Implementation of Baltimore City's COVID-19 Isolation Hotel.

In May 2020, Baltimore City, Maryland, implemented the Lord Baltimore Triage, Respite, and Isolation Center (LBTC), a multiagency COVID-19 isolation and quarantine site tailored for people experiencing homelessness. In the first year, 2020 individuals were served, 78% completed isolation at LBTC, and 6% were transferred to a hospital. Successful isolation can mitigate outbreaks in shelters and residential recovery programs, and planning for sustainable isolation services integrated within these settings is critical as the COVID-19 pandemic continues. (Am J Public Health. 2022;112(6):876-880. https://doi.org/10.2105/AJPH.2022.306778).

The Use of Intraosseous Fluid Resuscitation in a Pediatric Patient with Ebola Virus Disease.

BACKGROUND: Vomiting, diarrhea, and severe dehydration are common manifestations of Ebola virus disease (EVD), leading to its high mortality. Mortality is especially high in patients older than 45 years, younger than 5 years, and in pregnant women and their fetuses. The majority of patients with EVD are not able to tolerate the quantities of oral hydration solutions necessary to rehydrate properly. Although some have speculated that IV and intraosseous lines are not practical in the austere, resource-constrained settings of an Ebola treatment unit during an epidemic, it is necessary to provide parenteral fluids and electrolyte replacements to significantly decrease mortality. Due to the inability to spend long periods of time working in hot environments wearing personal protective equipment, it is necessary to maximize the use of rapidly obtainable and safe parenteral access. CASE REPORT: The authors present a case of a 9-month-old patient with EVD in Sierra Leone in whom an intraosseous line was lifesaving. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians respond to international crises, such as the most recent Ebola epidemic in West Africa. It is important for such responders, as well as their responding organizations, to know and understand that intraosseous access is an important and safe modality to use in patients with EVD and in the austere settings often found in disaster settings.

Self-administered versus clinician-performed BinaxNOW COVID rapid test: a comparison of accuracy.

We conducted a single-center study at a free community testing site in Baltimore City to assess the accuracy of self-performed rapid antigen tests (RATs) for COVID-19. Self-administered BinaxNOW RATs were compared with clinician-performed RATs and against a reference lab molecular testing as the gold standard. Of the 953 participants, 14.9% were positive for SARS- CoV-2 as determined by RT-PCR. The sensitivity and specificity were similar for both self- and clinician-performed RATs (sensitivity: 83.9% vs 88.2%, P = 0.40; specificity: 99.8% vs 99.6%, P = 0.6). Subgroup comparisons based on age and race yielded similar results. Notably, 5.2% (95% CI: 1.5% to 9.5%) of positive results were potentially missed due to participant misinterpretation of the self-test card. However, the false-positive rate for RATs was reassuringly comparable in accuracy to clinician-administered tests. These findings hold significant implications for physicians prescribing treatment based on patient-reported, self-administered positive test results. Our study provides robust evidence supporting the reliability and utility of patient-performed RATs, underscoring their comparable accuracy to clinician-performed RATs, and endorsing their continued use in managing COVID-19. Further studies using other rapid antigen test brands are warranted.IMPORTANCEAccurate and accessible COVID-19 testing is crucial for effective disease control and management. A recent single-center study conducted in Baltimore City examined the reliability of self-performed rapid antigen tests (RATs) for COVID-19. The study found that self-administered RATs yielded similar sensitivity and specificity to clinician-performed tests, demonstrating their comparable accuracy. These findings hold significant implications for physicians relying on patient-reported positive test results for treatment decisions. The study provides robust evidence supporting the reliability and utility of patient-performed RATs, endorsing their continued use in managing COVID-19. Furthermore, the study highlights the need for further research using different rapid antigen test brands to enhance generalizability. Ensuring affordable and widespread access to self-tests is crucial, particularly in preparation for future respiratory virus seasons and potential waves of reinfection of SARS-CoV-2 variants such as the Omicron variant.

Feasibility of and Experience with Free State Funded Telehealth Based Patient Self-referral for COVID-19 Monoclonal Antibody Therapy.

BACKGROUND: Monoclonal antibody (mAb) treatment for COVID-19 has been underutilized due to logistical challenges, lack of access and variable treatment awareness among patients and healthcare professionals. The use of telehealth during the pandemic provides an opportunity to increase access to COVID-19 care. METHODS: This is a single-center descriptive study of telehealth-based patient self-referral for mAb therapy between March 1, 2021, to October 31, 2021 at Baltimore Convention Center Field Hospital (BCCFH). RESULTS: Among the 1001 self-referral patients, the mean age was 47, and most were female (57%) white (66%), and had a primary care provider (62%). During the study period, self-referrals increased from 14 per month in March to 427 in October resulting in a 30-fold increase. About 57% of self-referred patients received a telehealth visit, and of those 82% of patients received mAb infusion therapy. The median time from self-referral to onsite infusion was 2 days (1-3 IQR). DISCUSSION: Our study shows the integration of telehealth with a self-referral process improved access to mAb infusion. A high proportion of self-referrals were appropriate and led to timely treatment. This approach helped those without traditional avenues for care and avoided potential delay for patients seeking referral from their PCPs.

