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OBJECTIVES: Medical Priority Dispatch System (MPDS) is a system used to assign medical 9-1-1 calls to one of 35 chief complaints that are further categorized in order of increasing priority, Alpha through Echo. In this descriptive study we demonstrate the methodology of matching MPDS codes to a county mortality registry. We also evaluated the ability of select MPDS codes (fall, respiratory, sick person, and abdominal pain) to predict mortality up to 30 d for all ages transported by Alameda County Emergency Medical Services (EMS). METHODS: Using Alameda County EMS data, we conducted a retrospective review of all EMS encounters that occurred from November 1, 2011, to November 1, 2016. To describe mortality in this population, we identified unique patients and linked them to the Alameda County Public Health Death Registry. We identified mortality at 48 h, 7 d, and 30 d after an EMS encounter. RESULTS: Approximately 99% of the EMS encounters were matched with unique patient identifiers, yielding a study sample of 202,431 (4% less than age 18, 53% between ages 18-65, and 43% over age 65). Patients with a respiratory chief complaint had the highest mortality percentage in each age group (0.23%, 2.7%, and 14.55% respectively). There was no correlation between the MPDS code and mortality for patients less than age 18. An increase in Alpha through Echo designation for respiratory complaints in patients 18-65 and older than 65 years corresponded with an increase in 30-day mortality. CONCLUSIONS: This study demonstrates an upward trend in mortality with increasing acuity of Alpha through Echo designations for adult patients with respiratory complaints. Mortality increased with age in this cohort. Most of the deaths occurred after 7 days.
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STUDY OBJECTIVE: Patients with acute psychiatric emergencies who receive an involuntary hold often spend hours in the emergency department (ED) because of a deficit in inpatient psychiatric beds. One solution to address the lack of prompt psychiatric evaluation in the ED has been to establish regional stand-alone psychiatric emergency services. However, patients receiving involuntary holds still need to be screened and evaluated to ensure that their behavior is not caused by an underlying and life-threatening nonpsychiatric illness. Although traditional regional emergency medical services (EMS) systems depend on the medical ED for this function, a field-screening protocol can allow EMS to directly transport a substantial portion of patients to a stand-alone psychiatric emergency service. The purpose of this investigation is to describe overall EMS use for patients receiving involuntary holds, compare patients receiving involuntary holds with all EMS patients, and evaluate the safety of field medical clearance of an established field-screening protocol in Alameda County, CA. METHODS: We obtained data for all EMS encounters between November 1, 2011, and November 1, 2016, using Alameda County's standardized data set. After unique patient identification, we describe the data at the patient level and at the encounter level. At the patient level, we compare "involuntary hold patients" (≥1 involuntary hold during the study period) with those who were "never held." Additionally, we assess the safety of out-of-hospital medical clearance by calculating the rate of failed diversion, defined as retransport of a patient to a medical ED within 12 hours of transport to the psychiatric emergency services by EMS. RESULTS: Of the 541,731 total EMS encounters in Alameda County during the study period, 10% (N=53,887) were identified as involuntary hold encounters. Of these involuntary hold patient encounters, 41% (N=22,074) resulted in direct transport of the patient to the stand-alone psychiatric emergency service for evaluation; 0.3% (N=60) failed diversion and required retransport within 12 hours. At the patient level, Alameda County EMS encountered 257,625 unique patients, and 10% (N=26,283) had at least one encounter for an involuntary hold during the study period. These "involuntary hold patients" were substantially younger, more likely to be men, and less likely to be insured. Additionally, they had higher overall EMS use: "involuntary hold patients" accounted for 24% of all encounters (N=128,003); 53,887 of these encounters were for involuntary holds, whereas an additional 74,116 were for other reasons. Similarly, 4% of "involuntary hold patients" had 20 or more encounters, whereas only 0.4% of "never held" patients were in this category. Last, the 7% of "involuntary hold patients" (N=1,907) who received greater than or equal to 5 involuntary holds during the study period accounted for 39% of all involuntary holds and 9% of all EMS encounters. CONCLUSION: Ten percent of all EMS encounters were for involuntary psychiatric holds. With an EMS-directed screening protocol, 41% of all such patient encounters resulted in direct transport of the patient to the psychiatric emergency service, bypassing medical clearance in the ED. Overall, only 0.3% of these patients required retransport to a medical ED within 12 hours of arrival to psychiatric emergency services. We found that 24% of all EMS encounters in Alameda County were attributable to "involuntary hold patients," reinforcing the importance of the effects of mental illness on EMS use.
