Vulnerability of Older Adults in Disasters: Emergency Department Utilization by Geriatric Patients After Hurricane Sandy.

OBJECTIVE: Older adults are a potentially medically vulnerable population with increased mortality rates during and after disasters. To evaluate the impact of a natural disaster on this population, we performed a temporal and geospatial analysis of emergency department (ED) use by adults aged 65 years and older in New York City (NYC) following Hurricane Sandy's landfall. METHODS: We used an all-payer claims database to analyze demographics, insurance status, geographic distribution, and health conditions for post-disaster ED visits among older adults. We compared ED patterns of use in the weeks before and after Hurricane Sandy throughout NYC and the most afflicted evacuation zones. RESULTS: We found significant increases in ED utilization by older adults (and disproportionately higher in those aged ≥85 years) in the 3 weeks after Hurricane Sandy, especially in NYC evacuation zone one. Primary diagnoses with notable increases included dialysis, electrolyte disorders, and prescription refills. Secondary diagnoses highlighted homelessness and care access issues. CONCLUSIONS: Older adults display heightened risk for worse health outcomes with increased ED visits after a disaster. Our findings suggest the need for dedicated resources and planning for older adults following a natural disaster by ensuring access to medical facilities, prescriptions, dialysis, and safe housing and by optimizing health care delivery needs to reduce the burden of chronic disease. (Disaster Med Public Health Preparedness. 2018;12:184-193).

Freestanding Emergency Critical Care During the Aftermath of Hurricane Sandy: Implications for Disaster Preparedness and Response.

OBJECTIVE: To assess the impact of an emergency intensive care unit (EICU) established concomitantly with a freestanding emergency department (ED) during the aftermath of Hurricane Sandy. METHODS: We retrospectively reviewed records of all patients in Bellevue's EICU from freestanding ED opening (December 10, 2012) until hospital inpatient reopening (February 7, 2013). Temporal and clinical data, and disposition upon EICU arrival, and ultimate disposition were evaluated. RESULTS: Two hundred twenty-seven patients utilized the EICU, representing approximately 1.8% of freestanding ED patients. Ambulance arrival occurred in 31.6% of all EICU patients. Median length of stay was 11.55 hours; this was significantly longer for patients requiring airborne isolation (25.60 versus 11.37 hours, P<0.0001 by Wilcoxon rank sum test). After stabilization and treatment, 39% of EICU patients had an improvement in their disposition status (P<0.0001 by Wilcoxon signed rank test); upon interhospital transfer, the absolute proportion of patients requiring ICU and SDU resources decreased from 37.8% to 27.1% and from 22.2% to 2.7%, respectively. CONCLUSIONS: An EICU attached to a freestanding ED achieved significant reductions in resource-intensive medical care. Flexible, adaptable care systems should be explored for implementation in disaster response. (Disaster Med Public Health Preparedness. 2016;10:496-502).

Geographic Distribution of Disaster-Specific Emergency Department Use After Hurricane Sandy in New York City.

OBJECTIVE: We aimed to characterize the geographic distribution of post-Hurricane Sandy emergency department use in administrative flood evacuation zones of New York City. METHODS: Using emergency claims data, we identified significant deviations in emergency department use after Hurricane Sandy. Using time-series analysis, we analyzed the frequency of visits for specific conditions and comorbidities to identify medically vulnerable populations who developed acute postdisaster medical needs. RESULTS: We found statistically significant decreases in overall post-Sandy emergency department use in New York City but increased utilization in the most vulnerable evacuation zone. In addition to dialysis- and ventilator-dependent patients, we identified that patients who were elderly or homeless or who had diabetes, dementia, cardiac conditions, limitations in mobility, or drug dependence were more likely to visit emergency departments after Hurricane Sandy. Furthermore, patients were more likely to develop drug-resistant infections, require isolation, and present for hypothermia, environmental exposures, or administrative reasons. CONCLUSIONS: Our study identified high-risk populations who developed acute medical and social needs in specific geographic areas after Hurricane Sandy. Our findings can inform coherent and targeted responses to disasters. Early identification of medically vulnerable populations can help to map "hot spots" requiring additional medical and social attention and prioritize resources for areas most impacted by disasters. (Disaster Med Public Health Preparedness. 2016;10:351-361).

Prehospital Indicators for Disaster Preparedness and Response: New York City Emergency Medical Services in Hurricane Sandy.

