Factors Influencing the Prioritization of Injured Patients for Transfer to a Burn or Trauma Center Following a Mass Casualty Event.

OBJECTIVES: In New York City, a multi-disciplinary Mass Casualty Consultation team is proposed to support prioritization of patients for coordinated inter-facility transfer after a large-scale mass casualty event. This study examines factors that influence consultation team prioritization decisions. METHODS: As part of a multi-hospital functional exercise, 2 teams prioritized the same set of 69 patient profiles. Prioritization decisions were compared between teams. Agreement between teams was assessed based on patient profile demographics and injury severity. An investigator interviewed team leaders to determine reasons for discordant transfer decisions. RESULTS: The 2 teams differed significantly in the total number of transfers recommended (49 vs 36; P = 0.003). However, there was substantial agreement when recommending transfer to burn centers, with 85.5% agreement and inter-rater reliability of 0.67 (confidence interval: 0.49-0.85). There was better agreement for patients with a higher acuity of injuries. Based on interviews, the most common reason for discordance was insider knowledge of the local community hospital and its capabilities. CONCLUSIONS: A multi-disciplinary Mass Casualty Consultation team was able to rapidly prioritize patients for coordinated secondary transfer using limited clinical information. Training for consultation teams should emphasize guidelines for transfer based on existing services at sending and receiving hospitals, as knowledge of local community hospital capabilities influence physician decision-making.

Hospitalizations Involving an Intensive Care Unit Admission Among Patients Aged 65 Years and Older Within New York City Hospitals During 2000-2014.

OBJECTIVE: To describe hospitalizations involving an intensive care unit (ICU) admission among patients aged 65 years and older within New York City (NYC) hospitals during 2000-2014. DESIGN: Observational study using an all-payer hospital discharge dataset. SETTING: The setting was in NYC hospitals. PATIENTS: Patients aged 65 years and older admitted to an ICU within a NYC hospital during 2000-2014. INTERVENTIONS: No interventions were carried out. MEASUREMENTS AND MAIN RESULTS: We calculated the mean annual number of hospitalizations involving an ICU admission. We also examined characteristics of hospitalizations, including the occurrence of in-hospital death and principal diagnosis. There were 5,338,577 hospitalizations of patients aged ≥65 years within NYC hospitals during 2000-2014, of which 765,084 (14.3%) involved an ICU admission. The mean annual number of hospitalizations involving an ICU admission for this age group decreased from 57,938 during 2000-2002 to 45,785 during 2012-2014. The proportion of hospitalizations involving an ICU admission in which in-hospital death occurred decreased from 15.9% during 2000-2002 to 14.5% during 2012-2014. During 2000-2002, 11.6% of hospitalizations involving an ICU admission listed an "infectious" principal diagnosis, increasing to 20.7% during 2012-2014. Listing of a "cardiovascular" principal diagnosis decreased from 46.4% to 33.4% between these time periods. "Infectious" principal diagnoses accounted for 31.0% of all hospitalizations involving an ICU admission in which in-hospital death occurred during the entire study period, while "cardiovascular" principal diagnoses accounted for 21.3%. CONCLUSIONS: This investigation provides a clearer understanding of ICU utilization among patients aged 65 years and older in NYC. Ongoing monitoring is warranted given projections that the proportion of New Yorkers aged 65 years and older will increase in coming years. In particular, in light of the observed increase of infectious principal diagnoses during the study period, further investigation is needed into the role of infectious disease in causing critical illness in NYC.

Variations in Healthcare Provider Use of Public Health and Other Information Sources by Provider Type and Practice Setting During New York City's Response to the Emerging Threat of Zika Virus Disease, 2016.

