Effectiveness of mRNA Covid-19 Vaccine among U.S. Health Care Personnel.

BACKGROUND: The prioritization of U.S. health care personnel for early receipt of messenger RNA (mRNA) vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (Covid-19), allowed for the evaluation of the effectiveness of these new vaccines in a real-world setting. METHODS: We conducted a test-negative case-control study involving health care personnel across 25 U.S. states. Cases were defined on the basis of a positive polymerase-chain-reaction (PCR) or antigen-based test for SARS-CoV-2 and at least one Covid-19-like symptom. Controls were defined on the basis of a negative PCR test for SARS-CoV-2, regardless of symptoms, and were matched to cases according to the week of the test date and site. Using conditional logistic regression with adjustment for age, race and ethnic group, underlying conditions, and exposures to persons with Covid-19, we estimated vaccine effectiveness for partial vaccination (assessed 14 days after receipt of the first dose through 6 days after receipt of the second dose) and complete vaccination (assessed ≥7 days after receipt of the second dose). RESULTS: The study included 1482 case participants and 3449 control participants. Vaccine effectiveness for partial vaccination was 77.6% (95% confidence interval [CI], 70.9 to 82.7) with the BNT162b2 vaccine (Pfizer-BioNTech) and 88.9% (95% CI, 78.7 to 94.2) with the mRNA-1273 vaccine (Moderna); for complete vaccination, vaccine effectiveness was 88.8% (95% CI, 84.6 to 91.8) and 96.3% (95% CI, 91.3 to 98.4), respectively. Vaccine effectiveness was similar in subgroups defined according to age (<50 years or ≥50 years), race and ethnic group, presence of underlying conditions, and level of patient contact. Estimates of vaccine effectiveness were lower during weeks 9 through 14 than during weeks 3 through 8 after receipt of the second dose, but confidence intervals overlapped widely. CONCLUSIONS: The BNT162b2 and mRNA-1273 vaccines were highly effective under real-world conditions in preventing symptomatic Covid-19 in health care personnel, including those at risk for severe Covid-19 and those in racial and ethnic groups that have been disproportionately affected by the pandemic. (Funded by the Centers for Disease Control and Prevention.).

Coronavirus Disease 2019 Infections Among Emergency Health Care Personnel: Impact on Delivery of United States Emergency Medical Care, 2020.

STUDY OBJECTIVE: In the early months of the coronavirus disease 2019 (COVID-19) pandemic and before vaccine availability, there were concerns that infected emergency department (ED) health care personnel could present a threat to the delivery of emergency medical care. We examined how the pandemic affected staffing levels and whether COVID-19 positive staff were potentially infectious at work in a cohort of US ED health care personnel in 2020. METHODS: The COVID-19 Evaluation of Risks in Emergency Departments (Project COVERED) project was a multicenter prospective cohort study of US ED health care personnel conducted from May to December 2020. During surveillance, health care personnel completed weekly electronic surveys and underwent periodic serology and nasal reverse transcription polymerase chain reaction testing for SARS-CoV-2, and investigators captured weekly data on health care facility COVID-19 prevalence and health care personnel staffing. Surveys asked about symptoms, potential exposures, work attendance, personal protective equipment use, and behaviors. RESULTS: We enrolled 1,673 health care personnel who completed 29,825 person weeks of surveillance. Eighty-nine (5.3%) health care personnel documented 90 (0.3%; 95% confidence interval [CI] 0.2% to 0.4%) person weeks of missed work related to documented or concerns for COVID-19 infection. Health care personnel experienced symptoms of COVID-19 during 1,256 (4.2%) person weeks and worked at least one shift whereas symptomatic during 1,042 (83.0%) of these periods. Seventy-five (4.5%) participants tested positive for SARS-CoV-2 during the surveillance period, including 43 (57.3%) who indicated they never experienced symptoms; 74 (98.7%; 95% CI 90.7% to 99.9%) infected health care personnel worked at least one shift during the initial period of infection, and 71 (94.7%) continued working until laboratory confirmation of their infection. Physician staffing was not associated with the facility or community COVID-19 levels within any time frame studied (Kendall tau's 0.02, 0.056, and 0.081 for no shift, one-week time shift, and 2-week time shift, respectively). CONCLUSIONS: During the first wave of the pandemic, COVID-19 infections in ED health care personnel were infrequent, and the time lost from the workforce was minimal. Health care personnel frequently reported for work while infected with SARS-CoV-2 before laboratory confirmation. The ED staffing levels were poorly correlated with facility and community COVID-19 burden.

Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study.

STUDY OBJECTIVE: To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs). METHODS: Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence. RESULTS: A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86). CONCLUSION: Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.

Endotracheal Intubation Strategy, Success, and Adverse Events Among Emergency Department Patients During the COVID-19 Pandemic.

STUDY OBJECTIVE: To describe endotracheal intubation practices in emergency departments by staff intubating patients early in the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Multicenter prospective cohort study of endotracheal intubations conducted at 20 US academic emergency departments from May to December 2020, stratified by known or suspected COVID-19 status. We used multivariable regression to measure the association between intubation strategy, COVID-19 known or suspected status, first-pass success, and adverse events. RESULTS: There were 3,435 unique emergency department endotracheal intubations by 586 participating physicians or advanced practice providers; 565 (18%) patients were known or suspected of having COVID-19 at the time of endotracheal intubation. Compared with patients not known or suspected of COVID-19, endotracheal intubations of patients with known or suspected COVID-19 were more often performed using video laryngoscopy (88% versus 82%, difference 6.3%; 95% confidence interval [CI], 3.0% to 9.6%) and passive nasal oxygenation (44% versus 39%, difference 5.1%; 95% CI, 0.9% to 9.3%). First-pass success was not different between those who were and were not known or suspected of COVID-19 (87% versus 86%, difference 0.6%; 95% CI, -2.4% to 3.6%). Adjusting for patient characteristics and procedure factors in those with low anticipated airway difficulty (n=2,374), adverse events (most commonly hypoxia) occurred more frequently in patients with known or suspected COVID-19 (35% versus 19%, adjusted odds ratio 2.4; 95% CI, 1.7 to 3.3). CONCLUSION: Compared with patients not known or suspected of COVID-19, endotracheal intubation of those confirmed or suspected to have COVID-19 was associated with a similar first-pass intubation success rate but higher risk-adjusted adverse events.

Firework injuries remain high in years after legalisation: its impact on children.

PURPOSE: We evaluated the impact of Senate Bill 489 passed in May 2017, allowing the sale and use of fireworks in Iowa 1 June to 8 July and 10 December to 3 January, on hospital presentations for firework injuries in the state. To identify the public health implications of this law, we conducted a detailed subanalysis of hospital presentations to the two level I trauma centres. METHODS: Hospital presentations for firework injuries from 1 June 2014 to 31 July 2019 were identified using the Iowa Hospital Admission database and registries and medical records of Iowa's two level 1 trauma centres. Trauma centres' data were reviewed to obtain demographics, injury information and hospital course. Prefirework and postfirework legalisation state data were compared using negative binomial regression analysis. Trauma centre data detailing injuries were compared using χ2 and Mann-Whitney U tests as appropriate. RESULTS: Emergency department (ED) visits and hospital admissions for firework injuries increased in Iowa post-legalisation (B-estimate=0.598±0.073, p<0.001 and B-estimate=0.612±0.322, p=0.058, respectively). ED visits increased postlegalisation in July (73.6% vs 64.5%; p=0.008), reflecting an increase in paediatric admissions (81.8% vs 62.5%; p=0.006). Trauma centres' data showed similar trends. The most common injury site across both study periods was the hands (48.5%), followed by the eyes (34.3%) and face (28.3%). Amputations increased from 0 prelegalisation to 16.2% postlegalisation. CONCLUSION: Firework legalisation led to an increase in the number of admissions and more severe injuries.

Adapted Helping Babies Breathe approach to neonatal resuscitation in Haiti: a retrospective cohort study.

