Assessing health care leadership and management for resilience and performance during crisis: The HERO-36.

BACKGROUND: Whereas organizational literature has provided much insight into the conceptual and theoretical underpinnings of organizational leadership and management during emergencies, measures to operationalize related effective practices during crises remain sparse. PURPOSE: To address this need, we developed the Healthcare Emergency Response Optimization survey, which set out to examine the leadership and management practices in health care organizations that support resilience and performance during crisis. METHODOLOGY: We administered an online survey in April to May 2022 to health care administrators and frontline staff intimately involved in their hospital's emergency response during the COVID-19 pandemic, which included a sample of 379 respondents across nine rural and urban hospitals (response rate: 44.4%). We used confirmatory factor analysis and quantile regressions to examine the results. RESULTS: Applying confirmatory factor analysis, we retained 36 items in our survey that comprised eight measures for formal and informal practices to assess crisis leadership and management. To test effectiveness of the specified practices, we regressed self-reported resilience and performance measures on the formality and informality scores. Findings show that informal practices mattered most for resilience, whereas formal practices mattered most for performance. We also identified specific practices (anticipation, transactional and relational interactions, and ad hoc collaborations) for resilience and performance. PRACTICE IMPLICATIONS: These validated measures of organizational practices assess emergency response during crisis, with an emphasis on the actions and decisions of leadership as well as the management of organizational structures and processes. Organizations using these measures may subsequently modify preparedness and planning approaches to better manage future crises.

Sustainable and Resilient Health Care in the Face of a Changing Climate.

Climate change is a threat multiplier, exacerbating underlying vulnerabilities, worsening human health, and disrupting health systems' abilities to deliver high-quality continuous care. This review synthesizes the evidence of what the health care sector can do to adapt to a changing climate while reducing its own climate impact, identifies barriers to change, and makes recommendations to achieve sustainable, resilient health care systems.

Feasibility and Acceptability of a Model Disaster Teleconsultation System for Regional Disaster Health Response.

Introduction: The federally funded Region 1 Regional Disaster Health Response System (RDHRS) and the American Burn Association partnered to develop a model regional disaster teleconsultation system within a Medical Emergency Operations Center (MEOC) to support triage and specialty consultation during a no-notice mass casualty incident. Our objective was to test the acceptability and feasibility of a prototype model system in simulated disasters as proof of concept. Methods: We conducted a mixed-methods simulation study using the Technology Acceptance Model framework. Participating physicians completed the Telehealth Usability Questionnaire (TUQ) and semistructured interviews after simulations. Results: TUQ item scores rating the model system were highest for usefulness and satisfaction, and lowest for interaction quality and reliability. Conclusions: We found high model acceptance, but desire for a simpler, more reliable technology interface with better audiovisual quality for low-frequency, high-stakes use. Future work will emphasize technology interface quality and reliability, automate coordinator roles, and field test the model system.

The First Statewide Implementation of a Regional Disaster Teleconsultation System to Expand Critical Care Surge Capacity: A Case Study in Vermont.

Background: In December 2021, the Region 1 Disaster Health Response System, the state of Vermont, and the National Emergency Tele-Critical Care Network partnered to provide statewide access to disaster teleconsultations during COVID-19 surge conditions. In this case report, we describe how a disaster teleconsultation system was implemented in Vermont to provide access to temporary tele-critical care consultations during the Omicron COVID-19 surge. Methods: We measured the time from request of service to implementation and calculated descriptive statistics. Results: Seven of Vermont's 14 hospitals requested the service. Despite a technology solution capable of providing services within hours, mean time to service implementation was 27 days (interquartile range 20-41 days). Conclusions: Integration of disaster teleconsultation systems into state and local emergency management plans are needed to bring administrative start-up times in line with technical readiness.

COVID-19 Seroprevalence in ED Health Care Professionals Study: A Cross-Sectional Study.