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Trastornos Mentales/diagnóstico , Adolescente , Adulto , Anciano , Internamiento Obligatorio del Enfermo Mental/estadística & datos numéricos , Servicios Médicos de Urgencia , Femenino , Humanos , Masculino , Pacientes no Asegurados/estadística & datos numéricos , Persona de Mediana Edad , Seguridad del Paciente , Guías de Práctica Clínica como Asunto , Estudios RetrospectivosRESUMEN
STUDY OBJECTIVE: Community-onset urinary tract infections (UTIs) caused by extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae, which are resistant to ceftriaxone and usually coresistant to fluoroquinolones, are increasing worldwide. We investigate and describe in detail UTIs caused by ESBL-producing Enterobacteriaceae in our emergency department (ED), and determine the proportion that occurred in patients without health care-associated risk factors and who received discordant initial antibiotic therapy. METHODS: At an urban public hospital in Northern California, microbiology staff prospectively reviewed ED urine culture results weekly for 1 year and presumptively identified ESBL-producing isolates by ceftriaxone plus ceftazidime resistance. For isolates associated with a clinical UTI, patient demographic and case clinical features were abstracted retrospectively. Health care-associated infections were defined by standard risk factors plus aged 65 years or older, bladder catheter, urologic procedure, functional dependence, or antibiotics in the previous 90 days. Community-associated infections were defined by absence of these. A subset of community-associated ESBL-producing Escherichia coli isolates underwent genotyping. Electronic health record query was used to determine the denominator of ED UTI patients who underwent urine culture during the study period. RESULTS: Between August 2016 and July 2017, there were 1,045 unique ED patients diagnosed with a UTI, whose specimens underwent culture. There were 62 ESBL-producing isolates (5.9%; 95% confidence interval [CI] 4.6% to 7.5%). Selected characteristics of the entire ESBL UTI cohort were median age 50 years, 37 (60%) patients were women, 28 (44%) Hispanic, 11 (18%) had been hospitalized in the previous 3 months, 19 (31%) had pyelonephritis, 49 (79%) of isolates were E coli, 44 (71%) were levofloxacin-resistant, and 24 (23%) nitrofurantoin-resistant. Initial antibiotic choice was discordant with isolate susceptibility in 26 of 56 cases (46%; 95% CI 33% to 60%), and the initial oral antibiotic prescred was discordant in 19 of 41 cases (46%; 95% CI 31% to 63%). Twenty-seven infections (44%; 95% CI 31% to 57%) were categorized as community-associated. Eight patients with community-associated infection were women younger than 50 years, with no comorbidities and no more than 1 UTI in the previous year. Of 12 community-associated E coli isolates tested, all were confirmed to harbor ESBL genes; the CTX-M1 ß-lactamase gene was found in 8 (67%); 4 belong to genotype ST131. CONCLUSION: At this single Northern California ED, greater than 5% of culture-proven UTI were caused by ESBL-producing Enterobacteriaceae, and in nearly half of cases there was no identifiable health care-associated risk factor. Levofloxacin co-resistance and discordant antibiotic therapy were common.
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Antibacterianos/uso terapéutico , Infecciones por Enterobacteriaceae/tratamiento farmacológico , Enterobacteriaceae/aislamiento & purificación , Infecciones Urinarias/tratamiento farmacológico , beta-Lactamasas/metabolismo , Adulto , Antibacterianos/administración & dosificación , Antibacterianos/farmacología , California/epidemiología , Estudios de Cohortes , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Infecciones Comunitarias Adquiridas/epidemiología , Infecciones Comunitarias Adquiridas/microbiología , Registros Electrónicos de Salud , Servicio de Urgencia en Hospital , Enterobacteriaceae/efectos de los fármacos , Enterobacteriaceae/genética , Enterobacteriaceae/metabolismo , Infecciones por Enterobacteriaceae/epidemiología , Infecciones por Enterobacteriaceae/microbiología , Femenino , Hospitales Públicos , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Infecciones Urinarias/epidemiología , Infecciones Urinarias/microbiologíaRESUMEN
OBJECTIVES: Patients commonly come to the emergency department (ED) with social needs. To address this, we created the Highland Health Advocates (HHA), an ED-based help desk and medical-legal partnership using undergraduate volunteers to help patients navigate public resources and provide onsite legal and social work referrals. We were able to provide these services in English and Spanish. We aimed to determine the social needs of the patients who presented to our ED and the potential impact of the programme in resolving those needs and connecting them to a 'medical home' (defined as a consistent, primary source of medical care such as a primary care doctor or clinic). METHODS: ED patients at a US safety net hospital were enrolled in a 1:2 ratio in a quasi-experiment comparing those who received intervention from the HHA during a limited access rollout with controls who received usual care on days with no help desk. We collected a baseline social needs evaluation, with follow-up assessments at 1 and 6 months. Primary outcomes were linkages for the primary identified need and to a medical home within 1 month. Other outcomes at 6 months included whether a patient (1) felt helped; 2) had a decreased number of ED visits; (3) had the primary identified need met; (4) had a primary doctor; and (5) had a change in self-reported health status. RESULTS: We enrolled 459 subjects (intervention=154, control=305). Housing (41%), employment (23%) and inability to pay bills (22%) were participants' top identified needs. At baseline, 32% reported the ED as their medical home, with the intervention cohort having higher ED utilisation (>1 ED visit in the prior month: 49% vs 24%). At 1 month, 185 (40%) subjects were reached for follow-up, with more HHA subjects linked to a resource (59% vs 37%) and a medical home (92% vs 76%). At 6 months, 75% of subjects felt HHA was helpful and more subjects in the HHA group had a doctor (93% v 69%). No difference was found in ED utilisation, primary need resolution or self-reported health status. CONCLUSIONS: Health-related social needs are common in this US safety net ED. Our help desk is one possible model for addressing social needs.
