A Statewide Analysis of Self-Inflicted Injuries During COVID-19 Pandemic: Is There Adequate Access to Mental Health?

INTRODUCTION: Many social and behavioral changes occurred during the COVID-19 pandemic. Our objective was to identify changes in incidence of self-inflicted injuries during COVID-19 compared to prepandemic years. Further, we aimed to identify risk factors associated with self-inflicted injuries before and during the pandemic. METHODS: A retrospective cohort study of patients aged ≥18 y with self-inflicted injuries from 2018 to 2021 was performed using the Pennsylvania Trauma Outcome Study registry. Patients were grouped into pre-COVID Era (pre-CE, 2018-2019) and COVID Era (CE, 2020-2021). Statistical comparisons were accomplished using Wilcoxon rank-sum tests and chi-square or Fisher's exact tests. RESULTS: There were a total of 1075 self-inflicted injuries in the pre-CE cohort and 482 during the CE. There were no differences in age, gender, race or ethnicity between the two cohorts. Among preexisting conditions, those within the pre-CE cohort had a higher incidence of mental/personality disorder (59.2% versus 52.3%, P = 0.01). There were no significant differences in the mechanism of self-inflicted injuries or place of injury between the two periods. Additionally, there were no differences in discharge destinations or mortality between the two cohorts. CONCLUSIONS: During the height of social isolation in Pennsylvania, there were no associated increases in self-inflicted injuries. However, there were increased incidences of self-inflicted injuries among those with a prior diagnosis of mental or personality disorder in the pre-CE group. Further investigations are required to study the access to mental health services in future pandemics or public health disasters.

Increase in Motor Vehicle Crash Severity: An Unforeseen Consequence of COVID-19.

INTRODUCTION: The 2019 coronavirus (COVID-19) pandemic led to stay-at-home (SAH) orders in Pennsylvania targeted at reducing viral transmission. Limitations in population mobility under SAH have been associated with decreased motor vehicle collisions (MVC) and related injuries, but the impact of these measures on severity of injury remains unknown. The goal of this study is to measure the incidence, severity, and outcomes of MVC-related injuries associated with SAH in Pennsylvania. MATERIALS & METHODS: We conducted a retrospective geospatial analysis of MVCs during the early COVID-19 pandemic using a state-wide trauma registry. We compared characteristics of patients with MVC-related injuries admitted to Pennsylvania trauma centers during SAH measures (March 21-July 31, 2020) with those from the corresponding periods in 2018 and 2019. We also compared incidence of MVCs for each zip code tabulation area (ZCTA) in Pennsylvania for the same time periods using geospatial mapping. RESULTS: Of 15,550 trauma patients treated during the SAH measures, 3486 (22.4%) resulted from MVCs. Compared to preceding years, MVC incidence decreased 10% under SAH measures with no change in mortality rate. However, in ZCTA where MVC incidence decreased, there was a 16% increase in MVC injury severity. CONCLUSIONS: Stay-at-home orders issued in response to the COVID-19 pandemic in Pennsylvania were associated with significant changes in MVC incidence and severity. Identifying such changes may inform resource allocation decisions during future pandemics or SAH events.

Identification of Seniors at Risk Scoring in Geriatric Trauma: Exploring Clinical Outcome Correlations.

