Association between prehospital transfer distance and surgical mortality in emergency thoracic aortic surgery.

OBJECTIVE: To examine whether there is an association between prehospital transfer distance and surgical mortality in emergency thoracic aortic surgery. METHODS: A retrospective cohort study using a national clinical database in Japan was conducted. Patients who underwent emergency thoracic aortic surgery from January 1, 2014, to December 31, 2016, were included. Patients with type B dissection were excluded. A multilevel logistic regression analysis was performed to examine the association between prehospital transfer distance and surgical mortality. In addition, an instrumental variable analysis was performed to address unmeasured confounding. RESULTS: A total of 12,004 patients underwent emergency thoracic aortic surgeries at 495 hospitals. Surgical mortality was 13.8%. The risk-adjusted mortality odds ratio for standardized distance (mean 12.8 km, standard deviation 15.2 km) was 0.94 (95% confidence interval, 0.87-1.01; P = .09). Instrumental variable analysis did not reveal a significant association between transfer distance and surgical mortality as well. CONCLUSIONS: No significant association was found between surgical mortality and prehospital transfer distance in emergency thoracic aortic surgery cases. Suspected cases of acute thoracic aortic syndrome may be transferred safely to distant high-volume hospitals.

Rationing With Respect to Age During a Pandemic: A Comparative Analysis of State Pandemic Preparedness Plans.

BACKGROUND: Faced with possible shortages due to COVID-19, many states updated or rapidly developed crisis standards of care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators. RESEARCH QUESTION: How have US states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans? STUDY DESIGN AND METHODS: This was an investigator-initiated, textual analysis conducted from April to June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and for Washington, DC. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (≤ 1 year), (B) 1 to 5 expected life-years, (C) total life-years, (D) "fair innings," that is, specific age cutoffs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized on the basis of whether age/life-years was a primary consideration. RESULTS: Thirty-five states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1 to 5 expected life-years, 13 rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the 21 plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, although use of terminology was inconsistent. Many documents were modified in light of controversy. INTERPRETATION: Guidance with respect to rationing by age and/or life-years varied widely. More than one-half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.

Smartphone application alerts for early trauma team activation: Millennial technology in healthcare.

BACKGROUND: Data access through smartphone applications (apps) has reframed procedure and policy in healthcare, but its impact in trauma remains unclear. Citizen is a free app that provides real-time alerts curated from 911 dispatch data. Our primary objective was to determine whether app alerts occurred earlier than recorded times for trauma team activation and emergency department arrival. METHODS: Trauma registry entries were extracted from a level one urban trauma center from January 1, 2018 to June 30, 2019 and compared with app metadata from the center catchment area. We matched entries to metadata according to description, date, time, and location then compared metadata timestamps to trauma team activation and emergency department arrival times. We computed percentage of time the app reported traumatic events earlier than trauma team activation or emergency department arrival along with exact binomial 95% confidence interval; median differences between times were presented along with interquartile ranges. RESULTS: Of 3,684 trauma registry entries, 209 (5.7%) matched app metadata. App alerts were earlier for 96.1% and 96.2% of trauma team activation and emergency department arrival times, respectively, with events reported median 36 (24-53, IQR) minutes earlier than trauma team activation and 32 (25-42, IQR) minutes earlier than emergency department arrival. Registry entries for younger males, motor vehicle-related injuries and penetrating traumas were more likely to match alerts (P < .0001). CONCLUSION: Apps like Citizen may provide earlier notification of traumatic events and therefore earlier mobilization of trauma service resources. Earlier notification may translate into improved patient outcomes. Additional studies into the benefit of apps for trauma care are warranted.

Physician perspectives on delays in cancer diagnosis in Alberta: a qualitative study.