The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) used multiple methods to provide guidance to healthcare providers on the management and prevention of Zika virus disease during 2016. To better understand providers' use of information sources related to emerging disease threats, this article describes reported use of information sources by NYC providers to stay informed about Zika, and patterns observed by provider type and practice setting. We sent an electronic survey to all email addresses in the Provider Data Warehouse, a system used to maintain information from state and local health department sources on all prescribing healthcare providers in NYC. The survey asked providers about their use of information sources, including specific information products offered by the NYC DOHMH, to stay informed about Zika during 2016. Trends by provider type and practice setting were described using summary statistics. The survey was sent to 44,455 unique email addresses; nearly 20% (8,711) of the emails were undeliverable. Ultimately, 1,447 (5.8%) eligible providers completed the survey. Most respondents (79%) were physicians. Overall, the most frequently reported source of information from the NYC DOHMH was the NYC Health Alert Network (73%). Providers in private practice reported that they did not use any NYC DOHMH source of information about Zika more frequently than did those working in hospital settings (29% vs 23%); similarly, private practitioners reported that they did not use any other source of information about Zika more frequently than did those working in hospital settings (16% vs 8%). Maintaining timely and accurate databases of healthcare provider contact information is a challenge for local public health agencies. Effective strategies are needed to identify and engage independently practicing healthcare providers to improve communications with all healthcare providers during public health emergencies.

Zika Virus Preparedness and Response Efforts Through the Collaboration Between a Health Care Delivery System and a Local Public Health Department.

ABSTRACTThe Zika virus was largely unknown to many health care systems before the outbreak of 2015. The unique public health threat posed by the Zika virus and the evolving understanding of its pathology required continuous communication between a health care delivery system and a local public health department. By leveraging an existing relationship, NYC Health+Hospitals worked closely with New York City Department of Health and Mental Hygiene to ensure that Zika-related processes and procedures within NYC Health+Hospitals facilities aligned with the most current Zika virus guidance. Support given by the public health department included prenatal clinical and laboratory support and the sharing of data on NYC Health+Hospitals Zika virus screening and testing rates, thus enabling this health care delivery system to make informed decisions and practices. The close coordination, collaboration, and communication between the health care delivery system and the local public health department examined in this article demonstrate the importance of working together to combat a complex public health emergency and how this relationship can serve as a guide for other jurisdictions to optimize collaboration between external partners during major outbreaks, emerging threats, and disasters that affect public health. (Disaster Med Public Health Preparedness. 2018;12:689-691).

Assessment of Hospital Emergency Department Response to Potentially Infectious Diseases Using Unannounced Mystery Patient Drills - New York City, 2016.

Recent outbreaks of infectious diseases have revealed significant health care system vulnerabilities and highlighted the importance of rapid recognition and isolation of patients with potentially severe infectious diseases. During December 2015-May 2016, a series of unannounced "mystery patient drills" was carried out to assess New York City Emergency Departments' (EDs) abilities to identify and respond to patients with communicable diseases of public health concern. Drill scenarios presented a patient reporting signs or symptoms and travel history consistent with possible measles or Middle East Respiratory Syndrome (MERS). Evaluators captured key infection control performance measures, including time to patient masking and isolation. Ninety-five drills (53 measles and 42 MERS) were conducted in 49 EDs with patients masked and isolated in 78% of drills. Median time from entry to masking was 1.5 minutes (range = 0-47 minutes) and from entry to isolation was 8.5 minutes (range = 1-57). Hospitals varied in their ability to identify potentially infectious patients and implement recommended infection control measures in a timely manner. Drill findings were used to inform hospital improvement planning to more rapidly and consistently identify and isolate patients with a potentially highly infectious disease.

Using "Mystery Patient" Drills to Assess Hospital Ebola Preparedness in New York City, 2014-2015.