Introduction: Geriatric trauma patients (GTP) make up an increasing percentage of the overall trauma population. Due to frailty, GTP are at an increased risk of morbidity and readmission. Therefore, it is becoming increasingly important to prognosticate outcomes to assist with resource utilization. We hypothesized that the "Identification of Seniors at Risk" (ISAR) score may correlate with both clinical outcomes and resource utilization for geriatric trauma patients. Methods: Patients older than 65 years who were admitted to the trauma service were screened using an ISAR scoring algorithm. Outcomes, including 30-day mortality, all-cause morbidity, hospital length of stay (LOS), intensive care unit (ICU) LOS, functional independence measures (FIM) at discharge, and percent discharged to a facility, were analyzed. Both descriptive and data-appropriate parametric and non-parametric statistical approaches were utilized, with significance set at α = 0.05. Results: One thousand and two hundred seventeen GTP were included in this study. The average age was 81, median injury severity score was 9, and 99% had a blunt trauma mechanism. ISAR scores were generally associated with increasing 30-day mortality (0%, 1.9%, 2.4%, and 2.1% for ISAR 0, ISAR 1-2, ISAR 3-4, and ISAR 5-6, respectively), morbidity (2.6%, 7.6%, 14.7%, and 7.3% for respective categories), longer hospital (3.1, 4.6, 5.1, and 4.3 days, respectively) and ICU stays (0.37, 0.64, 0.81, and 0.67, respectively), lower FIM score at discharge (18.5, 17.1, 15.8, and 14.4, for respective categories), as well as increasing percentage of patients discharged to a facility (29.8%, 58.9%, 72.1%, and 78.8% for respective categories). Conclusions: This exploratory study provides important early insight into potential relationships between ISAR and geriatric trauma outcomes. ISAR screening is a quick and easy-to-use tool that may be useful in GTP triage, level-of-care determination, and disposition planning. Understanding populations at risk, especially those with more intricate discharge needs, is an important step in mitigating those risks and implementing appropriate care plans.

Rising incidence of interpersonal violence in Pennsylvania during COVID-19 stay-at home order.

BACKGROUND: The coronavirus disease 2019 pandemic and associated policies have had important downstream consequences for individuals, communities, and the healthcare system, and they appear to have been accompanied by rising interpersonal violence. The objective of this study was to evaluate the incidence of injuries owing to interpersonal violence after implementation of a statewide stay-at-home order in Pennsylvania in March 2020. METHODS: Using the Pennsylvania Trauma Outcome Study registry, we conducted a retrospective cohort study of patients with gunshot wounds, stab wounds, and blunt assault-related injuries attributable to interpersonal violence treated at Pennsylvania trauma centers from March 16 to July 31 of 2018, 2019, and 2020. RESULTS: There were fewer total trauma admissions in 2020 (17,489) vs 2018 (19,290) and 2019 (19,561). Gunshot wounds increased in 2020 to 737 vs 647 for 2019 and 565 for 2018 (P = .028), whereas blunt assault injuries decreased (P = .03). In all time periods, interpersonal violence primarily impacted urban counties. African American men were predominantly affected by gunshot wounds and stab wounds, whereas Caucasian men were predominantly affected by blunt assault injuries. There were more patients with substance abuse disorders and positive drug screens during coronavirus disease than in comparison periods: (stab wound population 52.3% vs 33.9% vs 45.9%, coronavirus disease era vs 2018 vs 2019, respectively P = .0001), (blunt assault injury population 41.4% vs 33.1% vs 33.5%, coronavirus disease era vs 2018 vs 2019, respectively P < .0001). There was no correlation between the incidence of interpersonal violence and coronavirus disease 2019 rates at the county level. CONCLUSION: The implementation of a stay-at-home order was accompanied by rising incidence of gunshot and stab wound injuries in Pennsylvania. Preparedness for future resurgences of coronavirus disease 2019 and other pandemics calls for plans to address injury prevention, recidivism, and access to mental health and substance abuse prevention services.

Beyond Mortality: Does Trauma-related Injury Severity Score Predict Complications or Lengths of Stay Using a Large Administrative Dataset.

INTRODUCTION: Despite its shortcomings, trauma-related injury severity score (TRISS) correlates well with mortality in large trauma datasets. The aim of this study was to determine if TRISS correlates with morbidity and hospital lengths of stay using data from an institutional registry at a Level I Trauma Center. We hypothesized that higher TRISS correlates with increased complications and longer hospital stays. METHODS: A retrospective review of our institutional registry was performed, examining all trauma admissions between January 1999 and June 30, 2015. Out of a total of 32,026 patient records, TRISS data were available in 23,205 cases. Abstracted data included patient age, gender, ISS, TRISS, presence of complication, Glasgow Coma Scale (GCS), hospital length of stay, intensive care unit LOS, step-down unit LOS, functional independence measure, and 30-day mortality. RESULTS: TRISS was highly predictive of mortality, with the AUC value of 0.95 (95% confidence interval 0.936-0.954, P < 0.01) compared to ISS (AUC 0.794), GCS (AUC 0.827), and age (AUC 0.650). TRISS also performed better than the other variables in terms of the ability to predict morbidity events (AUC 0.813). TRISS was comparable to ISS in terms of prediction of ICU admission (AUC 0.801 versus 0.811, respectively). After correcting for patient age and gender, higher TRISS significantly correlated with longer hospital stays . CONCLUSIONS: Despite previous criticisms, we found that TRISS is superior to ISS for mortality and morbidity prediction. TRISS correlated significantly with a hospital, step down, and ICU lengths of stay using a large administrative dataset.

