Demographics and Clinical Characteristics of Adult Patients Hospitalized due to COVID-19 in a Rural/Suburban Integrated Health System in Southcentral Pennsylvania, March Through May 2020.

Existing characterizations of coronavirus disease 2019 (COVID-19) admissions have occurred primarily in urban settings. This report describes demographic and clinical characteristics of the first COVID-19 patients presenting to a 6-hospital integrated health care system in rural/suburban southcentral Pennsylvania. Medical records of adult patients admitted with COVID-19 between March and May of 2020 were retrospectively reviewed for demographics, symptomatology, imaging, and lab values. Results were largely consistent with previous studies, although gastrointestinal manifestations were more prevalent, with diarrhea reported in 25.4% of patients hospitalized due to COVID-19. Nursing home patients represented 10.1% of admissions but accounted for 35.5% of total deaths in our sample. Patients self-identifying as Hispanic were disproportionately affected. Although Hispanic ethnicity was self-reported in only 9% of the community population, Hispanic patients accounted for 34% of admissions. Our data provide a unique focused review of hospitalized COVID-19 patients in a rural/suburban setting.

Factors Influencing Work-Life Balance in Physicians and Advance Practice Clinicians and the Effect of Heartfulness Meditation Conference on Burnout.

BACKGROUND: Burnout levels have risen in recent years and satisfaction with work-life balance has decreased. Individual and organizational factors may affect burnout in physicians and advance practice clinicians (APCs). Meditation is a tool to mitigate stress and enhance well-being. In this study, we assessed the factors affecting work-life balance in physicians and APCs. We also measured the impact of Heartfulness meditation conference on burnout. METHODS: Physicians and APCs were surveyed through an abbreviated Maslach burnout inventory (aMBI) to assess the burnout levels and a question to assess the factors influencing work-life balance. Wellness initiatives included either attending a Heartfulness meditation conference or reading a book about burnout and wellness (approximated at a 3-h read). A repeat aMBI survey was sent 8 weeks after the conference. Pre- and postburnout scores were assessed. RESULTS: Of the 1393 physicians and APCs, 537 responded to the aMBI, and there were 414 comments (663 factors) for the question on work-life balance. Among the respondents, 60.5% and 32% had symptoms of moderate to severe emotional exhaustion (EE) and depersonalization, respectively. Twenty-eight percent of the respondents had symptoms of moderate to low personal accomplishment. The major factors impacting work-life balance included work load, work flow, and scheduling. A follow-up aMBI survey was completed by 79 from the conference group and 264 from the nonconference group. In the age-group between 30 and 50 for the conference group (n = 40), mean EE decreased from 9.8 to 8.6 with statistical significance (P = .014). There was no statistically significant change in the nonconference group in any age-group. CONCLUSION: Workload, workflow, and scheduling issues were the major factors affecting work-life balance. There is a significant level of burnout in physicians and APCs. Heartfulness meditation conference was associated with a significant decrease in EE in those aged 30 to 50 years. There was no significant change seen in the nonconference/book reading group.

A crew resource management program tailored to trauma resuscitation improves team behavior and communication.

BACKGROUND: Crew Resource Management (CRM) is a team-building communication process first implemented in the aviation industry to improve safety. It has been used in health care, particularly in surgical and intensive care settings, to improve team dynamics and reduce errors. We adapted a CRM process for implementation in the trauma resuscitation area. STUDY DESIGN: An interdisciplinary steering committee developed our CRM process to include a didactic classroom program based on a preimplementation survey of our trauma team members. Implementation with new cultural and process expectations followed. The Human Factors Attitude Survey and Communication and Teamwork Skills assessment tool were used to design, evaluate, and validate our CRM program. RESULTS: The initial trauma communication survey was completed by 160 team members (49% response). Twenty-five trauma resuscitations were observed and scored using Communication and Teamwork Skills. Areas of concern were identified and 324 staff completed our 3-hour CRM course during a 3-month period. After CRM training, 132 communication surveys and 38 Communication and Teamwork Skills observations were completed. In the post-CRM survey, respondents indicated improvement in accuracy of field to medical command information (p = 0.029); accuracy of emergency department medical command information to the resuscitation area (p = 0.002); and team leader identity, communication of plan, and role assignment (p = 0.001). After CRM training, staff were more likely to speak up when patient safety was a concern (p = 0.002). CONCLUSIONS: Crew Resource Management in the trauma resuscitation area enhances team dynamics, communication, and, ostensibly, patient safety. Philosophy and culture of CRM should be compulsory components of trauma programs and in resuscitation of injured patients.

