Large-Scale Telemedicine Implementation for Outpatient Clinicians: Results From a Pandemic-Adapted Learning Collaborative.

Learning collaboratives are seldom used outside of health care quality improvement. We describe a condensed, 10-week learning collaborative ("Telemedicine Hack") that facilitated telemedicine implementation for outpatient clinicians early in the COVID-19 pandemic. Live attendance averaged 1688 participants per session. Of 1005 baseline survey respondents, 57% were clinicians with one-third identifying as from a racial/ethnic minoritized group. Practice characteristics included primary care (71%), rural settings (51%), and community health centers (28%). Of three surveys, a high of 438 (81%) of 540 clinicians had billed ≥1 video-based telemedicine visit. Our learning collaborative "sprint" is a promising model for scaling knowledge during emergencies and addressing health inequities.

Facilitating Real-Time, Multidirectional Learning for Clinicians in a Low-Evidence Pandemic Response.

As COVID-19 was declared a health emergency in March 2020, there was immense demand for information about the novel pathogen. This paper examines the clinician-reported impact of Project ECHO COVID-19 Clinical Rounds on clinician learning. Primary sources of study data were Continuing Medical Education (CME) Surveys for each session from the dates of March 24, 2020 to July 30, 2020 and impact surveys conducted in November 2020, which sought to understand participants' overall assessment of sessions. Quantitative analyses included descriptive statistics and Mann-Whitney testing. Qualitative data were analyzed through inductive thematic analysis. Clinicians rated their knowledge after each session as significantly higher than before that session. 75.8% of clinicians reported they would 'definitely' or 'probably' use content gleaned from each attended session and clinicians reported specific clinical and operational changes made as a direct result of sessions. 94.6% of respondents reported that COVID-19 Clinical Rounds helped them provide better care to patients. 89% of respondents indicated they 'strongly agree' that they would join ECHO calls again.COVID-19 Clinical Rounds offers a promising model for the establishment of dynamic peer-to-peer tele-mentoring communities for low or no-notice response where scientifically tested or clinically verified practice evidence is limited.

Virtual Peer-to-Peer Learning to Enhance and Accelerate the Health System Response to COVID-19: The HHS ASPR Project ECHO COVID-19 Clinical Rounds Initiative.

Tasked with identifying digital health solutions to support dynamic learning health systems and their response to COVID-19, the US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response partnered with the University of New Mexico's Project ECHO and more than 2 dozen other organizations and agencies to create a real-time virtual peer-to-peer clinical education opportunity: the COVID-19 Clinical Rounds Initiative. Focused on 3 "pressure points" in the COVID-19 continuum of care-(1) the out-of-hospital and/or emergency medical services setting, (2) emergency departments, and (3) inpatient critical care environments-the initiative has created a massive peer-to-peer learning network for real-time information sharing, engaging participants in all 50 US states and more than 100 countries. One hundred twenty-five learning sessions had been conducted between March 24, 2020 and February 25, 2021, delivering more than 58,000 total learner-hours of contact in the first 11 months of operation.

You're It-You've Got to Save Someone: Immediate Responders, Not Bystanders.

Recurring disasters and life-threatening emergencies mandate that communities across the world be adequately prepared to prevent, respond, and recover from these events. Experiences throughout the world with mass casualty incidents and other disasters have increasingly highlighted the vital role that "active bystanders"-persons at the scene of an event who step forward to help-can play in preventing, containing, reporting, saving lives, decreasing morbidity, and increasing resilience. This paper seeks to emphasize the importance of the public in response to emergencies. No longer should we use the passive word "bystanders." Rather immediate responders fill a critical silent gap before trained professionals arrive. In support of immediate responders this paper will identify the barriers to bystander action, and provide next steps to increase the number of individuals who take action at times of emergency. Immediate responders can and do play a valuable and unique role in reducing mortality, morbidity, and suffering from emergency events. While some cultures and countries have a long history of engaging the public as critical in an emergency response, others do not. The challenge is how best to increase the number of individuals who are motivated, prepared and ready to respond appropriately when they find themselves at the scene of an active shooter, bombing, hurricane, earthquake, tornado, fire, vehicle crash, or other life-threatening emergency.