In response to the Ebola virus disease (EVD) outbreak in West Africa, rapid measures were taken to ensure readiness at frontline New York City (NYC) healthcare facilities, including mandating monthly EVD mystery patient drills to test screening protocols. This study analyzed after-action reports to describe the use of mystery patient drills to test rapid identification and isolation of potential EVD cases in NYC emergency departments. NYC hospitals were required to develop protocols for EVD screening and isolation, and to conduct drills with an actor presenting to the emergency department with symptoms suggestive of EVD. Fifty-five hospitals that participate in NYC's hospital preparedness program were invited to submit after-action reports summarizing at least 1 drill conducted between October 2014 and April 2015. Summary statistics were generated from reported quantitative measures. Report narratives were reviewed, coded, extracted, and analyzed to identify strengths and challenges experienced. Forty-five hospitals submitted after-action reports (82%). The median time from patient entry to isolation was 9 minutes and from isolation to evaluation was 14 minutes. Recurrent strengths included consistent travel history screening and compliance with infection control protocols. Themes for improvement included ensuring timely screening, staff competency with personal protective equipment (PPE), and clarifying notification procedures and staff roles. Mystery patient drills gave hospitals the means to test screening and isolation protocols and identify key gaps, such as competency-based training in PPE, to improve their capacity to respond to highly communicable diseases. Findings from this study will inform the development of a standardized mystery patient drill program.

Preparing the Health System to Respond to Ebola Virus Disease in New York City, 2014.

The world's largest outbreak of Ebola virus disease began in West Africa in 2014. Although few cases were identified in the United States, the possibility of imported cases led US public health systems and health care facilities to focus on preparing the health care system to quickly and safely identify and respond to emerging infectious diseases. In New York City, early, coordinated planning among city and state agencies and the health care delivery system led to a successful response to a single case diagnosed in a returned health care worker. In this article we describe public health and health care system preparedness efforts in New York City to respond to Ebola and conclude that coordinated public health emergency response relies on joint planning and sustained resources for public health emergency response, epidemiology and laboratory capacity, and health care emergency management. (Disaster Med Public Health Preparedness. 2017;11:370-374).

Impact of the 5As brief counseling on smoking cessation among pregnant clients of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics in Ohio.

OBJECTIVES: We assessed whether smoking cessation improved among pregnant smokers who attended Women, Infants and Children (WIC) Supplemental Nutrition Program clinics trained to implement a brief smoking cessation counseling intervention, the 5As: ask, advise, assess, assist, arrange. METHODS: In Ohio, staff in 38 WIC clinics were trained to deliver the 5As from 2006 through 2010. Using 2005-2011 Pregnancy Nutrition Surveillance System data, we performed conditional logistic regression, stratified on clinic, to estimate the relationship between women's exposure to the 5As and the odds of self-reported quitting during pregnancy. Reporting bias for quitting was assessed by examining whether differences in infants' birth weight by quit status differed by clinic training status. RESULTS: Of 71,526 pregnant smokers at WIC enrollment, 23% quit. Odds of quitting were higher among women who attended a clinic after versus before clinic staff was trained (adjusted odds ratio, 1.16; 95% confidence interval, 1.04-1.29). The adjusted mean infant birth weight was, on average, 96 g higher among women who reported quitting (P<0.0001), regardless of clinic training status. CONCLUSIONS: Training all Ohio WIC clinics to deliver the 5As may promote quitting among pregnant smokers, and thus is an important strategy to improve maternal and child health outcomes.

A Mixed-Methods Assessment of a Brief Smoking Cessation Intervention Implemented in Ohio Public Health Clinics, 2013.

OBJECTIVES: In 2006, the state of Ohio initiated the implementation of a brief smoking cessation intervention (5As: Ask, Advise, Assess, Assist, and Arrange) in select public health clinics that serve low-income pregnant and post-partum women. Funds later became available to expand the program statewide by 2015. However, close to half of the clinics initially trained stopped implementation of the 5As. To help guide the proposed statewide expansion plan for implementation of the 5As, this study assessed barriers and facilitators related to 5As implementation among clinics that had ever received training. METHODS: A mixed-methods approach was used, comprising semi-structured interviews with clinic program directors (n = 21) and a survey of clinic staff members (n = 120), to assess implementation-related barriers, facilitators, training needs, and staff confidence in delivering the 5As. RESULTS: Semi-structured interviews of program directors elucidated implementation barriers including time constraints, low self-efficacy in engaging resistant clients, and paperwork-related documentation challenges. Facilitators included availability of community referral resources, and integration of cessation interventions into the clinic workflow. Program directors believed they would benefit from more hands-on training in delivering the 5As. The survey results showed that a majority of staff felt confident advising (61%) or referring clients for tobacco dependence treatment (74%), but fewer felt confident about discussing treatment options with clients (29%) or providing support to clients who had relapsed (30%). CONCLUSIONS: Time constraints and documentation issues were major barriers to implementing the 5As. Simplified documentation processes and training enhancements, coupled with systems change, may enhance delivery of evidence-based smoking cessation interventions.