The World Health Organization Collaborating Center for Emergency and Trauma (WHO-CCET) in South East Asia, The World Academic Council of Emergency Medicine (WACEM), and The American College of Academic International Medicine (ACAIM) 2021 Framework for using Telemedicine Technology at Healthcare Institutions.

The coronavirus disease 2019 crisis has forced the world to integrate telemedicine into health delivery systems in an unprecedented way. To deliver essential care, lawmakers, physicians, patients, payers, and health systems have all adopted telemedicine and redesigned delivery processes with accelerated speed and coordination in a fragmented way without a long-term vision or uniformed standards. There is an opportunity to learn from the experiences gained by this pandemic to help shape a better health-care system that standardizes telemedicine to optimize the overall efficiency of remote health-care delivery. This collaboration focuses on four pillars of telemedicine that will serve as a framework to enable a uniformed, standardized process that allows for remote data capture and quality, aiming to improve ongoing management outside the hospital. In this collaboration, we recommend learning from this experience by proposing a telemedicine framework built on the following four pillars-patient safety and confidentiality; metrics, analytics, and reform; recording of audio-visual data as a health record; and reimbursement and accountability.

Impact of blood alcohol concentration on hematologic and serum chemistry parameters in trauma patients: Analysis of data from a high-volume level 1 trauma center.

BACKGROUND: Alcohol (EtOH) intoxication is common among trauma patients. While providers are familiar with the clinical aspects of acute EtOH intoxication, few studies have investigated the effects that EtOH levels may have on common laboratory markers. The aim of this study was to identify hematologic and serum chemistry parameters that may be affected by the blood alcohol concentration (BAC), hypothesizing that BAC influences both comprehensive blood count (CBC) and comprehensive serum chemistry (CSC) components. METHODS: We performed an IRB-exempt institutional registry review of all trauma patients who had serum EtOH levels measured between January 2009 and June 2015. Data for each patient included: patient demographics, BAC determinations (g/dL), injury mechanism/severity information (ISS), hematologic parameters included in a CBC (hemoglobin, hematocrit, white blood cell [WBC] count, and platelet count), and CSC panel components (sodium, potassium, chloride, bicarbonate, blood urea nitrogen [BUN], creatinine, glucose, and hepatic function tests). Laboratory markers were contrasted across predefined categories of BAC: <0.10%, 10%-15%, 15%-20%, and >20%. Statistical comparisons were performed using SPSS 18 Software, employing analysis-of-covariance with adjustments performed for the patient demographics and injury characteristics. Statistical significance was set at α = 0.005. RESULTS: A total of 2167 patient records were analyzed. After adjusting for patient age, gender, and ISS, increasing BAC correlated with 4.8% increase in hemoglobin and 32.5% higher hematocrit (both P < 0.001), as well as a 27.8% decrease in WBC count. There were also statistically significant differences between low (<0.10%) and high (>0.20%) BAC groups across multiple CSC parameters, with largest impact on BUN (32.2% decrease); creatinine (31.5% decrease); and glucose (13.6% decrease) values. Elevated BAC (>0.20 g/dL) was also associated with 81.8% increase in total bilirubin, and hepatic transaminases were elevated among patients with BAC >0.10. CONCLUSION: Due to the paucity of literature relating to the effects of BAC on serum hematologic and biochemical markers in acute trauma, this study provides a foundation for further exploration of these relationships and their clinical impact. More specifically, we found that BAC levels significantly influenced key laboratory markers, suggesting that acute EtOH intoxication may lead to hematologic and CSC changes that are potentially important in acute trauma management by frontline clinical staff.

