Monoclonal Antibody Infusions for Outpatient Management of Mild-Moderate COVID-19.

BACKGROUND: The COVID-19 pandemic has led to a rapid, exponential increase in hospitalizations and morbidity/mortality. In November 2020, the Food and Drug Administration (FDA) issued Emergency Use Authorizations (EUAs) permitting administration of the first monoclonal antibodies (mAb) for outpatient treatment of COVID-19. Early data showed a reduction in COVID-19-related hospitalizations with few adverse events. However, since these treatments are only authorized under an EUA, real-world data are minimal. OBJECTIVE: To assess efficacy and safety of mAbs in a veteran population. METHODS: This retrospective study analyzed veterans at the Ralph H. Johnson Veterans Affairs Health Care System with mild-moderate COVID-19 and screened for mAb eligibility between December 1, 2020, and October 31, 2021. The primary outcome was hospitalizations and/or emergency department (ED) visits within 30 days. Secondary outcomes included 30-day mortality and post-COVID-19 conditions. Adverse events were also evaluated. Outcomes were compared between mAb-treated patients and eligible veterans who were not treated. RESULTS: There were 296 and 275 veterans in the mAb and control groups, respectively. No statistically significant difference was found for the primary outcome overall (25.7% vs 25.1%; P = 0.87), nor for COVID-19-related return visits or hospitalizations (13.9% v. 16%; P = 0.4). However, the mAb group had more return ED visits (P = 0.35), and the control group had significantly more hospitalizations (P = 0.02). Vaccinated veterans who received an mAb had fewer return visits and hospitalizations (P = 0.01). More mAb-treated veterans experienced post-COVID-19 conditions. No difference in mortality was found. Four nonsevere adverse events occurred after the mAb therapy. CONCLUSION AND RELEVANCE: Overall, the mAbs appeared safe and effective. Sicker, higher-risk mAb-treated veterans faired similarly to less-sick, high-risk veterans not treated. Those who were vaccinated seemed to benefit the most from mAb therapy. Future prospective studies with more matched groups are needed to assess full benefits and risks of mAbs shown to neutralize the predominant variants.

Airway pressure release ventilation does not increase intracranial pressure in patients with traumatic brain injury with poor lung compliance.

The use of Airway Pressure Release Ventilation (APRV) in patients with traumatic brain injury (TBI) remains controversial. Some believe that elevated mean airway pressures transmitted to the thorax may cause clinically significant increases in Central Venous Pressure (CVP) and intracranial pressure (ICP) from venous congestion. We perform a retrospective review from 2009 to 2015 of traumatically injured patients who were transitioned from traditional ventilator modes to APRV and also had an ICP monitor in place. Fifteen patients undergoing 19 transitions to APRV were identified. Prior to transitioning to APRV the average static and dynamic compliance was 22.9 +/- 5.6 and 16.5 +/- 4.12 mL/cm H2O. There was no statistical difference in ICP, MAP, and CPP prior to and after transition to APRV. There was a statistically significant increase in CVP, PaO2, and P:F ratio. Individually, only 4 patients had ICP values >20 in the first hour after transitioning to APRV and the rate of ICP elevations was similar between the two modes of ventilation. These data show that APRV is a viable mode of ventilation in patients with TBI who have low lung compliance. The increased CVP of this mode of ventilation did not affect ICP or hemodynamic parameters.

Preparing for the Surge: A Half-Day Emergency Preparedness Training Course for the "Second Front".

Purpose Clinical disaster medicine requires providers working collaboratively to care for multiple patients, yet many clinicians lack competency-based training. A 5-hour emergency preparedness training (EPT) curriculum was created using didactics, small group discussion, and scenario-based learning. The goal was to evaluate the effect of a short course on improving clinical-provider knowledge, confidence and skill. METHODS: Participants were enrolled in a medical university between 2011 and 2014. The course consisted of didactic lectures, small group exercises, and live mass-casualty training scenarios. Core competencies and performance objectives were developed by a task force and assessed via facilitator observation, pre- and posttesting, and a course evaluation. RESULTS: A total of 708 participants were trained, including 49.9% physicians, 31.9% medical students, 7.2% nurses, and 11% allied health personnel. The average percentage of correct answers increased from 39% to 60% (P<0.01). Following didactics, trainees met 73% and 96% of small group performance objectives. Trainees also met 68.5% and 61.1% of the mass-casualty performance objectives. Average trainee self-assessment of disaster-preparedness skill improved from 36 to 73 points out of 100. CONCLUSION: A brief, intensive EPT course can improve the disaster knowledge and comfort level of a diverse group of clinical providers as well as foster disaster-performance skills. (Disaster Med Public Health Preparedness. 2018;12:121-126).