Baltimore City Health Department's Use of Public-Private Partnerships to Create a Continuum of COVID-19 Services for Special Populations.

The Baltimore City Health Department (BCHD) has developed a COVID-19 continuum of services to protect special populations at high risk of COVID-19 made possible through inter-agency and public-private partnerships. We present descriptions of each element along with descriptive data. Lessons are discussed to inform future public health frameworks.

High Sensitivity and NPV for BinaxNOW Rapid Antigen Test in Children at a Mass Testing Site during Prevalent Delta Variant Period.

SARS-CoV-2 continues to develop new, increasingly infectious variants including delta and omicron. We evaluated the efficacy of the Abbott BinaxNOW Rapid Antigen Test against Reverse Transcription PCR (RT-PCR) in 1,054 pediatric participants presenting to a high-volume Coronavirus Disease 2019 (COVID-19) testing site while the delta variant was predominant. Both tests utilized anterior nares swabs. Participants were grouped by COVID-19 exposure and symptom status. 5.2% of samples tested positive by RT-PCR for SARS-CoV-2. For all participants, sensitivity of the BinaxNOW was 92.7% (95% CI 82.4%-98.0%), and specificity was 98.0% (95% CI 97.0%-98.8%). For symptomatic participants, positive predictive value (PPV) was 72.7% (95% CI 54.5%-86.7%) and negative predictive value (NPV) was 99.2% (95% CI 98.2%-100%). Among asymptomatic participants, PPV was 71.4% (95% CI 53.7%-85.4%) and NPV was 99.7% (95% CI 99.0%-100%). Our reported sensitivity and NPV are higher than other pediatric studies, potentially because of higher viral load from the delta variant, but specificity and PPV are lower. IMPORTANCE The BinaxNOW rapid antigen COVID-19 test had a sensitivity of nearly 92% in both symptomatic and asymptomatic children when performed at a high-throughput setting during the more transmissible delta variant dominant period. The test may play an invaluable role in asymptomatic screening and keeping children safe in school.

Posttussive emesis as a symptom of asthma in children.

BACKGROUND: Emesis can be triggered by cough in children, and cough is a common symptom of asthma. OBJECTIVE: To explore the association between posttussive emesis and asthma in the pediatric population. METHODS: A questionnaire was distributed to parents of children between the ages of 2 and 17 years in the pediatric and allergy-immunology clinics at our institution from August 16 through November 3, 2008. Prevalence of posttussive emesis was determined and compared among children with physician-diagnosed asthma, children with no evidence of asthma, and those not formally diagnosed as having asthma but with surrogate markers suggestive of asthma. The predictive value of posttussive emesis was compared with those of known markers of asthma. The prevalence of gastroesophageal reflux and pertussis was evaluated because these conditions might also cause posttussive emesis. RESULTS: The prevalence of posttussive emesis was 33% in our study population of 500 children. Among those with physician-diagnosed asthma (n = 122), 56% reported a history of posttussive emesis. For patients not formally diagnosed as having asthma but with surrogate markers suggestive of asthma (n = 62), 71% had a history of posttussive emesis. Both of these were significantly higher than in those with no evidence of asthma (n = 316), in whom 16% reported a history of posttussive emesis (P < .0005). Children with posttussive emesis were significantly more likely to have asthma than those without posttussive emesis (odds ratio, 7.9; 95% confidence interval, 5.2-12). Neither pertussis nor gastroesophageal reflux accounted for the degree of posttussive emesis reported. CONCLUSIONS: Posttussive emesis is more common among children with asthma than among nonasthmatic children. In children with cough and a history of posttussive emesis, asthma should be strongly considered in the differential diagnosis.

Finally "deliberate by design": milestones in the delivery of health care for U.S. military family members.

The development of medical care for U.S. military families and retirees was serendipitous, a fortunate accident. The formal development of military family medical care required the evolution of three factors: the emergence of a standing army, frontiers to guard, and a peace to defend. These factors were first realized in the late 19th Century, and beginning at that point in U.S. history, seven key years highlight major milestones in the history of military family member medical care. At the same time, these years exemplify changing ideas of disease and of health care and how the physical design of clinics and hospitals reflects and impacts these ideas. The Fort Belvoir Community Hospital, which opens in 2011, exemplifies the Nation's best example of green hospital construction, patient and family centered care, and evidence-based design in a Culture of Excellence that demonstrates that military family medical care is finally "deliberate by design."

