The 2019 Core Content of Emergency Medical Services Medicine.

On March 13, 2019 the EMS Examination Committee of the American Board of Emergency Medicine (ABEM) approved modifications to the Core Content of EMS Medicine. The Core Content is used to define the subspecialty of EMS Medicine, provides the basis for questions to be used during written examinations, and leads to development of a certification examination blueprint. The Core Content defines the universe of knowledge for the treatment of prehospital patients that is necessary to practice EMS Medicine. It informs fellowship directors and candidates for certification of the full range of content that might appear on certification examinations.

Facilitators and Barriers for Effective Academic-Community Collaboration for Disaster Preparedness and Response.

CONTEXT: For academic institutions to meaningfully contribute to community-disaster preparedness and response, they must effectively collaborate with governmental public health and emergency management agencies. OBJECTIVE: To explore the opinions of leaders of public health and emergency management agencies and academic institutions regarding the facilitators for and barriers to effective collaboration for disaster preparedness and response. DESIGN, SETTING, AND PARTICIPANTS: We convened focus groups of leaders of state and local public health and emergency management agencies and academic institutions in conjunction with the 2010 Public Health Preparedness Summit and the 2010 Southeastern Center for Emerging Biological Threats Meeting. We employed a semistructured interview guide to elicit information about resources leveraged for community preparedness and response and perceived facilitators and barriers to engagement and on-going collaboration. Focus groups were transcribed verbatim. We performed thematic analysis of the transcripts employing a data-coding scheme based on emergent themes. RESULTS: Academic institutions engaged with public health and emergency management agencies in the provision of an array of resources for community-disaster preparedness and response, ranging from technical expertise to the conduct of training activities, workforce surge capacity, and facility sharing. Recognized barriers to engagement included unfamiliarity of organizational personnel, concerns about ownership of outputs resulting from the collaboration, and differences in organizational culture and modus operandi. On-going relationships through shared training of students and staff and participation in community-level partner meetings facilitated collaboration in disaster response as does having a recognizable point of contact that can comprehensively represent academic institutional resources. Legal issues were identified as both facilitators (eg, contracts) and barriers (eg, liability concerns) to engagement. CONCLUSIONS: There are both recognized facilitators and barriers to effective and sustainable academic-community collaboration for disaster preparedness and response from the perspectives of leaders of public health and emergency management agencies and academic institutions.

"Picture to puncture": a novel time metric to enhance outcomes in patients transferred for endovascular reperfusion in acute ischemic stroke.

BACKGROUND: Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome. METHODS AND RESULTS: This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture ("picture-to-puncture" time). A total of 193 patients were analyzed, with a mean age of 65.8 ± 14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15-23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162-274] versus 89 minutes [interquartile range, 70-119]; P<0.001), which was attributable to the delays in transfer. This corresponded to fewer patients with favorable Alberta Stroke Program Early CT Scores on preprocedural computed tomographic imaging (Alberta Stroke Program Early CT Scores >7: 50% versus 76%; P<0.001) and significantly worse clinical outcomes (29% versus 51%; P=0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990-0.999; P=0.009). CONCLUSIONS: Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes.

Air Quality Monitoring During High-Level Biocontainment Ground Transport: Observations From Two Operational Exercises.

OBJECTIVE: Stretcher transport isolators provide mobile, high-level biocontainment outside the hospital for patients with highly infectious diseases, such as Ebola virus disease. Air quality within this confined space may pose human health risks. METHODS: Ambient air temperature, relative humidity, and CO2 concentration were monitored within an isolator during 2 operational exercises with healthy volunteers, including a ground transport exercise of approximately 257 miles. In addition, failure of the blower unit providing ambient air to the isolator was simulated. A simple compartmental model was developed to predict CO2 and H2O concentrations within the isolator. RESULTS: In both exercises, CO2 and H2O concentrations were elevated inside the isolator, reaching steady-state values of 4434 ± 1013 ppm CO2 and 22 ± 2 mbar H2O in the first exercise and 3038 ± 269 ppm CO2 and 20 ± 1 mbar H2O in the second exercise. When blower failure was simulated, CO2 concentration exceeded 10 000 ppm within 8 minutes. A simple compartmental model predicted CO2 and H2O concentrations by accounting for human emissions and blower air exchange. CONCLUSIONS: Attention to air quality within stretcher transport isolators (including adequate ventilation to prevent accumulation of CO2 and other bioeffluents) is needed to optimize patient safety.

A modeling study to inform screening and testing interventions for the control of SARS-CoV-2 on university campuses.