Investigation of an Outbreak of Variant Influenza A(H3N2) Virus Infection Associated With an Agricultural Fair-Ohio, August 2012.

BACKGROUND: In 2012, one third of cases in a multistate outbreak of variant influenza A(H3N2) virus ([H3N2]v) infection occurred in Ohio. We conducted an investigation of (H3N2)v cases associated with agricultural Fair A in Ohio. METHODS: We surveyed Fair A swine exhibitors and their household members. Confirmed cases had influenza-like illness (ILI) and a positive laboratory test for (H3N2)v, and probable cases had ILI. We calculated attack rates. We determined risk factors for infection, using multivariable log-binomial regression. RESULTS: We identified 20 confirmed and 94 probable cases associated with Fair A. Among 114 cases, the median age was 10 years, there were no hospitalizations or deaths, and 82% had swine exposure. In the exhibitor household cohort of 359 persons (83 households), we identified 6 confirmed cases (2%) and 40 probable cases (11%). An age of <10 years was a significant risk factor (P < .01) for illness. One instance of likely human-to-human transmission was identified. CONCLUSIONS: In this (H3N2)v outbreak, no evidence of sustained human-to-human (H3N2)v transmission was found. Our risk factor analysis contributed to the development of the recommendation that people at increased risk of influenza-associated complications, including children aged <5 years, avoid swine barns at fairs during the 2012 fair season.

Ebola virus disease in a humanitarian aid worker - New York City, October 2014.

In late October 2014, Ebola virus disease (Ebola) was diagnosed in a humanitarian aid worker who recently returned from West Africa to New York City (NYC). The NYC Department of Health and Mental Hygiene (DOHMH) actively monitored three close contacts of the patient and 114 health care personnel. No secondary cases of Ebola were detected. In collaboration with local and state partners, DOHMH had developed protocols to respond to such an event beginning in July 2014. These protocols included safely transporting a person at the first report of symptoms to a local hospital prepared to treat a patient with Ebola, laboratory testing for Ebola, and monitoring of contacts. In response to this single case of Ebola, initial health care worker active monitoring protocols needed modification to improve clarity about what types of exposure should be monitored. The response costs were high in both human resources and money: DOHMH alone spent $4.3 million. However, preparedness activities that include planning and practice in effectively monitoring the health of workers involved in Ebola patient care can help prevent transmission of Ebola.

Legionnaires' Disease Outbreak at a Long-Term Care Facility Caused by a Cooling Tower Using an Automated Disinfection System--Ohio, 2013.

On July 9, 2013, an outbreak of Legionnaires' disease (LD) was identified at Long-Term Care Facility A in central Ohio. This article describes the investigation of the outbreak and identification of the outbreak source, a cooling tower using an automated biocide delivery system. In total, 39 outbreak LD cases were identified; among these, six patients died. Water samples from a cooling tower were positive for Legionella pneumophila serogroup 1, reactive to monoclonal antibody 2, with matching sequence type to a patient isolate. An electronic control system turned off cooling tower pumps during low-demand periods, preventing delivery of disinfectant by a timed-release system, and leading to amplification of Legionella in the cooling tower. Guidelines for tower maintenance should address optimal disinfection when using automated systems.

Fatal Burkholderia pseudomallei infection initially reported as a Bacillus species, Ohio, 2013.