BACKGROUND: Helping Babies Breathe (HBB) is an American Academy of Pediatrics neonatal resuscitation program designed to reduce neonatal mortality in low resource settings. The 2017 neonatal mortality rate in Haiti was 28 per 1000 live births and an estimated 85 % of Haitian women deliver at home. Given this, the Community Health Initiative implemented an adapted HBB (aHBB) in Haiti to evaluate neonatal mortality. METHODS: Community Health Workers taught an aHBB program to laypeople, which didn't include bag-valve-mask ventilation. Follow-up after delivery assessed for maternal and neonatal mortality and health. RESULTS: Analysis included 536 births of which 84.3 % (n=452) were attended by someone trained in aHBB. The odds of neonatal mortality was not significantly different among the two groups (aOR=0.48 [0.16-1.44]). Composite outcome of neonatal health as reported by the mother (subjective morbidity and mortality) was significantly lower in aHBB attended births (aOR=0.31 [0.14-0.70]). CONCLUSION: This analysis of the aHBB program indicates that community training to laypersons in low resource settings may reduce neonatal ill-health but not neonatal mortality. This study is likely underpowered to find a difference in neonatal mortality. Further work is needed to evaluate which components of the aHBB program are instrumental in improving neonatal health.

Interim Estimates of Vaccine Effectiveness of Pfizer-BioNTech and Moderna COVID-19 Vaccines Among Health Care Personnel - 33 U.S. Sites, January-March 2021.

Throughout the COVID-19 pandemic, health care personnel (HCP) have been at high risk for exposure to SARS-CoV-2, the virus that causes COVID-19, through patient interactions and community exposure (1). The Advisory Committee on Immunization Practices recommended prioritization of HCP for COVID-19 vaccination to maintain provision of critical services and reduce spread of infection in health care settings (2). Early distribution of two mRNA COVID-19 vaccines (Pfizer-BioNTech and Moderna) to HCP allowed assessment of the effectiveness of these vaccines in a real-world setting. A test-negative case-control study is underway to evaluate mRNA COVID-19 vaccine effectiveness (VE) against symptomatic illness among HCP at 33 U.S. sites across 25 U.S. states. Interim analyses indicated that the VE of a single dose (measured 14 days after the first dose through 6 days after the second dose) was 82% (95% confidence interval [CI] = 74%-87%), adjusted for age, race/ethnicity, and underlying medical conditions. The adjusted VE of 2 doses (measured ≥7 days after the second dose) was 94% (95% CI = 87%-97%). VE of partial (1-dose) and complete (2-dose) vaccination in this population is comparable to that reported from clinical trials and recent observational studies, supporting the effectiveness of mRNA COVID-19 vaccines against symptomatic disease in adults, with strong 2-dose protection.

Symptoms of Anxiety, Burnout, and PTSD and the Mitigation Effect of Serologic Testing in Emergency Department Personnel During the COVID-19 Pandemic.

STUDY OBJECTIVE: Among a comprehensive range of frontline emergency department health care personnel, we assessed symptoms of anxiety and burnout, specific coronavirus disease 2019 (COVID-19) work-related stressors, and risk for post-traumatic stress disorder (PTSD). We also determined whether COVID-19 serologic testing of HCP decreased their self-reported anxiety. METHODS: In a prospective cohort study from May 13, 2020, to July 8, 2020, we used electronic surveys to capture participant self-reported symptoms before and after serologic testing for anti-SARS-CoV-2 immunoglobulin G antibodies. Participants were physicians, nurses, advanced practice providers, and nonclinical ED personnel at 20 geographically diverse United States EDs. We evaluated these domains: 1) the effects of the COVID-19 pandemic on overall stress and anxiety; 2) COVID-19-related work stressors; 3) burnout; and 4) PTSD risk (measured using the Primary Care-PTSD Screen for DSM-5, a 5-item screening instrument in which a score of ≥3 signifies high risk for PTSD). We also assessed perceptions of whether results of COVID-19 antibody testing decreased participants' self-reported anxiety. RESULTS: Of 1,606 participants, 100% and 88% responded to the baseline and follow-up surveys, respectively. At baseline, approximately half (46%) reported symptoms of emotional exhaustion and burnout from their work, and 308 (19.2%, 95% confidence interval [CI] 17.3% to 21.1%) respondents screened positive for increased PTSD risk. Female respondents were more likely than males to screen positive (odds ratio [OR] 2.03, 95% CI 1.49 to 2.78). Common concerns included exposing their family and the health of coworkers diagnosed with COVID-19. After receiving antibody test results, 54% (95% CI 51.8 to 56.7) somewhat agreed, agreed, or strongly agreed that knowledge of their immune status had decreased their anxiety. A positive serology result indicating prior SARS-CoV-2 infection was associated with a higher likelihood of reporting decreased anxiety (2.83, 95% CI 1.37 to 5.83). CONCLUSION: Symptoms of anxiety and burnout were prevalent across the spectrum of ED staff during the COVID-19 pandemic. One-fifth of ED personnel appeared to be at risk for PTSD. Increased provision of serologic testing may help to mitigate anxiety.