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Servicio de Urgencia en Hospital/tendencias , Difusión de la Información/métodos , Evaluación de Programas y Proyectos de Salud/métodos , Servicio Social/métodos , Adulto , Servicio de Urgencia en Hospital/normas , Empleo/estadística & datos numéricos , Femenino , Vivienda/estadística & datos numéricos , Humanos , Renta/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Pacientes , Sistemas de Apoyo Psicosocial , Proveedores de Redes de Seguridad/organización & administración , Estados UnidosRESUMEN
STUDY OBJECTIVE: We describe the results of an emergency department (ED) hepatitis C virus testing program that integrated birth cohort screening and screening of patients with a history of injection drug use, as well as physician diagnostic testing, according to national guidelines. METHODS: We conducted a retrospective cohort study using data collected as part of clinical care. The primary outcome was the hepatitis C virus prevalence among tested patients. We evaluated factors associated with testing positive with logistic regression. RESULTS: Of the 26,639 unique adults aged 18 years or older and presenting to the ED during the 6-month study, 2,581 (9.7%) completed hepatitis C virus screening (2,028) or diagnostic testing (553), of whom 267 were antibody positive (10.3% prevalence). Factors associated with testing positive for hepatitis C virus included injection drug use (38.4% prevalence; odds ratio [OR] 10.8; 95% confidence interval [CI] 7.5 to 15.5), homeless (25.5% prevalence; OR 3.1; 95% CI 1.5 to 6.8), diagnostic testing (14.8% prevalence; OR 2.6; 95% CI 1.7 to 3.9), birth cohort (13.7% prevalence; OR 3.6; 95% CI 2.4 to 5.3), and male sex (12.4% prevalence; OR 1.4; 95% CI 1.0 to 2.0). Of the 267 patients testing positive for hepatitis C virus antibody, 137 (51%) had documentation of result disclosure and 180 (67%) had confirmatory ribonucleic acid testing performed, of whom 126 (70%) had a positive result. Follow-up appointments at the hepatitis C virus clinic were arranged for 57 of the 126 (45%) patients with confirmed positive results, of which 30 attended. CONCLUSION: This ED screening and diagnostic testing program found a high prevalence of hepatitis C virus antibody positivity across all groups. Challenges encountered with hepatitis C virus screening included result disclosure, confirmatory testing, and linkage to care. Our results warrant continued efforts to develop and evaluate policies for ED-based hepatitis C virus screening.
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Servicio de Urgencia en Hospital , Hepatitis C/diagnóstico , Tamizaje Masivo/métodos , Adulto , Anciano , Femenino , Hepatitis C/epidemiología , Hospitales Urbanos , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Triaje , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: Nontargeted human immunodeficiency virus (HIV) screening and targeted hepatitis C virus (HCV) screening for selected high-risk patients (those born between 1945 and 1965 and those who report injection drug use) was integrated into our ED triage process and carried out by nurses. Determining whether emergency nurses accurately perceive what patients experience is important to know because staff misperceptions may pose a barrier to program adherence and sustainability. METHODS: We performed a cross-sectional survey study of emergency nurses and patients to assess the accuracy of emergency nurses' perception of patient experience with the HIV/HCV screening program. Respondents evaluated their level of agreement using a 5-item Likert scale for 9 statements across 4 domains related to the patient experience with the screening process (satisfaction, sense of autonomy, sense of privacy, and comfort level). RESULTS: Surveys were completed by 65 of the 153 eligible emergency nurses (42%). Of the 1040 patients approached, 610 (59%) were eligible, and 491 of the 610 eligible patients (80%) completed surveys. Across all domains, statistically significant differences were found between emergency nurse perception and patient report, P < .001. Emergency nurses perceived patients to be less satisfied with the screening program, more uncomfortable with being asked screening questions, more concerned about privacy issues, and less likely to feel that the decision to decline screening was autonomous than were patients. DISCUSSION: Emergency nurses not only frequently misperceive how patients experience ED-based HIV/HCV screening, but these misperceptions are skewed toward the negative, representing a type of staff bias. Further research is recommended to determine if such misperceptions adversely affect implementation of screening.
