The impact and efficiency of medical screening exams in forward treatment areas at New York City public hospitals during the initial COVID-19 surge.

BACKGROUND: New York City (NYC) emergency departments (EDs) experienced a surge of patients because of coronavirus disease 2019 (COVID-19) in March 2020. NYC Health and Hospitals established rapid medical screening exams (MSE) and each hospital designated areas to perform their MSE. Five of the 11 hospitals created a forward treatment area (FTA) external to the ED to disposition patients before entering who presented with COVID-like symptoms. Three hospitals used paper-based, and 2 used an electronic medical record (EMR)-based MSE. This study evaluated the effectiveness of safely discharging patients home from the FTA while also evaluating the efficiency of using paper-based versus EMR-based MSEs. METHODS: Charts were reviewed using standardized data extraction templates. Patients discharged from the FTA were contacted by phone, and a structured interview captured additional data regarding subsequent clinical courses. Chi-square tests were used to compare proportions of patients hospitalized, as well as proportions of patients with vital signs recorded. Mortality rates were compared with Fisher exact test. A logistic regression model with fixed effects to account for clustering at hospitals was used to compare the odds of being sent to the ED for further evaluation based on vital signs and adjusted for age and sex. RESULTS: Across 5 EDs, 3335 patients were evaluated in their FTAs from March 17, 2020, to April 27, 2020. A total of 970 (29.1%) patients were referred for further evaluation into the ED, of which 203 (20.9%) were hospitalized and 19 (2.0%) died. Of 2302 patients discharged from the FTA, 182 (7.9%) returned to the ED within 7 days, resulting in 42 (1.8%) hospitalizations and 7 (0.3%) deaths. Facilities using EMR-MSE discharged more patients from their FTA (81.9% vs 65.3%, P < 0.001) and had similar 7-day return (9.3% vs 7.1%, P = 0.055) and mortality rates (0.49% vs 0.20%, P = 0.251). CONCLUSION: MSEs in an FTA are an effective process to disposition patients safely in a high-volume situation. Differences exist in paper- versus EMR-based approaches, suggesting EMR-MSEs provide better data, efficiency, and effectiveness. This suggests prioritizing an EMR-based MSE should be considered in future circumstances.

Impact of Provider-In-Triage in a Safety-Net Hospital.

BACKGROUND: Increasing emergency department (ED) utilization has contributed to ED overcrowding, with longer ED length of stay (EDLOS) and more patients leaving without being seen (LWBS), and is associated with higher morbidity and mortality rates. Previous studies of provider in triage (PIT) have shown decreased LWBS, but variable improvements in EDLOS. OBJECTIVES: We evaluated the impact of PIT implementation in an urban safety-net hospital on commonly reported ED throughput metrics. METHODS: This before-and-after study was performed at an academic urban safety hospital. We implemented a PIT team that screened ambulatory ED patients for early discharge or expedited workup. The PIT intervention was implemented 3 days a week from January through April 2019. As controls, we compared throughput metrics from when PIT was unavailable (Group 2) and from 1 year prior (Group 3). RESULTS: There were significantly (p < 0.001) lower rates of LWBS in Group 1 (4.8%, 95% confidence interval [CI] 4.1-5.8%) compared with 2 (7.3%, 95% CI 5.5-9.7%) and 3 (7.8%, 95% CI 6.9-9.0%). Door-to-doctor times were significantly (p < 0.001) lower for Group 1 (148 min, interquartile range [IQR] 88, 226 min) compared with 2 (187 min, IQR 95.5, 266 min) and 3 (215 min, IQR 131, 290 min). EDLOS was significantly (p < 0.001) shorter for Group 1 (337 min, IQR 215, 468 min) compared with 2 (385 min, IQR 271, 516 min) and 3 (413 min, IQR 299, 538 min). CONCLUSIONS: We found significantly lower LWBS rates, shorter EDLOS, and shorter door-to-doctor times after PIT implementation. Compared with previous studies in a variety of settings, we found that PIT significantly improved LWBS and all throughput metrics in a safety net setting.

Heat or cold packs for neck and back strain: a randomized controlled trial of efficacy.