BACKGROUND: Delays in cancer diagnosis have been associated with reduced survival, decreased quality of life after treatment, and suboptimal patient experience. The objective of the study was to explore the perspectives of a group of family physicians and other specialists regarding potentially avoidable delays in diagnosing cancer, and approaches that may help expedite the process. METHODS: We conducted a qualitative study using interviews with physicians practising in primary and outpatient care settings in Alberta between July and September 2019. We recruited family physicians and specialists who were in a position to discuss delays in cancer diagnosis by email via the Cancer Strategic Clinical Network and the Alberta Medical Association. We conducted semistructured interviews over the phone, and analyzed data using thematic analysis. RESULTS: Eleven family physicians and 22 other specialists (including 7 surgeons or surgical oncologists, 3 pathologists, 3 radiologists, 2 emergency physicians and 2 hematologists) participated in interviews; 22 were male (66.7%). We identified 4 main themes describing 9 factors contributing to potentially avoidable delays in diagnosis, namely the nature of primary care, initial presentation, investigation, and specialist advice and referral. We also identified 1 theme describing 3 suggestions for improvement, including system integration, standardized care pathways and a centralized advice, triage and referral support service for family physicians. INTERPRETATION: These findings suggest the need for enhanced support for family physicians, and better integration of primary and specialty care before cancer diagnosis. A multifaceted and coordinated approach to streamlining cancer diagnosis is required, with the goals of enhancing patient outcomes, reducing physician frustration and optimizing efficiency.

The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes.

BACKGROUND: Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns. METHODS: Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital. RESULTS: The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death. CONCLUSIONS: Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Recommendations for Orthopedic Surgeons during the COVID-19 Pandemic.

BACKGROUND: Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance. OBJECTIVES: To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery. METHODS: We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage. RESULTS: We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation. CONCLUSIONS: Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

Association of COVID-19 Hospitalization Volume and Case Growth at US Hospitals with Patient Outcomes.

BACKGROUND: Whether the volume of coronavirus disease 2019 (COVID-19) hospitalizations is associated with outcomes has important implications for the organization of hospital care both during this pandemic and future novel and rapidly evolving high-volume conditions. METHODS: We identified COVID-19 hospitalizations at US hospitals in the American Heart Association COVID-19 Cardiovascular Disease Registry with ≥10 cases between January and August 2020. We evaluated the association of COVID-19 hospitalization volume and weekly case growth indexed to hospital bed capacity, with hospital risk-standardized in-hospital case-fatality rate (rsCFR). RESULTS: There were 85 hospitals with 15,329 COVID-19 hospitalizations, with a median hospital case volume was 118 (interquartile range, 57, 252) and median growth rate of 2 cases per 100 beds per week but varied widely (interquartile range: 0.9 to 4.5). There was no significant association between overall hospital COVID-19 case volume and rsCFR (rho, 0.18, P = .09). However, hospitals with more rapid COVID-19 case-growth had higher rsCFR (rho, 0.22, P = 0.047), increasing across case growth quartiles (P trend = .03). Although there were no differences in medical treatments or intensive care unit therapies (mechanical ventilation, vasopressors), the highest case growth quartile had 4-fold higher odds of above median rsCFR, compared with the lowest quartile (odds ratio, 4.00; 1.15 to 13.8, P = .03). CONCLUSIONS: An accelerated case growth trajectory is a marker of hospitals at risk of poor COVID-19 outcomes, identifying sites that may be targets for influx of additional resources or triage strategies. Early identification of such hospital signatures is essential as our health system prepares for future health challenges.

Rapid implementation of triaging system for assessment of breast referrals from primary care centres during the COVID-19 pandemic.