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Actitud del Personal de Salud , Enfermería de Urgencia/estadística & datos numéricos , Servicio de Urgencia en Hospital , Infecciones por VIH/diagnóstico , Hepatitis C/diagnóstico , Satisfacción del Paciente/estadística & datos numéricos , Adulto , California , Estudios Transversales , Femenino , Infecciones por VIH/psicología , Encuestas de Atención de la Salud/estadística & datos numéricos , Hepatitis C/psicología , Humanos , Masculino , Personal de Enfermería en Hospital/psicología , Personal de Enfermería en Hospital/estadística & datos numéricosRESUMEN
BACKGROUND: Although norovirus is the most common cause of gastroenteritis, there are few data on the community incidence of infection/disease or the patterns of acquired immunity or innate resistance to norovirus. METHODS: We followed a community-based birth cohort of 194 children in Ecuador with the aim to estimate (1) the incidence of norovirus gastroenteritis from birth to age 3 years, (2) the protective effect of norovirus infection against subsequent infection/disease, and (3) the association of infection and disease with FUT2 secretor status. RESULTS: Over the 3-year period, we detected a mean of 2.26 diarrheal episodes per child (range, 0-12 episodes). Norovirus was detected in 260 samples (18%) but was not found more frequently in diarrheal samples (79 of 438 [18%]), compared with diarrhea-free samples (181 of 1016 [18%]; P = .919). A total of 66% of children had at least 1 norovirus infection during the first 3 years of life, and 40% of children had 2 infections. Previous norovirus infections were not associated with the risk of subsequent infection. All genogroup II, genotype 4 (GII.4) infections were among secretor-positive children (P < .001), but higher rates of non-GII.4 infections were found in secretor-negative children (relative risk, 0.56; P = .029). CONCLUSIONS: GII.4 infections were uniquely detected in secretor-positive children, while non-GII.4 infections were more often found in secretor-negative children.
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Infecciones por Caliciviridae/genética , Infecciones por Caliciviridae/virología , Fucosiltransferasas/genética , Gastroenteritis/genética , Gastroenteritis/virología , Norovirus/genética , Infecciones por Caliciviridae/epidemiología , Preescolar , Estudios de Cohortes , Diarrea/epidemiología , Diarrea/virología , Ecuador/epidemiología , Heces/virología , Gastroenteritis/epidemiología , Predisposición Genética a la Enfermedad/genética , Genotipo , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , Norovirus/inmunología , Norovirus/aislamiento & purificación , Saliva/química , Galactósido 2-alfa-L-FucosiltransferasaRESUMEN
Noroviruses are the leading cause of gastroenteritis in the United States, but timely measures of disease are lacking. BioSense, a national-level electronic surveillance system, assigns data on chief complaints (patient symptoms) collected during emergency department (ED) visits to 78 subsyndromes in near real-time. In a series of linear regression models, BioSense visits mapped by chief complaints of diarrhea and nausea/vomiting subsyndromes as a monthly proportion of all visits correlated strongly with reported norovirus outbreaks from 6 states during 2007-2010. Higher correlations were seen for diarrhea (R = 0.828-0.926) than for nausea/vomiting (R = 0.729-0.866) across multiple age groups. Diarrhea ED visit proportions exhibited winter seasonality attributable to norovirus; rotavirus contributed substantially for children <5 years of age. Diarrhea ED visit data estimated the onset, peak, and end of norovirus season within 4 weeks of observed dates and could be reliable, timely indicators of norovirus activity.
