Wilderness Medical Society Clinical Practice Guidelines on Water Treatment for Wilderness, International Travel, and Austere Situations: 2024 Update.

To provide guidance to medical providers, wilderness users, and travelers, the Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for treating water in situations where the potability of available water is not assured, including wilderness and international travel, areas impacted by disaster, and other areas without adequate sanitation. The guidelines present the available methods for reducing or eliminating microbiological contamination of water for individuals, groups, or households; evaluation of their effectiveness; and practical considerations. The evidence base includes both laboratory and clinical publications. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according to the criteria published by the American College of Chest Physicians.

Mass Immunizations: A Pocket Guide.

Numerous state, national, and global resources exist for planning and executing mass vaccination campaigns. However, they are disparate and can be complex. The COVID-19 pandemic highlighted the need for clear, easy to use mass vaccination resources. Meanwhile, annual influenza vaccination, as well as outbreaks such as mpox, demonstrates the need for continued emphasis on timely and effective vaccinations to mitigate outbreaks. This pocket guide seeks to combine relevant resources and basic steps for setting up a mass vaccination clinic, utilizing experience from COVID-19 mass vaccination sites.

Rapid Expansion and Adaptability of California Medical Disaster Teams.

The California Medical Assistance Team (CAL-MAT) program is coordinated by the California Emergency Medical Services Authority (EMSA). The program was developed to deploy and support medical personnel for disaster medical response. During the coronavirus disease (COVID-19) pandemic, the program and missions grew rapidly in response to medical surge, programs for testing and vaccination, and other concurrent disasters. CAL-MAT enrollment increased 10-fold from approximately 200 members at the beginning of 2020, to an estimated 2200 members by June 2021. This article describes the flexible use of a state-managed disaster medical response program within California and some of the challenges associated with rapid expansion and varied demands during the COVID-19 surges of March 2020-March 2022. CAL-MAT may serve as a model for development of similar state-sponsored or other disaster medical response teams.

Reduction in Hospital Transfers at a US COVID-19 Alternate Care Site: Maintaining Surge Capacity Support in Imperial County, California.

OBJECTIVE: The transfer rate for patients from an Alternate Care Site (ACS) back to a hospital may serve as a metric of appropriate patient selection and the ability of an ACS to treat moderate to severely ill patients accepted from overwhelmed health-care systems. During the coronavirus infectious disease 2019 (COVID-19) pandemic, hospitals worldwide experienced acute surges of patients presenting with acute respiratory failure. METHODS: An ACS in Imperial County, California was re-established in November 2020 to help decompress 2 local hospitals experiencing surges of COVID-19 cases. The patients treated often had multiple comorbid illnesses and required a median supplemental oxygen of 3 L/min (LPM) on admission. Numerous interventions were initiated during a 2-wk period to improve clinical care delivery. RESULTS: The objectives of this retrospective observational study are to evaluate the impact of these clinical and staff interventions at an ACS on the transfer rate and to provide issues to consider for future ACS sites managing COVID-19 patients. CONCLUSIONS: The data suggest that continuous, real-time process-improvement interventions helped reduce the transfer rate back to hospitals from 36.7% to 14.5% and that an ACS is a viable option for managing symptomatic COVID-19 positive patients requiring hospital-level care when hospitals are overburdened.

Utilization of Alternate Care Sites During the COVID-19 Surge and Mass Care: California, 2020-2021.

The coronavirus disease (COVID-19) pandemic caused critical hospital bed and staffing shortages in parts of California for most of 2020 and 2021. Alternate Care Sites (ACS) were established in several regions to alleviate the hospital patient surge and to maximize staffed bed capacity. Over 1900 patients were successfully provided medical care (with physician, nursing, respiratory therapy, oxygen, and pharmacy services) in relatively austere settings. This paper examines the challenges faced at these ACS facilities and how adaptations were incorporated according to the changing dynamics of the COVID-19 pandemic to successfully manage higher acuity patients. ACS facilities were 1 approach to California's surge of COVID-19 patients, despite limited medical supplies and staffing.

Medical Support for California Wildfire Response.

