Perceived Disruption of COVID-19 on Medical Education in Incoming Psychiatric Residents.

Background: In 2020, the global COVID-19 pandemic caused educational disruptions to many medical students nationally. Societal and hospital guidelines, including social distancing protocols, resulted in the cancellation or postponement of many elective procedures. A shortage in personal protective equipment also contributed to restrictions in clinical experiences for trainees. The purpose of this study was to determine resident-perceived preparedness in core clinical competencies and evaluate the disruptions to core clerkships. Methods: A survey was developed to assess self-perceptions of clinical competencies and disruptions to core clerkship experiences. It was distributed to 63 incoming psychiatric residents who matched to training programs in the United States. Results: The survey response rate was 97%. The majority of respondents achieved self-expected levels of proficiency in clinical skills. Deficits were greatest for pelvic/rectal exams and transitions of care. Most students did not experience disruptions to clerkships. Internal medicine, obstetrics, and gynecology clerkships reported the highest rates of virtual completion. Procedures with the lowest reported perceived preparation were arterial puncture, airway management, and IV placement, respectively. Conclusion: Our survey results indicated that most learners did not perceive disruptions to their medical education and incoming psychiatry residents felt well-prepared to start residency. Some specific procedural skills appear to have been affected. Attempts to mitigate these specific inadequacies may help mitigate disruptions due to future events.

Characteristics and Factors Associated With Nonoperative Management and Hospital Outcomes After Hip Fractures Among Community-Dwelling Older Adults: Retrospective Analysis.

Nonoperative treatment is used at varying rates among older adults with hip fractures despite the high mortality. This retrospective analysis of 7803 patients 65 and older admitted with hip fractures is to estimate the odds of nonoperative treatment and in-hospital mortality after hip fractures among community-dwelling older adults. 13.6% underwent nonoperative treatment. Compared to the group with operative treatment, the nonoperative group had a higher in-hospital mortality rate (6.51% vs. 1.32%, p < .0001). Male sex, nondisplaced fracture, and comorbidities of acute myocardial infarction, congestive heart failure, cerebrovascular disorder, dementia, and liver disease were associated with an increased likelihood of nonoperative treatment. Nonoperative treatment, advanced age, use of osteoporosis pharmacotherapy, multiple medical comorbidities, and hospital-acquired complications were associated with increased in-hospital mortality. Specific characteristics were associated with nonoperative management and in-hospital mortality among older adults with hip fractures. Additional research is necessary to improve the care of this vulnerable population.

Use of an Opt-Out vs Opt-In Strategy Increases Use of Residency Mental Health Services.

Background Residents report high levels of distress but low utilization of mental health services. Prior research has shown several barriers that prevent residents from opting into available mental health services. Objective To determine the impact of a mental health initiative centered around an opt-out versus an opt-in approach to help-seeking, on the use of psychotherapy. Methods Resident use of psychotherapy was compared between 2 time frames. During the first time frame (July 1, 2020 to January 31, 2021), residents were offered access to therapy that they could self-initiate by calling to schedule an appointment (opt-in). The second time frame (February 1, 2021 to April 30, 2021) involved the switch to an opt-out structure, during which the same residents were scheduled for a session but could choose to cancel. Additional changes were implemented to reduce stigma and minimize barriers. The outcome was psychotherapy use by residents. Results Of the 114 residents, 7 (6%) self-initiated therapy during the opt-in period. When these same residents were placed in an opt-out context, 59 of the remaining 107 residents (55%) kept their initial appointment, and 23 (39%) self-initiated additional sessions. Altogether, across both phases, a total of 30 of the 114 residents initiated therapy (ie, 7 during the opt-in and 23 during the opt-out). The differences in therapy use between the 2 phases are statistically significant (P<.001 by McNemar's test). Conclusions There was a substantial increase in residents' use of psychotherapy after the opt-out initiative that included efforts to reduce stigma and encourage mental health services.

Characteristics and Hospital Outcomes of 1403 Patients Hospitalized at Community Hospitals With Ankylosing Spondylitis.

