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McCormick G, Mohr NM, Ablordeppey E, Stephens RJ, Fuller BM, Roberts BW. Partial pressure of carbon dioxide/pH interaction and its association with mortality among patients mechanically ventilated in the emergency department. Am J Emerg Med 2024; 79:105-110. [PMID: 38417220 DOI: 10.1016/j.ajem.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/29/2024] [Accepted: 02/18/2024] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVES There is currently conflicting data as to the effects of hypercapnia on clinical outcomes among mechanically ventilated patients in the emergency department (ED). These conflicting results may be explained by the degree of acidosis. We sought to test the hypothesis that hypercapnia is associated with increased in-hospital mortality and decreased ventilator-free days at lower pH, but associated with decreased in-hospital mortality and increased ventilator-free days at higher pH, among patients requiring mechanical ventilation in the emergency department (ED). METHODS Secondary analysis of patient level data from prior clinical trials and cohort studies that enrolled adult patients who required mechanical ventilation in the ED. Patients who had a documented blood gas while on mechanical ventilation in the ED were included in these analyses. The primary outcome was in-hospital mortality, and secondary outcome was ventilator-free days. Mixed-effects logistic, linear, and survival-time regression models were used to test if pH modified the association between partial pressure of carbon dioxide (pCO2) and outcome measures. RESULTS Of the 2348 subjects included, the median [interquartile range (IQR)] pCO2 was 43 (35-54) and pH was 7.31 (7.22-7.39). Overall, in-hospital mortality was 27%. We found pH modified the association between pCO2 and outcomes, with higher pCO2 associated with increased probability of in-hospital mortality when pH is below 7.00, and decreased probability of in-hospital mortality when pH is above 7.10. These results remained consistent across multiple sensitivity and subgroup analyses. A similar relationship was found with ventilator-free days. CONCLUSIONS Higher pCO2 is associated with decreased mortality and greater ventilator-free days when pH is >7.10; however, it is associated with increased mortality and fewer ventilator-free days when the pH is below 7.00. Targeting pCO2 based on pH in the ED may be a potential intervention target for future clinical trials to improve clinical outcomes.
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Affiliation(s)
- Gregory McCormick
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesia, Division of Critical Care Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, United States of America
| | - Enyo Ablordeppey
- Departments of Emergency Medicine and Anesthesia, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Robert J Stephens
- Department of Medicine, Division of Critical Care, University of Maryland School of Medicine, United States of America
| | - Brian M Fuller
- Departments of Emergency Medicine and Anesthesia, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Brian W Roberts
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
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Ternes S, Lavin L, Vakkalanka JP, Healy HS, Merchant KA, Ward MM, Mohr NM. The role of increasing synchronous telehealth use during the COVID-19 pandemic on disparities in access to healthcare: A systematic review. J Telemed Telecare 2024:1357633X241245459. [PMID: 38646804 DOI: 10.1177/1357633x241245459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
INTRODUCTION The COVID-19 public health emergency led to an unprecedented rapid increase in telehealth use, but the role of telehealth in reducing disparities in access to care has been questioned. The objective of this study was to conduct a systematic review to summarize the available evidence on how telehealth during the COVID-19 pandemic was associated with telehealth utilization for minority groups and its role in health disparities. METHODS We conducted a systematic review focused on health equity and access to care by searching for interventional and observational studies using the following four search domains: telehealth, COVID-19, health equity, and access to care. We searched PubMed, Embase, Cochrane CENTRAL, CINAHL, telehealth.hhs.gov, and the Rural Health Research Gateway, and included any study that reported quantitative results with a control group. RESULTS Our initial search yielded 1970 studies, and we included 48 in our final review. The most common dimensions of health equity studied were race/ethnicity, rurality, insurance status, language, and socioeconomic status, and the telehealth applications studied were diverse. Included studies had a moderate risk of bias. In aggregate, most studies reported increased telehealth use during the pandemic, with the greatest increase in non-minority populations, including White, younger, English-speaking people from urban areas. DISCUSSION We found that despite rapid adoption and increased telehealth use during the public health emergency, telehealth did not reduce existing disparities in access to care. We recommend that future work measuring the impact of telehealth focus on equity so that features of telehealth innovation can reduce disparities in health outcomes.