INTRODUCTION: ED health care professionals are at the frontline of evaluation and management of patients with acute, and often undifferentiated, illness. During the initial phase of the SARS-CoV-2 outbreak, there were concerns that ED health care professionals may have been at increased risk of exposure to SARS-CoV-2 due to difficulty in early identification of patients. This study assessed the seroprevalence of SARS-CoV-2 antibodies among ED health care professionals without confirmed history of COVID-19 infection at a quaternary academic medical center. METHODS: This study used a cross-sectional design. An ED health care professional was deemed eligible if they had worked at least 4 shifts in the adult emergency department from April 1, 2020, through May 31, 2020, were asymptomatic on the day of blood draw, and were not known to have had prior documented COVID-19 infection. The study period was December 17, 2020, to January 27, 2021. Eligible participants completed a questionnaire and had a blood sample drawn. Samples were run on the Roche Cobas Elecsys Anti-SARS-CoV-2 antibody assay. RESULTS: Of 103 health care professionals (16 attending physicians, 4 emergency residents, 16 advanced practice professionals, and 67 full-time emergency nurses), only 3 (2.9%; exact 95% CI, 0.6%-8.3%) were seropositive for SARS-CoV-2 antibodies. DISCUSSION: At this quaternary academic medical center, among those who volunteered to take an antibody test, there was a low seroprevalence of SARS-CoV-2 antibodies among ED clinicians who were asymptomatic at the time of blood draw and not known to have had prior COVID-19 infection.

Update on Ebola Treatment Center Costs and Sustainability, United States, 2019.

We surveyed 56 Ebola treatment centers (ETCs) in the United States and identified costs incurred since 2014 ($1.76 million/ETC) and sustainability strategies. ETCs reported heavy reliance on federal funding. It is uncertain if, or for how long, ETCs can maintain capabilities should federal funding expire in 2020.

When Pigs Fly: A Multidisciplinary Approach to Navigating a Critical Heparin Shortage.

A recent outbreak of African swine fever (ASF) in China has claimed the lives of millions of pigs, and although this virus has no health impacts on humans, the disruption of the global pig population has far-reaching negative impacts on economic and pork-derived products, including the creation of the critical drug heparin. The active pharmaceutical ingredient in heparin is derived from pig intestines, and because of the ASF outbreak, the U.S. faces an imminent shortage of heparin. This drug shortage has the potential for profound implications, as heparin is used in a substantial and varied number of medical conditions. In response to notification of the heparin shortage crisis, our institution, Massachusetts General Hospital, activated its Hospital Incident Command System to streamline organization of major stakeholders and oversee operational and clinical activities required to mitigate the potential risks and optimize alternative effective strategies. This article describes the essential elements of our institution's emergency response plan, including detailed clinical algorithms developed by our experts for maximal heparin conservation and waste reduction by promoting safe and effective alternative strategies. Through this practice, we have also identified opportunities to change providers' prescribing and utilization behaviors for the better. As the ASF has not yet been contained and this crisis continues, the strategies and policies employed by our institution can provide a framework for other institutions to tackle this ongoing challenge and future drug shortage crises. IMPLICATIONS FOR PRACTICE: A detailed description of how one institution addressed the current heparin crisis, to support heparin conservation and waste reduction, is provided. The strategies used helped decrease heparin use by 80% in less than 2 months of establishing the task force. This accomplishment can be credited to the development of a task force and strategic plan in which experts and stakeholders were quickly identified, offered a part in the decision-making process, and frequently updated. Furthermore, the response system was dynamic, accessible, and one in which challenges were recognized and acted upon. The key to any crisis management is respect for one another and constant and open communication. Heparin is such a widespread drug that this shortage can potentially affect every patient population and provider. Understanding one's institutional needs and the effect of this crisis on those needs is one of the first steps when developing a strategic plan. Continually evaluating and adjusting that approach in response to the needs of the institution are critical to its success. Moreover, as it did for the authors' institution, a constant appraisal of the strategies can lead to opportunities for improvements in organization and practice that can be sustained well beyond the crisis.

Paraneoplastic Limbic Encephalitis in a Patient with Primary Well-differentiated Teratoma and Metastatic Poorly Differentiated Embryonal Carcinoma.

Testicular tumors account for 1-2% of all tumors in men, with 95% of these being germ cell tumors. Paraneoplastic limbic encephalitis is a rare sequela of testicular tumors associated with anti-Ma2 and KLH11 antibodies. The most effective treatment for paraneoplastic limbic encephalitis is treatment of the primary malignancy. We report a 41-year-old male that presented to the emergency department with episodic alteration of consciousness and memory disturbances. Negative neurologic evaluation and imaging led to concern for a paraneoplastic process from a distant malignancy. CT imaging revealed an enlarged, necrotic para-aortic lymph node and subsequent ultrasound demonstrated a right-sided testicular mass. Right radical orchiectomy was performed. Microscopically, the mass consisted of mixed respiratory epithelium, gastrointestinal glands, and squamous epithelium with keratinization consistent with a post-pubertal testicular teratoma with associated in situ germ cell neoplasia. Resection of the para-aortic mass revealed large anaplastic cells with epithelioid features, nuclear pleomorphism and frequent mitoses. Immunostaining was positive for Pan-Keratin and OCT4, consistent with poorly differentiated embryonal carcinoma. Resection of the primary and metastatic disease, as well as treatment with corticosteroids, resulted in resolution of the encephalitis. This presentation of severe neurological disturbances in the setting of a metastatic mixed non-seminomatous germ cell tumor represents a rare presentation of paraneoplastic limbic encephalitis.