Wildfires have become a regular seasonal disaster across the Western region of the United States. Wildfires require a multifaceted disaster response. In addition to fire suppression, there are public health and medical needs for responders and the general population in the path of the fire, as well as a much larger population impacted by smoke. This paper describes key aspects of the health and medical response to wildfires in California, including facility evacuation and shelter medical support, with emphasis on the organization, coordination, and management of medical teams deployed to fire incident base camps. This provides 1 model of medical support and references resources to help other jurisdictions that must respond to the rising incidence of large wildland fires.

Medical Care at California Wildfire Incident Base Camps.

OBJECTIVE: The California Emergency Medical Services Authority manages and deploys California Medical Assistance Teams (CAL-MAT) to disaster medical incidents in the state. This analysis reviews diagnoses for ambulatory medical visits at multiple wildland fire incident base camp field sites in California during the 2020 fire season. METHODS: Clinical data without personal health information were extracted retrospectively from patient care records from all patients seen by a provider. Results were entered into Excel spreadsheets with calculation of summary statistics. RESULTS: During the 2020 fire season, CAL-MAT teams deployed 21 times for a total of 327 days to base camps supporting large fire incidents and cared for 1756 patients. Impacts of heat and environmental smoke are a constant factor near wildfires; however, our most common medical problem was rhus dermatitis (54.5%) due to poison oak. All 2020 medical missions were further complicated by prevention and management of coronavirus disease (COVID-19). CONCLUSIONS: There is very little literature regarding the acute medical needs facing responders fighting wildland fires. Ninety-five percent of clinical conditions presenting to a field medical team at the wildfire incident base camp during a severe fire season in California can be managed by small teams operating in field tents.

Oxygen and Ventilator Logistics During California's COVID-19 Surge: When Oxygen Becomes a Scarce Resource.

The state of California, in the United States of America, has a population of nearly 40 million people and is the 5th largest economy in the world. During the coronavirus disease 2019 (COVID-19) pandemic in 2020-2021, the state experienced a medical surge that stressed its sophisticated health-care and public health system. During this period, ventilators, oxygen, and other equipment necessary for providing ventilatory support became a scarce resource in many health-care settings. When demand overwhelms supply, creative solutions are required at all levels of disaster management and health care. This study describes the disaster response by the state of California to mitigate the emergency demands for oxygen delivery resources.

Establishment of an Alternate Care Site (ACS) in Imperial County During COVID-19.

Imperial County is in southern California, one of the state's two counties at the international United States-Mexico border. The county is one of the most resource-limited in the state, with only two hospitals serving its 180,000 citizens, and no tertiary care centers. A significant portion of the population cared for at the local hospitals commutes from Mexicali, a large city of 1.2 million persons, just south of Imperial County's ports of entry. Since May 2020, following an outbreak in Mexicali, Imperial County has seen a significant increase in the number of COVID-19 patients, quickly outpacing its local resources. In response to this surge an alternate care site (ACS) was created as part of a collaboration between the California State Emergency Medical Service Authority (EMSA) and the county. In the first month of operations (May 26-June 26, 2020) the ACS received 106 patients with an average length of stay of 3.6 days. The average patient age was 55.5 years old with a range of 19-95 years. Disposition of patients included 25.5% sent to the emergency department for acute care needs, 1.8% who left against medical advice, and 72.7% who were discharged home or to a skilled nursing facility. There were no deaths on site. This study shares early experiences, challenges, and innovations created with the implementation of this ACS. Improving communication with local partners was the single most significant step in overcoming initial barriers.

Wilderness Medical Society Clinical Practice Guidelines for Water Disinfection for Wilderness, International Travel, and Austere Situations.

To provide guidance to clinicians, the Wilderness Medical Society convened experts to develop evidence-based guidelines for water disinfection in situations where the potability of available water is not ensured, including wilderness and international travel, areas affected by disaster, and other areas without adequate sanitation. The guidelines present the available methods for reducing or eliminating microbiologic contamination of water for individuals, groups, or households; evaluation of their effectiveness; and practical considerations. The evidence evaluation includes both laboratory and clinical publications. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks or burdens, according to the criteria published by the American College of Chest Physicians.