Securing the second front: achieving first receiver safety and security through competency-based tools.

INTRODUCTION: Limited research has focused on the safety and security of First Responders and Receivers, including clinicians, hospital workers, public safety officials, community volunteers, and other lay personnel, during public health emergencies. These providers are, in some cases, at greater peril during large-scale disasters due to their lack of training and inadequate resources to handle major influxes of patients. Exemplified in the 1995 Tokyo sarin gas attacks and the 2008 Wenchuan earthquakes, lack of training results in poor outcomes for both patients and First Receivers. OBJECTIVE: The improvement of knowledge and comfort level of First Receivers preparing for a medical disaster via an affordable, repeatable emergency preparedness training (EPT) curriculum. METHODS: A 5-hour EPT curriculum was developed including nine learning objectives, 18 competencies, and 34 performance objectives. Following brief didactic and small group sessions, interprofessional teams of four to six trainees were observed in a large patient simulator designed to recreate environmentally challenging (ie, flood evacuation), multi-patient scenarios using a novel technique developed to utilize trainees as actors. Trained observers assessed successful completion of 16 individual and 18 team performance objectives. Prior to training, team members completed a 24-question knowledge assessment, a demographic survey, and a comfort level self-assessment. Following training, trainees repeated the 24 questions, self-assessment, and course assessment. RESULTS: One hundred ninety-five participants completed the course between November 2012 and August 2013. One hundred ninety-one (98.5%), 150 (76.9%), and 66 (33.8%) participants completed the pretest, post-test, and course assessment, respectively. The mean (SD) percentage of correct answers between the pretest and post-test increased from 46.3 (13.4) to 75.3 (12.2), P < .0001. Thirty-eight participants (19.5%) reported more than three hours of disaster EPT each year while 157 participants (80.5%) reported three hours or less of yearly EPT. Sixty-six (100%) reported the course relevant to care providers and 61 (92.4%) highly recommended the course. Comfort level increased from 37.0/100 (n = 192) before training to 76.3/100 (n = 145) after training. CONCLUSION: The Center for Health Professional Training and Emergency Response's (CHPTER's) 5-hour EPT curriculum for patient care providers recreates simultaneous multi-actor disasters, measures EPT performance, and improves trainee knowledge and comfort level to save patient and provider lives during a disaster, via an affordable, repeatable EPT curriculum. A larger-scale study, or preferably a multi-center trial, is needed to further study the impact of this curriculum and its potential to enhance the safety and security of the "Second Front.

Competency in chaos: lifesaving performance of care providers utilizing a competency-based, multi-actor emergency preparedness training curriculum.