U.S. High-Level Isolation Unit Clinical Laboratory Capabilities Update.

In late 2014, 56 hospitals in the United States were designated by state and federal public health authorities as specially designed high-level isolation units (HLIUs) equipped with advanced infrastructure, laboratory capabilities, and trained staff to care for patients with highly hazardous communicable diseases (HHCDs), such as Ebola virus disease. This survey describes the clinical laboratory support capabilities of U.S. HLIUs, including the specific test menus that HLIUs have identified to safely manage HHCD patients and the locations where such testing would be performed. In spring 2016, a survey was electronically distributed, as a fillable pdf file, to the 56 U.S. HLIUs. Site representatives completed the surveys, and data were coded and analyzed in an electronic spreadsheet, using descriptive statistics. Thirty-six HLIUs (64%) responded, and 33 completed the laboratory capabilities section. Thirty-one HLIUs (94%) had performed risk analyses for all laboratory procedures and equipment. Twenty-nine (88%) had decontamination procedures specified for all laboratory equipment used for patients with suspected or confirmed HHCDs. On-site laboratories in 27 HLIUs (81%) had the capacity to inventory and to securely store HHCD patient specimens. Ten HLIUs (31%) had at least one test they would conduct within the patient isolation room. The high-risk nature of HHCDs and the occupational exposures that may occur in clinical laboratories demand advanced preparation and risk assessment of work practices, laboratory equipment, and instrumentation by HLIU laboratories. Although risk analyses of clinical laboratory testing and equipment that HLIUs have conducted have likely focused on those for Ebola virus, HLIUs must be prepared to revise their current procedures for other HHCDs.

Personnel Management and Biosecurity of U.S. High-Level Isolation Units.

OBJECTIVE: To describe strategies used by US high-level isolation units (HLIUs) to recruit, train, and sustain a full team of multidisciplinary staff and identify how units are secured. BACKGROUND: Fifty-six US hospitals have been designated HLIUs, capable of providing safe care to patients with highly infectious disease. METHODS: An electronic survey was administered to the 56 HLIUs in spring of 2016. Responses were collected via a fillable PDF and analyzed using descriptive statistics. RESULTS: Thirty-six HLIUs (64%) responded; 33 completed surveys, and 3 reported no longer being a designated HLIU. HLIUs reported large numbers of multidisciplinary staff, primarily consisting of RNs and critical care clinicians. Nearly all HLIUs (94%) required orientation training, although hours varied. CONCLUSIONS: Over a short period, HLIUs recruited and trained significant numbers of staff with little guidance. Costs of ongoing trainings are considerable, and it remains unclear how HLIUs will continue funding these activities.

Cytokeratin-8 in Anaplastic Thyroid Carcinoma: More Than a Simple Structural Cytoskeletal Protein.

Anaplastic thyroid carcinoma (ATC) is almost universally fatal. Elevated keratin-8 (KRT8) protein expression is an established diagnostic cancer biomarker in several epithelial cancers (but not ATC). Several keratins, including KRT8, have been suggested to have a role in cell biology beyond that of structural cytoskeletal proteins. Here, we provide evidence that KRT8 plays a direct role in the growth of ATCs. Genomic and transcriptomic analysis of >5000 patients demonstrates that KRT8 mutation and copy number amplification are frequently evident in epithelial-derived cancers. Carcinomas arising from diverse tissues exhibit KRT8 mRNA and protein overexpression when compared to normal tissue levels. Similarly, in a panel of patient-derived ATC cell lines and patient tumors, KRT8 expression shows a similar pattern. sh-RNA-mediated KRT8 knockdown in these cell lines increases apoptosis, whereas forced overexpression of KRT8 confers resistance to apoptosis under peroxide-induced cell stress conditions. We further show that KRT8 protein binds to annexin A2, a protein known to mediate apoptosis as well as the redox pathway.

