Community Testing and SARS-CoV-2 Rates for Latinxs in Baltimore.

INTRODUCTION: Latinxs have been disproportionately impacted by COVID-19. Latinx immigrants, in particular, face significant barriers to SARS-CoV-2 testing, including lack of insurance, language barriers, stigma, work conflicts, and limited transportation. METHODS: In response to a disproportionately high SARS-CoV-2 positivity rate among Latinxs at the Johns Hopkins Health System, investigators implemented free community-based testing by partnering with religious leaders and leveraging the skill of trusted community health workers. Data were extracted from the electronic health record and a Research Electronic Data Capture database. SARS-CoV-2 positivity was evaluated per event stratified by race/ethnicity. Total rates of SARS-CoV-2 positivity and categorical patient characteristics were compared between groups using chi-square tests. RESULTS: Between June 25, 2020 and October 15, 2020, a total of 1,786 patients (57.5% Latinx, 31.2% non-Hispanic White, 5.9% non-Hispanic Black, and 5.3% non-Hispanic other) were tested for SARS-CoV-2 in 18 testing events. Among them, 355 (19.9%) tested positive. The positivity rate was 31.5% for Latinxs, 7.6% for non-Hispanic Blacks, 3.4% for non-Hispanic Whites, and 5.3% for patients of other races/ethnicities. Compared with Latinxs who tested negative, Latinxs who tested positive were more likely to report Spanish as their preferred language (91.6% vs 81.7%, p<0.001), be younger (30.4 vs 33.4 years, p<0.008), and have a larger household size (4.8 vs 4.3 members, p<0.002). CONCLUSIONS: Community-based testing identified high levels of ongoing SARS-CoV-2 transmission among primarily Latinxs with limited English proficiency. During this period, the overall positivity rate at this community testing site was almost 10 times higher among Latinxs than among non-Hispanic Whites.

Hospital-based shootings in the United States: 2000 to 2011.

STUDY OBJECTIVE: Workplace violence in health care settings is a frequent occurrence. Emergency departments (EDs) are considered particularly vulnerable. Gunfire in hospitals is of particular concern; however, information about such workplace violence is limited. Therefore, we characterize US hospital-based shootings from 2000 to 2011. METHODS: Using LexisNexis, Google, Netscape, PubMed, and ScienceDirect, we searched reports for acute care hospital shooting events in the United States for 2000 through 2011. All hospital-based shootings with at least 1 injured victim were analyzed. RESULTS: Of 9,360 search "hits," 154 hospital-related shootings were identified, 91 (59%) inside the hospital and 63 (41%) outside on hospital grounds. Shootings occurred in 40 states, with 235 injured or dead victims. Perpetrators were overwhelmingly men (91%) but represented all adult age groups. The ED environs were the most common site (29%), followed by the parking lot (23%) and patient rooms (19%). Most events involved a determined shooter with a strong motive as defined by grudge (27%), suicide (21%), "euthanizing" an ill relative (14%), and prisoner escape (11%). Ambient society violence (9%) and mentally unstable patients (4%) were comparatively infrequent. The most common victim was the perpetrator (45%). Hospital employees composed 20% of victims; physician (3%) and nurse (5%) victims were relatively infrequent. Event characteristics that distinguished the ED from other sites included younger perpetrator, more likely in custody, and unlikely to have a personal relationship with the victim (ill relative, grudge, coworker). In 23% of shootings within the ED, the weapon was a security officer's gun taken by the perpetrator. Case fatality inside the hospital was much lower in the ED setting (19%) than other sites (73%). CONCLUSION: Although it is likely that not every hospital-based shooting was identified, such events are relatively rare compared with other forms of workplace violence. The unpredictable nature of this type of event represents a significant challenge to hospital security and effective deterrence practices because most perpetrators proved determined and a significant number of shootings occur outside the hospital building.

Association of allogeneic red-blood cell transfusion with surgeon case-volume.