The impact of COVID-19 infection on outcomes after injury in a state trauma system.

BACKGROUND: The COVID-19 pandemic reshaped the health care system in 2020. COVID-19 infection has been associated with poor outcomes after orthopedic surgery and elective, general surgery, but the impact of COVID-19 on outcomes after trauma is unknown. METHODS: We conducted a retrospective cohort study of patients admitted to Pennsylvania trauma centers from March 21 to July 31, 2020. The exposure of interest was COVID-19 (COV+) and the primary outcome was inpatient mortality. Secondary outcomes were length of stay and complications. We compared demographic and injury characteristics between positive, negative, and not-tested patients. We used multivariable regression with coarsened exact matching to estimate the impact of COV+ on outcomes. RESULTS: Of 15,550 included patients, 8,170 (52.5%) were tested for COVID-19 and 219 (2.7%) were positive (COV+). Compared with COVID-19-negative (COV-) patients, COV+ patients were similar in terms of age and sex, but were less often white (53.5% vs. 74.7%, p < 0.0001), and more often uninsured (10.1 vs. 5.6%, p = 0.002). Injury severity was similar, but firearm injuries accounted for 11.9% of COV+ patients versus 5.1% of COV- patients (p < 0.001). Unadjusted mortality for COV+ was double that of COV- patients (9.1% vs. 4.7%, p < 0.0001) and length of stay was longer (median, 5 vs. 4 days; p < 0.001). Using coarsened exact matching, COV+ patients had an increased risk of death (odds ratio [OR], 6.05; 95% confidence interval [CI], 2.29-15.99), any complication (OR, 1.85; 95% CI, 1.08-3.16), and pulmonary complications (OR, 5.79; 95% CI, 2.02-16.54) compared with COV- patients. CONCLUSION: Patients with concomitant traumatic injury and COVID-19 infection have elevated risks of morbidity and mortality. Trauma centers must incorporate an understanding of these risks into patient and family counseling and resource allocation during this pandemic. LEVEL OF EVIDENCE: Level II, Prognostic Study.

Answering the Challenge of COVID-19 Pandemic Through Innovation and Ingenuity.

The novel coronavirus disease 2019 (COVID-19) pandemic has created a maelstrom of challenges affecting virtually every aspect of global healthcare system. Critical hospital capacity issues, depleted ventilator and personal protective equipment stockpiles, severely strained supply chains, profound economic slowdown, and the tremendous human cost all culminated in what is questionably one of the most profound challenges that humanity faced in decades, if not centuries. Effective global response to the current pandemic will require innovation and ingenuity. This chapter discusses various creative approaches and ideas that arose in response to COVID-19, as well as some of the most impactful future trends that emerged as a result. Among the many topics discussed herein are telemedicine, blockchain technology, artificial intelligence, stereolithography, and distance learning.

Protocol Failure Detection: The Conflation of Acute Respiratory Distress Syndrome, SARS-CoV-2 Pneumonia and Respiratory Dysfunction.

In medicine, protocols are applied to assure the provision of the treatment with the greatest probability of success. However, the development of protocols is based on the determination of the best intervention for the group. If the group is heterogeneous, there will always be a subset of patients for which the protocol will fail. Furthermore, over time, heterogeneity of the group may not be stable, so the percentage of patients for which a given protocol may fail may change depending on the dynamic patient mix in the group. This was thrown into stark focus during the severe acute respiratory syndrome-2 coronavirus (SARS-CoV-2) pandemic. When a COVID-19 patient presented meeting SIRS or the Berlin Criteria, these patients met the criteria for entry into the sepsis protocol and/or acute respiratory distress syndrome (ARDS) protocol, respectively and were treated accordingly. This was perceived to be the correct response because these patients met the criteria for the "group" definitions of sepsis and/or ARDS. However, the application of these protocols to patients with SARS-CoV-2 infection had never been studied. Initially, poor outcomes were blamed on protocol noncompliance or some unknown patient factor. This initial perception is not surprising as these protocols are standards and were perceived as comprising the best possible evidence-based care. While the academic response to the pandemic was robust, recognition that existing protocols were failing might have been detected sooner if protocol failure detection had been integrated with the protocols themselves. In this review, we propose that, while protocols are necessary to ensure that minimum standards of care are met, protocols need an additional feature, integrated protocol failure detection, which provides an output responsive to protocol failure in real time so other treatment options can be considered and research efforts rapidly focused.