The Special Pathogens Research Network: Enabling Research Readiness.

The 2013-2016 epidemic of Ebola virus disease (EVD) that originated in West Africa underscored many of the challenges to conducting clinical research during an ongoing infectious disease epidemic, both in the most affected countries of Guinea, Liberia, and Sierra Leone, as well as in the United States and Europe, where a total of 27 patients with EVD received care in biocontainment units. The Special Pathogens Research Network (SPRN) was established in the United States in November 2016 to provide an organizational structure to leverage the expertise of the 10 Regional Ebola and Other Special Pathogen Treatment Centers (RESPTCs); it was intended to develop and support infrastructure to improve readiness to conduct clinical research in the United States. The network enables the rapid activation and coordination of clinical research in the event of an epidemic and facilitates opportunities for multicenter research when the RESPTCs are actively caring for patients requiring a biocontainment unit. Here we provide an overview of opportunities identified in the clinical research infrastructure during the West Africa EVD epidemic and the SPRN activities to meet the ongoing challenges in the context of Ebola virus and other special pathogens.

The National Ebola Training and Education Center: Preparing the United States for Ebola and Other Special Pathogens.

The National Ebola Training and Education Center (NETEC) was established in 2015 in response to the 2014-2016 Ebola virus disease outbreak in West Africa. The US Department of Health and Human Services office of the Assistant Secretary for Preparedness and Response and the US Centers for Disease Control and Prevention sought to increase the competency of healthcare and public health workers, as well as the capability of healthcare facilities in the United States, to deliver safe, efficient, and effective care to patients infected with Ebola and other special pathogens nationwide. NYC Health + Hospitals/Bellevue, Emory University, and the University of Nebraska Medical Center/Nebraska Medicine were awarded this cooperative agreement, based in part on their experience in safely and successfully evaluating and treating patients with Ebola virus disease in the United States. In 2016, NETEC received a supplemental award to expand on 3 initial primary tasks: (1) develop metrics and conduct peer review assessments; (2) develop and provide educational materials, resources, and tools, including exercise design templates; (3) provide expert training and technical assistance; and, to add a fourth task, create a special pathogens clinical research network.

A national model for developing, implementing, and evaluating evidence-based guidelines for prehospital care.

In 2007, the Institute of Medicine's (IOM's) Committee on the Future of Emergency Care recommended that a multidisciplinary panel establish a model for developing evidence-based protocols for the treatment of emergency medical systems (EMS) patients. In response, the National EMS Advisory Council (NEMSAC) and the Federal Interagency Committee on EMS (FICEMS) convened a panel of multidisciplinary experts to review current strategies for developing evidence-based guidelines (EBGs) and to propose a model for developing such guidelines for the prehospital milieu. This paper describes the eight-step model endorsed by FICEMS, NEMSAC, and a panel of EMS and evidence-based medicine experts. According to the model, prehospital EBG development would begin with the input of evidence from various external sources. Potential EBG topics would be suggested following a preliminary evidentiary review; those topics with sufficient extant foundational evidence would be selected for development. Next, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology would be used to determine a quality-of-evidence rating and a strength of recommendation related to the patient care guidelines. More specific, contextualized patient care protocols would then be generated and disseminated to the EMS community. After educating EMS professionals using targeted teaching materials, the protocols would be implemented in local EMS systems. Finally, effectiveness and uptake would be measured with integrated quality improvement and outcomes monitoring systems. The constituencies and experts involved in the model development process concluded that the use of such transparent, objective, and scientifically rigorous guidelines could significantly increase the quality of EMS care in the future.

Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011.