Background: In this study, we aimed to assess the hospital course, outcomes after hospitalization, and predictors of outcomes in patients with ankylosing spondylitis (AS). Methods: We included 1403 patients with AS between 2016 and 2021 who were identified using International Classification of Disease (ICD) codes from a large for-profit healthcare system database. Demographics and clinical characteristics were compared between those who had a favorable outcome, defined as being discharged to home without readmission within 3 months of discharge, versus those who had an unfavorable outcome. A stepwise logistic regression was used to identify demographic and clinical characteristics associated with home discharge and readmission. Results: The mean age for all AS patients was 56.06 ± 17.01 years, which was younger in the favorable outcome group, and 82.47% of patients were discharged to home after the average length of stay of 3.72 ± 4.09 days, also shorter in the favorable outcome group. Of 1403 patients, 37.56% were readmitted within 3 months of discharge, at a lower rate in the group with home discharge. Opioids were the most commonly used medication during hospitalization (67.07%), prescribed at a lower rate in the favorable outcome group. Medical coverage by Medicare and Medicaid, fall at admission, hospital-acquired anemia, steroid, acetaminophen, muscle relaxant use, and an increased dose of morphine milligram equivalent at discharge were significantly associated with decreased odds of home discharge. Surgical procedures during admission, gastrointestinal complications, discharge to inpatient rehabilitation units, and use of benzodiazepine were associated with an increased risk of readmission within 3 months. Conclusion: Recognizing factors that put patients with AS at risk of unfavorable outcomes is useful information to improve patient care during hospitalization.

Characteristics, Outcomes, and Its Associated Factors Among Patients Hospitalized With Mild Traumatic Brain Injuries.

OBJECTIVE: The aim of the study is to investigate the characteristics and hospital outcomes of patients with mild traumatic brain injuries. DESIGN: A total of 1940 patients with mild traumatic brain injuries from seven community hospitals between 2017 and 2019 were identified using International Classification of Disease codes and an documented initial Glasgow Coma Scale score of 13-15. A stepwise logistic regression was used to identify demographics and clinical characteristics associated with in-hospital mortality and home discharge. RESULTS: The median age was 69 yrs old with 66.6% associated with falls at admission. Subdural hemorrhage was the most common brain lesion and more common in the group with falls. Increased age, male sex, epidural hemorrhage, presence of hemiplegia, paraplegia, renal disease, cancer, hospital-acquired sepsis, anemia, and use of direct vasodilator were associated with increased odds of in-hospital mortality. Increased age, medical coverage by Medicare, cerebral edema, lower initial Glasgow Coma Scale, length of stay, comorbidity of acute myocardiac infarction, and use of thiamine and opioids were associated with decreased likelihood of discharge to home. CONCLUSIONS: Recognizing characteristics of hospitalized patients with mild traumatic brain injuries and their association with increased in-hospital mortality and nonhome discharge can be useful for improving care of this vulnerable population.

The Impact of Gender and Race When Using the GRACE ACS Score to Predict Mortality.

Background: Acute coronary syndrome (ACS) causes significant global morbidity and mortality and requires early risk stratification. The global registry of acute coronary events (GRACE) score is a well-known, validated risk stratification system that does not include race and gender. We aimed to assess whether the addition of gender and race could add to the predictability of the GRACE score model. Methods: We performed a retrospective cohort study of 46 764 ACS patients from the files of a national healthcare system. We compared the predictability of the GRACE score in conjunction with gender and race versus the original GRACE score. Different possible associations of predictability were investigated and statistically calculated. The accuracy of the prediction models was assessed using the receiver operating characteristic curve and its respective area under the curve (AUC). We compared the AUC of the 2 models, with the significance set at a P value of less than .05. Results: Our comparison favored the original GRACE score over the modified prediction model with gender and race added (AUC = 0.838 and 0.839 respectively, P = .008). Although the P value comparing the AUC shows that the original GRACE was superior, due to our large dataset, the actual numbers are similar and may not be clinically significant. Gender and race were significantly associated with in-hospital mortality (P < .001, P = .002, respectively). However, this relationship disappeared in the multivariate analysis. Gender significantly predicted in-hospital mortality, with females 1.167 times more likely to die (P < .001). Non-white racial groups had lower in-hospital mortality than whites (OR: 0.823, P = .03). Conclusion: The GRACE score was valid in its original form and its ability to predict mortality was not substantially improved by including gender and race.

Epidemiology of demographic, clinical characteristics and hospital course of patients with spinal cord injury associated with vertebral fracture in a large private health care system in the United States.