Short Term Home Oxygen Therapy for COVID-19 patients: The COVID-HOT algorithm.

Innovative solutions are required to effectively address the unprecedented surge of demand on our healthcare systems created by the COVID-19 pandemic. Home treatment and monitoring of patients who are asymptomatic or mildly symptomatic can be readily implemented to ameliorate the health system burden while maintaining safety and effectiveness of care. Such endeavor requires careful triage and coordination, telemedicine and technology support, workforce and education, as well as robust infrastructure. In the understandable paucity of evidence-based, protocolized approaches toward HOT for COVID-19 patients, our group has created the current document based on the cumulative experience of members of the Joint ACAIM-WACEM COVID-19 Clinical Management Taskforce. Utilizing available evidence-based resources and extensive front-line experience, the authors have suggested a pragmatic pathway for providing safe and effective home oxygen therapy in the community setting.

The impact of comprehensive air purification on patient duration of stay, discharge outcomes, and health care economics: A retrospective cohort study.

BACKGROUND: Infectious airborne and surface pathogens constitute a substantial and poorly explored source of patient subclinical illness and infections. With that in mind, a system of advanced air purification technology was designed to destroy the DNA and RNA of all bacteria, fungi, and viruses. This study compares the effects of advanced air purification technology versus high efficiency particulate air filtration with respect to certain metrics of health care economics and resource utilization at a large, community-based, urban hospital. Our hypothesis was that the use of the advanced air purification technology would decrease health care durations of stay, lead to fewer nonhome discharges, and decrease hospital charges. METHODS: After the installation of advanced air purification technology, 3 resultant air purification "zones" were established: zone C, a control floor with high efficiency particulate air filtration; zone B, a mixed high efficiency particulate air and advanced air purification technology floor; and zone A, a comprehensive advanced air purification technology remediation. This study included nonbariatric surgical patients admitted to any zone between December 2017 and December 2018, with reported case mix index on discharge. We analyzed hospital duration of stays, discharge destination, and hospital charges with adjustment for severity of illness using the case mix index. The likelihood of mortality, health care-associated infection, and readmission for each study zone was examined using logistic regression adjusting for case mix index, age, sex, and source of admission. RESULTS: The study included 1,002 patients across the 3 zones, with mean age of 55.8 years (53.7% female), average case mix index of 1.98, and mortality of 1.7%. Compared with zone C, patients in zones A and B demonstrated decreased hospital stays, a greater percentage of home discharges (86.5-87.8% vs 64.7%), and less hospital charges. In addition, logistic regression modeling performed on 999 study patients showed that the likelihood of mortality, hospital-acquired infections, and readmissions did not differ among the 3 zones. A trend toward a lesser incidence of hospital-acquired infections was noted in zones A and B (0.40% and 0.48%, respectively) when compared with zone C (0.63%). CONCLUSION: Patients in the advanced air purification technology zones demonstrated statistically significant improvements in durations of stay, discharge to home, and costs after adjusting for case mix index. In addition, a trend toward fewer hospital-acquired infections in advanced air purification technology zones was noted. These findings suggest that environmental factors may affect key clinical and economic outcomes, supporting further research in this important and largely unexplored area.

The 2019-2020 Novel Coronavirus (Severe Acute Respiratory Syndrome Coronavirus 2) Pandemic: A Joint American College of Academic International Medicine-World Academic Council of Emergency Medicine Multidisciplinary COVID-19 Working Group Consensus Paper.