Diagnosed and Undiagnosed COVID-19 in US Emergency Department Health Care Personnel: A Cross-sectional Analysis.

STUDY OBJECTIVE: We determine the percentage of diagnosed and undiagnosed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among a sample of US emergency department (ED) health care personnel before July 2020. METHODS: This was a cross-sectional analysis of ED health care personnel in 20 geographically diverse university-affiliated EDs from May 13, to July 8, 2020, including case counts of prior laboratory-confirmed coronavirus disease 2019 (COVID-19) diagnoses among all ED health care personnel, and then point-in-time serology (with confirmatory testing) and reverse transcriptase-polymerase chain reaction testing in a sample of volunteers without a previous COVID-19 diagnosis. Health care staff were categorized as clinical (physicians, advanced practice providers, and nurses) and nonclinical (clerks, social workers, and case managers). Previously undiagnosed infection was based on positive SARS-CoV-2 serology or reverse transcriptase-polymerase chain reaction result among health care personnel without prior diagnosis. RESULTS: Diagnosed COVID-19 occurred in 2.8% of health care personnel (193/6,788), and the prevalence was similar for nonclinical and clinical staff (3.8% versus 2.7%; odds ratio 1.5; 95% confidence interval 0.7 to 3.2). Among 1,606 health care personnel without previously diagnosed COVID-19, 29 (1.8%) had evidence of current or past SARS-CoV-2 infection. Most (62%; 18/29) who were seropositive did not think they had been infected, 76% (19/25) recalled COVID-19-compatible symptoms, and 89% (17/19) continued to work while symptomatic. Accounting for both diagnosed and undiagnosed infections, 4.6% (95% confidence interval 2.8% to 7.5%) of ED health care personnel were estimated to have been infected with SARS-CoV-2, with 38% of those infections undiagnosed. CONCLUSION: In late spring and early summer 2020, the estimated prevalence of severe acute respiratory syndrome coronavirus 2 infection was 4.6%, and greater than one third of infections were undiagnosed. Undiagnosed SARS-CoV-2 infection may pose substantial risk for transmission to other staff and patients.

The Iowa less aggressive protocol: A mixed-methods study on the novel treatment protocol of atrial fibrillation.

OBJECTIVES: Atrial fibrillation is the most common cardiac dysrhythmia in the United States. Our aim was to determine if a novel protocol for management of atrial fibrillation was feasible to implement in an emergency department (ED). Interviews were conducted with ED physicians and physician assistants to identify themes in relation to the clinical use and impleon of the protocol. METHODS: A novel protocol was developed by a multi-disciplinary team and implemented in an academic ED. The protocol used cardiac computed tomography (CT) to rule out left atrial thrombus in patients with greater than 12 h of symptoms and high risk of thromboembolism, or any patient with greater than 48 h of symptoms. Patients who underwent cardiac CT or electrical cardioversion were followed up at 30 days via telephone to monitor for recurrence or adverse thromboembolic events. Providers were interviewed to identify themes regarding protocol usage, barriers to its use, and future changes to increase utilization. RESULTS: Patients with atrial fibrillation in the ED were eligible for inclusion. Twenty-nine patients were treated using the protocol. Seven patients (24%) underwent cardiac CT prior to electrical cardioversion. Cardioversion success rate was 83%, with 69% of patients discharged home. Thirty-day follow-up was completed on 25 patients (86%). Six patients (24%) had reoccurrence of atrial fibrillation requiring subsequent cardioversion. No patients experienced stroke or thromboembolic event. Interviews were conducted with 14 providers. Usage barriers included time, availability, and additional work-up. Six subthemes were identified for future changes including EMR order set, frequent reminders, increased education, increased awareness, activation energy, and EMR pop-ups. CONCLUSION: The Iowa Less Aggressive Protocol is a novel treatment protocol for the ED management of atrial fibrillation that was feasible to implement and use. Providers viewed the protocol favorably and identified areas of improvement for future use.