University administrators face decisions about how to safely return and maintain students, staff and faculty on campus throughout the 2020-21 school year. We developed a susceptible-exposed-infectious-recovered (SEIR) deterministic compartmental transmission model of SARS-CoV-2 among university students, staff, and faculty. Our goals were to inform planning at our own university, Emory University, a medium-sized university with around 15,000 students and 15,000 faculty and staff, and to provide a flexible modeling framework to inform the planning efforts at similar academic institutions. Control strategies of isolation and quarantine are initiated by screening (regardless of symptoms) or testing (of symptomatic individuals). We explored a range of screening and testing frequencies and performed a probabilistic sensitivity analysis. We found that among students, monthly and weekly screening can reduce cumulative incidence by 59% and 87%, respectively, while testing with a 2-, 4- and 7-day delay between onset of infectiousness and testing results in an 84%, 74% and 55% reduction in cumulative incidence. Smaller reductions were observed among staff and faculty. Community-introduction of SARS-CoV-2 onto campus may be controlled with testing, isolation, contract tracing and quarantine. Screening would need to be performed at least weekly to have substantial reductions beyond disease surveillance. This model can also inform resource requirements of diagnostic capacity and isolation/quarantine facilities associated with different strategies.

Web-based self-triage of influenza-like illness during the 2009 H1N1 influenza pandemic.

The sudden emergence of 2009 H1N1 influenza in the spring of that year sparked a surge in visits to emergency departments in New York City and other communities. A larger, second wave of cases was anticipated the following autumn. To reduce a potential surge of health system utilization without denying needed care, we enlisted the input of experts from medicine, public health, nursing, information technology, and other disciplines to design, test, and deploy clinical algorithms to help minimally trained health care workers and laypeople make informed decisions about care-seeking for influenza-like illness. The product of this collaboration, named Strategy for Off-Site Rapid Triage (SORT) was disseminated in 2 forms. Static algorithms, posted on the Centers for Disease Control and Prevention's Web site, offered guidance to clinicians and telephone call centers on how to manage adults and children with influenza-like illness. In addition, 2 interactive Web sites, http://www.Flu.gov and http://www.H1N1ResponseCenter.com, were created to help adults self-assess their condition and make an informed decision about their need for treatment. Although SORT was anchored in a previously validated clinical decision rule, incorporated the input of expert clinicians, and was subject to small-scale formative evaluations during rapid standup, prospective evaluation is lacking. If its utility and safety are confirmed, SORT may prove to be a useful tool to blunt health system surge and rapidly collect epidemiologic data on future disease outbreaks.

Development and Usability Testing of a Web-based COVID-19 Self-triage Platform.

INTRODUCTION: The development and deployment of a web-based, self-triage tool for severe respiratory syndrome coronavirus 2 (COVID-19 disease) aimed at preventing surges in healthcare utilization could provide easily understandable health guidance with the goal of mitigating unnecessary emergency department (ED) and healthcare visits. We describe the iterative development and usability testing of such a tool. We hypothesized that adult users could understand and recall the recommendations provided by a COVID-19 web-based, self-triage tool. METHODS: We convened a multidisciplinary panel of medical experts at two academic medical schools in an iterative redesign process of a previously validated web-based, epidemic screening tool for the current COVID-19 pandemic. We then conducted a cross-sectional usability study over a 24-hour period among faculty, staff, and students at the two participating universities. Participants were randomly assigned a pre-written health script to enter into the self-triage website for testing. The primary outcome was immediate recall of website recommendations. Secondary outcomes included usability measures. We stratified outcomes by demographic characteristics. RESULTS: A final sample of 877 participants (mean age, 32 years [range, 19-84 years]; 65.3% female) was used in the analysis. We found that 79.4% of the participants accurately recalled the recommendations provided by the website. Almost all participants (96.9%) found the website easy to use and navigate. CONCLUSION: Adult users of a COVID-19 self-triage website, recruited from an academic setting, were able to successfully recall self-care instructions from the website and found it user-friendly. This website appears to be a feasible way to provide evidence-based health guidance to adult patients during a pandemic. Website guidance could be used to reduce unnecessary ED and healthcare visits.

The engagement of academic institutions in community disaster response: a comparative analysis.

OBJECTIVE: Using comparative analysis, we examined the factors that influence the engagement of academic institutions in community disaster response. METHODS: We identified colleges and universities located in counties affected by four Federal Emergency Management Agency-declared disasters (Kentucky ice storms, Hurricanes Ike and Gustav, California wildfires, and the Columbia space shuttle disintegration) and performed key informant interviews with officials from public health, emergency management, and academic institutions in those counties. We used a comparative case study approach to explore particular resources provided by academic institutions, processes for engagement, and reasons for engagement or lack thereof in the community disaster response. RESULTS: Academic institutions contribute a broad range of resources to community disaster response. Their involvement and the extent of their engagement is variable and influenced by (1) their resources, (2) preexisting relationships with public health and emergency management organizations, (3) the structure and organizational placement of the school's disaster planning and response office, and (4) perceptions of liability and lines of authority. Facilitators of engagement include (1) the availability of faculty expertise or special training programs, (2) academic staff presence on public health and emergency management planning boards, (3) faculty contracts and student practica, (4) incident command system or emergency operations training of academic staff, and (5) the existence of mutual aid or memoranda of agreements. CONCLUSION: While a range of relationships exist between academic institutions that engage with public health and emergency management agencies in community disaster response, recurrent win-win themes include co-appointed faculty and staff; field experience opportunities for students; and shared planning and training for academic, public health, and emergency management personnel.

