Declines in SARS-CoV-2 Transmission, Hospitalizations, and Mortality After Implementation of Mitigation Measures- Delaware, March-June 2020.

Mitigation measures, including stay-at-home orders and public mask wearing, together with routine public health interventions such as case investigation with contact tracing and immediate self-quarantine after exposure, are recommended to prevent and control the transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1-3). On March 11, the first COVID-19 case in Delaware was reported to the Delaware Division of Public Health (DPH). The state responded to ongoing community transmission with investigation of all identified cases (commencing March 11), issuance of statewide stay-at-home orders (March 24-June 1), a statewide public mask mandate (from April 28), and contact tracing (starting May 12). The relationship among implementation of mitigation strategies, case investigations, and contact tracing and COVID-19 incidence and associated hospitalization and mortality was examined during March-June 2020. Incidence declined by 82%, hospitalization by 88%, and mortality by 100% from late April to June 2020, as the mask mandate and contact tracing were added to case investigations and the stay-at-home order. Among 9,762 laboratory-confirmed COVID-19 cases reported during March 11-June 25, 2020, two thirds (6,527; 67%) of patients were interviewed, and 5,823 (60%) reported completing isolation. Among 2,834 contacts reported, 882 (31%) were interviewed and among these contacts, 721 (82%) reported completing quarantine. Implementation of mitigation measures, including mandated mask use coupled with public health interventions, was followed by reductions in COVID-19 incidence and associated hospitalizations and mortality. The combination of state-mandated community mitigation efforts and routine public health interventions can reduce the occurrence of new COVID-19 cases, hospitalizations, and deaths.

Adoption of Strategies to Mitigate Transmission of COVID-19 During a Statewide Primary Election - Delaware, September 2020.

Elections occurring during the coronavirus disease 2019 (COVID-19) pandemic have been affected by notable changes in the methods of voting, the number and type of polling locations, and in-person voting procedures (1). To mitigate transmission of COVID-19 at polling locations, jurisdictions have adopted changes to protocols and procedures, informed by CDC's interim guidance, developed in collaboration with the Election Assistance Commission (2). The driving principle for this guidance is that voting practices with lower infection risk will be those which reduce the number of voters who congregate indoors in polling locations by offering a variety of methods for voting and longer voting periods. The guidance for in-person voting includes considerations for election officials, poll workers, and voters to maintain healthy environments and operations. To assess knowledge and adoption of mitigation strategies, CDC collaborated with the Delaware Department of Health and Social Services and the Delaware State Election Commission on a survey of poll workers who served during the statewide primary election on September 15, 2020. Among 522 eligible poll workers, 93% correctly answered all three survey questions about COVID-19 transmission. Respondents noted that most voters and poll workers wore masks. However, masks were not always worn correctly (i.e., covering both the nose and mouth). Responses suggest that mitigation measures recommended for both poll workers and voters were widely adopted and feasible, but also highlighted gaps in infection prevention control efforts. Strengthening of measures intended to minimize the risk of poll workers acquiring COVID-19 from ill voters, such as additional training and necessary personal protective equipment (PPE), as well as support for alternative voting options for ill voters, are needed. Adherence to mitigation measures is important not only to protect voters but also to protect poll workers, many of whom are older adults, and thus at higher risk for severe COVID-19-associated illness. Enhanced attention to reducing congregation in polling locations, correct mask use, and providing safe voting options for ill voters are critical considerations to minimize risk to voters and poll workers. Evidence from the Delaware election supports the feasibility and acceptability of implementing current CDC guidance for election officials, poll workers, and voters for mitigating COVID-19 transmission at polling locations (2).

Media Reports as a Tool for Timely Monitoring of COVID-19-Related Deaths Among First Responders-United States, April 2020.