Steering Teens Safe: translation to a workplace wellness program in the USA.

Parent-based teen driving interventions have been shown to increase safe teen driving but few have been translated beyond the research setting. As employers focus more on total worker health, the workplace offers a unique opportunity to implement a safe teen driving program into a workplace wellness program. The aim of this study was to adapt the evidence-based, parent-focused teen safe driving program Steering Teens Safe (STS) into workplace wellness programs, and to evaluate the implementation process and effect on parent-teen communication. The Replicating Effective Programs framework was used to modify STS to fit the workplace setting. The implementation process of the STS workplace wellness program was measured using direct observation and recordings of parent communication trainings while the effectiveness was measured by parent questionnaires. Forty-five parent employees across three businesses participated in the study. STS trainers were skilled in training parents in effective communication, including using open-ended questions and reflections. Parents reported increased success in conversations with their teens regarding safe driving through increased affection, receptivity, trust and equality in conversations. Workplaces may play a key role in assisting parents with teaching their children about safe driving.

Sedation Depth is Associated with Increased Hospital Length of Stay in Mechanically Ventilated Air Medical Transport Patients: A Cohort Study.

Background: Analgesics, sedatives, and neuromuscular blockers are commonly used medications for mechanically ventilated air medical transport patients. Prior research in the emergency department (ED) and intensive care unit (ICU) has demonstrated that depth of sedation is associated with increased mechanical ventilation duration, delirium, increased hospital length-of-stay (LOS), and decreased survival. The objectives of this study were to evaluate current sedation practices in the prehospital setting and to determine the impact on clinical outcomes. Methods: A retrospective cohort study of mechanically ventilated patients transferred by air ambulance to a single 812-bed Midwestern academic medical center from July 2013 to May 2018 was conducted. Prehospital sedation medications and depth of sedation [Richmond Agitation-Sedation Scale score (RASS)] were measured. Primary outcome was hospital LOS. Secondary outcomes were delirium, length of mechanical ventilation, in-hospital mortality, and need for neurosurgical procedures. Univariate analyses were used to measure the association between sedatives, sedation depth, and clinical outcomes. Multivariable models adjusted for potentially confounding covariates to measure the impact of predictors on clinical outcomes. Results: Three hundred twenty-seven patients were included. Among those patients, 79.2% of patients received sedatives, with 41% of these patients achieving deep sedation (RASS = -4). Among patients receiving sedation, 58.3% received at least one dose of benzodiazepines. Moderate and deep sedation was associated with an increase in LOS of 59% (aRR: 1.59; 95% CI: 1.40-1.81) and 24% (aRR: 1.24; 95% CI: 1.10-1.40), respectively. Benzodiazepines were associated with a mean increase of 2.9 days in the hospital (95% CI, 0.7-5.1). No association existed between either specific medications or depth of sedation and the development of delirium. Conclusions: Prehospital moderate and deep sedation, as well as benzodiazepine administration, is associated with increased hospital LOS. Our findings point toward sedation being a modifiable risk factor and suggest an important need for further research of sedation practices in the prehospital setting.

State-level teen dating violence education laws and teen dating violence victimisation in the USA: a cross-sectional analysis of 36 states.