OBJECTIVES: To evaluate the demographics, clinical characteristics, hospital course, and factors associated with outcomes in patients with spinal cord injury associated with vertebral fracture (SCI-VF). DESIGN: Retrospective analysis of data collected from electronic health record. SETTING: A large for-profit United States health care system. PARTICIPANTS: 2219 inpatients with SCI-VF between 2014 and 2020 identified using International Classification of Disease codes. MAIN OUTCOME MEASURE: : In-hospital mortality, and disposition (home vs. no-home discharge) after hospitalization. RESULTS: The mean age of patients admitted with a diagnosis of SCI-VF was 54.80 ± 20.85 years with 68.27% identified as male. The cervical spine was the most prevalent site of fracture, displaced vertebral fracture was the most common radiographic diagnosis, and the majority of injuries were classified as incomplete. 836 (37.67% of all 2219) patients were discharged home and had a shorter length of stay (7.56 ± 13.58 days) when compared to the average of the total study population (11.56 ± 19.2 days). The most common hospital-acquired complication (HAC) was falls (n = 259, 11.67%). Characteristics associated with in-hospital mortality in the 96 patients (6.94% of 1,383 patients with no-home discharge) included initial respiratory failure, ICU stay, increased medical comorbidity index value, insulin use, and presence of cardiovascular, pulmonary, and gastrointestinal HACs. CONCLUSIONS: A large observational study of patients with SCI-VF can add to the knowledge of SCI characteristics in the U.S. population. Recognizing the common hospital-acquired conditions and clinical characteristics associated with increased in-hospital mortality can be helpful to improve the care of patients with SCI-VF.

Clinical Characteristics and Outcomes of Inpatient Falls During Inpatient Rehabilitation: A Case-Control Study.

ABSTRACT: Inpatient falls have a significant impact on the outcomes of older patients during inpatient rehabilitation. A retrospective case-control study was conducted using data of 7066 adults aged 55 yrs or older to evaluate significant predictors of inpatient falls during inpatient rehabilitation and the association of inpatient falls with discharge destination and length of stay. A stepwise logistic regression was used to model odds of inpatient falls and home discharge with demographic and clinical characteristic variables and a multivariate linear regression to evaluate the association between inpatient falls and length of stay.Nine hundred thirty-one of 7066 patients (13.18%) had inpatient falls during inpatient rehabilitation. The group with inpatient falls had longer length of stay (14.22 ± 7.82 vs. 11.85 ± 5.33 days, P < 0.0001) and a decreased proportion of home discharges when compared with the group without inpatient falls. There were increased odds of inpatient falls among patients with diagnoses of head injury, other injuries, a history of falls, dementia, a divorced marital status, and a use of laxatives or anticonvulsants. Inpatient falls were associated with an increased length of stay (coefficient = 1.62, confidence interval = 1.19-2.06) and decreased odds of home discharge (odds ratio = 0.79, confidence interval = 0.65-0.96) after inpatient rehabilitation. This knowledge may be incorporated into strategies for reducing inpatient falls during inpatient rehabilitation.

COVID-19 vaccination decreased COVID-19 hospital length of stay, in-hospital death, and increased home discharge.

COVID-19 vaccination impact on hospital outcome metrics among patients hospitalized with COVID-19 is not well known. We evaluated if covid-19 vaccination was associated with better hospital outcomes such as in-hospital mortality, overall length of stay, and home discharge. This retrospective study analyzed data from the electronic health records of 29,732 patients admitted with COVID-19 with or without vaccination (21,525 unvaccinated and 8207 vaccinated) from January to December 2021. The association of COVID-19 vaccination status with overall length of hospitalization, in-hospital mortality rate, home discharge after hospitalization was investigated using a multivariate logistic regression and a generalized linear model. The mean age of all groups was 58.16 ± 17.39 years. The unvaccinated group was younger (54.95 ± 16.75) and had less comorbidities compared to the vaccinated group. Patients that had received COVID-19 vaccination exhibited decreased in-hospital mortality (OR 0.666, 95 % CI 0.580-0.764), decreased length of stay (-2.13 days, CI 2.73-1.55 days), and increased rate of home discharge (OR 1.168, CI 1.037-1.315). Older age and cerebrovascular accident diagnosis at admission demonstrated a negative effect on hospital outcomes with decreased home discharge (OR 0.950 per 1 year, CI 0.946-0.953 and OR 0.415, CI 0.202-0.854) and increased inhospital mortality (OR 1.04 per 1 year, CI 1.036-1.045 and OR 3.005, CI 1.961-4.604). This study shows the additional positive impact of COVID-19 vaccination has not just on in-hospital mortality but also in reducing overall length of stay and improved hospital outcome metrics including increasing likelihood of home discharge after hospitalization.