OBJECTIVE: Providing comprehensive emergency preparedness training (EPT) to care providers is important to the future success of disaster operations in the US. Few EPT programs possess both competency-driven goals and metrics to measure performance during a multi-patient simulated disaster. METHODS: A 1-day (8-hour) EPT course for care providers was developed to enhance provider knowledge, skill, and comfort necessary to save lives during a simulated disaster. Nine learning objectives, 18 competencies, and 34 performance objectives were developed. During the 2-year demonstration of the curriculum, 24 fourth-year medical students and 17 Veterans Hospital Administration (VHA) providers were recruited and volunteered to take the course (two did not fully complete the research materials). An online pre-test, two post-tests, course assessment, didactic and small group content, and a 6-minute clinical casualty scenario were developed. During the scenario, trainees working in teams were confronted with three human simulators and 10 actor patients simultaneously. Unless appropriate performance objectives were met, the simulators "died" and the team was exposed to "anthrax." After the scenario, team members participated in a facilitator-led debriefing using digital video and then repeated the scenario. RESULTS: Trainees (N = 39) included 24 (62%) medical students; seven (18%) physicians; seven (18%) nurses; and one (3%) emergency manager. Forty-seven percent of the VHA providers reported greater than 16 annual hours of disaster training, while 15 (63%) of the medical students reported no annual disaster training. The mean (SD) score for the pre-test was 12.3 (3.8), or 51% correct, and after the training, the mean (SD) score was 18.5 (2.2), or 77% (P < .01). The overall rating for the course was 96 out of 100. Trainee self-assessment of "Overall Skill" increased from 63.3 out of 100 to 83.4 out of 100 and "Overall Knowledge" increased from 49.3 out of 100 to 78.7 out of 100 (P < .01). Of the 34 performance objectives during the disaster scenario, 23 were completed by at least half of the teams during their first attempt. All teams except one (8 of 9) could resuscitate two simulators and all teams (9 of 9) helped prevent anthrax exposure during their second scenario attempt. CONCLUSIONS: The 1-day EPT course for novice and experienced care providers recreated a multi-actor clinical disaster and enhanced provider knowledge, comfort level, and EPT skill. A larger-scale study, or multi-center trial, is needed to further study the impact of this curriculum and its potential to protect provider and patient lives.

Regional approach to competency-based patient care provider disaster training: the Center for Health Professional Training and Emergency Response.

OBJECTIVES: This article details the development of the Center for Health Professional Training and Emergency Response (CHPTER), including its innovative, competency-based emergency preparedness training (EPT) curriculum, and the results of a regional preparedness workforce assessment. METHODS: CHPTER was established in 2009 with the goal of enhancing regional health security and patient surge competency by offering patient care providers, including clinicians and volunteers, hands-on lessons that will protect and save lives during a disaster. A 1-day emergency preparedness training (EPT) course that includes a loud, chaotic clinical disaster scenario was developed. A two-part workforce assessment survey to further refine regional EPT needs was administered. RESULTS: The 1-day EPT course enhanced patient care providers' knowledge, comfort level, and skills required to save lives during a disaster. Twenty-one emergency department directors and 400 patient care providers responded to the surveys. The majority of emergency department directors surveyed believe that one in five of their provider workforce would fail to properly perform their expected duties in a disaster. More than half of the patient care providers reported fewer than 2 hours of annual EPT training and 40% of employers required no annual training. The most significant barriers to widespread dissemination of EPT were financial constraints and time availability of providers. CONCLUSIONS: Patient care providers in our region (North and South Carolina) are not prepared for a disaster. The CHPTER 1-day competency-based EPT curricula improved trainee knowledge, comfort level, and disaster care skills. CHPTER may serve as a model for other regions seeking to improve care provider EPT programs.

High-fidelity multiactor emergency preparedness training for patient care providers.

BACKGROUND: Providing comprehensive emergency preparedness training (EPT) for patient care providers is important to the future success of emergency preparedness operations in the United States. Disasters are rare, complex events involving many patients and environmental factors that are difficult to reproduce in a training environment. Few EPT programs possess both competency-driven goals and metrics to measure life-saving performance during a multiactor simulated disaster. METHODS: The development of an EPT curriculum for patient care providers-provided first to medical students, then to a group of experienced disaster medical providers-that recreates a simulated clinical disaster using a combination of up to 15 live actors and six high-fidelity human simulators is described. Specifically, the authors detail the Center for Health Professional Training and Emergency Response's (CHPTER's) 1-day clinical EPT course including its organization, core competency development, medical student self-evaluation, and course assessment. RESULTS: Two 1-day courses hosted by CHPTER were conducted in a university simulation center. Students who completed the course improved their overall knowledge and comfort level with EPT skills. CONCLUSIONS: The authors believe this is the first published description of a curriculum method that combines high-fidelity, multiactor scenarios to measure the life-saving performance of patient care providers utilizing a clinical disaster scenario with > 10 patients at once. A larger scale study, or preferably a multicenter trial, is needed to further study the impact of this curriculum and its potential to protect provider and patient lives.

Antacids, altered mental status, and milk-alkali syndrome.

