Rethinking Surge Preparedness After COVID-19: Effective Patient Load Balancing Within Health Systems and Beyond.

Within weeks of New York State's first confirmed case of COVID-19, New York City became the epicenter of the nation's COVID-19 pandemic. With more than 80,000 COVID-19 hospitalizations during the first wave alone, hospitals in downstate New York were forced to adapt existing procedures to manage the surge and care for patients facing a novel disease. Given the unprecedented surge, effective patient load balancing-moving patients from a hospital with diminishing capacity to another hospital within the same health system with relatively greater capacity-became chief among the capabilities required of New York health systems. The Greater New York Hospital Association invited members of downstate New York's 6 largest health systems to talk about how each of their systems evolved their patient load balancing procedures throughout the pandemic. Informed by their insights, experiences, lessons learned, and collaboration, we collectively present a set of consensus recommendations and best practices for patient load balancing at the facility and health system level, which may inform regional approaches to patient load balancing.

Brainstem inflammation modulates the ventilatory pattern and its variability after acute lung injury in rodents.

KEY POINTS: Compared with sham rats, rats a week after acute lung injury (ALI) express more pro-inflammatory cytokines in their brainstem respiratory control nuclei, exhibit a higher respiratory frequency (fR) and breathe with a more predictable pattern. These characteristics of the respiratory pattern persist in in situ preparations even after minimizing pulmonary and chemo-afferent inputs. Interleukin (IL)-1ß microinjected in the nucleus tractus solitarii increases fR and the predictability of the ventilatory pattern similar to rats with ALI. Intracerebroventricular infusion of indomethacin, an anti-inflammatory drug, mitigates the effect of ALI on fR and ventilatory pattern variability. We conclude that changes in the ventilatory pattern after ALI result not only from sensory input due to pulmonary damage and dysfunction but also from neuro-inflammation. ABSTRACT: Acute lung injury (ALI) increases respiratory rate (fR) and ventilatory pattern variability (VPV), but also evokes peripheral and central inflammation. We hypothesized that central inflammation has a role in determining the ventilatory pattern after ALI. In rat pups, we intratracheally injected either bleomycin to induce ALI or saline as a sham control. One week later, we recorded the ventilatory pattern of the rat pups using flow-through plethysmography, then formed in situ preparations from these pups and recorded their 'fictive' patterns from respiratory motor nerves. Compared with the ventilatory pattern of the sham rat pups, injured rat pups had increased fR and predictability. Surprisingly, the fictive patterns of the in situ preparations from ALI pups retained these characteristics despite removing their lungs to eliminate pulmonary sensory inputs and perfusing them with hyperoxic artificial cerebral spinal fluid to minimize peripheral chemoreceptor input. Histological processing revealed increased immunoreactivity of the pro-inflammatory cytokine Interleukin-1ß (IL-1ß) in the nucleus tractus solitarii (nTS) from ALI but not sham rats. In subsequent experiments, we microinjected IL-1ß in the nTS bilaterally in anaesthetized naïve adult rats, which increased fR and predictability of ventilatory pattern variability (VPV) after 2 h. Finally, we infused indomethacin intracerebroventricularly during the week of survival after ALI. This did not affect sham rats, but mitigated changes in fR and VPV in ALI rats. We conclude that neuro-inflammation has an essential role in determining the ventilatory pattern of ALI rats.

Predictable Unpredictability: the Problem with Basing Medicare Policy on Long-Term Financial Forecasting.

The authors assess how Medicare financing and projections of future costs have changed since 2000. They also assess the impact of legislative reforms on the sources and levels of financing and compare cost forecasts made at different times. Although the aging U.S. population and rising health care costs are expected to increase the share of gross domestic product devoted to Medicare, changes made in the program over the past decade have helped stabilize Medicare's financial outlook--even as benefits have been expanded. Long-term forecasting uncertainty should make policymakers and beneficiaries wary of dramatic changes to the program in the near term that are intended to alter its long-term forecast: the range of error associated with cost forecasts rises as the forecast window lengthens. Instead, policymakers should focus on the immediate policy window, taking steps to reduce the current burden of Medicare costs by containing spending today.

Accidental and nonaccidental poisonings as a cause of apparent life-threatening events in infants.

BACKGROUND: Apparent life-threatening events are a relatively common event in children for which there may be a number of causes. Previous reports have suggested that poisonings, either accidental or intentional, may be causes of some events. However, this theory has not been systematically studied. METHODS: We conducted a prospective, descriptive study of infants aged <2 years presenting to a pediatric emergency department of a large, urban tertiary care children's hospital with signs and symptoms of an apparent life-threatening event. All of the children presenting with an apparent life-threatening event were to undergo a standardized evaluation, which included obtaining a comprehensive urine toxicology screen. A positive toxicology screen result was defined as follows: a clinically insignificant screen result (identification of a medication that would not cause an apparent life-threatening event) or a clinically significant screen result (identification of a medication that could cause apnea or other event consistent with an apparent life-threatening event, even if it was a medication that the child was known to be taking). RESULTS: During the study period, 596 children presented to the emergency department with an apparent life-threatening event, and 274 (46.0%) had a toxicology screen performed. Of 274 toxicology screen results, 50 were considered truly positive (18.2%), and 23 positive screen results were considered clinically significant (23 of 274 [8.4%]). Thirteen toxicology screen results were positive for an over-the-counter cold preparation (13 of 274 [4.7%]). No parent admitted to having given his or her child an over-the-counter cold preparation. CONCLUSIONS: A substantial number of children presenting to the emergency department with an apparent life-threatening event had a positive toxicology screen result. In particular, a number of children were found to have been given an over-the-counter cold preparation. We would recommend that toxicology screens be included as part of the routine evaluation of children who present with an apparent life-threatening event.