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Affiliation(s)
- Sara Ternes
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Lauren Lavin
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA
| | - J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Heather S Healy
- Hardin Library for the Health Sciences, University of Iowa, Iowa City, IA, USA
| | - Kimberly As Merchant
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
- Department of Anesthesia Critical Care, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Hoth KF, Ten Eyck P, Harland KK, Krishnadasan A, Rodriguez RM, Montoy JCC, Wendt LH, Mower W, Wallace K, Santibañez S, Talan DA, Mohr NM. Availability and use of institutional support programs for emergency department healthcare personnel during the COVID-19 pandemic. PLoS One 2024; 19:e0298807. [PMID: 38626053 PMCID: PMC11020772 DOI: 10.1371/journal.pone.0298807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 01/30/2024] [Indexed: 04/18/2024] Open
Abstract
OBJECTIVES The COVID-19 pandemic placed health care personnel (HCP) at risk for stress, anxiety, burnout, and post-traumatic stress disorder (PTSD). To address this, hospitals developed programs to mitigate risk. The objectives of the current study were to measure the availability and use of these programs in a cohort of academic emergency departments (EDs) in the United States early in the pandemic and identify factors associated with program use. METHODS Cross-sectional survey of ED HCP in 21 academic EDs in 15 states between June and September 2020. Site investigators provided data on the availability of 28 programs grouped into 9 categories. Individual support programs included: financial, workload mitigation, individual COVID-19 testing, emotional (e.g., mental health hotline), and instrumental (e.g., childcare) Clinical work support programs included: COVID-19 team communication (e.g., debriefing critical incident), patient-family communication facilitation, patient services (e.g., social work, ethics consultation), and system-level exposure reduction. Participants provided corresponding data on whether they used the programs. We used generalized linear mixed models clustered on site to measure the association between demographic and facility characteristics and program use. RESULTS We received 1,541 survey responses (96% response rate) from emergency physicians or advanced practice providers, nurses, and nonclinical staff. Program availability in each of the 9 categories was high (>95% of hospitals). Program use was variable, with clinical work support programs used more frequently (28-50% of eligible HCP across categories) than individual employee support programs (6-13% of eligible HCP across categories). Fifty-seven percent of respondents reported that the COVID-19 pandemic had affected their stress and anxiety, and 12% were at elevated risk for PTSD. Program use did not significantly differ for HCP who reported symptoms of anxiety and/or stress compared to those who did not. CONCLUSIONS Early in the pandemic, support programs were widely available to ED HCP, but program use was low. Future work will focus on identifying barriers and facilitators to use and specific programs most likely to be effective during periods of highest occupational stress.
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Affiliation(s)
- Karin F. Hoth
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, United States of America
- Iowa Neuroscience Institute, University of Iowa, Iowa City, IA, United States of America
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA, United States of America
| | - Karisa K. Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States of America
| | - Anusha Krishnadasan
- Olive View-UCLA Education and Research Institute, Los Angeles, CA, United States of America
| | - Robert M. Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Juan Carlos C. Montoy
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Linder H. Wendt
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA, United States of America
| | - William Mower
- Department of Emergency Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, United States of America
| | - Kelli Wallace
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States of America
| | - Scott Santibañez
- Division of Infectious Disease Readiness and Innovation, Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States of America
| | - David A. Talan
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States of America
- Department of Emergency Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, United States of America
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States of America
