Leadership Principles to Decrease Psychological Casualties in COVID-19 and Other Disasters of Uncertainty.

Coronavirus disease (COVID-19) is a "disaster of uncertainty" with ambiguity about its nature and trajectory. These features amplify its psychological toxicity and increase the number of psychological casualties it inflicts. Uncertainty was fueled by lack of knowledge about the lethality of a disaster, its duration, and ambiguity in messaging from leaders and health care authorities. Human resilience can have a buffering effect on the psychological impact. Experts have advocated "flattening the curve" to slow the spread of the infection. Our strategy for crisis leadership is focused on flattening the rise in psychological casualties by increasing resilience among health care workers. This paper describes an approach employed at Johns Hopkins to promote and enhance crisis leadership. The approach is based on 4 factors: vision for the future, decisiveness, effective communication, and following a moral compass. We make specific actionable recommendations for implementing these factors that are being disseminated to frontline leaders and managers. The COVID-19 pandemic is destined to have a strong psychological impact that extends far beyond the end of quarantine. Following these guidelines has the potential to build resilience and thus reduce the number of psychological casualties and speed the return to normal - or at least the new normal in the post-COVID world.

A Hospital-Based Initiative to Reduce Postdischarge Sudden Unexpected Infant Deaths.

BACKGROUND AND OBJECTIVES: Sudden unexpected infant deaths (SUID) most often occur because infants are placed in unsafe sleep environments. Although authors of previous literature have demonstrated that parents who receive comprehensive safe sleep education increase knowledge and intention to place children in safe sleep environments, no studies have demonstrated improved outcomes. We describe the development of a hospital-based newborn SUID risk reduction quality improvement project and its effectiveness in reducing subsequent SUIDs in a community using linked outcome data from local Child Fatality Review Teams. METHODS: Qualitative and quantitative evaluation of a long-term iterative performance improvement intervention for a nursery-based comprehensive safe sleep program in a community teaching hospital. Key themes and exemplary comments were noted. The rate of infant deaths per 1000 births was the primary quantitative outcome. The rate is calculated quarterly and monitored with control charts by using Child Fatality Review data about infant sleep deaths. RESULTS: The average death rate fell from 1.08 infants per 1000 births preintervention to 0.48 infants per 1000 births after complete intervention, and the average number of deaths between deliveries increased from 1 in every 584 deliveries (upper control limit: 3371) to 1 in every 1420 deliveries (upper control limit: 8198). Qualitative observation of nursery providers revealed 3 themes, including routine inclusion of sleep safety information, dissemination of safety information by all staff, and personal commitment to success. CONCLUSIONS: A comprehensive sleep safety culture change can be effectively integrated into a nursery setting over time by using feedback from Child Fatality Review and performance improvement methodology. Repeated messaging and education by the entire nursery staff has the potential to play a role in reducing sleep-related deaths in infants born at their hospital.

Race and insurance disparities in discharge to rehabilitation for patients with traumatic brain injury.

Post-acute inpatient rehabilitation services are associated with improved functional outcomes among persons with traumatic brain injury (TBI). We sought to investigate racial and insurance-based disparities in access to rehabilitation. Data from the Nationwide Inpatient Sample from 2005-2010 were analyzed using standard descriptive methods and multivariable logistic regression to assess race- and insurance-based differences in access to inpatient rehabilitation after TBI, controlling for patient- and hospital-level variables. Patients with moderate to severe TBI aged 18-64 years with complete data on race and insurance status discharged alive from inpatient care were eligible for study. Among 307,675 TBI survivors meeting study criteria and potentially eligible for discharge to rehabilitation, 66% were white, 12% black, 15% Hispanic, 2% Asian, and 5% other ethnic minorities. Most whites (70%), Asians (70%), blacks (59%), and many Hispanics (49%) had insurance. Compared with insured whites, insured blacks had reduced odds of discharge to rehabilitation (odds ratio [OR] 0.84; 95% confidence interval [CI] 0.75-0.95). Also, insured Hispanics (OR 0.52; 95% CI 0.44-0.60) and insured Asians (OR 0.54; 95% CI 0.39-0.73) were less likely to be discharged to rehabilitation than insured whites. Compared with insured whites, uninsured whites (OR 0.57; 95% CI 0.51-0.63), uninsured blacks (OR 0.33; 95% CI 0.26-0.42), uninsured Hispanics (OR 0.27; 95% CI 0.22-0.33), and uninsured Asians (OR 0.40; 95% CI 0.22-0.73) were less likely to be discharged to rehabilitation. Race and insurance are strong predictors of discharge to rehabilitation among adult TBI survivors in the United States. Efforts are needed to understand and eliminate disparities in access to rehabilitation after TBI.