OBJECTIVE: We aimed to evaluate emergency medical services (EMS) data as disaster metrics and to assess stress in surrounding hospitals and a municipal network after the closure of Bellevue Hospital during Hurricane Sandy in 2012. METHODS: We retrospectively reviewed EMS activity and call types within New York City's 911 computer-assisted dispatch database from January 1, 2011, to December 31, 2013. We evaluated EMS ambulance transports to individual hospitals during Bellevue's closure and incremental recovery from urgent care capacity, to freestanding emergency department (ED) capability, freestanding ED with 911-receiving designation, and return of inpatient services. RESULTS: A total of 2,877,087 patient transports were available for analysis; a total of 707,593 involved Manhattan hospitals. The 911 ambulance transports disproportionately increased at the 3 closest hospitals by 63.6%, 60.7%, and 37.2%. When Bellevue closed, transports to specific hospitals increased by 45% or more for the following call types: blunt traumatic injury, drugs and alcohol, cardiac conditions, difficulty breathing, "pedestrian struck," unconsciousness, altered mental status, and emotionally disturbed persons. CONCLUSIONS: EMS data identified hospitals with disproportionately increased patient loads after Hurricane Sandy. Loss of Bellevue, a public, safety net medical center, produced statistically significant increases in specific types of medical and trauma transports at surrounding hospitals. Focused redeployment of human, economic, and social capital across hospital systems may be required to expedite regional health care systems recovery. (Disaster Med Public Health Preparedness. 2016;10:333-343).

Drug Use in the Twittersphere: A Qualitative Contextual Analysis of Tweets About Prescription Drugs.

Tweets about prescription opioid use may reveal insights into the prescription drug epidemic. We qualitatively assessed 2,100 tweets about prescription opioids utilizing a Twitter Archiving Google Spreadsheet® and determined whether the tweet represented: abuse (i.e., use to get high), not abuse (i.e., use as analgesic), or was not characterizable (e.g., "I need a Percocet") and whether the connotation was positive (i.e. promote psychoactive or analgesic use), negative (i.e., adverse event), or not characterizable. Abuse was commonly described and the majority of terms (>66%) represented a positive connotation. Twitter can be a resource to observe trends in perceptions about prescription opioid use.

Rebuilding Emergency Care After Hurricane Sandy.

A freestanding, 911-receiving emergency department was implemented at Bellevue Hospital Center during the recovery efforts after Hurricane Sandy to compensate for the increased volume experienced at nearby hospitals. Because inpatient services at several hospitals remained closed for months, emergency volume increased significantly. Thus, in collaboration with the New York State Department of Health and other partners, the Health and Hospitals Corporation and Bellevue Hospital Center opened a freestanding emergency department without on-site inpatient care. The successful operation of this facility hinged on key partnerships with emergency medical services and nearby hospitals. Also essential was the establishment of an emergency critical care ward and a system to monitor emergency department utilization at affected hospitals. The results of this experience, we believe, can provide a model for future efforts to rebuild emergency care capacity after a natural disaster such as Hurricane Sandy. (Disaster Med Public Health Preparedness. 2014;0:1-4).

Likeability and abuse liability of commonly prescribed opioids.

INTRODUCTION: Nonmedical use of prescription opioid analgesics is associated with epidemic levels of morbidity and mortality. There are several factors that affect the abuse liability of the various opioids, including likability or the pleasurable subjective effects. Due to rising public health concerns over escalating prescription opioid abuse, we sought to examine the literature about abuse liability with a specific focus on likability studies. METHODS: A search of EMBASE and MEDLINE databases identified articles that described the comparative likeability and/or abuse potential of hydrocodone and oxycodone relative to each other and/or of either one to morphine. After an assessment of study quality using the Oxford/Jadad scale, relevant details such as demographics, study design, and outcome measures were compiled into an evidence table. RESULTS: We identified nine studies that met inclusion criteria. All were double-blinded, randomized, placebo-controlled crossover studies and scored 5 out of 5 Jadad scale. There was no consistent clinically significant difference between abuse liability of morphine and hydrocodone. Oxycodone demonstrated high abuse liability on the basis of its high likability scores and a relative lack of negative subjective effects. CONCLUSION: Oral oxycodone has an elevated abuse liability profile compared to oral morphine and hydrocodone.

Attack rates assessment of the 2009 pandemic H1N1 influenza A in children and their contacts: a systematic review and meta-analysis.

BACKGROUND: The recent H1N1 influenza A pandemic was marked by multiple reports of illness and hospitalization in children, suggesting that children may have played a major role in the propagation of the virus. A comprehensive detailed analysis of the attack rates among children as compared with their contacts in various settings is of great importance for understanding their unique role in influenza pandemics. METHODOLOGY/PRINCIPAL FINDINGS: We searched MEDLINE (PubMed) and Embase for published studies reporting outbreak investigations with direct measurements of attack rates of the 2009 pandemic H1N1 influenza A among children, and quantified how these compare with those of their contacts. We identified 50 articles suitable for review, which reported school, household, travel and social events. The selected reports and our meta-analysis indicated that children had significantly higher attack rates as compared to adults, and that this phenomenon was observed for both virologically confirmed and clinical cases, in various settings and locations around the world. The review also provided insight into some characteristics of transmission between children and their contacts in the various settings. CONCLUSION/SIGNIFICANCE: The consistently higher attack rates of the 2009 pandemic H1N1 influenza A among children, as compared to adults, as well as the magnitude of the difference is important for understanding the contribution of children to disease burden, for implementation of mitigation strategies directed towards children, as well as more precise mathematical modeling and simulation of future influenza pandemics.