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Infecciones por Caliciviridae/epidemiología , Diarrea/epidemiología , Gastroenteritis/epidemiología , Norovirus , Adolescente , Adulto , Anciano , Niño , Preescolar , Diarrea/virología , Brotes de Enfermedades , Registros Electrónicos de Salud , Servicio de Urgencia en Hospital , Monitoreo Epidemiológico , Gastroenteritis/virología , Humanos , Lactante , Modelos Lineales , Persona de Mediana Edad , Infecciones por Rotavirus/epidemiología , Estaciones del Año , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Systemic lupus erythematosus (SLE) is a complex autoimmune disease that is associated with poor health-related quality-of-life outcomes. OBJECTIVES: The objectives of this study were to identify correlates of the domains of the Medical Outcomes Study (MOS) Sleep Scale in SLE and to determine the factors most associated with overall sleep quality. METHODS: Sleep in 118 SLE patients was assessed using the self-administered MOS Sleep Scale. Bivariate correlations were determined between each of 6 MOS Sleep subscale scores and each sociodemographic, clinical, or psychological predictor variable. Serial hierarchical multiple regression analyses were computed to identify the variables associated with the individual sleep domains and the overall Sleep Problems Index. RESULTS: The MOS Sleep Scale scores of patients with SLE were poorer than the US general population. Depression moderately correlated with 5 (all P < 0.01) and anxiety with 4 subscale scores (all P < 0.05). The SLE Disease Activity Index did not significantly correlate with any of the subscale scores. Results of a multivariate regression model showed that sleep adequacy and sleep disturbance were independently associated with depression (ß = -0.84; 95% confidence interval [CI], -1.37 to -0.32; and ß = 0.80; 95% CI, 0.15-1.45; respectively). Daytime somnolence was significantly associated with daily prednisone dosage (ß = 0.54; 95% CI, 0.29-0.80) and anxiety trait (ß = 0.81; 95% CI, 0.41-1.21). Snoring independently correlated with anxiety (ß = 1.64; 95% CI, 0.80-2.29). When demographic, clinical, and psychological variables were simultaneously regressed on the Sleep Problems Index, pain trended toward association with overall sleep problems (ß = 0.17; 95% CI, -0.02 to 0.36). CONCLUSIONS: Patients with SLE have greater sleep problems relative to the general population. Psychosocial factors, particularly depression and anxiety, are important determinants that are significantly associated with sleep abnormalities in SLE.
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Centros Médicos Académicos , Instituciones de Atención Ambulatoria , Lupus Eritematoso Sistémico/epidemiología , Índice de Severidad de la Enfermedad , Trastornos del Sueño-Vigilia/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Ansiedad/epidemiología , Chicago , Comorbilidad , Estudios Transversales , Depresión/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Análisis de Regresión , Encuestas y Cuestionarios , Adulto JovenRESUMEN
Background: Pediatric patients with behavioral health emergencies (BHEs) are often transported to an emergency department (ED) by emergency medical services (EMS), despite having no physical medical complaints, to await psychiatric evaluation and treatment. This process leads to significant delays in their care. We examined the safety of directly transporting pediatric patients with BHEs from the field to an alternative destination of a psychiatric emergency service (PES) facility using an EMS protocol. Methods: A retrospective review from November 1, 2011, to November 1, 2016, was conducted for pediatric EMS encounters using EMS data from Alameda County, California. Our primary outcome was the safety of a prehospital alternative destination protocol. We identified the proportion of patients who required retransport to an ED within 24 h after arriving at PES (defined as a failed diversion). We also describe the mortality of all patients being transported for a BHE. Results: There were 38,241 total pediatric encounters, with 20.1% for BHEs. A total of 3122 (41%) BHE encounters met protocol criteria and were transported directly to the PES. Only 16 (0.5%) patients had a secondary transport (failed diversion) to an ED within 24 h of arrival. No patients with a BHE transported to the PES died within 30 days of the EMS encounter. Conclusion: Death and adverse clinical outcomes are extremely rare in pediatric patients using a prehospital alternative destination protocol. This information could significantly improve the care of children with BHEs.
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Objective: Emergency medical services (EMS) transport for mental and behavioral health (MBH) emergencies occurs frequently in children, yet little is understood regarding prehospital physical restraint use despite the potential for serious adverse events. We aim to describe restraint use prevalence and primary impressions among children with MBH emergencies. Methods: This is a retrospective cross-sectional study of children with MBH emergencies evaluated by Alameda County (ALCO), California EMS from January 1, 2012 to December 31, 2018. Patient demographics and clinical variables were collected from the EMS records including sex, age at time of encounter, year of encounter, transport destination, medication use, and primary impression(s). The primary outcome was the use of physical restraints. Descriptive statistics were used to characterize the primary outcome and associated demographic and diagnostic features, as well as temporal use patterns. Sex and age were compared between restrained and non-restrained youth using chi-square analysis. Results: Over the 7-year study period, ALCO EMS transported 9775 children with MBH emergencies. Of these transports, 1205 (12.3%) were physically restrained. Most children restrained had the primary impression of "behavioral/psychiatric crisis" (51.1%), "psychiatric crisis" (27.4%), and "behavioral-other" (12.4%) and the remaining children (9.1%) had a non-psychiatric/behavioral health primary impression. Over time, there was no statistically significant change in either number of children with MBH emergencies transported or physical restraint rate. Conclusions: More than 1 in 8 children with MBH emergencies are being physically restrained during EMS transport. Restraint rate did not substantially change over time. Further studies to understand existing restraint rates and EMS resources available to address acute agitation in children are needed to inform quality and care enhancing initiatives.