BACKGROUND: Approximately 10% of teens report experiencing sexual dating violence (SDV) or physical dating violence (PDV), collectively represented as teen dating violence (TDV). This study examines the association between laws incorporating TDV education in schools on TDV prevalence. METHODS: TDV prevalence was estimated using data contributed by 36 states that participated in the 2015 Youth Risk Behavioral Surveillance Survey (YRBS). Presence of TDV laws was determined using Westlaw, a legal search engine. The adjusted odds of TDV victimisation was estimated by the presence or absence of a state law and length of time the law was in effect using hierarchical regression modelling, clustering on state, controlling for individual-level and state-level covariates and incorporating the YRBS-weighted survey design. RESULTS: After controlling for individual-level and state-level covariates, the presence of a law was not associated with TDV (adjusted OR (aOR) 0.97; 95% CI 0.88 to 1.06), PDV (aOR 1.12; 95% CI 0.95 to 1.33) or SDV (aOR 0.99; 95% CI 0.91 to 1.08). These odds did not differ across the length of time the policies were in effect. CONCLUSIONS: This study suggest that just the presence of a law incorporating TDV education in schools is not associated with reduced TDV victimisation but further research is needed to understand the association of the content of these laws and their implementation on TDV victimisation.

Use of a Bidirectional Text Messaging System for Emergency Department Follow-Up Versus Usual Follow-Up.

Background: The use of text messaging is a growing trend. Usual care for follow-up with patients (no dedicated communication) has proven unreliable, and alternative communication methods may be beneficial. Introduction: The objective was to evaluate the effect of text messaging as a means of follow-up communication compared to usual care on patient satisfaction among patients discharged from the emergency department (ED). Materials and Methods: Participants completed a baseline survey about their text message usage and ED visit satisfaction. The participants completed a follow-up survey 2 weeks later. Participants randomized to text messaging received a text message at 24 h, 1 week, and 2 weeks after discharge. Control participants received usual care (typically no dedicated communication). Bivariate analyses were performed, and intent-to-treat and per protocol analyses were completed to examine follow-up satisfaction with ED communication/care. Results: A total of 802 subjects were recruited (text messaging-398 subjects, usual care-404 subjects). In the intent-to-treat analysis, text messaging subjects were not more likely to report satisfaction with follow-up communication (adjusted odds ratio [aOR] 0.90 [0.46-1.75]) or follow-up care (aOR 0.66 [0.30-1.46]) than usual care subjects. In per-protocol analysis, text messaging subjects had 2.95 (1.52-5.73) higher odds of reporting satisfaction with follow-up communication and 3.24 (1.46-7.16) higher odds of reporting satisfaction with follow-up care. Discussion: The use of text messaging for follow-up, when comparing satisfaction with follow-up communication and follow-up care after discharge, performs at least equally as well as usual follow-up. Conclusions: Text messaging is a provider time-saving and resource-conserving technology allowing health care providers to potentially reach a larger proportion of patients, making it a valuable form of follow-up communication.

Central Venous Access Capability and Critical Care Telemedicine Decreases Inter-Hospital Transfer Among Severe Sepsis Patients: A Mixed Methods Design.

OBJECTIVES: Severe sepsis is a complex, resource intensive, and potentially lethal condition and rural patients have worse outcomes than urban patients. Early identification and treatment are important to improving outcomes. The objective of this study was to identify hospital-specific factors associated with inter-hospital transfer. DESIGN: Mixed method study integrating data from a telephone survey and retrospective cohort study of state administrative claims. SETTING AND SUBJECTS: Survey of Iowa emergency department administrators between May 2017 and June 2017 and cohort of adults seen in Iowa emergency departments for severe sepsis and septic shock between January 2005 and December 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multivariable logistic regression was used to identify independent predictors of inter-hospital transfer. We included 114 institutions that provided data (response rate = 99%), and responses were linked to a total of 150,845 visits for severe sepsis/septic shock. In our adjusted model, having the capability to place central venous catheters or having a subscription to a tele-ICU service was independently associated with lower odds of inter-hospital transfer (adjusted odds ratio, 0.69; 95% CI, 0.54-0.86 and adjusted odds ratio, 0.69; 95% CI, 0.54-0.88, respectively). A facility's participation in a sepsis-specific quality improvement initiative was associated with 62% higher odds of transfer (adjusted odds ratio, 1.62; 95% CI, 1.10-2.39). CONCLUSIONS: The insertion of central venous catheters and access to a critical care physician during sepsis treatment are important capabilities in hospitals that transfer fewer sepsis patients. In the future, hospital-specific capabilities may be used to identify institutions as regional sepsis centers.