In the United States, injury is the leading cause of death for persons aged 1-44 years. In 2008, approximately 30 million injuries were serious enough to require the injured person to visit a hospital emergency department (ED); 5.4 million (18%) of these injured patients were transported by Emergency Medical Services (EMS). On arrival at the scene of an injury, the EMS provider must determine the severity of injury, initiate management of the patient's injuries, and decide the most appropriate destination hospital for the individual patient. These destination decisions are made through a process known as "field triage," which involves an assessment not only of the physiology and anatomy of injury but also of the mechanism of the injury and special patient and system considerations. Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process through its "Field Triage Decision Scheme." This guidance was updated with each version of the decision scheme (published in 1986, 1990, 1993, and 1999). In 2005, CDC, with financial support from the National Highway Traffic Safety Administration, collaborated with ACS-COT to convene the initial meetings of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme; the revised version was published in 2006 by ACS-COT (American College of Surgeons. Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons; 2006). In 2009, CDC published a detailed description of the scientific rationale for revising the field triage criteria (CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR 2009;58[No. RR-1]). In 2011, CDC reconvened the Panel to review the 2006 Guidelines in the context of recently published literature, assess the experiences of states and local communities working to implement the Guidelines, and recommend any needed changes or modifications to the Guidelines. This report describes the dissemination and impact of the 2006 Guidelines; outlines the methodology used by the Panel for its 2011 review; explains the revisions and modifications to the physiologic, anatomic, mechanism-of-injury, and special considerations criteria; updates the schematic of the 2006 Guidelines; and provides the rationale used by the Panel for these changes. This report is intended to help prehospital-care providers in their daily duties recognize individual injured patients who are most likely to benefit from specialized trauma center resources and is not intended as a mass casualty or disaster triage tool. The Panel anticipates a review of these Guidelines approximately every 5 years.

Large cost savings realized from the 2006 Field Triage Guideline: reduction in overtriage in U.S. trauma centers.

BACKGROUND: Ambulance transport of injured patients to the most appropriate medical care facility is an important decision. Trauma centers are designed and staffed to treat severely injured patients and are increasingly burdened by cases involving less-serious injury. Yet, a cost evaluation of the Field Triage national guideline has never been performed. OBJECTIVES: To examine the potential cost savings associated with overtriage for the 1999 and 2006 versions of the Field Triage Guideline. METHODS: Data from the National Hospital Ambulatory Medical Care Survey and the National Trauma Databank (NTDB) produced estimates of injury-related ambulatory transports and exposure to the Field Triage guideline. Case costs were approximated using a cost distribution curve of all cases found in the NTDB. A two-way sensitivity analysis was also used to determine the impact of data uncertainty on medical costs and the reduction in trauma center visits (12%) after implementation of the 2006 Field Triage guideline compared with the 1999 Field Triage guideline. RESULTS: At a 40% overtriage rate, the average case cost was $16,434. The cost average of 44.2% reduction in case costs if patients were treated in a non-trauma center compared with a trauma center was found in the literature. Implementation of the 2006 Field Triage guideline produced a $7,264 cost savings per case, or an estimated annual national savings of $568,000,000. CONCLUSION: Application of the 2006 Field Triage guideline helps emergency medical services personnel manage overtriage in trauma centers, which could result in a significant national cost savings.

Adoption of the 2006 field triage decision scheme for injured patients.

BACKGROUND: When emergency medical services (EMS) providers respond to the scene of an injury, they must decide where to transport the injured patients for further evaluation and treatment. This is done through a process known as "field triage", whereby a patient's injuries are matched to the most appropriate hospital. In 2005-2006 the National Expert Panel on Field Triage, convened by the Centers for Disease Control and Prevention and the National Highway Traffic Safety Administration, revised the 1999 American College of Surgeons Committee on Trauma Field Triage Decision Scheme. This revision, the 2006 Field Triage Decision Scheme, was published in 2006. METHODS: State Public Health departments' and EMS' external websites were evaluated to ascertain the current status of implementation of the 2006 Field Triage Decision Scheme. RESULTS: Information regarding field triage was located for 41 states. In nine states no information regarding field triage was available on their websites. Of the 41 states where information was located, seven were classified as "full adopters" of the 2006 Field Triage Decision Scheme; nine were considered "partial adopters"; 17 states were found to be using a full version or modification of the 1999 Field Triage Decision Scheme; and eight states were considered to be using a different protocol or scheme for field triage. CONCLUSION: Many states have adopted the 2006 Decision Scheme (full or partial). Further investigation is needed to determine the reasons why some states do not adopt the guidelines.