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CONTEXT: Norovirus outbreaks are common among vulnerable, elderly populations in US nursing homes. OBJECTIVES: To assess whether all-cause hospitalization and mortality rates are increased during norovirus outbreak vs nonoutbreak periods in nursing homes, and to identify factors associated with increased risk. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of Medicare-certified nursing homes in Oregon, Wisconsin, and Pennsylvania that reported at least 1 confirmed or suspected norovirus outbreak to the Centers for Disease Control and Prevention's National Outbreak Reporting System (NORS), January 2009 to December 2010. Deaths and hospitalizations occurring among residents of these nursing homes were identified through the Medicare Minimum Data Set (MDS). MAIN OUTCOME MEASURES: Rates of all-cause hospitalization and mortality during outbreak compared with nonoutbreak periods were estimated using a random-effects Poisson regression model controlling for background seasonality in both outcomes. RESULTS: The cohort consisted of 308 nursing homes that reported 407 norovirus outbreaks to NORS. Per MDS, 67 730 hospitalizations and 26 055 deaths occurred in these homes during the 2-year study. Hospitalization rates were 124.0 (95% CI, 119.4-129.1) vs 109.5 (95% CI, 108.6-110.3) hospitalizations per nursing home−year during outbreak vs nonoutbreak periods, yielding a seasonally adjusted rate ratio (RR) of 1.09 (95% CI, 1.05-1.14). Similarly, mortality rates were 53.7 (95% CI, 50.6-57.0) vs 41.9 (95% CI, 41.4-42.4) deaths per nursing home−year in outbreak vs nonoutbreak periods (seasonally adjusted RR, 1.11; 95% CI, 1.05-1.18). The increases in hospitalizations and mortality were concentrated in the first 2 weeks (week 0 and 1) and the initial week (week 0) of the outbreak, respectively. Homes with lower daily registered nurse (RN) hours per resident (<0.75) had increased mortality rates during norovirus outbreaks compared with baseline (RR, 1.26; 95% CI, 1.14-1.40), while no increased risk (RR, 1.03; 95% CI, 0.96-1.12) was observed in homes with higher daily RN hours per resident (P = .007 by likelihood ratio test); the increase in hospitalization rates did not show a similar pattern. CONCLUSION: Norovirus outbreaks were associated with significant concurrent increases in all-cause hospitalization and mortality in nursing homes.
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Infecciones por Caliciviridae/mortalidad , Brotes de Enfermedades , Gastroenteritis/mortalidad , Mortalidad Hospitalaria/tendencias , Norovirus , Casas de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Masculino , Notificación Obligatoria , Oregon/epidemiología , Pennsylvania/epidemiología , Vigilancia de la Población/métodos , Estudios Retrospectivos , Wisconsin/epidemiologíaRESUMEN
BACKGROUND: Shareable e-scooters have become popular, but injuries to riders and bystanders have not been well characterized. The goal of this study was to describe e-scooter injuries and estimate the rate of injury per e-scooter trip. METHODS AND FINDINGS: Retrospective review of patients presenting to 180 clinics and 2 hospitals in greater Los Angeles between January 1, 2014 and May 14, 2020. Injuries were identified using a natural language processing (NLP) algorithm not previously used to identify injuries, tallied, and described along with required healthcare resources. We combine these tallies with municipal data on scooter use to report a monthly utilization-corrected rate of e-scooter injuries. We searched 36 million clinical notes. Our NLP algorithm correctly classified 92% of notes in the testing set compared with the gold standard of investigator review. In total, we identified 1,354 people injured by e-scooters; 30% were seen in more than one clinical setting (e.g., emergency department and a follow-up outpatient visit), 29% required advanced imaging, 6% required inpatient admission, and 2 died. We estimate 115 injuries per million e-scooter trips were treated in our health system. CONCLUSIONS: Our observed e-scooter injury rate is likely an underestimate, but is similar to that previously reported for motorcycles. However, the comparative severity of injuries is unknown. Our methodology may prove useful to study other clinical conditions not identifiable by existing diagnostic systems.
