Coronavirus Disease 2019 Infections Among Emergency Health Care Personnel: Impact on Delivery of United States Emergency Medical Care, 2020.

STUDY OBJECTIVE: In the early months of the coronavirus disease 2019 (COVID-19) pandemic and before vaccine availability, there were concerns that infected emergency department (ED) health care personnel could present a threat to the delivery of emergency medical care. We examined how the pandemic affected staffing levels and whether COVID-19 positive staff were potentially infectious at work in a cohort of US ED health care personnel in 2020. METHODS: The COVID-19 Evaluation of Risks in Emergency Departments (Project COVERED) project was a multicenter prospective cohort study of US ED health care personnel conducted from May to December 2020. During surveillance, health care personnel completed weekly electronic surveys and underwent periodic serology and nasal reverse transcription polymerase chain reaction testing for SARS-CoV-2, and investigators captured weekly data on health care facility COVID-19 prevalence and health care personnel staffing. Surveys asked about symptoms, potential exposures, work attendance, personal protective equipment use, and behaviors. RESULTS: We enrolled 1,673 health care personnel who completed 29,825 person weeks of surveillance. Eighty-nine (5.3%) health care personnel documented 90 (0.3%; 95% confidence interval [CI] 0.2% to 0.4%) person weeks of missed work related to documented or concerns for COVID-19 infection. Health care personnel experienced symptoms of COVID-19 during 1,256 (4.2%) person weeks and worked at least one shift whereas symptomatic during 1,042 (83.0%) of these periods. Seventy-five (4.5%) participants tested positive for SARS-CoV-2 during the surveillance period, including 43 (57.3%) who indicated they never experienced symptoms; 74 (98.7%; 95% CI 90.7% to 99.9%) infected health care personnel worked at least one shift during the initial period of infection, and 71 (94.7%) continued working until laboratory confirmation of their infection. Physician staffing was not associated with the facility or community COVID-19 levels within any time frame studied (Kendall tau's 0.02, 0.056, and 0.081 for no shift, one-week time shift, and 2-week time shift, respectively). CONCLUSIONS: During the first wave of the pandemic, COVID-19 infections in ED health care personnel were infrequent, and the time lost from the workforce was minimal. Health care personnel frequently reported for work while infected with SARS-CoV-2 before laboratory confirmation. The ED staffing levels were poorly correlated with facility and community COVID-19 burden.

Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study.

STUDY OBJECTIVE: To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs). METHODS: Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence. RESULTS: A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86). CONCLUSION: Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.

Endotracheal Intubation Strategy, Success, and Adverse Events Among Emergency Department Patients During the COVID-19 Pandemic.

STUDY OBJECTIVE: To describe endotracheal intubation practices in emergency departments by staff intubating patients early in the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Multicenter prospective cohort study of endotracheal intubations conducted at 20 US academic emergency departments from May to December 2020, stratified by known or suspected COVID-19 status. We used multivariable regression to measure the association between intubation strategy, COVID-19 known or suspected status, first-pass success, and adverse events. RESULTS: There were 3,435 unique emergency department endotracheal intubations by 586 participating physicians or advanced practice providers; 565 (18%) patients were known or suspected of having COVID-19 at the time of endotracheal intubation. Compared with patients not known or suspected of COVID-19, endotracheal intubations of patients with known or suspected COVID-19 were more often performed using video laryngoscopy (88% versus 82%, difference 6.3%; 95% confidence interval [CI], 3.0% to 9.6%) and passive nasal oxygenation (44% versus 39%, difference 5.1%; 95% CI, 0.9% to 9.3%). First-pass success was not different between those who were and were not known or suspected of COVID-19 (87% versus 86%, difference 0.6%; 95% CI, -2.4% to 3.6%). Adjusting for patient characteristics and procedure factors in those with low anticipated airway difficulty (n=2,374), adverse events (most commonly hypoxia) occurred more frequently in patients with known or suspected COVID-19 (35% versus 19%, adjusted odds ratio 2.4; 95% CI, 1.7 to 3.3). CONCLUSION: Compared with patients not known or suspected of COVID-19, endotracheal intubation of those confirmed or suspected to have COVID-19 was associated with a similar first-pass intubation success rate but higher risk-adjusted adverse events.