OBJECTIVE: The aim of this study was to establish a triaging system for assessment of breast referrals from primary care to ensure safe and effective breast services without compromising breast cancer management. BACKGROUND: COVID-19 was officially declared a global pandemic on 11 March 2020, and with no effective treatment available, preventing spread has been paramount. Previously, all referrals from primary care were seen in the rapid-access breast clinic (RABC). Clinic appointments exposed patients and healthcare professionals to risk. METHOD: Initial triage during the lockdown was in line with national governing body guidance, rejected low risk referrals and streamed remaining patients through a telephone consultation to RABC or discharge. A modified triage pathway streamed all patients through virtual triage to RABC, telephone clinic or discharge with advice and guidance categories. Demographics, reasons for referral and outcomes data were collected and presented as median with range and frequency with percentages. RESULTS: Initial triage (23 March-23 April 2020) found fewer referrals with a higher percentage of breast cancer diagnoses. Modified triage (22 June-17 July 2020) resulted in a 35.1% (99/282) reduction in RABC attendance. Overall cancer detection rate remained similar at 4.2% of all referrals pre-COVID (18/429) and 4.3% (12/282) during modified triage. After six months follow-up of patients not seen in RABC during the modified triage pathway, 18 patients were re-referred to RABC and none were diagnosed with cancer. CONCLUSION: A modified triage pathway has the potential to improve triage efficiency and prevent unnecessary visits during the COVID-19 pandemic. Further refinement of pathway is feasible in collaboration with primary care.

A mixed-methods study describing behavioral factors that influenced general practitioners' experiences using triage during the COVID-19 pandemic.

BACKGROUND: Early in the COVID-19 pandemic, general practices were asked to expand triage and to reduce unnecessary face-to-face contact by prioritizing other consultation modes, e.g., online messaging, video, or telephone. The current study explores the potential barriers and facilitators general practitioners experienced to expanding triage systems and their attitudes towards triage during the COVID-19 pandemic. METHOD: A mixed-method study design was used in which a quantitative online survey was conducted along with qualitative interviews to gain a more nuanced appreciation for practitioners' experiences in the United Kingdom. The survey items were informed by the Theoretical Domains Framework so they would capture 14 behavioral factors that may influence whether practitioners use triage systems. Items were responded to using seven-point Likert scales. A median score was calculated for each item. The responses of participants identifying as part-owners and non-owners (i.e., "partner" vs. "non-partner" practitioners) were compared. The semi-structured interviews were conducted remotely and examined using Braun and Clark's thematic analysis. RESULTS: The survey was completed by 204 participants (66% Female). Most participants (83%) reported triaging patients. The items with the highest median scores captured the 'Knowledge,' 'Skills,' 'Social/Professional role and identity,' and 'Beliefs about capabilities' domains. The items with the lowest median scores captured the 'Beliefs about consequences,' 'Goals,' and 'Emotions' domains. For 14 of the 17 items, partner scores were higher than non-partner scores. All the qualitative interview participants relied on a phone triage system. Six broad themes were discovered: patient accessibility, confusions around what triage is, uncertainty and risk, relationships between service providers, job satisfaction, and the potential for total digital triage. Suggestions arose to optimize triage, such as ensuring there is sufficient time to conduct triage accurately and providing practical training to use triage efficiently. CONCLUSIONS: Many general practitioners are engaging with expanded triage systems, though more support is needed to achieve total triage across practices. Non-partner practitioners likely require more support to use the triage systems that practices take up. Additionally, practical support should be made available to help all practitioners manage the new risks and uncertainties they are likely to experience during non-face-to-face consultations.

Implementation of a triage nurse role and the effect on hospitalist workload.

OBJECTIVES: Hospital medicine groups vary staffing models to match available workforce with expected patient volumes and acuity. Larger groups often assign a single hospitalist to triage pager duty which can be burdensome due to frequent interruptions and multitasking. We introduced a new role, the Triage nurse, to hold the triage pager and distribute patients. We sought to determine the effect of this Triage Nurse on the perceived workload of hospitalists and frequency of pages. METHODS: We partnered with our patient throughput department to implement the Triage Nurse role who took the responsibility of tracking and distributing admissions among three admitting physicians along with coordinating report. We used the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) to measure perceived workload and accessed pager logs of admitters for 3 months before and after implementation. RESULTS: Overall, 50 of an expected 67 NASA-TLX surveys (74.6%) were returned in the pre-intervention period and 64 of 92 (69.6%) were returned in the post-intervention period. We found a statistically significant reduction in the domains of physical demand, temporal demand, effort and frustration from pre- to post-intervention periods (p < 0.01). There was also a significant decrease in the performance domain (p = 0.01) with a lower number indicative of better perceived performance. There was a significant reduction in the mean number of pages received by admitting hospitalists over their 9-h shifts (81.3 + 17.3 vs 52.4 + 7.3; p < 0.01). CONCLUSION: The implementation of the Triage Nurse role was associated with a significant decrease in the perceived workload of admitting hospitalists. Our findings are important because workload and interruptions can contribute to errors and burnout. Future studies should test interventions to improve hospitalist workload and evaluate their effect on patient outcomes and physician wellness.