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Accidentes de Tránsito , Procesamiento de Lenguaje Natural , Servicio de Urgencia en Hospital , Humanos , Motocicletas , Estudios RetrospectivosRESUMEN
Variants of the osteopontin (OPN) gene have been associated with systemic lupus erythematosus (SLE) susceptibility and cytokine profiles in SLE patients. It is not known whether these alleles are associated with specific clinical phenotypes in SLE. We studied 252 well-characterized SLE patients from a multiethnic cohort, genotyping the rs11730582, rs28357094, rs6532040, and rs9138 SNPs in the OPN gene. Ancestry informative markers were used to control for genetic ancestry. The SLE-risk allele rs9138C in the 3' UTR region was associated with photosensitivity in lupus patients across all ancestral backgrounds (meta-analysis OR = 3.2, 95% CI = 1.6-6.5, P = 1.0 × 10⻳). Additionally, the promoter variant rs11730582C demonstrated suggestive evidence for association with two hematologic traits: thrombocytopenia (OR = 2.1, P = 0.023) and hemolytic anemia (OR = 2.6, P = 0.036). These clinical associations with SNPs in the promoter and 3' UTR regions align with previously reported SLE-susceptibility SNPs in OPN and suggest potential roles for these variants in antibody-mediated cytopenias and skin inflammation in SLE.
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Estudios de Asociación Genética/métodos , Lupus Eritematoso Sistémico/genética , Lupus Eritematoso Sistémico/patología , Osteopontina/genética , Regiones no Traducidas 3'/genética , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Alelos , Anemia Hemolítica/genética , Estudios de Cohortes , Femenino , Predisposición Genética a la Enfermedad , Humanos , Masculino , Persona de Mediana Edad , Fenotipo , Polimorfismo de Nucleótido Simple/genética , Regiones Promotoras Genéticas/genética , Trombocitopenia/genética , Adulto JovenRESUMEN
Importance: Since September 2017, standing electric scooters have proliferated rapidly as an inexpensive, easy mode of transportation. Although there are regulations for safe riding established by both electric scooter companies and local governments, public common use practices and the incidence and types of injuries associated with these standing electric scooters are unknown. Objective: To characterize injuries associated with standing electric scooter use, the clinical outcomes of injured patients, and common use practices in the first US metropolitan area to experience adoption of this technology. Design, Setting, and Participants: This study of a case series used retrospective cohort medical record review of all patients presenting with injuries associated with standing electric scooter use between September 1, 2017, and August 31, 2018, at 2 urban emergency departments associated with an academic medical center in Southern California. All electric scooter riders at selected public intersections in the community surrounding the 2 hospitals were also observed during a 7-hour observation period in September 2018. Main Outcomes and Measures: Incidence and characteristics of injuries and observation of riders' common use practices. Results: Two hundred forty-nine patients (145 [58.2%] male; mean [SD] age, 33.7 [15.3] years) presented to the emergency department with injuries associated with standing electric scooter use during the study period. Two hundred twenty-eight (91.6%) were injured as riders and 21 (8.4%) as nonriders. Twenty-seven patients were younger than 18 years (10.8%). Ten riders (4.4%) were documented as having worn a helmet, and 12 patients (4.8%) had either a blood alcohol level greater than 0.05% or were perceived to be intoxicated by a physician. Frequent injuries included fractures (79 [31.7%]), head injury (100 [40.2%]), and contusions, sprains, and lacerations without fracture or head injury (69 [27.7%]). The majority of patients (234 [94.0%]) were discharged home from the emergency department; of the 15 admitted patients, 2 had severe injuries and were admitted to the intensive care unit. Among 193 observed electric scooter riders in the local community in September 2018, 182 (94.3%) were not wearing a helmet. Conclusions and Relevance: Injuries associated with standing electric scooter use are a new phenomenon and vary in severity. In this study, helmet use was low and a significant subset of injuries occurred in patients younger than 18 years, the minimum age permitted by private scooter company regulations. These findings may inform public policy regarding standing electric scooter use.
Asunto(s)
Contusiones/epidemiología , Traumatismos Craneocerebrales/epidemiología , Fracturas Óseas/epidemiología , Laceraciones/epidemiología , Vehículos a Motor , Esguinces y Distensiones/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Consumo de Bebidas Alcohólicas/efectos adversos , California/epidemiología , Niño , Traumatismos Craneocerebrales/prevención & control , Servicio de Urgencia en Hospital , Femenino , Dispositivos de Protección de la Cabeza , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Población Urbana , Adulto JovenRESUMEN
PURPOSE: To describe the prevalence and effects on applicants of being asked potentially illegal questions during the residency interview process by surveying all residency applicants to all specialties. METHOD: The authors surveyed all applicants from U.S. medical schools to residency programs in all specialties in 2012-2013. The survey included questions about the prevalence of potentially illegal questions, applicants' level of comfort with such questions, and whether such questions affected how applicants ranked programs. Descriptive statistics, tests of proportions, t tests, and logistic regression modeling were used to analyze the data. RESULTS: Of 21,457 eligible applicants, 10,976 (51.1%) responded to the survey. Overall, 65.9% (7,219/10,967) reported receiving at least one potentially illegal question. More female respondents reported being asked questions about gender (513/5,357 [9.6%] vs. 148/5,098 [2.9%]), marital status (2,895/5,283 [54.8%] vs. 2,592/4,990 [51.9%]), or plans for having children (889/5,241 [17.0%] vs. 521/4,931 [10.6%]) than male respondents (P < .001). Those in surgical specialties were more likely to have received a potentially illegal question than those in nonsurgical specialties (1,908/2,330 [81.9%] vs. 5,311/8,281 [64.1%]). Questions regarding their commitment to the program were reported by 15.5% (1,608/10,378) of respondents. Such potentially illegal questions negatively affected how respondents ranked programs. CONCLUSIONS: Two-thirds of applicants reported being asked potentially illegal questions. More women than men reported receiving questions about marital status or family planning. Potentially illegal questions negatively influence how applicants perceive and rank programs. A formal interview code of conduct or interviewer training could help to address these issues.