We aimed to describe coronavirus disease 2019 (COVID-19) deaths among first responders early in the COVID-19 pandemic. We used media reports to gather timely information about COVID-19-related deaths among first responders during March 30-April 30, 2020, and evaluated the sensitivity of media scanning compared with traditional surveillance. We abstracted information about demographic characteristics, occupation, underlying conditions, and exposure source. Twelve of 19 US public health jurisdictions with data on reported deaths provided verification, and 7 jurisdictions reported whether additional deaths had occurred; we calculated the sensitivity of media scanning among these 7 jurisdictions. We identified 97 COVID-19-related first-responder deaths during the study period through media and jurisdiction reports. Participating jurisdictions reported 5 deaths not reported by the media. Sixty-six decedents worked in law enforcement, and 31 decedents worked in fire/emergency medical services. Media reports rarely noted underlying conditions. The media scan sensitivity was 88% (95% CI, 73%-96%) in the subset of 7 jurisdictions. Media reports demonstrated high sensitivity in documenting COVID-19-related deaths among first responders; however, information on risk factors was scarce. Routine collection of data on industry and occupation could improve understanding of COVID-19 morbidity and mortality among all workers.

Do Patients Require Emergency Department Interventions After Prehospital Naloxone?

OBJECTIVE: Patients receiving naloxone for suspected opioid overdose in the prehospital setting are typically transported to the emergency department (ED) for further evaluation, regardless of Glasgow Coma Scale (GCS). The objective of our study is to determine whether patients with GCS ≥14 after receiving prehospital naloxone received additional doses of naloxone and medical interventions in the ED compared with those with GCS <14 after prehospital naloxone. METHODS: Our retrospective observational study included patients ≥18 years old treated with naloxone and transported by an inner-city hospital-based Emergency Medical Services (EMS) to its affiliated ED from January 2, 2016 to December 31, 2016. Investigators collected demographic data, prehospital interventions, GCS, ED interventions, and dispositions. Institutional Review Board approval was obtained. The main outcome measures were repeat doses of naloxone and ED interventions. RESULTS: In all, 473 patient encounters were reviewed. Most common route of prehospital naloxone administration was intranasal (68%). Nearly two-thirds (n = 473) of patients had GCS ≥14 upon ED arrival. Repeat naloxone was administered to 3.5% (n = 314) of patients with GCS ≥14 versus 14.6% (n = 159) of patients with GCS <14. ED interventions, such as airway maneuvers, laboratory and radiology testing, and cardiac monitoring, were less common among patients who had improved GCS of 14 or higher (n = 314). There were 8 deaths among patients with GCS <14 (n = 159) and no deaths among patients with GCS ≥14 (n = 314). CONCLUSION: Patients with GCS score ≥14 after administration of prehospital naloxone are less likely to receive additional naloxone doses and medical interventions in the ED compared with those with a GCS score <14 after prehospital naloxone and may present an invaluable opportunity for the ED to initiate an addiction treatment program for patients with nonfatal overdose.

Pertussis outbreak in an Amish Community: Kent County, Delaware, 2018.

The Amish lead a very simplistic lifestyle free of modern conveniences. They have unique perceptions and beliefs regarding health and illness and generally do not adhere to conventional preventive measures such as immunizations, which can result in un- or under-immunized populations. Populations with low vaccination coverage are at greater risk of outbreaks compared to vaccinated populations as a result of low herd immunity. Over the past two decades, the Delaware Division of Public Health (DPH) has recorded three distinct outbreaks of pertussis in Delaware's Amish community. The third, and most recent, outbreak was detected in May 2018. DPH conducted an outbreak investigation in the Amish community to identify cases, estimate the burden of disease in the community, and implement control measures including vaccination, treatment, and post-exposure prophylaxis. Through the conduct of active surveillance activities, DPH interviewed 134 families and identified 181 confirmed and probable cases of pertussis. The majority of pertussis cases (77%) occurred among children ≤10 years of age, of which 87% were unvaccinated. DPH engaged the Amish community in meetings, distributed educational materials, and provided medication and vaccines in the community to encourage prevention and implement control measures. DPH officially closed the outbreak investigation on December 20, 2018 following three full incubation periods (63 days) without any new pertussis cases identified in the community.

Examination of EMS Decision Making in Determining Suitability of Patient Diversion to Urgent Care Centers.