BACKGROUND: Surgeon case-volume predicts a variety of patient outcomes. We hypothesize that surgeon case-volume predicts RBC transfusion across different surgical procedures. METHODS: We performed a cohort study of 372,670 in-patient surgical cases in the 52 non-federal hospitals in Maryland between 2004 and 2005. The main outcome measure was relative risk of receiving a transfusion. RESULTS: Overall, 13.9% of patients received a transfusion. Patients seen by the highest case-volume surgeons (>161 cases/y) were more likely to receive a transfusion (16% versus 11%, P < 0.01) compared with middle case-volume surgeons (89-161 cases/y). After adjusting for confounders, the highest case-volume patients were still at increased risk of transfusion [relative risk (RR) 1.10, 1.07-1.14]. This result was true across many surgery types. CONCLUSIONS: Surgeon case-volume is independently associated with the likelihood of RBC transfusion across a broad range of surgical procedures. Future efforts should be directed towards studying and standardization of transfusion practices.

Characterizing hospital workers' willingness to respond to a radiological event.

INTRODUCTION: Terrorist use of a radiological dispersal device (RDD, or "dirty bomb"), which combines a conventional explosive device with radiological materials, is among the National Planning Scenarios of the United States government. Understanding employee willingness to respond is critical for planning experts. Previous research has demonstrated that perception of threat and efficacy is key in the assessing willingness to respond to a RDD event. METHODS: An anonymous online survey was used to evaluate the willingness of hospital employees to respond to a RDD event. Agreement with a series of belief statements was assessed, following a methodology validated in previous work. The survey was available online to all 18,612 employees of the Johns Hopkins Hospital from January to March 2009. RESULTS: Surveys were completed by 3426 employees (18.4%), whose demographic distribution was similar to overall hospital staff. 39% of hospital workers were not willing to respond to a RDD scenario if asked but not required to do so. Only 11% more were willing if required. Workers who were hesitant to agree to work additional hours when required were 20 times less likely to report during a RDD emergency. Respondents who perceived their peers as likely to report to work in a RDD emergency were 17 times more likely to respond during a RDD event if asked. Only 27.9% of the hospital employees with a perception of low efficacy declared willingness to respond to a severe RDD event. Perception of threat had little impact on willingness to respond among hospital workers. CONCLUSIONS: Radiological scenarios such as RDDs are among the most dreaded emergency events yet studied. Several attitudinal indicators can help to identify hospital employees unlikely to respond. These risk-perception modifiers must then be addressed through training to enable effective hospital response to a RDD event.

Role of emergency medical services in disaster response: resource document for the National Association of EMS Physicians position statement.

The National Association of EMS Physicians (NAEMSP) advocates for a strong emergency medical services (EMS) role in all phases of disaster management--preparedness, response, and recovery. Emergency medical services administrators and medical directors should play a leadership role in preparedness activities such as training and education, development of performance metrics, establishment of memoranda of understanding (MOUs), and planning for licensure and liability issues. During both the planning and response phases, EMS leadership should advocate for participation in unified command, modified scope of practice appropriate for providers and the event, and expanded roles in community and federal response efforts. To enhance recovery, EMS leadership should strongly advocate for national recognition for EMS efforts and further research into strategies that foster healthy coping techniques and resiliency in the EMS workforce. This resource document will outline the basis for the corresponding NAEMSP position statement on the role of EMS in disaster management.

Characterizing public health emergency perceptions and influential modifiers of willingness to respond among pediatric healthcare staff.

OBJECTIVES: The aim of this study was to characterize the public health emergency perceptions and willingness to respond (WTR) of hospital-based pediatric staff and to use these findings to propose a methodology for developing an institution-specific training package to improve response willingness. METHODS: A prospective anonymous web-based survey was conducted at the Johns Hopkins Hospital, including the 180-bed Johns Hopkins Children's Center, between January and March 2009. In this survey, participants' attitudes/beliefs regarding emergency response to a pandemic influenza and a radiological dispersal device (RDD or "dirty bomb") event were assessed. RESULTS: Of the 1,620 eligible pediatric staff 246 replies (15.2 percent response rate) were received, compared with an overall staff response rate of 18.4 percent. Characteristics of respondent demographics and professions were similar to those of overall hospital staff. Self-reported WTR was greater for a pandemic influenza than for an RDD event if required (84.6 percent vs 75.1 percent), and if asked, but not required (74.4 percent vs 64.5 percent). The majority of pediatric staff were not confident in their safety at work (pandemic influenza: 51.8 percent and RDD: 76.6 percent), were far less likely to respond if personal protective equipment was unavailable (pandemic influenza: 33.5 percent and RDD: 21.6percent), and wanted furtherpre-event preparation and training (pandemic influenza: 89.6 percent and RDD: 82.6 percent). The following six distinct perceived attitudes / beliefs were identified as having institution-specific high impact on response willingness: colleague response, skill mastery, safety getting to work, safety at work, ability to perform duties, and individual response efficacy. CONCLUSIONS: Children represent a uniquely vulnerable population in public health emergencies, and pediatric hospital staff accordingly represent a vital subset of responders distinguished by specialized education, training, clinical skills, and disaster competencies. Even though the majority of pediatric hospital staff report WTR, nearly 15 percent for a pandemic influenza emergency and 25 percent for an RDD event would not respond if required. Other institutions can apply the methodology used here to identify particularly influential response willingness modifiers for pediatric care providers. These insights can inform customized preparedness training for pediatric healthcare workers, through identification of high-impact attitudes/beliefs, and training initiatives focused on addressing these modifiers.