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Plumb ID, Briggs Hagen M, Wiegand R, Dumyati G, Myers C, Harland KK, Krishnadasan A, James Gist J, Abedi G, Fleming-Dutra KE, Chea N, Lee JE, Kellogg M, Edmundson A, Britton A, Wilson LE, Lovett SA, Ocampo V, Markus TM, Smithline HA, Hou PC, Lee LC, Mower W, Rwamwejo F, Steele MT, Lim SC, Schrading WA, Chinnock B, Beiser DG, Faine B, Haran JP, Nandi U, Chipman AK, LoVecchio F, Eucker S, Femling J, Fuller M, Rothman RE, Curlin ME, Talan DA, Mohr NM. Effectiveness of a bivalent mRNA vaccine dose against symptomatic SARS-CoV-2 infection among U.S. Healthcare personnel, September 2022-May 2023. Vaccine 2024; 42:2543-2552. [PMID: 37973512 PMCID: PMC10994739 DOI: 10.1016/j.vaccine.2023.10.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Bivalent mRNA vaccines were recommended since September 2022. However, coverage with a recent vaccine dose has been limited, and there are few robust estimates of bivalent VE against symptomatic SARS-CoV-2 infection (COVID-19). We estimated VE of a bivalent mRNA vaccine dose against COVID-19 among eligible U.S. healthcare personnel who had previously received monovalent mRNA vaccine doses. METHODS We conducted a case-control study in 22 U.S. states, and enrolled healthcare personnel with COVID-19 (case-participants) or without COVID-19 (control-participants) during September 2022-May 2023. Participants were considered eligible for a bivalent mRNA dose if they had received 2-4 monovalent (ancestral-strain) mRNA vaccine doses, and were ≥67 days after the most recent vaccine dose. We estimated VE of a bivalent mRNA dose using conditional logistic regression, accounting for matching by region and four-week calendar period. We adjusted estimates for age group, sex, race and ethnicity, educational level, underlying health conditions, community COVID-19 exposure, prior SARS-CoV-2 infection, and days since the last monovalent mRNA dose. RESULTS Among 3,647 healthcare personnel, 1,528 were included as case-participants and 2,119 as control-participants. Participants received their last monovalent mRNA dose a median of 404 days previously; 1,234 (33.8%) also received a bivalent mRNA dose a median of 93 days previously. Overall, VE of a bivalent dose was 34.1% (95% CI, 22.6%-43.9%) against COVID-19 and was similar by product, days since last monovalent dose, number of prior doses, age group, and presence of underlying health conditions. However, VE declined from 54.8% (95% CI, 40.7%-65.6%) after 7-59 days to 21.6% (95% CI 5.6%-34.9%) after ≥60 days. CONCLUSIONS Bivalent mRNA COVID-19 vaccines initially conferred approximately 55% protection against COVID-19 among U.S. healthcare personnel. However, protection waned after two months. These findings indicate moderate initial protection against symptomatic SARS-CoV-2 infection by remaining up-to-date with COVID-19 vaccines.
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Affiliation(s)
- Ian D Plumb
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control & Prevention, Atlanta, GA, USA.
| | - Melissa Briggs Hagen
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Ryan Wiegand
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Ghinwa Dumyati
- University of Rochester Medical Center, Rochester, NY, USA
| | | | | | | | - Jade James Gist
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Glen Abedi
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Katherine E Fleming-Dutra
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Nora Chea
- National Center for Emerging and Zoonotic Diseases, Centers for Disease Control & Prevention, USA
| | - Jane E Lee
- California Emerging Infections Program, Oakland, CA, USA
| | | | - Alexandra Edmundson
- Connecticut Emerging Infections Program, Yale School of Public Health, CT, USA
| | - Amber Britton
- Georgia Emerging Infections Program and Emory University School of Medicine, Atlanta, GA, USA
| | - Lucy E Wilson
- Maryland Emerging Infections Program, Maryland Department of Health and University of Maryland, Baltimore, MD, USA
| | | | - Valerie Ocampo
- Public Health Division, Oregon Health Authority, OR, USA
| | | | | | - Peter C Hou
- Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | - Mark T Steele
- University of Missouri-Kansas City, Kansas City, MO, USA
| | - Stephen C Lim
- University Medical Center New Orleans, LSU Health Sciences Center, New Orleans, LA, USA
| | | | | | | | | | - John P Haran
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Utsav Nandi
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | | | | | - Jon Femling
- University of New Mexico Health Science Center, USA
| | | | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
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5