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Internado y Residencia/legislación & jurisprudencia , Entrevistas como Asunto/métodos , Criterios de Admisión Escolar/estadística & datos numéricos , Adolescente , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Internado y Residencia/normas , Entrevistas como Asunto/normas , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudiantes de Medicina/psicología , Encuestas y Cuestionarios , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: Recent studies demonstrate high rates of previously undiagnosed hepatitis C virus (HCV) infection among patients screened in urban emergency departments (ED). Experts caution, however, that public health interventions, such as screening for infectious diseases, must not interfere with the primary mission of EDs to provide timely acute care. Increases in ED length of stay (LOS) have been associated with decreased quality of ED care. OBJECTIVE: In this study, we assess the influence of an integrated HCV screening protocol on ED LOS. METHODS: This was a retrospective cohort study analyzing timestamp data for all discharged patients over a 1-year period. The primary outcome compared the median LOS in minutes between patients who completed HCV screening and those who did not. Further analysis compared LOS for HCV screening by whether or not complete blood count (CBC) testing was conducted. RESULTS: Of 69,639 visits, 2,864 (4%) had HCV screening tests completed and 272 (9.5%) were antibody positive. The median LOS for visits that included HCV screening was greater than visits that did not include screening (151 versus 119 minutes, P < 0.001). Among the subset of visits in which CBC testing was conducted, there was no significant difference in median LOS between visits that also included HCV screening and those that did not (240 versus 242 minutes, P = 0.68). CONCLUSION: Integrated HCV screening modestly prolongs ED LOS. However, among patients undergoing other blood tests, screening had no effect on LOS. Programs may consider routinely offering HCV screening to patients who are undergoing laboratory testing.
Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Hepatitis C/diagnóstico , Tiempo de Internación/estadística & datos numéricos , Tamizaje Masivo , Adulto , Estudios de Cohortes , Femenino , Humanos , Masculino , Alta del Paciente/estadística & datos numéricos , Calidad de la Atención de Salud/estadística & datos numéricos , Estudios RetrospectivosRESUMEN
BACKGROUND: During 8-20 April 2012, an outbreak of gastrointestinal illness occurred among guests and employees of a resort hotel in St. Thomas, US Virgin Islands. We describe outbreak characteristics, and estimate indirect (non-medical) costs to travellers. METHODS: Employees who met the case definition were interviewed and provided stool samples. Samples were tested for norovirus by real-time reverse-transcription polymerase chain reaction. Guests were asked to complete a survey aimed to identify and characterize cases, and to estimate quality adjusted vacation days (QAVD) lost. RESULTS: Overall, 66 persons (20 employees and 46 guests) met the probable case definition. The first reported illness onset occurred in a hotel employee on 8 April, while the first reported onset in a guest occurred on 13 April. An employee suffered a public diarrhoea incident on 13 April in the central kitchen, followed by illness onset in the next day among employees that assisted with the clean-up. On 15 April, after 10 guests reported ill, the hotel implemented an outbreak response protocol instructing ill employees to take a 3-day leave, and obtain medical clearance prior to resuming work. Ill guests were advised to self-isolate, and rapid cleaning of public areas and guest rooms where suspected contamination occurred was implemented. We estimated that 65 QAVDs were lost by 43 guests (1.5 days/guest). Using an approximate cost of $450 per vacation day, we estimated indirect illness cost at $675 per guest case. Seven (64%) of 11 cases' stool specimens were positive for norovirus genotype GII.4 Den Haag. CONCLUSIONS: A norovirus outbreak in a resort hotel resulted in substantial indirect costs and loss of vacation days to ill travellers. We recommend outbreak control measures including exclusion of ill employees, until ≥48-72 h after resolution of symptoms, self-isolation of ill guests and appropriate cleaning in hotel-associated norovirus outbreaks.