Statewide Method of Measuring Ambulance Patient Offload Times.

OBJECTIVE: Ambulance patient offload time (APOT) also known colloquially as "Wall time" has been described in various jurisdictions but seems to be highly variable. Any attempt to improve APOT requires the use of common definitions and standard methodology to measure the extent of the problem. METHODS: An Ambulance Offload Delay Task Force in California developed a set of standard definitions and methodology to measure APOT for transported 9-1-1 patients. It is defined as the time "interval between the arrival of an ambulance at an emergency department and the time that the patient is transferred to an ED gurney, bed, chair or other acceptable location and the ED assumes responsibility for care of the patient." Local EMS agencies voluntarily reported data according to the standard methodology to the California EMS Authority (State agency). RESULTS: Data were reported for 9-1-1 transports during 2017 from 9 of 33 local EMS Agencies in California that comprise 37 percent of the state population. These represent 830,637 ambulance transports to 126 hospitals. APOT shows significant variation by EMS agency with half of the agencies demonstrating significant delays. Offload times vary markedly by hospital as well as by region. Three-fourths of hospitals detained EMS crews more than one hour, 40% more than two hours, and one-third delayed EMS return to service by more than three hours. CONCLUSION: This first step to address offload delays in California consists of standardized definitions for data collection to address the significant variability inherent in obtaining data from 33 local agencies, hundreds of EMS provider agencies, and 320 acute care hospital Emergency Departments that receive 9-1-1 ambulance transports. The first year of standardized data collection of ambulance patient offload times revealed significant ambulance patient offload time delays that are not distributed uniformly, resulting in a substantial financial burden for some EMS providers in California.

Vaccination delivery by chain pharmacies in California: Results of a 2007 survey.

OBJECTIVE: To better understand the practice standards and scope of pharmacist-administered vaccination services at chain pharmacies in California. DESIGN: Cross sectional. SETTING: California in 2006-2007. PARTICIPANTS: Eight state-level immunization coordinator corporate liaisons to chain pharmacies' immunization programs. INTERVENTION: Key informant phone survey with follow-up written survey. MAIN OUTCOME MEASURES: Policies, procedures, and vaccine usage. RESULTS: All eight chains provided immunization services to adults; four chains also vaccinated adolescents. More than 1,000 California pharmacists employed at chain pharmacies have been trained to vaccinate; more than 500 locations participate with evening, weekend, and walk-in hours. Influenza and pneumococcal vaccines were the most common vaccines administered. Other vaccines were used less frequently. Respondents expressed interest in partnering with public health to improve record sharing, build awareness, receive vaccine news updates, and explore other activities. CONCLUSION: Chain pharmacies in California have started to vaccinate adults and adolescents--two commonly undervaccinated age groups. To date, patients seeking vaccination at pharmacies are most likely to receive influenza and pneumococcal vaccines. Community locations and extended hours offer patients convenience, although out-of-pocket fees may be a barrier to some patients. Opportunities exist to build and strengthen partnerships among public health, the medical community, and pharmacists in order to vaccinate and protect patients not vaccinated in traditional settings.

Severe pediatric influenza in California, 2003-2005: implications for immunization recommendations.