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Lewis NM, Zhu Y, Peltan ID, Gaglani M, McNeal T, Ghamande S, Steingrub JS, Shapiro NI, Duggal A, Bender WS, Taghizadeh L, Brown SM, Hager DN, Gong MN, Mohamed A, Exline MC, Khan A, Wilson JG, Qadir N, Chang SY, Ginde AA, Mohr NM, Mallow C, Lauring AS, Johnson NJ, Gibbs KW, Kwon JH, Columbus C, Gottlieb RL, Raver C, Vaughn IA, Ramesh M, Johnson C, Lamerato L, Safdar B, Casey JD, Rice TW, Halasa N, Chappell JD, Grijalva CG, Talbot HK, Baughman A, Womack KN, Swan SA, Harker E, Price A, DeCuir J, Surie D, Ellington S, Self WH. Vaccine Effectiveness Against Influenza A-Associated Hospitalization, Organ Failure, and Death: United States, 2022-2023. Clin Infect Dis 2024; 78:1056-1064. [PMID: 38051664 DOI: 10.1093/cid/ciad677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/07/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Influenza circulation during the 2022-2023 season in the United States largely returned to pre-coronavirus disease 2019 (COVID-19)-pandemic patterns and levels. Influenza A(H3N2) viruses were detected most frequently this season, predominately clade 3C.2a1b.2a, a close antigenic match to the vaccine strain. METHODS To understand effectiveness of the 2022-2023 influenza vaccine against influenza-associated hospitalization, organ failure, and death, a multicenter sentinel surveillance network in the United States prospectively enrolled adults hospitalized with acute respiratory illness between 1 October 2022, and 28 February 2023. Using the test-negative design, vaccine effectiveness (VE) estimates against influenza-associated hospitalization, organ failures, and death were measured by comparing the odds of current-season influenza vaccination in influenza-positive case-patients and influenza-negative, SARS-CoV-2-negative control-patients. RESULTS A total of 3707 patients, including 714 influenza cases (33% vaccinated) and 2993 influenza- and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-negative controls (49% vaccinated) were analyzed. VE against influenza-associated hospitalization was 37% (95% confidence interval [CI]: 27%-46%) and varied by age (18-64 years: 47% [30%-60%]; ≥65 years: 28% [10%-43%]), and virus (A[H3N2]: 29% [6%-46%], A[H1N1]: 47% [23%-64%]). VE against more severe influenza-associated outcomes included: 41% (29%-50%) against influenza with hypoxemia treated with supplemental oxygen; 65% (56%-72%) against influenza with respiratory, cardiovascular, or renal failure treated with organ support; and 66% (40%-81%) against influenza with respiratory failure treated with invasive mechanical ventilation. CONCLUSIONS During an early 2022-2023 influenza season with a well-matched influenza vaccine, vaccination was associated with reduced risk of influenza-associated hospitalization and organ failure.
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Affiliation(s)
- Nathaniel M Lewis
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ithan D Peltan
- Department of Medicine, Intermountain Medical Center, Murray, Utah, and University of Utah, Salt Lake City, Utah, USA
| | - Manjusha Gaglani
- Baylor Scott and White Health, Temple and Dallas, Texas, and Texas A&M University College of Medicine, Temple, Texas, USA
| | - Tresa McNeal
- Baylor Scott and White Health, and Baylor College of Medicine, Temple, Texas, USA
| | - Shekhar Ghamande
- Baylor Scott and White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Jay S Steingrub
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Leyla Taghizadeh
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Samuel M Brown
- Department of Medicine, Intermountain Medical Center, Murray, Utah, and University of Utah, Salt Lake City, Utah, USA
| | - David N Hager
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michelle N Gong
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Amira Mohamed
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Matthew C Exline
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Akram Khan
- Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Jennifer G Wilson
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nida Qadir
- Department of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Steven Y Chang
- Department of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nicholas M Mohr
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | | | - Adam S Lauring
- Departments of Internal Medicine and Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine and Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Kevin W Gibbs
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jennie H Kwon
- Department of Medicine, Washington University, St.Louis, Missouri, USA
| | | | - Robert L Gottlieb
- Baylor University Medical Center Dallas, Baylor, Scott & White Heart and Vascular Hospital, Baylor, Scott and White Research Institute, Dallas, Texas, USA
| | | | - Ivana A Vaughn
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
| | - Mayur Ramesh
- Division of Infectious Diseases, Henry Ford Health, Detroit, Michigan, USA
| | - Cassandra Johnson
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lois Lamerato
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
| | - Basmah Safdar
- Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jonathan D Casey
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd W Rice
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Natasha Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James D Chappell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - H Keipp Talbot
