Timing of Transport of Patients with COVID-19.

RATIONALE: The objective of this study was to evaluate the risk of mortality or ECMO cannulation for patients with confirmed or suspected COVID-19 transferred from sending hospitals to receiving tertiary care centers as a function of the duration of time at the sending hospital. OBJECTIVE: To determine outcomes of critically ill patients with COVID-19 who were transferred to tertiary or quarternary care medical centers. MATERIALS AND METHODS: Retrospective cohort study of critical care transports of patients to one of seven consortium tertiary care centers from March 1, 2020, through September 4, 2020. Age 14 years and older with confirmed or suspected COVID-19 transported from a sending hospital to a receiving tertiary care center by the critical care transport organization. RESULTS: Patients transported with confirmed or suspected COVID-19 to tertiary care centers had a mortality rate of 38.0%. Neither the number of days admitted, nor the number of days intubated at the sending hospital correlated with mortality (correlation coefficient 0.051 and -0.007, respectively). Similarly, neither the number of days admitted, nor number of days intubated at the sending hospital correlated with ECMO cannulation (correlation coefficient 0.008 and -0.036, respectively). CONCLUSION: It may be reasonable to transfer a critically ill COVID-19 patient to a tertiary care center even if they have been admitted at the sending hospital for several days.

Critical Care Transport of Patients With COVID-19.

PURPOSE: Critical care transport is associated with a high rate of adverse events, and the risks and outcomes of transporting critically ill patients during the COVID-19 pandemic have not been previously described. MATERIALS AND METHODS: We performed a retrospective review of transports of subjects with suspected or confirmed COVID-19 from sending hospitals to tertiary care hospitals in Boston. Follow-up data were obtained for patients transported between March 1st and April 20th, 2020. RESULTS: Of 254 charts identified, 250 patients were transported. Nine patients (3.5%) had cardiac arrest prior to transport. Twenty-nine (11.6%) had hypotension, 22 (8.8%) had a critical desaturation, and 4 (1.6%) had both en route. Hospital follow-up data were available for 189 patients. Of those intubated during their hospitalization, 44 (25.0%) had died, 59 (33.5%) had been extubated, and 13 (17.6%) had been discharged alive. For the subgroup with prior cardiac arrest, follow-up data available for 6. Of these 6, 2 died and 4 (66.7%) have been discharged alive. CONCLUSIONS: Few patients with COVID-19 had an adverse event in transport. The in-hospital mortality rate was 25%, with a 33.5% extubation rate. Patients resuscitated from cardiac arrest prior to transport had a 66.7% discharge rate among those transported to consortium hospitals.

Characteristics of emergency department "doctor shoppers".

BACKGROUND: There is a need to accurately identify patients at risk for drug abuse before giving a prescription for a scheduled medication. OBJECTIVE: Our aim was to describe a subset of emergency department (ED) patients that had eight or more schedule II-V prescriptions filled from eight or more providers in 1 year, known as "doctor-shopping" (DS) behavior, to compare demographic features of DS and non-DS patients, and to determine clinical factors associated with DS. METHODS: We conducted a prospective, observational study of emergency providers' (EPs) assessment of patients with back pain, dental pain, or headache. EPs recorded patient demographics, clinical characteristics, and numbers of schedule II-V prescriptions, subset opioid prescriptions, providers, and pharmacies utilized in a 12-month period, as reported on the state prescription drug-monitoring program. χ(2) and t-tests were used to compare DS with non-DS patients on demographics; a multivariate logistic regression was performed to determine clinical factors associated with DS. RESULTS: Five hundred and forty-four patient visits were recorded; 12.3% (n = 67) had DS behavior. DS and non-DS patients were similar in sex but differed in age, race, chief complaint, and weekday vs. weekend arrival. DS patients utilized a median of 12.0 (interquartile range [IQR] 9.0-18.0) providers compared with a median of 1.0 (IQR 0-2.0) providers in the non-DS group. Reporting allergies to non-narcotic medications (odds ratio [OR] = 3.1; 95% confidence interval [CI] 1.4-6.9; p = 0.01), requesting medications by name (OR = 2.7; 95% CI 1.5-4.9; p < 0.01), and hospital site (OR = 2.0; 95% CI 1.1-3.6; p = 0.03) were significantly associated with DS. CONCLUSIONS: There are multiple clinical characteristics associated with DS in this patient population.

The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster.

OBJECTIVE: We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions. BACKGROUND: Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes. METHODS: A collaborative effort among Boston's trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack. RESULTS: A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity. CONCLUSIONS: Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

The effect of an ambulance diversion ban on emergency department length of stay and ambulance turnaround time.