OBJECTIVE: The 2003-2004 influenza season was marked by both the emergence of a new drift "Fujian" strain of influenza A virus and prominent reports of increased influenza-related deaths in children in the absence of baseline data for comparison. In December 2003, the California Department of Health Services initiated surveillance of children who were hospitalized in California with severe influenza in an attempt to measure its impact and to identify additional preventive measures. METHODS: From December 2003 to May 2005, surveillance of children who were hospitalized in PICUs or dying in the hospital with laboratory evidence of influenza was performed by hospital infection control practitioners and local public health departments using a standardized case definition and reporting form. RESULTS: In the 2003-2004 and 2004-2005 influenza seasons, 125 and 35 cases, respectively, of severe influenza in children were identified in California. The mean and median age of cases were 3.1 years and 1.5 years, with breakdown as follows: < 6 months, 39 (24%); 6 to 23 months, 53 (33%); 2 to 4 years, 40 (25%); 5 to 11 years, 15 (9%); and 12 to 17 years, 13 (8%). Fifty-three percent (85 of 160) had an underlying medical condition(s), including a neurologic disorder (n = 36), chronic pulmonary disease (n = 26), genetic disorder (n = 19), cardiac disease (n = 18), prematurity (n = 14), immunocompromised status (n = 12), endocrine/renal disease (n = 2), and other (n = 1). Only 16% (15 of 96) of all patients had received influenza vaccination. Thirty-seven patients had an underlying illness that met existing Advisory Committee on Immunization Practices (ACIP) or American Academy of Pediatrics (AAP) recommendations for immunization, but only 8 had been vaccinated. CONCLUSIONS: More than 3 times as many children were reported to be hospitalized in intensive care with influenza in California during the 2003-2004 season compared with the 2004-2005 season. Because children who are younger than 6 months remain at highest risk for severe influenza yet cannot currently be immunized, development and validation of preventive measures for them (eg, maternal immunization, breastfeeding, immunization of young infants and their close contacts) are urgently needed. ACIP's recent recommendation for influenza vaccination of children with conditions that can compromise respiratory function (eg, cognitive dysfunction, spinal cord injuries, seizure disorders, other neuromuscular disorders) is further supported by the frequency of underlying neurologic disease in these cases of severe influenza. A significant proportion of children with severe influenza in California, including children who are aged 2 to 4 years or have underlying genetic syndromes or prematurity, would not have been routinely recommended for influenza vaccination in 2005-2006 ACIP and AAP recommendations, calling into question whether such guidelines should be expanded. Continued surveillance for severe influenza-related morbidity and mortality is important to measure the impact of influenza on children.

Reproducibility of increased blood pressure during an emergency department or urgent care visit.

STUDY OBJECTIVE: We determine the reproducibility of increased blood pressure measurements among adults in the emergency department or minor injury clinic. METHODS: The study was conducted at Kaiser Permanente Medical Center in Hayward, CA, a large, group-model health maintenance organization providing capitated insurance coverage. All patients were included in the study who had no current diagnosis of hypertension but had increased blood pressure on their presentation to the ED or minor injury clinic during the 2-month study period. The staff was asked to repeat the blood pressure later during the index visit and provide these patients with written instructions to return for additional repeat measures. We compared blood pressures taken in the ED to measurements before and after the ED visit. RESULTS: Four hundred seven patients were included in the study. Of the initial elevated blood pressures, 211 (51.8%) were stage 1 elevation, 147 (36.1%) were stage 2, and 49 (12.0%) were stage 3 by criteria of the Joint National Committee on Hypertension. Sixty-five percent of patients had repeat measures in the clinic during our 5-month follow-up period, despite active outreach and reminders. Seventy percent of those who had repeat blood pressure documented had at least 1 increased blood pressure after their ED visit. The proportion of patients with at least 1 abnormal blood pressure on subsequent measurement increased with increasing stage of initial blood pressure (64.4% for stage 1, 77.1% for stage 2, 97.1% for stage 3), but was similar for patients with and without pain as a chief complaint and was similar for patients seen in the ED compared with patients seen in urgent care. Compared with blood pressures taken during the ED visit, matched blood pressures taken before or after showed no statistically significant differences. CONCLUSION: Increased blood pressure is common among emergency or urgent care patients without a history of current hypertension, and most of these will have mixed or consistently abnormal results on repeat measures. Patients should be referred for repeat measures after a single abnormal measure in the ED.

Water disinfection for international and wilderness travelers.

Acquisition of waterborne disease is a substantial risk for international travelers to countries with inadequate sanitation facilities. It also poses smaller but still significant risks for wilderness travelers who rely on surface water in developed countries with low rates of diarrheal illness, such as the United States. This article reviews the etiology and risks associated with waterborne disease that might be encountered by both types of travelers. It also summarizes--and makes recommendations for--the various water-treatment methods available to travelers for reducing their risk of contracting waterborne disease.