Impact of the COVID-19 pandemic on health care activities at a Uruguayan mastology unit.

PURPOSE: Health emergency due to COVID-19 started in Uruguay on March 13, 2020; our mastology unit tried to ensure adequate oncological care, and protect patients from the virus infection and complications. OBJECTIVE: To assess the health care activities in the "peak" of the pandemic during 3 months. MATERIALS AND METHODS: we collected data from the electronic health record. RESULTS: There were a total of 293 medical appointments from 131 patients (221 face-to-face), that decreased by 16.7% compared to the same period in 2019 (352 appointments). The medical appointments were scheduled to evaluate the continuity of systemic treatment or modifications (95 patients; 72.5%), follow-up (17; 12.9%), first-time consultation (12; 9.1%), and assess paraclinical studies (7; 5.3%). The patients were on hormone therapy (81 patients; 74%), chemotherapy (CT) (21; 19%), and anti-HER2 therapies (9; 8%). New twenty treatments were initiated. Of the 14 patients that were on adjuvant/neoadjuvant CT, 9 (64.3%) continued with the same regimen with the addition of prophylactic granulocyte-colony-stimulating factors (G-CSF), and 5 (35.7%), who were receiving weekly paclitaxel, continued the treatment with no changes. Of the seven patients that were on palliative CT, 2 (28.5%) continued the treatment with the addition of G-CSF, 3 (42.8%) continued with weekly capecitabine or paclitaxel with no treatment changes, and 2 (28.5%) changed their treatment regimen (a less myelosuppressive regimen was selected for one and due to progression of the disease in the other patient). The ninety patients who were receiving adjuvant, neoadjuvant, or palliative criteria hormone therapy and/or anti-HER2 therapies, continued the treatment with no changes. CONCLUSIONS: The evidence suggests that, although medical appointments decreased by approximately 17%, we could maintain healthcare activities, continued most of the treatments while the most modified was CT with G-CSF to avoid myelosuppression.

Decision-making for children requiring interhospital transport: assessment of a novel triage tool.

OBJECTIVE: The use of specialist retrieval teams to transport critically ill children is associated with reduced risk-adjusted mortality and morbidity; however, there is a paucity of data to guide decision-making related to retrieval team activation. We aimed to assess the accuracy of a novel triage tool designed to identify critically ill children at the time of referral for interhospital transport. DESIGN: Prospective observational study. SETTING: Regional paediatric retrieval and transport services. PATIENTS: Data were collected for 1815 children referred consecutively for interhospital transport from 87 hospitals in Queensland and northern New South Wales. INTERVENTION: Implementation of the Queensland Paediatric Transport Triage Tool. MAIN OUTCOME MEASURES: Accuracy was assessed by calculating the sensitivity, specificity and negative predictive value for predicting transport by a retrieval team, or admission to intensive care following transport. RESULTS: A total of 574 (32%) children were transported with a retrieval team. Prediction of retrieval (95% CIs): sensitivity 96.9% (95% CI 95.1% to 98.1%), specificity 91.4% (95% CI 89.7% to 92.9%), negative predictive value 98.4% (95% CI 97.5% to 99.1%). There were 412 (23%) children admitted to intensive care following transport. Prediction of intensive care admission: sensitivity 96.8% (95% CI 94.7% to 98.3%), specificity 81.2% (95% CI 79.0% to 83.2%), negative predictive value 98.9% (95% CI 98.1% to 99.4%). CONCLUSIONS: The triage tool predicted the need for retrieval or intensive care admission with high sensitivity and specificity. The high negative predictive value indicates that, in our setting, children categorised as acutely ill rather than critically ill are generally suitable for interhospital transport without a retrieval team.