Emergency medicine residents' use of psychostimulants and sedatives to aid in shift work.

OBJECTIVES: We evaluated the frequency that emergency medicine house staff report use of stimulants and sedatives to aid in shift work and circadian transitions. METHODS: We surveyed residents from 12 regional emergency medicine programs inviting them to complete a voluntary, anonymous electronic questionnaire regarding their use of stimulants and sedatives. RESULTS: Out of 485 eligible residents invited to participate in the survey, 226 responded (47% response frequency). The reported use of prescription stimulants for shift work is uncommon (3.1% of respondents.) In contrast, 201 residents (89%) report use of caffeine during night shifts, including 118 residents (52%) who use this substance every night shift. Eighty-six residents (38%) reported using sedative agents to sleep following shift work with the most common agents being anti-histamines (31%), nonbenzodiazepine hypnotics such as zolpidem (14%), melatonin (10%), and benzodiazepines (9%). CONCLUSION: Emergency medicine residents report substantial use of several classes of hypnotics to aid in shift work. Despite anecdotal reports, use of prescription stimulants appears rare, and is notably less common than use of sedatives and non-prescription stimulants.

Agent of opportunity risk mitigation: people, engineering, and security efficacy.

BACKGROUND: Agents of opportunity (AO) are potentially harmful biological, chemical, radiological, and pharmaceutical substances commonly used for health care delivery and research. AOs are present in all academic medical centers (AMC), creating vulnerability in the health care sector; AO attributes and dissemination methods likely predict risk; and AMCs are inadequately secured against a purposeful AO dissemination, with limited budgets and competing priorities. We explored health care workers' perceptions of AMC security and the impact of those perceptions on AO risk. METHODS: Qualitative methods (survey, interviews, and workshops) were used to collect opinions from staff working in a medical school and 4 AMC-affiliated hospitals concerning AOs and the risk to hospital infrastructure associated with their uncontrolled presence. Secondary to this goal, staff perception concerning security, or opinions about security behaviors of others, were extracted, analyzed, and grouped into themes. RESULTS: We provide a framework for depicting the interaction of staff behavior and access control engineering, including the tendency of staff to "defeat" inconvenient access controls. In addition, 8 security themes emerged: staff security behavior is a significant source of AO risk; the wide range of opinions about "open" front-door policies among AMC staff illustrates a disparity of perceptions about the need for security; interviewees expressed profound skepticism concerning the effectiveness of front-door access controls; an AO risk assessment requires reconsideration of the security levels historically assigned to areas such as the loading dock and central distribution sites, where many AOs are delivered and may remain unattended for substantial periods of time; researchers' view of AMC security is influenced by the ongoing debate within the scientific community about the wisdom of engaging in bioterrorism research; there was no agreement about which areas of the AMC should be subject to stronger access controls; security personnel play dual roles of security and customer service, creating the negative perception that neither role is done well; and budget was described as an important factor in explaining the state of security controls. CONCLUSIONS: We determined that AMCs seeking to reduce AO risk should assess their institutionally unique AO risks, understand staff security perceptions, and install access controls that are responsive to the staff's tendency to defeat them. The development of AO attribute fact sheets is desirable for AO risk assessment; new funding and administrative or legislative tools to improve AMC security are required; and security practices and methods that are convenient and effective should be engineered.

Developing a consensus framework and risk profile for agents of opportunity in academic medical centers: implications for public health preparedness.

Agents of opportunity (AO) in academic medical centers (AMC) are defined as unregulated or lightly regulated substances used for medical research or patient care that can be used as "dual purpose" substances by terrorists to inflict damage upon populations. Most of these agents are used routinely throughout AMC either during research or for general clinical practice. To date, the lack of careful regulations for AOs creates uncertain security conditions and increased malicious potential. Using a consensus-based approach, we collected information and opinions from staff working in an AMC and 4 AMC-affiliated hospitals concerning identification of AO, AO attributes, and AMC risk and preparedness, focusing on AO security and dissemination mechanisms and likely hospital response. The goal was to develop a risk profile and framework for AO in the institution. Agents of opportunity in 4 classes were identified and an AO profile was developed, comprising 16 attributes denoting information critical to preparedness for AO misuse. Agents of opportunity found in AMC present a unique and vital gap in public health preparedness. Findings of this project may provide a foundation for a discussion and consensus efforts to determine a nationally accepted risk profile framework for AO. This foundation may further lead to the implementation of appropriate regulatory policies to improve public health preparedness. Agents of opportunity modeling of dissemination properties should be developed to better predict AO risk.