Infection Prevention Considerations for a Multi-Mission Convention Center Field Hospital in Baltimore, Maryland, During the COVID-19 Pandemic.

The state of Maryland identified its first case of coronavirus disease 2019 (COVID-19) on March 5, 2020. The Baltimore Convention Center (BCCFH) quickly became a selected location to set up a 250-bed inpatient field hospital and alternate care site. In contrast to other field hospitals throughout the United States, the BCCFH remained open throughout the pandemic and took on additional COVID-19 missions, including community severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diagnostic testing, monoclonal antibody infusions for COVID-19 outpatients, and community COVID-19 vaccinations.To prevent the spread of pathogens during operations, infection prevention and control guidelines were essential to ensure the safety of staff and patients. Through multi-agency collaboration, use of infection prevention best practices, and answering what we describe as PPE-ESP, an operational framework was established to reduce infection risks for those providing or receiving care at the BCCFH during the COVID-19 pandemic.

Implementation and Accuracy of BinaxNOW Rapid Antigen COVID-19 Test in Asymptomatic and Symptomatic Populations in a High-Volume Self-Referred Testing Site.

Rapid antigen tests are simple to perform and provide results within 15 min. We describe our implementation and assess performance of the BinaxNOW COVID-19 Antigen Test (Abbott Laboratories) in 6,099 adults at a self-referred walk-up testing site. Participants were grouped by self-reported COVID-19 exposure and symptom status. Most (89%) were asymptomatic, of whom 17% reported potential exposure. Overall test sensitivity compared with reference laboratory reverse-transcription [RT] PCR testing was 81% (95% confidence interval [CI] 75%, 86%). It was higher in symptomatic (87%; 95% CI 80%, 91%) than asymptomatic (71%; 95% CI 61%, 80%) individuals. Sensitivity was 82% (95% CI 66%, 91%) for asymptomatic individuals with potential exposure and 64% (95% CI 51%, 76%) for those with no exposure. Specificity was greater than 99% for all groups. BinaxNOW has high accuracy among symptomatic individuals and is below the FDA threshold for emergency use authorization in asymptomatic individuals. Nonetheless, rapid antigen testing quickly identifies positive among those with symptoms and/or close contact exposure and could expedite isolation and treatment. IMPORTANCE The BinaxNOW rapid antigen COVID-19 test had a sensitivity of 87% in symptomatic and 71% asymptomatic individuals when performed by health care workers in a high-throughput setting. The performance may expedite isolation decisions or referrals for time-sensitive monoclonal antibody treatment in communities where timely COVID PCR tests are unavailable.

Concurrent use of metered-dose and dry powder inhalers by children with persistent asthma does not adversely affect spacer/inhaler technique.

BACKGROUND: Studies conducted in adults have suggested that patients who use a metered-dose inhaler/holding chamber spacer (MDI/S) and dry powder inhaler (DPI) concurrently will have poorer MDI/S technique than that of patients who use MDI/S exclusively. To our knowledge, as of August 31, 2006, no studies have been performed in pediatric patients. OBJECTIVE: To compare MDI/S technique scores of children using only MDI/S with scores of those using both MDI/S and DPIs. METHODS: The MDI/S technique of children aged 6-17 years, with persistent asthma, recruited from a general pediatric practice population for an asthma intervention study project was scored using a standardized checklist. MDI/S scores of children who were being treated with maintenance and rescue medication delivered only by MDI/S were compared with those treated with both MDI/S (rescue) and DPI (maintenance). Scores lower than 70% were considered to be inadequate. RESULTS: A total of 117 patients (73 male, 44 female), aged 9.70 +/- 3.1 years (mean +/- SD), with persistent asthma, participated in the study. There were 83 children (54 male, 29 female, age 9.4 +/- 3.2 y) in the MDI/S only group and 34 (19 male, 15 female, age 10.3 +/- 2.9 y) in the MDI/S + DPI group. In the MDI/S + DPI group, Diskus was the DPI used for 32 patients, and Turbuhaler was used by 2 children. Sixteen patients had severe persistent asthma, 80 had moderate persistent asthma, and 21 had mild persistent asthma as classified by National Heart Lung and Blood Institute guidelines. No difference in sex and age demographics existed; however, there was a difference in the distribution of asthma severity between groups (ie, no patients with mild persistent asthma in the MDI/S + DPI group; p < or = 0.01). Mean score for the MDI/S only group was 86 +/- 17% and, for the MDI/S + DPI group, 90.1 +/- 12% (p = 0.15). More patients in the MDI/S group had inadequate scores (18%) compared with those in the MDI/S + DPI group (3%; p < 0.05). CONCLUSIONS: While DPI and MDI/S techniques are markedly different in several significant ways, concurrent use of these inhalers did not adversely affect MDI/S technique scores of pediatric patients with persistent asthma, compared with those using MDI/S alone. Patients in the MDI/S only group had an inadequate MDI/S score (<70%) more often than did patients in the MDI/S + DPI group.