Cellular Therapy During COVID-19: Lessons Learned and Preparing for Subsequent Waves.

An evidence-based triage plan for cellular therapy distribution is critical in the face of emerging constraints on healthcare resources. We evaluated the impact of treatment delays related to COVID-19 on patients scheduled to undergo hematopoietic cell transplantation (HCT) or chimeric antigen receptor T-cell (CAR-T) therapy at our center. Data were collected in real time between March 19 and May 11, 2020, for patients who were delayed to cellular therapy. We evaluated the proportion of delayed patients who ultimately received cellular therapy, reasons for not proceeding to cellular therapy, and changes in disease and health status during delay. A total of 85 patients were delayed, including 42 patients planned for autologous HCT, 36 patients planned for allogeneic HCT, and 7 patients planned for CAR-T therapy. Fifty-six of these patients (66%) since received planned therapy. Five patients died during the delay. The most common reason for not proceeding to autologous HCT was good disease control in patients with plasma cell dyscrasias (75%). The most common reason for not proceeding to allogeneic HCT was progression of disease (42%). All patients with acute leukemia who progressed had measurable residual disease (MRD) at the time of delay, whereas no patient without MRD at the time of delay progressed. Six patients (86%) ultimately received CAR-T therapy, including 3 patients who progressed during the delay. For patients with high-risk disease such as acute leukemia, and particularly those with MRD at the time of planned HCT, treatment delay can result in devastating outcomes and should be avoided if at all possible.

Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.

The burdens of the coronavirus disease (COVID-19) pandemic have fallen disproportionately on disadvantaged groups, including the poor and Black, Latinx, and Indigenous communities. There is substantial concern that the use of existing ICU triage protocols to allocate scarce ventilators and critical care resources-most of which are designed to save as many lives as possible-may compound these inequities. As governments and health systems revisit their triage guidelines in the context of impending resource shortages, scholars have advocated a range of alternative allocation strategies, including the use of a random lottery to give all patients in need an equal chance of ICU treatment. However, both the save-the-most-lives approach and random allocation are seriously flawed. In this Perspective, we argue that ICU triage policies should simultaneously promote population health outcomes and mitigate health inequities. These ethical goals are sometimes in conflict, which will require balancing the goals of maximizing the number of lives saved and distributing health benefits equitably across society. We recommend three strategies to mitigate health inequities during ICU triage: introducing a correction factor into patients' triage scores to reduce the impact of baseline structural inequities; giving heightened priority to individuals in essential, high-risk occupations; and rejecting use of longer-term life expectancy and categorical exclusions as allocation criteria. We present a practical triage framework that incorporates these strategies and attends to the twin public health goals of promoting population health and social justice.

Allocating scarce intensive care resources during the COVID-19 pandemic: practical challenges to theoretical frameworks.

The COVID-19 pandemic strained health-care systems throughout the world. For some, available medical resources could not meet the increased demand and rationing was ultimately required. Hospitals and governments often sought to establish triage committees to assist with allocation decisions. However, for institutions operating under crisis standards of care (during times when standards of care must be substantially lowered in the setting of crisis), relying on these committees for rationing decisions was impractical-circumstances were changing too rapidly, occurring in too many diverse locations within hospitals, and the available information for decision making was notably scarce. Furthermore, a utilitarian approach to decision making based on an analysis of outcomes is problematic due to uncertainty regarding outcomes of different therapeutic options. We propose that triage committees could be involved in providing policies and guidance for clinicians to help ensure equity in the application of rationing under crisis standards of care. An approach guided by egalitarian principles, integrated with utilitarian principles, can support physicians at the bedside when they must ration scarce resources.