STUDY OBJECTIVE: Massachusetts became the first state in the nation to ban ambulance diversion in 2009. It was feared that the diversion ban would lead to increased emergency department (ED) crowding and ambulance turnaround time. We seek to characterize the effect of a statewide ambulance diversion ban on ED length of stay and ambulance turnaround time at Boston-area EDs. METHODS: We conducted a retrospective, pre-post observational analysis of 9 Boston-area hospital EDs before and after the ban. We used ED length of stay as a proxy for ED crowding. We compared hospitals individually and in aggregate to determine any changes in ED length of stay for admitted and discharged patients, ED volume, and turnaround time. RESULTS: No ED experienced an increase in ED length of stay for admitted or discharged patients or ambulance turnaround time despite an increase in volume for several EDs. There was an overall 3.6% increase in ED volume in our sample, a 10.4-minute decrease in length of stay for admitted patients, and a 2.2-minute decrease in turnaround time. When we compared high- and low-diverting EDs separately, neither saw an increase in length of stay, and both saw a decrease in turnaround time. CONCLUSION: After the first statewide ambulance diversion ban, there was no increase in ED length of stay or ambulance turnaround time at 9 Boston-area EDs. Several hospitals actually experienced improvements in these outcome measures. Our results suggest that the ban did not worsen ED crowding or ambulance availability at Boston-area hospitals.

Clinician impression versus prescription drug monitoring program criteria in the assessment of drug-seeking behavior in the emergency department.

STUDY OBJECTIVE: We compare emergency provider impression of drug-seeking behavior with objective criteria from a state prescription drug monitoring program, assess change in opioid pain reliever prescribing after prescription drug monitoring program review, and examine clinical factors associated with suspected drug-seeking behavior. METHODS: This was a prospective observational study of emergency providers assessing a convenience sample of patients aged 18 to 64 years who presented to either of 2 academic medical centers with chief complaint of back pain, dental pain, or headache. Drug-seeking behavior was objectively defined as present when a patient had greater than or equal to 4 opioid prescriptions by greater than or equal to 4 providers in the 12 months before emergency department evaluation. Emergency providers completed data forms recording their impression of the likelihood of drug-seeking behavior, patient characteristics, and plan for prescribing pre- and post-prescription drug monitoring program review. Descriptive statistics were generated. We calculated agreement between emergency provider impression of drug-seeking behavior and prescription drug monitoring program definition, and sensitivity, specificity, and positive predictive value of emergency provider impression, using prescription drug monitoring program criteria as the criterion standard. A multivariate logistic regression analysis was conducted to determine clinical factors associated with drug-seeking behavior. RESULTS: Thirty-eight emergency providers with prescription drug monitoring program access participated. There were 544 patient visits entered into the study from June 2011 to January 2013. There was fair agreement between emergency provider impression of drug-seeking behavior and prescription drug monitoring program (κ=0.30). Emergency providers had sensitivity 63.2% (95% confidence interval [CI] 54.8% to 71.7%), specificity 72.7% (95% CI 68.4% to 77.0%), and positive predictive value 41.2% (95% CI 34.4% to 48.2%) for identifying drug-seeking behavior. After exposure to prescription drug monitoring program data, emergency providers changed plans to prescribe opioids at discharge in 9.5% of cases (95% CI 7.3% to 12.2%), with 6.5% of patients (n=35) receiving opioids not previously planned and 3.0% (n=16) no longer receiving opioids. Predictors for drug-seeking behavior by prescription drug monitoring program criteria were patient requests opioid medications by name (odds ratio [OR] 1.91; 95% CI 1.13 to 3.23), multiple visits for same complaint (OR 2.5; 95% CI 1.49 to 4.18), suspicious history (OR 1.88; 95% CI 1.1 to 3.19), symptoms out of proportion to examination (OR 1.83; 95% CI 1.1 to 3.03), and hospital site (OR 3.1; 95% CI 1.76 to 5.44). CONCLUSION: Emergency providers had fair agreement with objective criteria from the prescription drug monitoring program in suspecting drug-seeking behavior. Program review changed management plans in a small number of cases. Multiple clinical factors were predictive of drug-seeking behavior.

Trial to end ambulance diversion in Boston: report from the conference of the Boston teaching hospitals consortium.

INTRODUCTION: Annual ambulance diversion hours in Boston increased more than six-fold from 1997 to 2006. Although interventions and best practices were implemented, there was no reduction in the number of diversion hours. OBJECTIVES: A consortium of Boston teaching hospitals instituted a two-week moratorium on citywide diversion from 02 October 2006 to 15 October 2006. The hypothesis was that there would be no significant difference in measures of hospital and emergency medical services (EMS) efficiency compared with the two weeks immediately prior. METHODS: A total of nine hospitals and the municipal emergency medical services in Boston submitted data for analysis. The following mean daily hospital measures were studied: (1) emergency department volume; (2) number of emergency department admissions; (3) length of stay (LOS) for all patients; and (4) number of elopements. Mean EMS at-hospital time by destination and the percent of all Boston EMS transports to each hospital destination were calculated. The median differences (MD) were calculated as "before" minus "during" the study period and were compared with paired, Wilcoxon, non-parametric tests. Additional mean EMS measures for all destinations included: (1) to hospital time; (2) number of responses with transport initiated per day; (3) incident entry to arrival; and (4) at-hospital time. RESULTS: The LOS for admitted patients (MD = 0.30 hours; IQR 0.10,1.30; p = 0.03) and number of daily admissions (MD = -1.50 patients; IQR -1.50, -0.10; p = 0.04) were significantly different statistically. The results for LOS for all patients, LOS for discharged patients, ED volume, EMS time at hospital by destination, number of elopements, and percent of Boston EMS transports to each hospital revealed no statistically significant differences. The difference between the study and control periods for mean EMS to hospital time, at-hospital time, and incident entry to arrival was a maximum of 0.6 minutes. The vast majority of EMS respondents to an online survey believed that the "no diversion" policy should be made routine practice. CONCLUSIONS: The LOS for admitted patients decreased by 18 minutes, and the number of admissions increased by 1.5 patients per day during the study period. The "no diversion" policy resulted in minimal changes in EMS efficiency and operations. Diversion was temporarily eliminated in a major city without significant detrimental changes in ED, hospital, or EMS efficiency.

