or transport.

The study evaluated a novel protocol for detecting and managing HK in the prehospital setting. It is feasible for EMS crews to administer this protocol, although a larger study is needed to make the results generalizable.

Early identification of diabetic ketoacidosis (DKA) may improve clinical outcomes. Prior studies suggest exhaled end tidal carbon dioxide (ETCO2) provides a non-invasive, real-time method to screen for DKA in the emergency department (ED).

This a retrospective cohort study among patients who activated Emergency Medical Services (EMS) during a one-year period. Initial out-of-hospital vital signs documented by EMS personnel, including ETCO2 and first recorded blood glucose level (BGL), as well as in-hospital records, including laboratory values and diagnosis, were collected. The main outcome was the association between ETCO2 and the diagnosis of DKA.

Of the 118 patients transported with hyperglycemia (defined by BGL >200), six (5%) were diagnosed with DKA. The mean level of ETCO2 in those without DKA was 35mmHg (95% CI, 33-38mmHg) compared to mean levels of 15mmHg (95% CI, 8-21mmHg) in those with DKA (P <.001). The Area Under the Receiver Operating Characteristics (ROC) Curve (AUC) for ETCO2 identifying DKA was 0.96 (95% CI, 0.92-1.00). The correlation coefficient between ETCO2 and serum bicarbonate (HCO3) was 0.436 (P <.001) and the correlation coefficient between ETCO2 and anion gap was -0.397 (P <.001).

Among patients with hyperglycemia, prehospital levels of ETCO2 were significantly lower in patients with DKA compared to those without and were predictive of the diagnosis of DKA. Furthermore, out-of-hospital ETCO2 was significantly correlated with measures of metabolic acidosis.

End-tidal carbon dioxide (EtCO2) is a non-invasive method giving information about the perfusion, ventilation, and metabolic condition of patients. The correlation was studied here between the metabolic (pH, bicarbonate) values and EtCO2 during the treatment of diabetic ketoacidosis (DKA).

A 23-year-old male patient with diabetes mellitus was admitted to the emergency department (ED) with the complaints of nausea, vomiting, and fever. The patient with a diagnosis of DKA was continuously monitored with EtCO2; EtCO2 was correlated with serum bicarbonate (HCO3; r = 0.96; P < .001) and pH (r = 0.93; P < .001).

Continuous EtCO2 monitoring should be considered by emergency physicians in the metabolic monitoring of the patients as it is an easy-to-use, non-invasive, and cost-effective method that provides instant and reliable information.

The primary aim of our study is to identify physicians who have witnessed a complication attributed to sodium-glucose cotransporter (SGLT2) inhibitors. The secondary aim is to determine the type, severity, and setting of the event (inpatient versus outpatient).

Diabetes is an increasing public health burden with 9.9% of Canadians expected to be diagnosed with it in 2020. A prominent change with respect to treatment options since the publication of the revised Diabetes Canada guidelines in May 2016 concerned the SGLT2 inhibitors. Their favorable clinical profile has increased interest among clinicians, but there is still reason for caution. Because these drugs are new, the balance of benefits versus risks is not well understood.

We conducted a cross-sectional survey of all in-practice physicians (excluding pediatricians). Data were collected through an online survey.

Our survey identified 154 physicians who have identified one or more adverse drug reactions (ADRs) related to SGLT2 inhibitor use. A total of 173 ADRs were identified. In total, 20.6% of family physician respondents had witnessed one or more ADRs. The most common complication is mycotic infection (82 cases) with 47% identified as a low level of severity and occurring mostly in the outpatient setting. The second most common complication is diabetic ketoacidosis (43 cases) with 67% identified as a high level of severity and occurring mostly in the inpatient setting. Other identified complications include hyperkalemia (6 cases), renal insufficiency (15 cases), and even amputation (2 cases). Our survey is the first to document real-world complications from SGLT2 inhibitors. In the outpatient setting, mycotic infections are most common and most often benign. In the inpatient setting, diabetic ketoacidosis is the most common and is severe. This is an important take-home message for family physicians to tailor their practice and vigilance according to the practice setting.