The Iowa less aggressive protocol: A mixed-methods study on the novel treatment protocol of atrial fibrillation.

OBJECTIVES: Atrial fibrillation is the most common cardiac dysrhythmia in the United States. Our aim was to determine if a novel protocol for management of atrial fibrillation was feasible to implement in an emergency department (ED). Interviews were conducted with ED physicians and physician assistants to identify themes in relation to the clinical use and impleon of the protocol. METHODS: A novel protocol was developed by a multi-disciplinary team and implemented in an academic ED. The protocol used cardiac computed tomography (CT) to rule out left atrial thrombus in patients with greater than 12 h of symptoms and high risk of thromboembolism, or any patient with greater than 48 h of symptoms. Patients who underwent cardiac CT or electrical cardioversion were followed up at 30 days via telephone to monitor for recurrence or adverse thromboembolic events. Providers were interviewed to identify themes regarding protocol usage, barriers to its use, and future changes to increase utilization. RESULTS: Patients with atrial fibrillation in the ED were eligible for inclusion. Twenty-nine patients were treated using the protocol. Seven patients (24%) underwent cardiac CT prior to electrical cardioversion. Cardioversion success rate was 83%, with 69% of patients discharged home. Thirty-day follow-up was completed on 25 patients (86%). Six patients (24%) had reoccurrence of atrial fibrillation requiring subsequent cardioversion. No patients experienced stroke or thromboembolic event. Interviews were conducted with 14 providers. Usage barriers included time, availability, and additional work-up. Six subthemes were identified for future changes including EMR order set, frequent reminders, increased education, increased awareness, activation energy, and EMR pop-ups. CONCLUSION: The Iowa Less Aggressive Protocol is a novel treatment protocol for the ED management of atrial fibrillation that was feasible to implement and use. Providers viewed the protocol favorably and identified areas of improvement for future use.

Statistical methods and reporting practices in the study of dyslexia.

This report presents findings from a review of the journals Dyslexia and Annals of Dyslexia over a 10-year period from 2005 to 2014. Three hundred articles were reviewed to examine statistical methodology and reporting practices. Articles were coded according to their reported covariates, effect sizes, and statistical methods. In addition, trends were examined in relation to the 2008 release of the What Works Clearinghouse Procedures and Standards Handbook from the Institute of Education Sciences in order to evaluate any potential impact of recommended practices. We found an increase in prevalence of specific statistical methods as well as increases in reporting of effect sizes following publication of the handbook. The reporting of effect sizes statistically significantly increased following publication of the manual (55% prepublication vs. 72% post-publication). The use of analysis of variance increased post-publication, whereas articles using no statistical methods or descriptives only decreased. Approximately one third of articles included covariates in their analysis; inclusion of covariates was consistent from prepublication to post-publication. Findings indicate that over the past 10 years, articles are becoming increasingly rigorous in methodology and reporting practices.

Emergency medicine residency pathways for MD/PhD trainees: A national cross-sectional study of physician-scientist training programs.