Mass casualty triage: an evaluation of the science and refinement of a national guideline.

Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were developed to be a national guideline for mass casualty triage to ensure interoperability and standardization when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

Early biosignature of oxidative stress in the retinal pigment epithelium.

The retinal pigment epithelium (RPE) is essential for retinoid recycling and phagocytosis of photoreceptors. Understanding of proteome changes that mediate oxidative stress-induced degeneration of RPE cells may provide further insight into the molecular mechanisms of retinal diseases. In the current study, comparative proteomics has been applied to investigate global changes of RPE proteins under oxidative stress. Proteomic techniques, including 2D SDS-PAGE, differential gel electrophoresis (DIGE), and tandem time-of-flight (TOF-TOF) mass spectrometry, were used to identify early protein markers of oxidative stress in the RPE. Two biological models of RPE cells revealed several differentially expressed proteins that are involved in key cellular processes such as energy metabolism, protein folding, redox homeostasis, cell differentiation, and retinoid metabolism. Our results provide a new perspective on early signaling molecules of redox imbalance in the RPE and putative therapeutic target proteins of RPE diseases caused by oxidative stress.

Prohibitin as an oxidative stress biomarker in the eye.

Identification of biomarker proteins in the retina and retinal pigment epithelium (RPE) under oxidative stress may imply new insights into signaling mechanisms of retinal degeneration at the molecular level. Proteomic data from an in vivo mice model in constant light and an in vitro oxidative stress model are compared to controls under normal conditions. Our proteomic study shows that prohibitin is involved in oxidative stress signaling in the retina and RPE. The identity of prohibitin in the retina and RPE was studied using 2D electrophoresis, immunohistochemistry, western blot, and mass spectrometry analysis. Comparison of expression levels with apoptotic markers as well as translocation between mitochondria and the nucleus imply that the regulation of prohibitin is an early signaling event in the RPE and retina under oxidative stress. Immunohistochemical analysis of murine aged and diabetic eyes further suggests that the regulation of prohibitin in the RPE/retina is related to aging- and diabetes-induced oxidative stress. Our proteomic approach implies that prohibitin in the RPE and the retina could be a new biomarker protein of oxidative stress in aging and diabetes.

Cleavage of the retinal pigment epithelium-specific protein RPE65 under oxidative stress.

The regeneration of the 11-cis-retinyl imine chromophore of rhodopsin during the visual cycle and mechanisms that control this process are central questions in the field of vision research. The retinal pigment epithelium (RPE)-specific protein RPE65 is centrally involved in the isomerization and hydrolysis of all-trans-retinyl esters. In this study, we investigated RPE65 cleavage and potential regulatory mechanisms under oxidative stress conditions. The D407 RPE cell cultures were exposed to H(2)O(2) (100-1000 microM). Changes in the levels of RPE65 and proteins related to apoptosis were investigated using gel electrophoresis and western blotting. Mass spectrometry was used to confirm the identity of RPE65. C57BL/6J (M450) and C3HeB/FeJ (L450) mice were used for in vivo experiments. We found that a novel 45kDa truncated fragment of the RPE65 protein, designated RPE45, appears in RPE cells upon light exposure or oxidative stress. RPE45 is generated in vitro by recombinant caspases via an ubiquitination-dependent mechanism. Collectively, our results indicate that oxidative stress during the visual cycle results in cleavage of RPE65.