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Critical illness-related cardiac arrest (CIRCA) as a distinct entity is not well described epidemiologically. There is currently a knowledge gap regarding how many occur in the UK or the impact on patient outcome. The CIRCA study is a prospective multi-centre observational cohort study of patients in the United Kingdom experiencing a cardiac arrest while in a Critical Care Unit embedded in the Case Mix Programme and National Cardiac Arrest Audit. The duration of data collection is 12 months, with surviving patients and family members receiving questionnaire follow-up at 90 days, 180 days and 12 months. This paper describes the protocol for the CIRCA study which received favourable ethical opinion from South Central – Berkshire Research Ethics Committee and approval from the Health Research Authority. Study registration is on clinicaltrials.gov (NCT04219384).

To evaluate, in UK acute hospitals, the early implementation of Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which embeds cardiopulmonary resuscitation (CPR) recommendations within wider emergency treatment plans To understand for whom and how the process was being used and the quality of form completion. A retrospective observational study evaluating emergency care and treatment planning approaches used in acute UK hospitals (2015-2019), and in six English hospital trusts the extent of ReSPECT use, patient characteristics and completion quality in a sample 3000 patient case notes. The use of stand-alone Do Not Attempt Cardiopulmonary Resuscitation forms fell from 133/186 hospitals in 2015 to 64/186 in 2019 (a 38% absolute reduction). ReSPECT accounted for 52% (36/69) of changes. In the six sites, ReSPECT was used for approximately 20% of patients (range 6%-41%). They tended to be older, to have had an emergency medical admission, to have cognitive impairment and a lower predicted 10 year survival. Most (653/706 (92%)) included a 'not for attempted resuscitation' recommendation 551/706 (78%) had at least one other treatment recommendation. Capacity was not recorded on 13% (95/706) of forms; 11% (79/706) did not record patient/family involvement. ReSPECT use accounts for 52% of the change, observed between 2015 and 2019, from using standalone DNACPR forms to approaches embedding DNACPR decisions within in wider emergency care plans in NHS hospitals in the UK. Whilst recommendations include other emergencies most still tend to focus on recommendations relating to CPR. Completion of ReSPECT forms requires improvement. https://www.isrctn.com/ISRCTN11112933. [Abstract copyright: Copyright © 2022. Published by Elsevier B.V.]

Background Smoking is a risk factor for most respiratory infections, but it may protect against SARS-CoV-2 infection. The objective was to assess whether smoking and e-cigarette use were associated with severe COVID-19. Methods This cohort ran from 24 January 2020 until 30 April 2020 at the height of the first wave of the SARS-CoV-2 epidemic in England. It comprised 7 869 534 people representative of the population of England with smoking status, demographic factors and diseases recorded by general practitioners in the medical records, which were linked to hospital and death data. The outcomes were COVID-19-associated hospitalization, intensive care unit (ICU) admission and death. The associations between smoking and the outcomes were assessed with Cox proportional hazards models, with sequential adjustment for confounding variables and indirect causal factors (body mass index and smoking-related disease). Results Compared with never smokers, people currently smoking were at lower risk of COVID-19 hospitalization, adjusted hazard ratios (HRs) were 0.64 (95% confidence intervals 0.60 to 0.69) for Conclusions Current smoking was associated with a reduced risk of severe COVID-19 but the association with e-cigarette use was unclear. All-cause mortality remained higher despite this possible reduction in death from COVID-19 during an epidemic of SARS-CoV-2. Findings support investigating possible protective mechanisms of smoking for SARS-CoV-2 infection, including the ongoing trials of nicotine to treat COVID-19.

ObjectivesWith the aim of shifting the emphasis from mortality to pressure on the NHS, we, first, mapped the nine priority groups outlined by the Joint Committee on Vaccination and Immunisation (JCVI) for Phase 1 of the vaccination strategy to available critical care data fields in the ICNARC COVID-19 study. Second, we examined the likely impact of vaccinating these priority groups on the numbers of patients becoming critically ill with COVID-19. Third, we described the characteristics of the critically ill patients with confirmed COVID-19 not covered by the Phase 1 priority groups for vaccination with a view to informing groupings for Phase 2 of the vaccination strategy. MethodsPhase 1 priority groups for vaccination were those identified by the JCVI. Data fields on patient characteristics, available from the ICNARC COVID-19 study built on the Case Mix Programme - the national clinical audit for adult critical care, were mapped to each of the nine priority groups. General population estimates, by age and sex for England, Wales and Northern Ireland combined, were obtained from the Office for National Statistics. The number and percentage of patients covered by the Phase 1 priority groups were calculated, applying the mapped ICNARC COVID-19 study data fields, using data on patients critically ill with confirmed COVID-19 from 1 February 2020 to 31 January 2021. The characteristics of patients not covered by the Phase 1 priority groups were reported as numbers and percentages and, where possible, as rates per one million general population.ResultsOf the 12 groups/subgroups (derived from the nine Phase 1 priority groups), eight mapped precisely. Of the remaining four, two were unable to be mapped due to absence of occupation data fields in the ICNARC COVID-19 study and two were partially mapped. Between 1 February 2020 and 31 January 2021, there were a total of 31,489 patients critically ill with confirmed COVID-19. Applying the data on the characteristics of these patients to the mapped Phase 1 priority groups, 26,628 (84.6%) were covered. For priority groups 1-4, 8,811 (28%) were covered.Of the 4,861 (15.4%) patients critically ill with confirmed COVID-19 not covered, older age groups and male sex dominated with two-thirds 40 years or older and two-thirds male. Per one million general population, the disparity between males and females increased with increasing age. Almost half were from non-White ethnic groups with one quarter of these categorised as Asian. Almost 60% resided in areas of greater deprivation with over 90% residing in urban environments.ConclusionOur mapping suggests that Phase 1 of the vaccination strategy has the potential to impact the numbers of patients becoming critically ill with COVID-19, substantially. Among those not covered by the nine Phase 1 priority groups, age remains a dominant factor, however, males and some ethnic groups appear disproportionally represented. Given the current and recent overwhelming burden of COVID-19 on critical care services in the NHS, our estimates for a substantial reduction in the numbers of patients becoming critically ill with COVID-19 will be welcome news.