Telemedicine Is Associated with Faster Diagnostic Imaging in Stroke Patients: A Cohort Study.

BACKGROUND: Meeting time goals for patients with time-sensitive conditions can be challenging in rural emergency departments (EDs), and adopting policies is critical. ED-based telemedicine has been proposed to improve quality and timeliness of care in rural EDs. INTRODUCTION: The objective of this study was to test the hypothesis that diagnostic testing in telemedicine-supplemented ED care for patients with myocardial infarction (MI) and stroke would be faster than nontelemedicine care in rural EDs. MATERIALS AND METHODS: This observational cohort study included all ED patients with MI or stroke in 19 rural critical access hospitals served by a single real-time contract-based telemedicine provider in the upper Midwest (2007-2015). The primary outcome for the MI cohort was time-to-electrocardiogram (EKG) and for the stroke cohort was time-to-head computed tomography (CT) interpretation. To measure the relationship between telemedicine and timeliness parameters, generalized estimating equations models were used, clustering on presenting hospital. RESULTS: Of participating ED visits, 756 were included in the MI cohort (29% used telemedicine) and 140 were included in the stroke cohort (30% used telemedicine). Time-to-EKG did not differ when telemedicine was used (1% faster, 95% confidence interval [CI] -4% to 7%), or after telemedicine was implemented (4% faster, 95% CI -3% to 10%). Head CT interpretation was faster for telemedicine cases (15% faster, 95% CI 4-26%). No differences were observed in time to reperfusion therapy. CONCLUSIONS: Telemedicine implementation was associated with more timely head CT interpretation for rural patients with stroke, but no difference in early MI care. Future work will focus on the specific manner in which telemedicine changes ED care processes and ongoing professional education.

Safety of reassessment-and-release practice for mental health patients boarded in the emergency department.

OBJECTIVES: Among emergency department (ED) mental health and substance abuse (MHSA) patients, we sought to compare mortality and healthcare utilization by ED discharge disposition and inpatient bed request status. METHODS: A retrospective cohort study of 492 patients was conducted at a single University ED. We reviewed three groups of MHSA patients including ED patients that were admitted, ED patients with a bed request that were discharged from the ED, and ED patients with no bed request that were discharged from the ED. We identified main outcomes as ED return visit, re-hospitalization and mortality within 12months based on chart review and reference from the National Death Index. RESULTS: The average age of patients presenting was 30.5 (SD16.4) years and 251 (51.0%) were female patients. Of these patients, 216 (43.9%) presented with mood disorder and 93 (18.9%) with self-harm. The most common reason for discharge from the ED after an admission request was placed was from stabilization of the patient (n=138). An ED revisit within 12months was significantly higher among patients discharged who had a bed request in place prior to departure (54.0%, p<0.001), than those discharged from the ED (40.9%) or admitted to inpatient care (30.5%). The rate of suicide attempt and death did not show statistical significance (p=0.55 and p=0.88). CONCLUSION: MHSA patients who were discharged from ED after bed requests were placed were at greater risk for return visits to the ED. This implicates that these patients require outpatient planning to prevent further avoidable healthcare utilization.

Emergency department charges may be associated with mortality in patients with severe sepsis and septic shock: a cohort study.

BACKGROUND: Sepsis severity of illness is challenging to measure using claims, which makes sepsis difficult to study using administrative data. We hypothesized that emergency department (ED) charges may be associated with hospital mortality, and could be a surrogate marker of severity of illness for research purposes. The objective of this study was to measure concordance between ED charges and mortality in admitted patients with severe sepsis or septic shock. METHODS: Cohort study of all adult patients presenting to a 60,000-visit Midwestern academic ED with severe sepsis or septic shock (by ICD-9 codes) between July 1, 2008 and June 30, 2010. Data on demographics, admission APACHE-II score, and disposition was extracted from the medical record, and comorbidities were identified from diagnosis codes using the Elixhauser methodology. Summary statistics were reported and bivariate concordance was tested using Pearson correlation. Logistic regression models for 28-day mortality were developed to measure the independent association with mortality. RESULTS: We included a total of 294 patients in the analysis. We found that ED charges were inversely related to mortality (adjusted OR 0.829 per $1000 increase in total ED charges, 95%CI 0.702-0.980). ED charges were also independently associated with 28-day hospital-free and ICU-free days (0.74 days increase per $1000 additional ED charges, 95%CI 0.06-1.41 and 0.81 days increase per $1000 additional ED charges, 95%CI 0.05-1.56, respectively). ED charges were also associated with APACHE-II score ($34 total ED charges per point increase in APACHE-II score, 95%CI $6-62). CONCLUSIONS: ED charges in administrative data sets are associated with in-hospital mortality and health care utilization, likely related to both illness severity and intensity of early sepsis resuscitation. ED charges may have a role in risk adjustment models using administrative data for acute care research.