Clinical implementation of prostate image guided radiation therapy: a prospective study to define the optimal field of interest and image registration technique using automated x-ray volumetric imaging software.

Alignment of the CBCT with the reference CT is called image registration (IR). The parameters for utilizing the automated Elekta XVI IR software for IGRT of the prostate still remain to be defined. In this study, we compare several automated XVI IR parameters to manual registration to identify the optimal automated IR technique for the prostate gland. 280 prostate IRs were conducted as follows: 210 automated, and 70 manual IR were performed using 70 CBCT scans of seven patients. The three arms of the automated registrations were: (i) extended FOI/Bone + grey scale (double IR); (ii) limited FOI/GS (single IR); and (iii) extended FOI/GS (single IR). Automated IRs were compared to manual IRs; x, y, z shifts, failures, and errors recorded for off-line analysis. Based on the most successful parameters, a departmental protocol was developed and 432 automated IR were performed (on 20 patients) for analysis. Automated IR were classified as: Successful, failed, error, or unregistered. In arm 1, the rate of successful, failed, error, and unregistered IR were 52.8%, 1.5%, 8.6%, 37.1%, respectively, arm 2: 90% successful, 10% failed, arm 3: 100% successful. Using the arm 3 parameters for the 432 automated IRs, the incidence of unregistered scans was 0%, rescanning was required in 1% of treatments, and the time for performing the auto IR was < 5.5 minutes. We found that extended FOI + single (GS) IR results in shifts comparable to manual IR using automated XVI software. We experienced multiple unsuccessful registrations with the other methods. We conclude that when utilizing the Elekta XVI automated IR software, the extended FOI/single IR results in successful registrations most often. In addition, it is currently effectively used in our clinical practice.

A public access defibrillation programme in non-inpatient hospital areas.

INTRODUCTION: Automatic external defibrillators (AED) have proven to be valuable and life saving for out of hospital cardiac arrests. Their use in hospital arrests is less well documented, but they offer the opportunity to improve survival in the hospital setting also. METHODS: The implementation of a public access defibrillation (PAD) programme at a tertiary care hospital is described, with reference specifically to targeting areas where time from arrest to arrival of defibrillation would be greater than 3 min. RESULTS: Nine AEDs were placed in areas of the hospital distant from inpatient or outpatient floors. The locations of the AEDs were chosen based on a 3 min walk from currently available defibrillators to all areas of the hospital, including parking garages and walkways from building to building. In this programme AED use in non-inpatient hospital locations resulted in the resuscitation of a patient in ventricular fibrillation. CONCLUSION: PAD in non-inpatient hospital settings can be life saving and similar programmes should be considered for other hospitals.

An investigation of completion times on the Screener and Opioid Assessment for Patients with Pain - revised (SOAPP-R).

BACKGROUND: Respondents' scores to the Screener and Opioid Assessment for Patients with Pain - revised (SOAPP-R) have been shown to be predictive of aberrant drug-related behavior (ADB). However, research is lacking on whether an individual's completion time (the amount of time that he/she takes to finish the screener) has utility in predicting ADB, despite the fact that response speed has been useful in predicting behavior in other fields. The purpose of this study was to evaluate the degree to which SOAPP-R completion time is predictive of ADB. MATERIALS AND METHODS: This retrospective study analyzed completion-time data from 82 adult emergency department patients who completed the SOAPP-R on a tablet computer. The utility of SOAPP-R completion times in predicting ADB was assessed via logistic regression and the area under the curve (AUC) statistic. An external measure of ADB using Prescription Drug Monitoring Program data defined ADB to have occurred in individuals with at least four opioid prescriptions and at least four prescribers in 12 months. RESULTS: Although there was a slight trend for individuals with greater completion times to have greater odds of ADB (odds ratio 1.004 in simple logistic regression), the association between SOAPP-R completion time and ADB was not statistically significant in either simple logistic regression (P=0.307) or multiple logistic regression adjusting for SOAPP-R score (P=0.419). AUC values for the prediction of ADB using completion time alone, SOAPP-R score alone, and both completion time and SOAPP-R score were 0.63, 0.64, and 0.65, respectively. CONCLUSION: There was no significant evidence that SOAPP-R completion times were predictive of ADB among emergency department patients. However, the AUC value for completion times was only slightly less than that for SOAPP-R total scores.