Impact of the COVID-19 Pandemic on Trauma Encounters.

OBJECTIVES: The Coronavirus Disease 2019 pandemic has affected the health care system significantly. We compare 2019 to 2020 to evaluate how trauma encounters has changed during the pandemic. METHODS: Retrospective analysis using a large US health care system to compare trauma demographics, volumes, mechanisms of injury, and outcomes. Statistical analysis was used to evaluate for significant differences comparing 2019 to 2020. RESULTS: Data was collected from 88 hospitals across 18 states. 169 892 patients were included in the study. There were 6.3% fewer trauma patient encounters in 2020 compared to 2019. Mechanism of injury was significantly different between 2019 and 2020 with less blunt injuries (89.64% vs. 88.39%, P < .001), more burn injuries (1.84% vs. 2.00%, P = .021), and more penetrating injuries (8.58% vs. 9.75%, P < .001). Compared to 2019, patients in 2020 had higher mortality (2.62% vs. 2.88%, P < .001), and longer hospital LOS (3.92 ± 6.90 vs. 4.06 ± 6.56, P < .001). CONCLUSION: The COVID-19 pandemic has significantly affected trauma patient demographics, LOS, mechanism of injury, and mortality.

Clinical characteristics, hospital course, and disposition of patients with nontraumatic spinal cord injury in a large private health care system in the United States.

OBJECTIVES: To evaluate the clinical characteristics, hospital courses, outcomes after hospitalization, and factors associated with outcomes in patients with nontraumatic spinal cord injuries (NTSCI). DESIGN: Retrospective analysis. SETTING: A large for-profit United States health care system. PARTICIPANTS: 2807 inpatients with NTSCI between 2014 and 2020 were identified using International Classification of Disease codes. MAIN OUTCOME MEASURE: Demographic, clinical characteristics, hospital course, and disposition data collected from electronic health record. RESULTS: The mean age was 57.91 ± 16.41 years with 69.83% being male. Incomplete cervical level injury was the most common injury type, spinal stenosis was the most common diagnostic etiology and central cord syndrome was the most common clinical syndrome. The average length of stay was 9.52 ± 15.8 days, with the subgroup of 1308 (46.6%) patients who were discharged home demonstrating a shorter length of stay (6.42 ± 10.24 days). Falls were the most common hospital-acquired complication (n = 424, 15.11%) and 83 patients deceased. There were increased odds of non-home discharge among patients with the following characteristics: older age, Medicare insurance, non-black racial minority, increased Charlson Comorbidity Index (CCI), intensive care unit (ICU) stay, use of steroid or anticoagulant medications, and hospital-acquired pulmonary complications. Increased in-hospital mortality was observed in those with Medicaid insurance, ICU stay, increased CCI, diagnosis of degenerative spine disease, other unspecified level of injury, and hospital-acquired pulmonary complications. CONCLUSIONS: NTSCI in this sample were predominantly incomplete cervical central SCIs. Increased CCI, ICU stay, and hospital-acquired pulmonary complications were associated with poorer outcomes after acute care hospitalization among patients with NTSCI.

COVID-19 related disruptions to medical education and perceived clinical capability of new resident physicians: a nationwide study of over 1200 first-year residents.

The COVID-19 pandemic transformed the final year of undergraduate medical education for thousands of medical students across the globe. Out of concern for spreading SARS-CoV-2 and conserving personal protective equipment, many students experienced declines in bedside clinical exposures. The perceived competency of this class within the context of the pandemic is unclear. We designed and distributed a survey to measure the degree to which recent medical school graduates from the USA felt clinically prepared on 13 core clinical skills. Of the 1283 graduates who matched at HCA Healthcare facilities, 90% (1156) completed the survey. In this national survey, most participants felt they were competent in their clinical skills. However, approximately one out of four soon-to-be residents felt they were clinically below where they should be with regard to calling consultations, performing procedures, and performing pelvic and rectal exams. One in five felt they were below where they should be with regard to safely transitioning care. These perceived deficits in important skill sets suggest the need for evaluation and revised educational approaches in these areas, especially when traditional in-person practical skills teaching and practice are disrupted.

Effect of Resident Involvement on Trauma Patient Outcomes: A Single-Institution Review.