Effectiveness of an Internet-based store-and-forward telemedicine system for pediatric subspecialty consultation.

BACKGROUND: Pediatric subspecialists are often separated from the children who need them by distance, time, or socioeconomic factors. The Electronic Children's Hospital of the Pacific is an Internet-based store-and-forward pediatric consultation system established to overcome these barriers. OBJECTIVE: To characterize the use of the Electronic Children's Hospital of the Pacific and its impact on access to specialty care, the quality of the care provided, and cost savings. DESIGN: Prospective trial. SETTING: Twenty-two military treatment facilities in the Pacific. PARTICIPANTS: Primary care providers, pediatric consultants, and 5 reviewers. MAIN OUTCOME MEASURES: Consult response time, physician panel review, and evacuation cost avoidance. RESULTS: There were 267 cases from 16 sites. The mean +/- SD response time by a consultant was 32 +/- 8 hours. The panel review deemed that the initial diagnosis was changed or modified in 15% (39/267) of the cases, the diagnostic plan was changed or modified in 21% (57/267), and the treatment plan was changed or modified in 24% (64/267) (P < .01 for all). Routine air evacuations to a tertiary care medical center were avoided in 32 cases (12%), with an estimated cost savings of $185 408. CONCLUSIONS: The Electronic Children's Hospital of the Pacific improved the quality of patient care by providing expeditious specialty consultation. Significant cost avoidance in this military pediatric population was documented. Store-and-forward Internet-based teleconsultation is an effective means of providing pediatric subspecialty consultation to a population of underserved children.

Bronchiectasis in children: orphan disease or persistent problem?

More than a decade ago, bronchiectasis unrelated to cystic fibrosis was termed an "orphan disease", because it had become an uncommon clinical entity among children in the developed world. Bronchiectasis is more common among children in lower socioeconomic classes and in developing countries, presumably due to more frequent and recurrent respiratory infections, environmental airway irritants, poor immunization rates, and malnutrition. Reports from the Southern Pacific and from Alaska Native children reveal persistently high rates of childhood bronchiectasis. Better epidemiologic data throughout the world are needed to reassess the importance of this condition. The pathophysiology includes airway inflammation, mucus production, and regional airway obstruction, yet the reasons why some children develop bronchiectasis while other do not is unclear. The coexistence of asthma with bronchiectasis is associated with more severe disease, yet the impact of asthma therapy in children with both disorders has not been studied. Similarly, the pattern of antibiotic use for children with bronchiectasis varies by region with little data to justify one particular approach. It may be that public health measures aimed at improving living conditions for children and prevention of respiratory infections with antiviral vaccines will have more impact on childhood bronchiectasis than medical treatments in the future.

Advanced statistics: applying statistical process control techniques to emergency medicine: a primer for providers.

Emergency medicine faces unique challenges in the effort to improve efficiency and effectiveness. Increased patient volumes, decreased emergency department (ED) supply, and an increased emphasis on the ED as a diagnostic center have contributed to poor customer satisfaction and process failures such as diversion/bypass. Statistical process control (SPC) techniques developed in industry offer an empirically based means to understand our work processes and manage by fact. Emphasizing that meaningful quality improvement can occur only when it is exercised by "front-line" providers, this primer presents robust yet accessible SPC concepts and techniques for use in today's ED.

Still falling: a community-wide infant walker injury prevention initiative.

Despite the well-known risk of injury associated with use of infant walkers, they remain popular, leading to large numbers of walker-related injuries. A coalition of health care providers and educators, with the assistance of retailers and medical and human service agencies, undertook an intensive multifaceted, community-wide intervention to educate the general and health care public regarding the dangers of infant walker use and thereby reduce the number of walker-related injuries in our community. Following this intervention, 28% fewer children presented annually at the two area pediatric emergency departments for walker-related falls down stairs than during the 30 months before the intervention. The magnitude of this reduction attributable to the intervention, however, is uncertain, as national trends during the study period revealed a similar decrease in walker-related injuries. Educational interventions alone may significantly reduce but not eliminate walker-related injuries; national policy measures are likely also necessary.