Mobile app helps trainees manage emergencies at the bedside.

BACKGROUND: Although emergency departments (ED) have standardized guidelines for low-frequency, high-acuity diagnoses, they are not immediately accessible at the bedside, and this can cause anxiety in trainees and delay patient care. This problem is exacerbated during events like COVID-19 that require the rapid creation, iteration, and dissemination of new guidelines. METHODS: Physician innovators used design thinking principles to develop EM Protocols (EMP), a mobile application that clinicians can use to immediately view guidelines, contact consultants (e.g., cath lab activation), and access code-running tools. The project became an institutional high priority, because it helps EM trainees and off-service rotators manage low-frequency, high-acuity emergencies at the point of care, and its COVID-19 guidelines can be rapidly updated and disseminated in real time. RESULTS: This intervention was deployed across two academic medical centers during the COVID-19 surge. Nearly 300 ED clinicians have downloaded EMP, and they have interacted with the app over 5,400 times. It continues to be used regularly, over 12 months after the initial surge. Since the app was received positively, there are efforts to build in additional adult and pediatric guidelines. DISCUSSION: Digital health tools like EMP can serve as invaluable adjuncts for managing acute, life-threatening emergencies at the point of care. They can benefit trainees during normal day-to-day operations as well as scenarios that cause large-scale operational disruptions, such as natural disasters, mass casualty events, and future pandemics.

STAT: Mobile app helps clinicians manage inpatient emergencies.

In response to the unprecedented surge of patients with COVID-19, Massachusetts General Hospital created both repurposed and de-novo COVID-19 inpatient general medicine and intensive care units. The clinicians staffing these new services included those who typically worked in these care settings (e.g., medicine residents, hospitalists, intensivists), as well as others who typically practice in other care environments (e.g., re-deployed outpatient internists, medical subspecialists, and other physician specialties). These surge clinicians did not have extensive experience managing low frequency, high acuity emergencies, such as those that might result from COVID-19. Physician-innovators, in collaboration with key hospital stakeholders, developed a comprehensive strategy to design, develop, and distribute a digital health solution to address this problem. MGH STAT is an intuitive mobile application that empowers clinicians to respond to medical emergencies by providing immediate access to up-to-date clinical guidelines, consultants, and code-running tools at the point-of-care. 100% of surveyed physicians found STAT to be easy to use and would recommend it to others. Approximately 1100 clinicians have downloaded the app, and it continues to enjoy consistent use over a year after the initial COVID-19 surge. These results suggest that STAT has helped clinicians manage life threatening emergencies during and after the pandemic, although formal studies are necessary to evaluate its direct impact on patient care.

Combined deficiency of dystrophin and beta1 integrin in the cardiac myocyte causes myocardial dysfunction, fibrosis and calcification.

The dystrophin-glycoprotein complex is a large complex of membrane-associated proteins linking the cytoskeleton to the extracellular matrix in muscle. Transmembrane heterodimeric (alphabeta) integrins serve also as cellular adhesion molecules and mechanotransducers. In the animal model for Duchenne muscular dystrophy, the mdx mouse, loss of dystrophin causes more severe abnormalities in skeletal than in cardiac muscle. We hypothesized that ablation of cardiac myocyte integrins in the mdx background would lead to a severe cardiomyopathic phenotype. Mdx mice were crossed to ones with cardiac myocyte-specific deletion of beta1 integrin (beta1KO) to generate beta1KOmdx. Unstressed beta1KOmdx mice were viable and had normal cardiac function; however, high mortality was seen in peri- and postpartum females by 6 months of age, when severe myocardial necrosis and fibrosis and extensive dystrophic calcification was seen. Decreased ventricular function and blunted adrenergic responsiveness was found in the beta1KOmdx mice compared with control (Lox/Lox, no Cre), beta1KO, and mdx. Similarly, adult beta1KOmdx males were more prone to isoproterenol-induced heart failure and death compared with control groups. Given the extensive calcification, we analyzed transcript levels of genes linked to fibrosis and calcification and found matrix gamma-carboxyglutamic acid protein, decorin, periostin, and the osteoblast transcription factor Runx2/Cbfa1 significantly increased in beta1KOmdx cardiac muscle. Our data show that combined deficiency of dystrophin and integrins in murine cardiac myocytes results in more severe cardiomyopathic changes in the stressed myocardium than reduction of either dystrophin or integrins alone and predisposes to myocardial calcification.