OBJECTIVE: The purpose of this study was to examine the mortality difference and other outcome measures amongst trauma patients with residents involved in the initial management versus those that were managed by attending physicians only without resident involvement. DESIGN: Retrospective review. Chi-square, Fisher's tests were used to analyze the outcomes, diagnostics, and interventions using the presence of residents in the initial care of patients as an independent variable. Linear and logistic regression were used to estimate adjusted outcomes. SETTING: Riverside Community Hospital, Riverside California (State-designated level I trauma center) PARTICIPANTS: Data on all trauma patients ≥18 years old that were admitted between July 1, 2018 and June 30, 2020 was collected retrospectively (total 2644 trauma patients). Trauma patients that were transferred from outside facilities were excluded from the study. RESULTS: There was no significant difference in mortality associated with resident involvement in both unadjusted and adjusted analysis. Patients treated by residents, however, had more comorbidities (higher CCI) and were more severely injured (higher ISS). On adjusted analysis, higher ISS was independently associated with resident presence. There was also a statistically significant increase in the use of diagnostic studies and therapeutic interventions in the resident-present group. CONCLUSIONS: Involvement of residents in the initial management of our trauma patient population was associated with no difference in overall mortality or morbidity, despite higher injury severity in the resident treated patient group.

Opioid Utility and Hospital Outcomes Among Inpatients Admitted With Osteoarthritis and Spine Disorders.

OBJECTIVE: The aim of the study is to evaluate opioid analgesic utilization and predictors for adverse events during hospitalization and discharge disposition among patients admitted with osteoarthritis or spine disorders. DESIGN: This is a retrospective study of 12,747 adult patients admitted to six private community hospitals from 2017 to 2020. Opioid use during hospitalization and risk factors for hospital-acquired adverse events and nonhome discharge were investigated. RESULTS: The total number of patients using opioids decreased; however, the daily morphine milligram equivalent use for patients on opioids increased from 2017 to 2020. Increased odds of nonhome discharge were associated with older age, Medicaid, Medicare insurance, and increased lengths of stay, increased body mass index, daily morphine milligram equivalent, and electrolyte replacement in the osteoarthritis group. In the spine group, older age, Black race, Medicaid, Medicare, no insurance, increased Charlson Comorbidity Index, lengths of stay, polypharmacy, and heparin use were associated with nonhome discharge. Adverse events were associated with increased age, lengths of stay, Medicare, polypharmacy, antiemetic, and benzodiazepine use in the osteoarthritis group and increased Charlson Comorbidity Index, lengths of stay, and electrolyte replacement in the spine group. CONCLUSIONS: Despite the decreasing number of patients using opioids over the years, patients on opioids had an increased daily morphine milligram equivalent over the same period.

The Effect of Adding Procalcitonin to the Systemic Inflammatory Response Syndrome (Sirs) and Quick Sepsis-Related Organ Failure Assessment (qSOFA) Scoring System in Predicting Sepsis Mortality.

OBJECTIVE:  The primary objective of this study was to determine if the addition of procalcitonin to the existing systemic inflammatory response syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA) scoring systems could improve the predictability of in-hospital sepsis-related mortality. Secondarily, we sought to determine if the addition of procalcitonin could predict the likelihood of ICU admission and discharge home. DESIGN: This is a retrospective, single-center, observational study that looked at data from January 1, 2017 to January 1, 2019. Patients were stratified into four groups: SIRS-positive + procalcitonin >2 ng/mL (pSIRS+), SIRS-positive + procalcitonin ≤2 ng/mL (pSIRS-), qSOFA-positive + procalcitonin >2 ng/mL (pqSOFA+), and qSOFA-positive + procalcitonin ≤2 ng/mL (pqSOFA-). SETTING: The study was conducted at a community hospital in Las Vegas, Nevada. PATIENTS: Patients were included in the study if they were >18 years of age and had hospital admission diagnosis of sepsis with at least one value of procalcitonin level. INTERVENTIONS: After patients which met the inclusion criteria, patients were divided into subgroups of SIRS, SIRS + procalcitonin > 2 ng/mL, qSOFA, qSOFA + procalcitonin >2 ng/mL. Primary outcomes were in-hospital mortality and secondary outcomes were ICU admission, length of stay, and discharge to home. RESULTS:  933 patients were included in the study with an overall mortality rate of 21.22%, an overall ICU admission rate of 56.15%, and an overall discharge home rate of 29.58%. In those identified with a sepsis-related diagnosis code, pSIRS+ predicted an in-hospital mortality rate of 31.89% compared to pSIRS- 16.15% (P < 0.0001). In regards to qSOFA, the addition of procalcitonin added no statistically significant difference in predicting in-hospital mortality. pSIRS+ patients were found to have an ICU admission rate of 76.16% and a discharge home rate of 19.20% compared to pSIRS- who had 47.40% and 34.90%, respectively (P < 0.0001). Like in our primary outcome, our data for qSOFA was not statistically significant. CONCLUSIONS:  Procalcitonin added utility to the SIRS scoring system in predicting sepsis-related in-hospital mortality, ICU admission, and discharge home. Procalcitonin did not add statistically significant benefit to the qSOFA scoring system in predicting sepsis-related in-hospital mortality, ICU admission, and discharge home.