Emergency Department Telemedicine Shortens Rural Time-To-Provider and Emergency Department Transfer Times.

BACKGROUND: Emergency department (ED)-based telemedicine has been implemented in many rural hospitals to provide specialty care and expertise to patients with critical time-sensitive conditions. INTRODUCTION: The purpose of this study was to measure the impact of ED-based telemedicine on timeliness of care in participating rural hospitals. MATERIALS AND METHODS: Matched cohort study of patients seen in 1 of 14 rural hospitals in a large Midwestern telemedicine network. Telemedicine cases were matched 2:1 with controls based on age, diagnosis, and hospital. The primary outcome was door-to-provider time, and secondary outcomes included ED length-of-stay (LOS) and time-to-transfer in those transferred to other hospitals. RESULTS: Of 127,928 qualifying ED encounters, 2,857 consulted telemedicine and were matched with nontelemedicine controls. Door-to-provider time was shorter in telemedicine patients by 6.0 min (95% confidence interval [CI] 4.3-7.8 min). The first provider seeing the patient was a telemedicine provider in 41.7% of telemedicine encounters, and in these cases, telemedicine was 14.7 min earlier than local providers. ED LOS was 22.1 min shorter (95% CI 3.1-41.2) among transferred patients, but total ED LOS was longer (40.2 min, 95% CI 30.8-49.6 min) for all telemedicine patients. CONCLUSIONS: Telemedicine decreases ED door-to-provider time, most commonly because the telemedicine provider was the first provider seeing a patient. Among transferred patients, ED LOS at the first hospital was shorter in patients who had telemedicine consulted. Future work will focus on the clinical impact of more timely rural ED care.

Telemedicine Use Decreases Rural Emergency Department Length of Stay for Transferred North Dakota Trauma Patients.

BACKGROUND: Telemedicine has been proposed as one strategy to improve local trauma care and decrease disparities between rural and urban trauma outcomes. OBJECTIVES: This study was conducted to describe the effect of telemedicine on management and clinical outcomes for trauma patients in North Dakota. METHODS: Cohort study of adult (age ≥18 years) trauma patients treated in North Dakota Critical Access Hospital (CAH) Emergency Departments (EDs) from 2008 to 2014. Records were linked to a telemedicine network's call records, indicating whether telemedicine was available and/or used at the institution at the time of the care. Multivariable generalized estimating equations were developed to identify associations between telemedicine consultation and availability and outcomes such as transfer, timeliness of care, trauma imaging, and mortality. RESULTS: Of the 7,500 North Dakota trauma patients seen in CAH, telemedicine was consulted for 11% of patients in telemedicine-capable EDs and 4% of total trauma patients. Telemedicine utilization was independently associated with decreased initial ED length of stay (LOS) (30 min, 95% confidence interval [CI] 14-45 min) for transferred patients. Telemedicine availability was associated with an increase in the probability of interhospital transfer (adjusted odds ratio [aOR] 1.2, 95% CI 1.1-1.4). Telemedicine availability was associated with increased total ED LOS (15 min, 95% CI 10-21 min), and computed tomography scans (aOR 1.6, 95% CI 1.3-1.9). CONCLUSIONS: ED-based telemedicine consultation is requested for the most severely injured rural trauma patients. Telemedicine consultation was associated with more rapid interhospital transfer, and telemedicine availability is associated with increased radiography use and transfer. Future work should evaluate how telemedicine could target patients likely to benefit from telemedicine consultation.