Characterizing hospital workers' willingness to report to duty in an influenza pandemic through threat- and efficacy-based assessment.

BACKGROUND: Hospital-based providers' willingness to report to work during an influenza pandemic is a critical yet under-studied phenomenon. Witte's Extended Parallel Process Model (EPPM) has been shown to be useful for understanding adaptive behavior of public health workers to an unknown risk, and thus offers a framework for examining scenario-specific willingness to respond among hospital staff. METHODS: We administered an anonymous online EPPM-based survey about attitudes/beliefs toward emergency response, to all 18,612 employees of the Johns Hopkins Hospital from January to March 2009. Surveys were completed by 3426 employees (18.4%), approximately one third of whom were health professionals. RESULTS: Demographic and professional distribution of respondents was similar to all hospital staff. Overall, more than one-in-four (28%) hospital workers indicated they were not willing to respond to an influenza pandemic scenario if asked but not required to do so. Only an additional 10% were willing if required. One-third (32%) of participants reported they would be unwilling to respond in the event of a more severe pandemic influenza scenario. These response rates were consistent across different departments, and were one-third lower among nurses as compared with physicians. Respondents who were hesitant to agree to work additional hours when required were 17 times less likely to respond during a pandemic if asked. Sixty percent of the workers perceived their peers as likely to report to work in such an emergency, and were ten times more likely than others to do so themselves. Hospital employees with a perception of high efficacy had 5.8 times higher declared rates of willingness to respond to an influenza pandemic. CONCLUSIONS: Significant gaps exist in hospital workers' willingness to respond, and the EPPM is a useful framework to assess these gaps. Several attitudinal indicators can help to identify hospital employees unlikely to respond. The findings point to certain hospital-based communication and training strategies to boost employees' response willingness, including promoting pre-event plans for home-based dependents; ensuring adequate supplies of personal protective equipment, vaccines and antiviral drugs for all hospital employees; and establishing a subjective norm of awareness and preparedness.

Change in use of allogeneic red blood cell transfusions among surgical patients.

BACKGROUND: Although RBC transfusions can be lifesaving, recent evidence suggests that their use is associated with added morbidity and mortality and that a lower transfusion threshold is safe. It is unclear if this new evidence has translated into decreased RBC use among surgical patients. The purpose of this study is to measure the change in use of RBCs during the last decade. STUDY DESIGN: We performed a cross-sectional cohort study of all patients who underwent inpatient operations in the 52 hospitals in Maryland in 1997 to 1998 and 2004 to 2005. The primary outcomes variable was whether or not the patient received an allogeneic RBC transfusion. We controlled for confounders related to RBC transfusion, including age, gender, race, type of admission, comorbid conditions, and surgeon patient-volume. RESULTS: Patients receiving RBCs were older (63 versus 52 years), were more likely to be admitted through the emergency department (37% versus 24%) or as a readmission (12% versus 6.9%), had more Romano-Charlson index comorbidities, and had a higher unadjusted mortality (6.5% versus 1.1%). Comparing 1997 to 1998 to 2004 to 2005, RBC use in surgical patients increased (8.9% versus 14%), although unadjusted mortality decreased (2.0% versus 1.5%). Factors associated with higher adjusted relative risk (RR) of transfusion include age older than 65 years (RR = 2.45), unscheduled admissions (emergency department RR = 1.32, readmission RR = 1.62), Romano-Charlson comorbidities (RR = 1.04 to 2.71), third quartile of surgeon volume (RR = 1.10), death (RR = 1.24), and having operations in 2004 to 2005 (RR = 1.42). CONCLUSIONS: Despite evidence supporting more restrictive use of RBC transfusions, RBC use among surgical patients has increased during the last decade.