Validity and Reliability of the Scale to Report Emotional Stress Signs-Multiple Sclerosis (STRESS-MS) in Assessing Abuse and Neglect of Adults With Multiple Sclerosis.

Background: Approximately 30% of people with multiple sclerosis (MS) require caregiving, with unknown prevalence of abuse and neglect. To explore these issues, we created the Scale to Report Emotional Stress Signs-Multiple Sclerosis (STRESS-MS). The objective was to develop, validate, and field-test a self-report questionnaire for screening people with MS for mistreatment. Methods: We developed the STRESS-MS questionnaire and administered it to 102 adults with advanced MS-related disability and 97 primary informal caregivers, correlating responses with direct observation of mistreatment, conducting an item analysis, and evaluating validity using a Longitudinal, Expert, All Data (LEAD) panel. Results: Most STRESS-MS subscales correlated highly with criterion-standard LEAD panel evaluations of mistreatment, with strong concurrent and discriminant validity. Nearly 53% of participants with MS reported experiencing psychological abuse; 9.8%, financial exploitation; 6.9%, physical abuse; 4.9%, neglect; and 3.9%, sexual abuse. Protective factors for people with MS included social support and older age; risk factors included depression and aggressiveness. The greatest risk factor was an informal caregiver who spent 20 or more hours per week caring for the person with MS. Conclusions: The STRESS-MS questionnaire is reasonably reliable and valid for detecting caregiver mistreatment in adults with MS. Although most informal caregivers are not abusive, this study highlights an underrecognized need to detect and prevent abuse and neglect of people with MS.

CO2 Levels Behind and in Front of Different Protective Mask Types.

Objectives: Many individuals have difficulty adapting to face mask use and report symptoms while using masks. Our primary objective was to determine whether continuous mask-wearing causes elevated levels of carbon dioxide (CO2) behind the facemasks. Methods: CO2 concentrations were measured behind 3 different types of face masks and were compared to CO2 concentrations at the mask front in 261 subjects who continuously wore masks for at least 5 minutes. These CO2 concentrations were also measured in several randomly selected subjects after a 5-minute walk. Results: There were significantly higher CO2 concentrations behind the mask (3176 ppm) compared to the front (843 ppm) with an average of 49 minutes of continuous mask use. Of all the subjects, 76.6% had a behind-the-mask CO2 concentration of more than 2000 ppm (the threshold for clinical symptoms), and 12.2% had a CO2 concentration of at least 5000 ppm (occupational health exposure limit). The CO2 level behind the N-95 masks was highest (especially after exertion) and was lowest behind cloth masks. The combination of warm ambient temperature, an N-95 mask, exercise, and young age appeared to induce exceedingly high CO2 levels that should be avoided. Discussion: Although masks might be necessary for healthcare workers or to lessen the spread of airborne disease, we found that elevated CO2 concentrations were present while wearing them. Elevated CO2 concentrations have historically caused symptoms of CO2 toxicity. Periodic mask breaks in designated areas may be needed to avoid adverse effects. Conclusion: The use of masks increased the CO2 concentration in the air behind them to levels historically associated with toxicity.

Protective Equipment Preparedness and Accessibility: A Survey of Medical Trainees.