Background: Combined clinical and research training is common in residency programs outside emergency medicine (EM), and these pathways are particularly valuable for combined MD/PhD graduates planning to pursue a career as a physician-scientist. However, EM departments may not know what resources to provide these trainees during residency to create research-focused, productive, future faculty, and trainees may not know which programs support their goal of becoming a physician-scientist in EM. The objective of this study was to describe research training and resources available to MD/PhD graduates in EM residency training with a focus on dedicated research pathways. Methods: This study was a cross-sectional inventory conducted through an electronic survey of EM residency program directors. We sought to identify dedicated MD/PhD research training pathways, with a focus on both resources and training priorities. Descriptive statistics were used to summarize survey responses. Results: We collected 192 survey responses (69.6% response rate). Among respondents, 41 programs (21.4%) offered a research pathway/track, 52 (27.4%) offered a research fellowship, 22 (11.5%) offered both a residency research pathway/track and a research fellowship, and two (1.0%) offered a dedicated EM physician-scientist training pathway. Most programs considered research a priority and were enthusiastic about interviewing applicants planning a research career, but recruitment of physician-scientist applicants was not generally prioritized. Conclusions: Some EM residency programs offer combined clinical and mentored research training for prospective physician-scientists, and nearly all residency programs considered research important. Future work will focus on improving the EM physician-scientist pipeline by optimizing pathways available to trainees during residency and fellowship.

Race, Ethnicity, and Delayed Time to COVID-19 Testing Among US Health Care Workers.

Importance: Access to COVID-19 testing is critical to reducing transmission and supporting early treatment decisions; when made accessible, the timeliness of testing may also be an important metric in mitigating community spread of the infection. While disparities in transmission and outcomes of COVID-19 have been well documented, the extent of timeliness of testing and the association with demographic factors is unclear. Objectives: To evaluate demographic factors associated with delayed COVID-19 testing among health care personnel (HCP) during the COVID-19 pandemic. Design, Setting, and Participants: This cross-sectional study used data from the Preventing Emerging Infections Through Vaccine Effectiveness Testing study, a multicenter, test-negative, case-control vaccine effectiveness study that enrolled HCP who had COVID-19 symptoms and testing between December 2020 and April 2022. Data analysis was conducted from March 2022 to Junne 2023. Exposure: Displaying COVID-19-like symptoms and polymerase chain reaction testing occurring from the first day symptoms occurred up to 14 days after symptoms occurred. Main Outcomes and Measures: Variables of interest included patient demographics (sex, age, and clinical comorbidities) and COVID-19 characteristics (vaccination status and COVID-19 wave). The primary outcome was time from symptom onset to COVID-19 testing, which was defined as early testing (≤2 days) or delayed testing (≥3 days). Associations of demographic characteristics with delayed testing were measured while adjusting for clinical comorbidities, COVID-19 characteristics, and test site using multivariable modeling to estimate relative risks and 95% CIs. Results: A total of 5551 HCP (4859 female [82.9%]; 1954 aged 25-34 years [35.2%]; 4233 non-Hispanic White [76.3%], 370 non-Hispanic Black [6.7%], and 324 non-Hispanic Asian [5.8%]) were included in the final analysis. Overall, 2060 participants (37.1%) reported delayed testing and 3491 (62.9%) reported early testing. Compared with non-Hispanic White HCP, delayed testing was higher among non-Hispanic Black HCP (adjusted risk ratio, 1.18; 95%CI, 1.10-1.27) and for non-Hispanic HCP of other races (adjusted risk ratio, 1.17; 95% CI, 1.03-1.33). Sex and age were not associated with delayed testing. Compared with clinical HCP with graduate degrees, all other professional and educational groups had significantly delayed testing. Conclusions and Relevance: In this cross-sectional study of HCP, compared with non-Hispanic White HCP and clinical HCP with graduate degrees, non-Hispanic Black HCP, non-Hispanic HCP of other races, and HCP all other professional and education backgrounds were more likely to have delayed COVID-19 testing. These findings suggest that time to testing may serve as a valuable metric in evaluating sociodemographic disparities in the response to COVID-19 and future health mitigation strategies.