A fatal case of melioidosis was diagnosed in Ohio one month after culture results were initially reported as a Bacillus species. To identify a source of infection and assess risk in patient contacts, we abstracted patient charts; interviewed physicians and contacts; genetically characterized the isolate; performed a Burkholderia pseudomallei antibody indirect hemagglutination assay on household contacts and pets to assess seropositivity; and collected household plant, soil, liquid, and insect samples for culturing and real-time polymerase chain reaction testing. Family members and pets tested were seronegative for B. pseudomallei. Environmental samples were negative by real-time polymerase chain reaction and culture. Although the patient never traveled internationally, the isolate genotype was consistent with an isolate that originated in Southeast Asia. This investigation identified the fifth reported locally acquired non-laboratory melioidosis case in the contiguous United States. Physicians and laboratories should be aware of this potentially emerging disease and refer positive cultures to a Laboratory Response Network laboratory.

Outbreak of variant influenza A(H3N2) virus in the United States.

BACKGROUND: Variant influenza virus infections are rare but may have pandemic potential if person-to-person transmission is efficient. We describe the epidemiology of a multistate outbreak of an influenza A(H3N2) variant virus (H3N2v) first identified in 2011. METHODS: We identified laboratory-confirmed cases of H3N2v and used a standard case report form to characterize illness and exposures. We considered illness to result from person-to-person H3N2v transmission if swine contact was not identified within 4 days prior to illness onset. RESULTS: From 9 July to 7 September 2012, we identified 306 cases of H3N2v in 10 states. The median age of all patients was 7 years. Commonly reported signs and symptoms included fever (98%), cough (85%), and fatigue (83%). Sixteen patients (5.2%) were hospitalized, and 1 fatal case was identified. The majority of those infected reported agricultural fair attendance (93%) and/or contact with swine (95%) prior to illness. We identified 15 cases of possible person-to-person transmission of H3N2v. Viruses recovered from patients were 93%-100% identical and similar to viruses recovered from previous cases of H3N2v. All H3N2v viruses examined were susceptible to oseltamivir and zanamivir and resistant to adamantane antiviral medications. CONCLUSIONS: In a large outbreak of variant influenza, the majority of infected persons reported exposures, suggesting that swine contact at an agricultural fair was a risk for H3N2v infection. We identified limited person-to-person H3N2v virus transmission, but found no evidence of efficient or sustained person-to-person transmission. Fair managers and attendees should be aware of the risk of swine-to-human transmission of influenza viruses in these settings.

Identifying breastfeeding-sensitive conditions by expert consensus.

BACKGROUND: Infant feeding-related health outcomes need to be consistently defined prior to inclusion in health services research. OBJECTIVE: To categorize conditions common in infants under 12 months old by their association with breastfeeding for use as outcome measures in a randomized, controlled trial of breastfeeding promotion. METHODS: A modified Delphi consensus method synthesized opinions of 13 physician experts on breastfeeding's association with ICD-9 infant diagnosis codes derived from literature review and medical center experience. A pilot round and 2 subsequent Delphi rounds were used. For the first round, consensus was achieved when more than 80% of experts agreed on a classification for a particular condition, with a predetermined level of certainty based on a 7-point Likert scale. For the second round, consensus was achieved when a majority of experts agreed on the classification from Round 1. RESULTS: An initial 68 diagnosis codes were identified for evaluation by the expert panel. After a pilot round, the codes were refined and condensed, which resulted in 38 diagnoses for categorization into 1 of 3 categories: (1) breastfeeding protects against the condition; (2) breastfeeding may cause or worsen the condition; and (3) breastfeeding is unrelated to the condition. At the conclusion of the process, consensus was achieved on the classification of 31 conditions, and 7 conditions remained unclassified because of a lack of consensus. CONCLUSIONS: This study provides a list of conditions common in infants under 12 months of age classified based on relationship to infant feeding method and validated by expert consensus. These conditions, based on readily available insurance claims data, contribute to the standardization of outcome measures used for health services research related to breastfeeding promotion.