Role of academic institutions in community disaster response since september 11, 2001.

OBJECTIVE: To describe the role of academic institutions in the community response to Federal Emergency Management Agency-declared disasters from September 11, 2001, to February 1, 2009. METHODS: We conducted a review of the published literature and Internet reports to identify academic institutions that participated in the community response to disaster events between September 11, 2001, to February 1, 2009, inclusive. From retrieved reports, we abstracted the identity of the academic institutions and the resources and services each provided. We characterized the resources and services in terms of their contribution to established constructs of community disaster resilience and disaster preparedness and response. RESULTS: Between September 11, 2001, and February 1, 2009, there were 98 published or Internet-accessible reports describing 106 instances in which academic institutions participated in the community response to 11 Federal Emergency Management Agency-declared disaster events that occurred between September 11, 2001, and February 1, 2009. Academic institutions included academic health centers and community teaching hospitals; schools of medicine, nursing, and public health; schools with graduate programs such as engineering and psychology; and 4-year programs. The services and resources provided by the academic institutions as part of the community disaster response could be categorized as contributing to community disaster resilience by reducing the consequences or likelihood of an event or to specific dimensions of public health preparedness and response, or both. The most common dimensions addressed by academic institutions (in order of occurrence) were resource management, enabling and sustaining a public health response, information capacity management, and performance evaluation. CONCLUSIONS: Since September 11, 2001, the participation of academic institutions in community disaster response has contributed to community resilience and the achievement of specific dimensions of disaster preparedness and response.

Situational uses of syndromic surveillance.

Since 2001, many state and local health departments have implemented automated systems to monitor healthcare use and to promptly identify and track epidemics and other public health threats. In 2007-08, we conducted case studies of selected events with actual or potential public health impacts to determine whether and how health departments and hospitals used these new systems. We interviewed public health and hospital representatives and applied qualitative analysis methods to identify response themes. So-called "syndromic" surveillance methods were most useful in situations with widespread health effects, such as respiratory illness associated with seasonal influenza or exposures to smoke from wildfires. In other instances, such as a tornado or hazardous material exposures, these systems were useful for detecting or monitoring health impacts that affected relatively few people, or they were used to affirm the absence of outbreaks following natural disasters or the detection of a potential pathogen in air samples. Typically, these data supplemented information from traditional sources to provide a timelier or fuller mosaic of community health status, and use was shaped by long-standing contacts between health department and hospital staffs. State or local epidemiologists generally preferred syndromic systems they had developed over the CDC BioSense system, citing lesser familiarity with BioSense and less engagement in its development. Instances when BioSense data were most useful to state officials occurred when analyses and reports were provided by CDC staff. Understanding the uses of surveillance information during such events can inform further investments in surveillance capacity in public health emergency preparedness programs.

Medical outreach following a remote disaster: lessons learned from Hurricane Katrina.

In the aftermath of Hurricane Katrina, many individuals were evacuated to the Atlanta area (1,306 medical evacuees, over 100,000 self-evacuees), placing considerable strain on an already overburdened healthcare system. With the aim of improving future disaster responsiveness, we designed this in-depth case study to identify systemic vulnerabilities and gaps in community responsiveness to an influx of evacuees from a remote disaster. Qualitative methods were used to interview key informants both individually and in focus groups. Coding and content analysis of transcribed interview data were used to identify shared observations and common themes. Twenty-three individuals in leadership roles at the Woodruff Health Sciences Center of Emory University or the Grady Health System completed individual interviews; an additional 24 healthcare providers participated in focus groups. A strategy-based data-coding scheme for interview data was used to identify key foci, including services that met needs of evacuees, unmet needs, service provision that was successful/unsuccessful, underlying reasons for success or failure, and future needs for disaster planning and responsiveness. Analysis of interview data revealed important accomplishments and deficits in the medical community's response in specific domains of community disaster planning and evaluation. For each key component of community disaster planning and evaluation, there are considerations at the institutional, regional, state, and federal levels. In the current study, these considerations were identified as instrumental in effectively meeting the healthcare needs of the evacuated population.