Introduction: After being removed from patient care due to equipment shortages, medical students and new residents around the United States are returning to clinical medicine/acute care settings as the SARS-CoV-2 (COVID-19) pandemic continues. We hypothesize that trainees returned with increased preparedness and had better access to and knowledge of personal protective equipment (PPE). Methods: Anonymous online surveys were distributed via snowball sampling to medical students and residents performing clinical duties in the United States. Respondents completed self-assessments for preparedness regarding PPE use, access to PPE and COVID-19 testing, and access to COVID-19 positive patients. Group comparisons were conducted using chi-square analysis and the Kruskal Wallis rank sum test. Multivariate ordinary least squares regression analysis was used to estimate the relationship between feeling prepared and other variables. Results: A total of 194 trainees (63 year 3 [MS3] medical students, 95 year 4 [MS4] medical students, and 36 year 1 [PGY1] postgraduates]) completed the survey. Collectively, 27% provided their own PPE on ≥ 1 rotation, 27% did not know how/where to obtain PPE, 36% did not know how/where to get tested, and 57% were never asked to demonstrate proficiency with PPE. In-person training was reported at 31.3% prior to 2020, which decreased to 21% during 2020. Mask-fit testing decreased from 83.1% to 56.9%. Online video lectures on PPE training increased from 52% to 80%. The mean (±SD) preparedness for return to clinical duty for MS3 students was 3.4/5 (±1.0), for MS4 students was 3.8/5 (±.90), and for PGY1 residents was 4.1/5(± .89) (P = .002). PPE training in 2020 was not associated with feeling prepared (P = .81). Conclusion: Survey respondents felt prepared by their institutions to return to clinical duties during the COVID-19 pandemic. There was some apprehension about knowledge of or access to PPE and COVID-19 testing. The confidence in the ability to don/doff PPE was the main factor associated with increased feelings of preparedness. While in-person training decreased from pre-2020 to during 2020, an increase of in-person training with supervised donning and doffing provides one potential avenue of further increasing the preparedness of trainees.

The Important Factors Applicants Consider When Choosing a Residency: A Survey Study.

Background: While medical school graduates compete to get matched into the best residency programs, programs also compete to attract the best applicants. The applicant's decision to rank their programs of interest is determined by several factors, many of which are not always apparent. Method: This study aimed to evaluate significant factors involved in an applicant's residency program selection. A 12-question survey was sent between June 2020 and September 2020 to all first-year internal medicine residents in the United States (US) through an online national database of residencies using the Survey Monkey platform. We asked them to rank the most significant factors that enticed or deterred them from choosing a specific program. We also compared domestic with international medical graduate (IMG) average ranked responses wherein differences were evaluated using an independent two mean samples t-test. The association between outcomes and predictors was analyzed using Pearson's correlation and chi-square analysis. Results: Out of 9,127 residents, 102 responded to the survey, which equaled a 1.11% response rate. The findings showed that the location, culture, and organization of a program are high-value factors for applicants. Salary, the number of cases seen, and friends near the residency location were not.There are statistically significant differences between graduates of US medical schools and IMG applicants, with the former placing higher importance on the quality of life during residency. Male and female residents also have different priorities with the latter emphasizing program culture and work environment improvement.Residents who chose programs based on academic competitiveness also placed significance on the prestige of the program (r = 0.418, P < .001), program organization/structure (r = 0.3, P = .006), fellowship match rate (r = 0.307, P = .006) and word of mouth (r = 0.520, P < .001). Residents who chose programs based on program culture also put an emphasis on the perceived happiness of the residents (r = 0.450, P = 0.001), and work-life balance (r = 0.359, P = .004). Conclusion: Programs can attract stronger applicants if they emphasize modifiable factors that are important to potential residents.

The effect of trauma center verification level on traumatic brain injury outcome after implementation of the Orange Book.

BACKGROUND: Previous literature demonstrates mortality discrepancies at Level II vs. Level I centers in patients with isolated Traumatic Brain Injury (TBI). Our hypothesis is that the implementation of the 2014 version of the resources manual ("the Orange Book") is associated with an elimination of this outcome disparity. METHODS: Utilizing the Trauma Quality Program Participant Use File for 2017, we compared TBI outcomes at ACS Level I vs. Level II centers. RESULTS: 39,764 records met inclusion criteria where 25,382 (63.8%) were admitted to a Level I center. Level I patients were younger (56.4 vs.59.1 years, p < 0.001) and less likely to have been injured in a single level fall (39.5%vs.45.5%, p < 0.001). The incidence of severe TBI (11.3%vs.10.3%, p < 0.001) was more common. Adjusted mortality at a Level II vs. Level I center were similar [7.8% vs. 8.4%, 0.669]. CONCLUSIONS: Implementation of 2014 version of the ACS resources manual is associated with improved TBI associated mortality in ACS Level II centers relative to their Level I counterparts.