What started as a cluster of patients with a mysterious respiratory illness in Wuhan, China, in December 2019, was later determined to be coronavirus disease 2019 (COVID-19). The pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel Betacoronavirus, was subsequently isolated as the causative agent. SARS-CoV-2 is transmitted by respiratory droplets and fomites and presents clinically with fever, fatigue, myalgias, conjunctivitis, anosmia, dysgeusia, sore throat, nasal congestion, cough, dyspnea, nausea, vomiting, and/or diarrhea. In most critical cases, symptoms can escalate into acute respiratory distress syndrome accompanied by a runaway inflammatory cytokine response and multiorgan failure. As of this article's publication date, COVID-19 has spread to approximately 200 countries and territories, with over 4.3 million infections and more than 290,000 deaths as it has escalated into a global pandemic. Public health concerns mount as the situation evolves with an increasing number of infection hotspots around the globe. New information about the virus is emerging just as rapidly. This has led to the prompt development of clinical patient risk stratification tools to aid in determining the need for testing, isolation, monitoring, ventilator support, and disposition. COVID-19 spread is rapid, including imported cases in travelers, cases among close contacts of known infected individuals, and community-acquired cases without a readily identifiable source of infection. Critical shortages of personal protective equipment and ventilators are compounding the stress on overburdened healthcare systems. The continued challenges of social distancing, containment, isolation, and surge capacity in already stressed hospitals, clinics, and emergency departments have led to a swell in technologically-assisted care delivery strategies, such as telemedicine and web-based triage. As the race to develop an effective vaccine intensifies, several clinical trials of antivirals and immune modulators are underway, though no reliable COVID-19-specific therapeutics (inclusive of some potentially effective single and multi-drug regimens) have been identified as of yet. With many nations and regions declaring a state of emergency, unprecedented quarantine, social distancing, and border closing efforts are underway. Implementation of social and physical isolation measures has caused sudden and profound economic hardship, with marked decreases in global trade and local small business activity alike, and full ramifications likely yet to be felt. Current state-of-science, mitigation strategies, possible therapies, ethical considerations for healthcare workers and policymakers, as well as lessons learned for this evolving global threat and the eventual return to a "new normal" are discussed in this article.

Potential Immunotherapeutic Targets for Hypoxia Due to COVI-Flu.

The world is currently embroiled in a pandemic of coronavirus disease 2019 (COVID-19), a respiratory illness caused by the novel betacoronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The severity of COVID-19 disease ranges from asymptomatic to fatal acute respiratory distress syndrome. In few patients, the disease undergoes phenotypic differentiation between 7 and 14 days of acute illness, either resulting in full recovery or symptom escalation. However, the mechanism of such variation is not clear, but the facts suggest that patient's immune status, comorbidities, and the systemic effects of the viral infection (potentially depending on the SARS-CoV-2 strain involved) play a key role. Subsequently, patients with the most severe symptoms tend to have poor outcomes, manifest severe hypoxia, and possess elevated levels of pro-inflammatory cytokines (including IL-1ß, IL-6, IFN-γ, and TNF-α) along with elevated levels of the anti-inflammatory cytokine IL-10, marked lymphopenia, and elevated neutrophil-to-lymphocyte ratios. Based on the available evidence, we propose a mechanism wherein SARS-CoV-2 infection induces direct organ damage while also fueling an IL-6-mediated cytokine release syndrome (CRS) and hypoxia, resulting in escalating systemic inflammation, multi-organ damage, and end-organ failure. Elevated IL-6 and hypoxia together predisposes patients to pulmonary hypertension, and the presence of asymptomatic hypoxia in COVID-19 further compounds this problem. Due to the similar downstream mediators, we discuss the potential synergistic effects and systemic ramifications of SARS-CoV-2 and influenza virus during co-infection, a phenomenon we have termed "COVI-Flu." Additionally, the differences between CRS and cytokine storm are highlighted. Finally, novel management approaches, clinical trials, and therapeutic strategies toward both SARS-CoV-2 and COVI-Flu infection are discussed, highlighting host response optimization and systemic inflammation reduction.