Availability and use of institutional support programs for emergency department healthcare personnel during the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic placed health care personnel (HCP) at risk for stress, anxiety, burnout, and post-traumatic stress disorder (PTSD). To address this, hospitals developed programs to mitigate risk. The objectives of the current study were to measure the availability and use of these programs in a cohort of academic emergency departments (EDs) in the United States early in the pandemic and identify factors associated with program use. METHODS: Cross-sectional survey of ED HCP in 21 academic EDs in 15 states between June and September 2020. Site investigators provided data on the availability of 28 programs grouped into 9 categories. Individual support programs included: financial, workload mitigation, individual COVID-19 testing, emotional (e.g., mental health hotline), and instrumental (e.g., childcare) Clinical work support programs included: COVID-19 team communication (e.g., debriefing critical incident), patient-family communication facilitation, patient services (e.g., social work, ethics consultation), and system-level exposure reduction. Participants provided corresponding data on whether they used the programs. We used generalized linear mixed models clustered on site to measure the association between demographic and facility characteristics and program use. RESULTS: We received 1,541 survey responses (96% response rate) from emergency physicians or advanced practice providers, nurses, and nonclinical staff. Program availability in each of the 9 categories was high (>95% of hospitals). Program use was variable, with clinical work support programs used more frequently (28-50% of eligible HCP across categories) than individual employee support programs (6-13% of eligible HCP across categories). Fifty-seven percent of respondents reported that the COVID-19 pandemic had affected their stress and anxiety, and 12% were at elevated risk for PTSD. Program use did not significantly differ for HCP who reported symptoms of anxiety and/or stress compared to those who did not. CONCLUSIONS: Early in the pandemic, support programs were widely available to ED HCP, but program use was low. Future work will focus on identifying barriers and facilitators to use and specific programs most likely to be effective during periods of highest occupational stress.

Factors Related to Data-Based Decision-Making: Examining Experience, Professional Development, and the Mediating Effect of Confidence on Teacher Graph Literacy.

In tiered instructional systems (Response to Intervention [RTI]/Multitier System of Supports [MTSS]) that rely on ongoing assessment of students at risk of experiencing academic difficulties, the ability to make informed decisions using student data is critical for student learning. Prior research has demonstrated that, on average, teachers have difficulty analyzing and interpreting student progress-monitoring (PM) data presented graphically (i.e., graph literacy). This study examines the impact that teacher training, experience, and confidence have on teacher graph literacy, using structural equation modeling. Data were gathered from a nationally representative sample of 309 teachers and included latent variables related to their experience (e.g., years teaching, years working with RTI), training (e.g., hours of data-based decision-making [DBDM] professional development), and confidence (e.g., confidence in interpreting data, confidence in determining student response) as well as data-based decision-making skills on a graph literacy assessment. Findings indicate that latent experience and confidence factors predicted graph literacy but training did not. Furthermore, training increased teacher confidence but experience did not. Finally, confidence did not mediate the effect of experience or training on graph literacy.

Outcomes Associated with Lower Doses of Ketamine by Emergency Medical Services for Profound Agitation.

INTRODUCTION: Ketamine is commonly used to treat profound agitation in the prehospital setting. Early in ketamine's prehospital use, intubation after arrival in the emergency department (ED) was frequent. We sought to measure the frequency of ED intubation at a Midwest academic medical center after prehospital ketamine use for profound agitation, hypothesizing that intubation has become less frequent as prehospital ketamine has become more common and prehospital dosing has improved. METHODS: We conducted a retrospective cohort study of adult patients receiving ketamine in the prehospital setting for profound agitation and transported to a midwestern, 60,000-visit, Level 1 trauma center between January 1, 2017-March 1, 2021. We report descriptive analyses of patient-level prehospital clinical data and ED outcomes. The primary outcome was proportion of patients intubated in the ED. RESULTS: A total of 78 patients received ketamine in the prehospital setting (69% male, mean age 36 years). Of the 42 (54%) admitted patients, 15 (36% of admissions) were admissions to the intensive care unit. Overall, 12% (95% confidence interval [CI]), 4.5-18.6%)] of patients were intubated, and indications included agitation (n = 4), airway protection not otherwise specified (n = 4), and respiratory failure (n = 1). CONCLUSION: Endotracheal intubation in the ED after prehospital ketamine use for profound agitation in our study sample was found to be less than previously reported.