A novel approach to multihazard modeling and simulation.

OBJECTIVE: To develop and apply a novel modeling approach to support medical and public health disaster planning and response using a sarin release scenario in a metropolitan environment. METHODS: An agent-based disaster simulation model was developed incorporating the principles of dose response, surge response, and psychosocial characteristics superimposed on topographically accurate geographic information system architecture. The modeling scenarios involved passive and active releases of sarin in multiple transportation hubs in a metropolitan city. Parameters evaluated included emergency medical services, hospital surge capacity (including implementation of disaster plan), and behavioral and psychosocial characteristics of the victims. RESULTS: In passive sarin release scenarios of 5 to 15 L, mortality increased nonlinearly from 0.13% to 8.69%, reaching 55.4% with active dispersion, reflecting higher initial doses. Cumulative mortality rates from releases in 1 to 3 major transportation hubs similarly increased nonlinearly as a function of dose and systemic stress. The increase in mortality rate was most pronounced in the 80% to 100% emergency department occupancy range, analogous to the previously observed queuing phenomenon. Effective implementation of hospital disaster plans decreased mortality and injury severity. Decreasing ambulance response time and increasing available responding units reduced mortality among potentially salvageable patients. Adverse psychosocial characteristics (excess worry and low compliance) increased demands on health care resources. Transfer to alternative urban sites was possible. CONCLUSIONS: An agent-based modeling approach provides a mechanism to assess complex individual and systemwide effects in rare events.

Overcoming legal obstacles involving the voluntary care of children who are separated from their legal guardians during a disaster.

A large-scale disaster may separate children from their parents or guardians and may strand many children in the care of temporary caregivers, including physicians and nurses. In general, unless a physician or nurse is a member of a public sector emergency response program (a "VHP"), parental consent is required for the treatment of minors outside of an emergency department unless the minor is suffering from an imminently life-threatening condition. Physicians or nurses who are not VHP's may be held liable (civilly, criminally and administratively) if they provide care without parental consent outside of an emergency room to a child who is not suffering from an imminently life-threatening condition. The existing rules regarding parental consent would, in many cases, limit (or at least discourage) the provision of optimal health care to children in a large-scale disaster by restricting care aimed to alleviate pain, the treatment of chronic conditions as well as the treatment of conditions, or potential conditions, that could worsen or develop in the absence of treatment.Additionally, "Good Samaritan" laws that generally limit the liability of health care providers who voluntarily provide care in an emergency may not apply when care is provided in a crude or makeshift clinic or when care is not provided at the scene of the emergency. Thus, benevolent physicians and nurses who voluntarily provide care during a large-scale disaster unjustly risk liability. The prospect of such liability may substantially deter the provision of optimal medical care to children in a disaster. This article discusses the shortcomings of current laws and proposes revisions to existing state laws. These revisions would create reasonable and appropriate liability rules for physicians and nurses providing gratuitous care in emergencies and thus would create reasonable incentives for health care providers to deliver such care. ("Gratuitous care" is the legal term for care provided voluntarily and without expectation of payment.).

Optimising the role of the public health community in planning and implementing large-scale evacuations.

The public health community must advocate for the design and administration of plans and regulations that protect public health, promote effective medical response in evacuations, and require active participation by public health officials in evacuation planning. The public health response during recent natural disasters has highlighted the inadequacies of meeting the needs of complex populations of vulnerable individuals. Critical issues in the emergency management and public health systems with regard to the evaluation of a population are delineated, and potential solutions are suggested.

Organization-based incident management: developing a disaster volunteer role on a university campus.

BACKGROUND: Catastrophic events are an ongoing part of life, affecting society both locally and globally. Recruitment, development, and retention of volunteers who offer their knowledge and skills in the event of a disaster are essential to ensuring a functional workforce during catastrophes. These opportunities also address the inherent need for individuals to feel necessary and useful in times of crisis. Universities are a particularly important setting for voluntary action, given that they are based in communities and have access to resources and capabilities to bring to bear on an emergency situation. METHODS: The purpose of the study was to discern how one large private organization might participate and respond in the case of a large scale disaster. Using a 2-phase random sample survey, 337 unique respondents (5.7%) out of a sample of 6000 replied to the survey. RESULTS: These data indicate that volunteers in a private organization are willing to assist in disasters and have skills that can be useful in disaster mitigation. DISCUSSION: Much is to be learned related to the deployment of volunteers during disaster. These findings suggest that volunteers can and will help and that disaster preparedness drills are a logical next step for university-based volunteers.