The frequency of milk-alkali syndrome decreased rapidly after the development of histamine-2 antagonists and proton pump inhibitors for the treatment of peptic ulcer disease; however, the availability and overconsumption of antacids and calcium supplements can still place patients at risk (D. P. Beall et al., 2006). Here we describe a patient who presented with altered mental status, hypercalcemia, metabolic alkalosis, and acute renal failure in the context of ingesting large amounts of antacids to control dyspepsia.

Fostering federal and local disaster preparedness partnerships.

In this project, we describe the experience of utilizing six AmeriCorps volunteers deployed to an urban, coastal city over a six-week period in 2011 to assist with a CBDP needs assessment survey and pre-deployment disaster training of health care personnel. Volunteer accomplishments included (1) a regional database of care providers to identify optimal emergency preparedness training (EPT) distribution, (2) an EPT assessment survey to gauge current care provider disaster preparedness, and (3) a high-fidelity EPT training demonstration project in the university's human simulation center. In contrast to their more traditional roles of response and recovery, we believe that we have demonstrated a model of how volunteers can be utilized to support CBDP mitigation and planning stages of disaster. We hope the volunteers' experiences, goals, mission and accomplishments documented here can be used as a potential model that may enhance CBDP activities around the nation.

Disaster 101: a novel approach to disaster medicine training for health professionals.

BACKGROUND: Despite efforts to improve preparedness training for health professionals, disaster medicine remains a peripheral component of traditional medical education in the United States (US) and is a rarely studied topic in the medical literature. OBJECTIVES: Using a pre-/post-test design, we measured the extent to which 4(th)-year medical students perceive, rapidly learn, and apply basic concepts of disaster medicine via a novel curriculum. METHODS: Via a modified Delphi technique, an expert curriculum panel developed a 90-min didactic training scenario and two 40-min training exercises for medical students: a hazardous material scene and a surprise mass casualty incident (MCI) scenario with 100 life-sized mannequins. Medical students were quizzed before and after the didactic training scenario about their perceptions and their disaster medicine knowledge. RESULTS: Students rated their overall knowledge as 3.76/10 pretest compared to 7.64/10 after the didactic program. Students' post-test scores improved by 54% and students participating in the MCI drill correctly tagged 94% of the victims in approximately 10 min. The average overall rating for the experience was 4.85/5. CONCLUSIONS: The results of this educational demonstration project reveal that students will value and can rapidly learn some core elements of disaster medicine via a novel addition to a medical school's curriculum. We believe the principle of a highly effective and well-received medical student course that can be easily added to a university curriculum has been demonstrated. Further research is needed to validate core competencies and performance-based education goals for US health professional trainees.

An analysis of paramedic verbal reports to physicians in the emergency department trauma room.

OBJECTIVE: To measure the verbal communication between emergency medical technician-paramedics (EMT-Ps) and physicians in an emergency department trauma room (EDTR) before and after an educational intervention. METHODS: Using a before-after design, we audio-recorded paramedic verbal trauma reports in a large EDTR over a 12-week period. Trained research assistants subsequently queried physicians about information from the paramedic report in a separate interview. Physician recall was quantified. Midway through the study, a web-based, educational intervention designed to enhance paramedic communication skills was administered to the three participating emergency medical services (EMS) systems. Physician recall of more severely injured trauma cases (red triage) was compared with their recall of less severely injured cases (yellow triage). Further comparisons were made between pre- and post-intervention physician recalls, and the extent to which physicians recalled three distinct categories of paramedic verbal information was measured. RESULTS: Overall, physicians accurately recalled 36% of the paramedic verbal report. Information from less severe "yellow" trauma reports was recalled more accurately than that from more severe "red" traumas (40% vs. 34% p = 0.02). Pre- and post-intervention recalls were not significantly different (33% vs. 38% p = 0.16). Physicians' recall of information about the crash scene (46%) was significantly greater than their recall of information about the patient's health status (34%) or information about prehospital patient care (30%) (p = 0.0012). CONCLUSION: Physicians appear to recall paramedic verbal reports about trauma patients poorly. Recall is probably multifactorial and will require further work to design appropriate interventions.