Widespread use of Emergency Medicine Services (EMS) for non-emergency care has increased recently, causing overcrowding of the Emergency Department (ED). The increased availability of urgent care centers (UCCs), with their ability to see large numbers of unscheduled patients with more acute presentations, may offer a viable option for many EMS systems to divert non-emergent cases. Using a survey-based study combined with retrospective chart review, EMS provider ability to determine patient suitability for diversion to UCCs was assessed. Results indicated a rate of inappropriate diversion of 11.6%. UCCs may be an alternative option for EMS transport, however strict protocols with medical direction are needed.

The emergency department for routine healthcare: race/ethnicity, socioeconomic status, and perceptual factors.

Our objective was to study the role of race/ethnicity and socioeconomic status (SES) in the use of the emergency department (ED) as a source of routine healthcare. Adult patients presenting to an urban ED were surveyed. We assessed demographics, race/ethnicity, SES, and perceptional factors related to choosing the ED for the current visit. Stepwise logistic regression analyses were used to explore whether SES accounted for racial/ethnic trends in ED use. Of 1375 patients, 936 (68%) were enrolled. After controlling for insurance status, income, employment status, and education, neither race nor ethnicity remained a strong predictor of routine ED use. Race/ethnicity-based disparities in routine ED use were due to the confounding effects of SES. Programs to reduce inappropriate ED use must be sensitive to an array of complex socioeconomic issues and may necessitate a substantial paradigm shift in how acute care is provided in low SES communities.

Presence of undertriage and overtriage in simple triage and rapid treatment.

OBJECTIVE: We evaluated the use of the Simple Triage and Rapid Treatment (START) method by Emergency Medical Services (EMS) and hypothesized that EMS can categorize patients using the START algorithm accurately. DESIGN: Retrospective Chart Review. SETTING: Inner-city Tertiary-Care Institutional Emergency Department (ED). PARTICIPANTS: Patients ≥ 18 years transported by EMS with a START color of Red, Yellow, or Green during the state triage tag exercise, October 9-15, 2011. INTERVENTIONS: EMS assigned each patient a START triage tag. Chart review of the electronic EMS run sheets was performed by investigators to determine a START color. MAIN OUTCOME MEASURES: START triage colors were re-categorized as Red = 1, Yellow = 2, and Green = 3. The difference between the investigators' color and EMS color were coded as: 0 for agreement in triage, -1 for undertriage by one category, -2 for undertriage by two categories, 1 for overtriage by one category, 2 for overtriage by two categories. RESULTS: Of 224 participants, START triage colors were: Red = 7.1 percent, Yellow = 19.2 percent, Green = 73.7 percent. The mean difference in triage categories was 0.228 (95% CI: 0.114-0.311, p<.001). 71.0 percent of patients were triaged to the same category, 5.8 percent undertriaged by one category, 0 percent undertriaged by two categories, 17.9 percent overtriaged by one category, and 5.4 percent overtriaged by two categories. CONCLUSION: EMS was more likely to overtriage using START. All patients who were overtriaged by two categories were ambulatory at the scene, which implies other findings not in START may affect triage.

Comparison of START triage categories to emergency department triage levels to determine need for urgent care and to predict hospitalization.

OBJECTIVE: To compare Emergency Severity Index (ESI) triage levels and Simple Triage and Rapid Treatment (START) triage colors for urgent care and hospitalization. DESIGN: Cross sectional. SETTING: Inner city emergency department (ED). PARTICIPANTS: Patients years transported by Emergency Medical Services (EMS) participating in the state triage tag exercise, October 9-15, 2011. INTERVENTIONS: EMS assigned each patient a START triage tag. ED staff recorded tag number and color. Demographics, vital signs, 22 emergent interventions, and disposition were obtained via chart review. Institutional review board approval was obtained. MAIN OUTCOME MEASURES: Presence of more than two abnormal vital sign on arrival and need for more than one emergent intervention in ED were considered indicators of acuity and severity. START triage colors were recategorized as urgent (Red, Yellow) and less acute (Green, White), and ESI was recategorized as urgent (1, 2, 3) and less acute (4, 5). RESULTS: Both ED and EMS staff were blinded to the study, and 95% confidence intervals were presented for statistical significance. Of 233 participants, START triage colors were Black=0, Red=12 percent, Yellow=26 percent, Green=53 percent, and White=9 percent. ESI triage levels were level 1=1 percent, level 2=34 percent, level 3=51 percent, level 4=14 percent, and level 5=1 percent. ESI (1, 2, 3) identified 88 percent (75-95 percent) of 49 patients with abnormal vital signs; START (Red, Yellow) only identified 51 percent (35-64 percent). Twenty-one patients needed emergent intervention. ESI (1, 2, 3) identified 95 percent (76-99 percent) of these patients; START (Red, Yellow) identified 33 percent (17-55 percent). ESI (1, 2, 3) identified 98 percent of the 96(92-100 percent) admitted patients; only 48 percent (38-58 percent) were tagged START (Red, Yellow). CONCLUSION: ESI better identified patients with abnormal vital signs, those who needed emergent interventions, and those admitted than START.