Development of evaluation modules for use in hospital disaster drills.

INTRODUCTION: Disaster drills are a valuable means of training healthcare providers to respond to mass casualty incidents resulting from acts of terrorism or public health crises. We present here a proposed hospital-based disaster drill evaluation tool that is designed to identify strengths and weaknesses of hospital disaster drill response, provide a learning opportunity for disaster drill participants, and promote integration of lessons learned into future responses. METHODS: Clinical specialists, experienced disaster drill coordinators and evaluators, and experts in questionnaire design developed the evaluation modules based upon a comprehensive review of the literature, including evaluations of disaster drills. The tool comprises six evaluation modules designed to capture strengths and weaknesses of different aspects of hospital disaster response. The Predrill Module is completed by the hospital during drill planning and is used to define the scope of the exercise. The Incident Command Center Module assesses command structure, communication between response areas and the command center, and communication to outside agencies. The Triage Zone Module captures the effect of a physical space on triage activities, efficiency of triage operations, and victim flow. The Treatment Zone Module assesses the relation of the zone's physical characteristics to treatment activities, efficacy of treatment operations, adequacy of supplies, and victim flow. A Decontamination Zone Module is available for evaluating decontamination operations and the use of decontamination and/or personal protective equipment in drills that involve biological or radiological hazardous materials. The Group Debriefing Module provides sample discussion points for drill participants in all types of drills. The tool also has addenda to evaluate specifics for 1) general observation and documentation, 2) victim tracking, 3) biological incidents, and 4) radiological incidents. CONCLUSION: This evaluation tool will help meet the need for standardized evaluation of disaster drills. The modular approach offers flexibility and could be used by hospitals to evaluate staff training on response to natural or man-made disasters.

Effectiveness of hospital staff mass-casualty incident training methods: a systematic literature review.

INTRODUCTION: Recently, mass-casualty incident (MCI) preparedness and training has received increasing attention at the hospital level. OBJECTIVES: To review the existing evidence on the effectiveness of disaster drills, technology-based interventions and tabletop exercises in training hospital staff to respond to an MCI. METHODS: A systematic, evidence-based process was conducted incorporating expert panel input and a literature review with the key terms: "mass casualty", "disaster", "disaster planning", and "drill". Paired investigators reviewed citation abstracts to identify articles that included evaluation of disaster training for hospital staff. Data were abstracted from the studies (e.g., MCI type, training intervention, staff targeted, objectives, evaluation methods, and results). Study quality was reviewed using standardized criteria. RESULTS: Of 243 potentially relevant citations, 21 met the defined criteria. Studies varied in terms of targeted staff, learning objectives, outcomes, and evaluation methods. Most were characterized by significant limitations in design and evaluation methods. Seventeen addressed the effectiveness of disaster drills in training hospital staff in responding to an MCI, four addressed technology-based interventions, and none addressed tabletop exercises. The existing evidence suggests that hospital disaster drills are effective in allowing hospital employees to become familiar with disaster procedures, identify problems in different components of response (e.g., incident command, communications, triage, patient flow, materials and resources, and security) and provide the opportunity to apply lessons learned to disaster response. The strength of evidence on other training methods is insufficient to draw valid recommendations. CONCLUSIONS: Current evidence on the effectiveness of MCI training for hospital staff is limited. A number of studies suggest that disaster drills can be effective in training hospital staff. However, more attention should be directed to evaluating the effectiveness of disaster training activities in a scientifically rigorous manner.

Threats in bioterrorism. I: CDC category A agents.

Although once considered unlikely, bioterrorism is now a reality in the United States since the anthrax cases began appearing in the fall of 2001. Intelligence sources indicate there are many countries and terrorist organizations that either possess biological weapons or are attempting to procure them. In the future it is likely that we will experience additional acts of bioterrorism. The CDC category A agents represent our greatest challenge because they have the potential to cause grave harm to the medical and public health systems of a given population. Thus, it is imperative that plans be developed now to deal with the consequences of an intentional release of any one or more of these pathogens.