OBJECTIVES: Acute back and neck strains are very common. In addition to administering analgesics, these strains are often treated with either heat or cold packs. The objective of this study was to compare the analgesic efficacy of heat and cold in relieving pain from back and neck strains. The authors hypothesized that pain relief would not differ between hot and cold packs. METHODS: This was a randomized, controlled trial conducted at a university-based emergency department (ED) with an annual census of 90,000 visits. ED patients >18 years old with acute back or neck strains were eligible for inclusion. All patients received 400 mg of ibuprofen orally and then were randomized to 30 minutes of heating pad or cold pack applied to the strained area. Outcomes of interest were pain severity before and after pack application on a validated 100-mm visual analog scale (VAS) from 0 (no pain) to 100 (worst pain), percentage of patients requiring rescue analgesia, subjective report of pain relief on a verbal rating scale (VRS), and future desire for similar packs. Outcomes were compared with t-tests and chi-square tests. A sample of 60 patients had 80% power to detect a 15-mm difference in pain scores. RESULTS: Sixty patients were randomized to heat (n = 31) or cold (n = 29) therapy. Mean (+/-standard deviation [SD]) age was 37.8 (+/-14.7) years, 51.6% were female, and 66.7% were white. Groups were similar in baseline patient and pain characteristics. There were no differences between the heat and cold groups in the severity of pain before (75 mm [95% CI = 66 to 83] vs. 72 mm [95% CI = 65 to 78]; p = 0.56) or after (66 mm [95% CI = 57 to 75] vs. 64 mm [95% CI = 56 to 73]; p = 0.75) therapy. Pain was rated better or much better in 16/31 (51.6%) and 18/29 (62.1%) patients in the heat and cold groups, respectively (p = 0.27). There were no between-group differences in the desire for and administration of additional analgesia. Twenty-five of 31 (80.6%) patients in the heat group and 22 of 29 (75.9%) patients in the cold group would use the same therapy if injured in the future (p = 0.65). CONCLUSIONS: The addition of a 30-minute topical application of a heating pad or cold pack to ibuprofen therapy for the treatment of acute neck or back strain results in a mild yet similar improvement in the pain severity. However, it is possible that pain relief is mainly the result of ibuprofen therapy. Choice of heat or cold therapy should be based on patient and practitioner preferences and availability.

Outflow reconstruction in right hepatic live donor liver transplantation.

BACKGROUND: Inconstant venous anatomy increases the risk of outflow complications in right hepatic live donor liver transplantation (RH-LDT), but no consensus has emerged guiding optimal reconstruction for venous outflow. METHODS: We retrospectively analyzed surgical venous reconstruction using a flexible approach to anterior accessory veins in 48 RH-LDTs performed between April, 1998 and July, 2002. RESULTS: Actuarial recipient graft and patient survival was 79% and 85%, respectively. Single hepatic venous anastomosis was performed in 74% of the patients. Twelve patients underwent reconstruction of 20 accessory veins, including 7 posterior segment veins and 13 anterior segment veins. Anterior vein reconstruction techniques included end-to-end anastomosis to the middle hepatic vein, interposition conduit, venoplasty, or a combination of techniques. Documented complications related to the venous anastomosis occurred in only 1 patient (2%), with no patient having a documented venous thrombosis of either the main RHV or a reconstructed accessory vein. There were no differences in outcome based on single versus multiple venous reconstruction. Anteromedial congestion was noted in 3 patients in the absence of anatomic venous anastomotic complication, but the clinical significance of this finding is unclear. CONCLUSIONS: Despite variations in segmental venous drainage and a propensity for anteromedial congestion in right hepatic grafts, RH-LDT can be performed without outflow obstruction with close attention to a wide RHV anastomosis. In addition, anterior accessory vein reconstruction can be reserved for grafts of marginal size or quality where early postoperative venous congestion may impair early graft function. Routine extended hepatectomy incorporating the MHV with the graft is unnecessary.

Aging and the representation of spatial situations in narrative understanding.

Age differences in the construction of the situation model during text understanding were investigated. Situation model processing was measured in terms of the distance effect, the tendency for readers to process information about objects in a narrative more quickly when the objects are spatially closer to the protagonist than when they are farther away. To examine readers' ability to construct the model directly from the text, the distance effect was contrasted for objects that were either presented in a layout of the narrative setting prior to reading (learned objects) or introduced in the narrative itself (new objects). Both younger and older readers showed strong distance effects for learned objects. When objects had not been learned but were only introduced in the text, however, younger adults did not show a reliable distance effect. Older adults with high levels of comprehension did, lending support to the position that older readers differentially rely on the situation model for effective narrative understanding.

Nuclear import and export signals in control of the p53-related protein p73.

The p53-family of proteins, including p53, p63, and p73, shares a high degree of structural similarity and can carry out some redundant functions. However, mechanisms that regulate the localization and activity of these proteins have not been fully clarified. In this study, a nuclear localization signal (NLS) was identified in p73, which is required for p73 nuclear import and which could promote the nuclear import of a heterologous, cytoplasmic protein. Mutants lacking the NLS localized to the cytoplasm and displayed diminished transcriptional activity. A nuclear export signal (NES) was also recognized in p73s C terminus, the deletion of which caused p73 to display a more nuclear localization pattern. This NES was sensitive to leptomycin B and could function as an independent export signal when fused to a heterologous protein. Interestingly, p73 mutant proteins lacking the NLS or the NES were more stable than wild-type p73, suggesting that nuclear import and nuclear export are required for efficient p73 degradation. Our results indicate that p73 localization is controlled by both nuclear import and export and suggest that the overall distribution of p73 is likely to result from the balance between these two processes. Proper control of nuclear import and export is likely to be an important regulatory determinant of p73.