Comparison of three prehospital cervical spine protocols for missed injuries.

INTRODUCTION: We wanted to compare 3 existing emergency medical services (EMS) immobilization protocols: the Prehospital Trauma Life Support (PHTLS, mechanism-based); the Domeier protocol (parallels the National Emergency X-Radiography Utilization Study [NEXUS] criteria); and the Hankins' criteria (immobilization for patients <12 or >65 years, those with altered consciousness, focal neurologic deficit, distracting injury, or midline or paraspinal tenderness).To determine the proportion of patients who would require cervical immobilization per protocol and the number of missed cervical spine injuries, had each protocol been followed with 100% compliance. METHODS: This was a cross-sectional study of patients ≥18 years transported by EMS post-traumatic mechanism to an inner city emergency department. Demographic and clinical/historical data obtained by physicians were recorded prior to radiologic imaging. Medical record review ascertained cervical spine injuries. Both physicians and EMS were blinded to the objective of the study. RESULTS: Of 498 participants, 58% were male and mean age was 48 years. The following participants would have required cervical spine immobilization based on the respective protocol: PHTLS, 95.4% (95% CI: 93.1-96.9%); Domeier, 68.7% (95% CI: 64.5-72.6%); Hankins, 81.5% (95% CI: 77.9-84.7%). There were 18 cervical spine injuries: 12 vertebral fractures, 2 subluxations/dislocations and 4 spinal cord injuries. Compliance with each of the 3 protocols would have led to appropriate cervical spine immobilization of all injured patients. In practice, 2 injuries were missed when the PHTLS criteria were mis-applied. CONCLUSION: Although physician-determined presence of cervical spine immobilization criteria cannot be generalized to the findings obtained by EMS personnel, our findings suggest that the mechanism-based PHTLS criteria may result in unnecessary cervical spine immobilization without apparent benefit to injured patients. PHTLS criteria may also be more difficult to implement due to the subjective interpretation of the severity of the mechanism, leading to non-compliance and missed injury.

Does the simple triage and rapid treatment method appropriately triage patients based on trauma injury severity score?

OBJECTIVES: To correlate the simple triage and rapid treatment (START) colors to trauma injury severity scores (ISS). DESIGN: Six volunteer healthcare providers unfamiliar with START were trained to triage. Each chart was designated a START color by a volunteer healthcare provider and the "expert" trainer. The colors and corresponding ISS were recorded. SETTING: Level I trauma center at a suburban tertiary care hospital. PATIENTS, PARTICIPANTS: One hundred charts of patients at least 65 years old who appear in Christiana Hospital's Trauma Registry were randomly chosen for the study, and 98 charts with complete data were included. MAIN OUTCOME MEASURE(S): Cohen's Kappa score measures the level of agreement between the "volunteer" and "expert" reviewers. Pearson correlation determines the association between the START colors and mean ISS. RESULTS: The Cohen's Kappa score between the volunteer and expert reviewers was 0.9915, indicating a highly significant agreement between the reviewers on the triage category of the patients. The mean ISS for each color was as follows: green = 11, yellow = 12, red = 20, black = 24. The mean ISS increases as the acuity of the triage category increases, with a Pearson correlation of 0.969. CONCLUSIONS: The START method is a simple technique used to triage quickly a large number of patients. Healthcare providers can undergo just-in-time training to learn this technique and use it effectively. The START colors also imply a correlation with the trauma ISS, with higher ISS more likely to be triaged "red" or "black."