US State Public Health Departments Special Pathogen Planning.

CONTEXT: US state public health departments played key roles in planning for and responding to confirmed and suspected cases of Ebola virus disease (EVD) during the 2014-2016 outbreak, including designating select hospitals as high-level isolation units (HLIUs) for EVD treatment in conjunction with the Centers for Disease Control and Prevention. OBJECTIVE: To identify existing guidelines and perspectives of state health departments pertaining to the management and transport of patients with EVD and other highly hazardous communicable diseases (HHCDs). DESIGN: An electronic 8-question survey with subquestions was administered as a fillable PDF. SETTING: The survey was distributed to publicly accessible e-mails of state health department employees. PARTICIPANTS: State epidemiologists, emergency preparedness directors, or chief medical officers from each of the 50 states and the District of Columbia were contacted; a representative from 36 states and the District of Columbia responded (73%). MAIN OUTCOME MEASURES: Descriptive statistics were used to identify the proportion of state health departments with various existing protocols. RESULTS: A majority of states reported that they would prefer patients confirmed with viral hemorrhagic fevers (eg, EVD, Marburg fever) and smallpox be transported to an HLIU for treatment rather than remain at the initial hospital of diagnosis. While most (89%) states had written guidelines for the safe transportation of patients with HHCDs, only 6 (16%) had written protocols for the management of accidents or other travel disruptions that may occur during HHCD transport within the state. Twenty-two state health departments (59%) had operationally exercised transport of a patient to an HLIU. CONCLUSIONS: Nearly half of states in the United States lack an HLIU, yet most prefer to have patients with HHCDs treated in high-level isolation. Recent budget cuts and uncertainty of future funding threaten the abilities of health departments to devote the necessary resources and staff to prepare for and deliver the desired care to HHCD cases. The lack of HLIUs in some states may complicate transport to a geographically proximate HLIU. Moreover, limited guidance on diseases that warrant high-level isolation may cause disagreement in HHCD patient placement between health departments, diagnosing facilities, and HLIUs.

Sustainability of High-Level Isolation Capabilities among US Ebola Treatment Centers.

To identify barriers to maintaining and applying capabilities of US high-level isolation units (HLIUs) used during the Ebola virus disease outbreak, during 2016 we surveyed HLIUs. HLIUs identified sustainability challenges and reported the highly infectious diseases they would treat. HLIUs expended substantial resources in development but must strategize models of sustainability to maintain readiness.

U.S. Ebola Treatment Center Clinical Laboratory Support.

Fifty-five hospitals in the United States have been designated Ebola treatment centers (ETCs) by their state and local health authorities. Designated ETCs must have appropriate plans to manage a patient with confirmed Ebola virus disease (EVD) for the full duration of illness and must have these plans assessed through a CDC site visit conducted by an interdisciplinary team of subject matter experts. This study determined the clinical laboratory capabilities of these ETCs. ETCs were electronically surveyed on clinical laboratory characteristics. Survey responses were returned from 47 ETCs (85%). Forty-one (87%) of the ETCs planned to provide some laboratory support (e.g., point-of-care [POC] testing) within the room of the isolated patient. Forty-four (94%) ETCs indicated that their hospital would also provide clinical laboratory support for patient care. Twenty-two (50%) of these ETC clinical laboratories had biosafety level 3 (BSL-3) containment. Of all respondents, 34 (72%) were supported by their jurisdictional public health laboratory (PHL), all of which had available BSL-3 laboratories. Overall, 40 of 44 (91%) ETCs reported BSL-3 laboratory support via their clinical laboratory and/or PHL. This survey provided a snapshot of the laboratory support for designated U.S. ETCs. ETCs have approached high-level isolation critical care with laboratory support in close proximity to the patient room and by distributing laboratory support among laboratory resources. Experts might review safety considerations for these laboratory testing/diagnostic activities that are novel in the context of biocontainment care.

Nanoscintillator-mediated X-ray inducible photodynamic therapy for in vivo cancer treatment.

Photodynamic therapy is a promising treatment method, but its applications are limited by the shallow penetration of visible light. Here, we report a novel X-ray inducible photodynamic therapy (X-PDT) approach that allows PDT to be regulated by X-rays. Upon X-ray irradiation, the integrated nanosystem, comprised of a core of a nanoscintillator and a mesoporous silica coating loaded with photosensitizers, converts X-ray photons to visible photons to activate the photosensitizers and cause efficient tumor shrinkage.