Application of San Francisco Syncope Rule in elderly ED patients.

OBJECTIVES: The San Francisco Syncope Rule (SFSR) is a decision rule with the potential to identify patients at risk for serious outcomes within 7 days of the emergency department (ED) visit for syncope. The initial studies of the SFSR reported a high sensitivity and specificity for identifying patients, of all ages, with serious outcomes. Our objective was to determine if the SFSR can be safely and accurately applied to ED patients aged 65 and older with syncope or near-syncope. METHODS: A retrospective review of ED patients aged 65 years and older with syncope or near-syncope between January 2000 and August 2001 was performed. Charts were reviewed for evidence of SFSR risks for the ED visit and serious outcomes within 7 days of the ED visit. RESULTS: Of 773 subjects identified as having syncope or near-syncope, 517 subjects were included. There were 98 patients with serious outcomes. Twenty-three patients who were negative on SFSR had serious outcomes. The sensitivity and specificity of the SFSR were 76.5% (95% confidence interval [CI], 66.7%-84.3%) and 36.8% (95% CI, 32.2%-41.6%), respectively. The negative and positive predictive values were 87.0% (95% CI, 80.9%-91.4%) and 22.1% (95% CI, 17.8%-26.9%), respectively. CONCLUSIONS: In our cohort of elderly ED patients, the SFSR had a lower sensitivity and specificity. The SFSR may not be applicable to the elderly ED population. Future prospective validation is necessary before application to the ED elderly population.

Selective use of blood cultures in emergency department pneumonia patients.

Our objectives were to identify factors associated with positive blood cultures and to evaluate blood culture use in the management of hospitalized pneumonia patients to limit their use. A retrospective chart review was conducted at a community teaching hospital. Emergency Department patients with an admission diagnosis of pneumonia during calendar years 2001-2002 were included. Patients younger than age 18 years and those with a non-pneumonia discharge diagnosis were excluded. Of 684 eligible patients, 23 (3.4%) had true positive blood cultures. All organisms were sensitive to empiric antibiotics. Three risk factors were associated with positive blood cultures: oxygen saturation < 90%, serum sodium < 130 and respiratory rate > 30 breaths/min. No patient had antibiotic coverage broadened based on blood culture results. Positive blood culture rates were low and did not affect the clinical management of pneumonia patients. We recommend eliminating blood cultures in community-acquired pneumonia (CAP) patients, but obtaining blood cultures in patients at risk for multi-drug resistant pathogens, such as health-care-associated pneumonia (HCAP) patients.

Evaluation of emergency medicine resident death notification skills by direct observation.

UNLABELLED: Emergency physicians commonly perform death notifications. Physician training in death notification has been limited. Resident physicians are rarely evaluated in their performance of death notifications. OBJECTIVE: To evaluate death notification skills by direct observation of actual notifications performed by trained emergency medicine (EM) residents. METHODS: This was a prospective, observational study of EM resident death notification performance. EM residents received training and then were directly observed and evaluated by trained evaluators during actual death notifications in a 64,000-visit community teaching hospital emergency department. RESULTS: There were 327 evaluations of 70 different EM residents. Overall performance evaluations were 55% excellent, 40% satisfactory, and 5% unsatisfactory. Third-year EM residents and female EM residents were more likely to be rated excellent. CONCLUSIONS: Death notification is a skill that can be evaluated like other EM skills. Trained EM residents performed well in actual death notifications when directly observed and evaluated. Senior residents and female residents were more likely to be rated excellent.