- Departments of Medicine and Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adrienne Baughman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelsey N Womack
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sydney A Swan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth Harker
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Ashley Price
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Jennifer DeCuir
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Diya Surie
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Sascha Ellington
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt Institute for Clinical and Translational Research, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
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6
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Surie D, Yuengling KA, DeCuir J, Zhu Y, Lauring AS, Gaglani M, Ghamande S, Peltan ID, Brown SM, Ginde AA, Martinez A, Mohr NM, Gibbs KW, Hager DN, Ali H, Prekker ME, Gong MN, Mohamed A, Johnson NJ, Srinivasan V, Steingrub JS, Leis AM, Khan A, Hough CL, Bender WS, Duggal A, Bendall EE, Wilson JG, Qadir N, Chang SY, Mallow C, Kwon JH, Exline MC, Shapiro NI, Columbus C, Vaughn IA, Ramesh M, Mosier JM, Safdar B, Casey JD, Talbot HK, Rice TW, Halasa N, Chappell JD, Grijalva CG, Baughman A, Womack KN, Swan SA, Johnson CA, Lwin CT, Lewis NM, Ellington S, McMorrow ML, Martin ET, Self WH. Severity of Respiratory Syncytial Virus vs COVID-19 and Influenza Among Hospitalized US Adults. JAMA Netw Open 2024; 7:e244954. [PMID: 38573635 DOI: 10.1001/jamanetworkopen.2024.4954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
Importance On June 21, 2023, the Centers for Disease Control and Prevention recommended the first respiratory syncytial virus (RSV) vaccines for adults aged 60 years and older using shared clinical decision-making. Understanding the severity of RSV disease in adults can help guide this clinical decision-making. Objective To describe disease severity among adults hospitalized with RSV and compare it with the severity of COVID-19 and influenza disease by vaccination status. Design, Setting, and Participants In this cohort study, adults aged 18 years and older admitted to the hospital with acute respiratory illness and laboratory-confirmed RSV, SARS-CoV-2, or influenza infection were prospectively enrolled from 25 hospitals in 20 US states from February 1, 2022, to May 31, 2023. Clinical data during each patient's hospitalization were collected using standardized forms. Data were analyzed from August to October 2023. Exposures RSV, SARS-CoV-2, or influenza infection. Main Outcomes and Measures Using multivariable logistic regression, severity of RSV disease was compared with COVID-19 and influenza severity, by COVID-19 and influenza vaccination status, for a range of clinical outcomes, including the composite of invasive mechanical ventilation (IMV) and in-hospital death. Results Of 7998 adults (median [IQR] age, 67 [54-78] years; 4047 [50.6%] female) included, 484 (6.1%) were hospitalized with RSV, 6422 (80.3%) were hospitalized with COVID-19, and 1092 (13.7%) were hospitalized with influenza. Among patients with RSV, 58 (12.0%) experienced IMV or death, compared with 201 of 1422 unvaccinated patients with COVID-19 (14.1%) and 458 of 5000 vaccinated patients with COVID-19 (9.2%), as well as 72 of 699 unvaccinated patients with influenza (10.3%) and 20 of 393 vaccinated patients with influenza (5.1%). In adjusted analyses, the odds of IMV or in-hospital death were not significantly different among patients hospitalized with RSV and unvaccinated patients hospitalized with COVID-19 (adjusted odds ratio [aOR], 0.82; 95% CI, 0.59-1.13; P = .22) or influenza (aOR, 1.20; 95% CI, 0.82-1.76; P = .35); however, the odds of IMV or death were significantly higher among patients hospitalized with RSV compared with vaccinated patients hospitalized with COVID-19 (aOR, 1.38; 95% CI, 1.02-1.86; P = .03) or influenza disease (aOR, 2.81; 95% CI, 1.62-4.86; P < .001). Conclusions and Relevance Among adults hospitalized in this US cohort during the 16 months before the first RSV vaccine recommendations, RSV disease was less common but similar in severity compared with COVID-19 or influenza disease among unvaccinated patients and more severe than COVID-19 or influenza disease among vaccinated patients for the most serious outcomes of IMV or death.
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Affiliation(s)
- Diya Surie
- Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katharine A Yuengling
- Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jennifer DeCuir
- Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adam S Lauring
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor
| | - Manjusha Gaglani
- Baylor Scott & White Health, Temple, Texas
- Texas A&M University College of Medicine, Temple
- Baylor College of Medicine, Temple, Texas
| | - Shekhar Ghamande
- Baylor Scott & White Health, Temple, Texas
- Texas A&M University College of Medicine, Temple
- Baylor College of Medicine, Temple, Texas
| | - Ithan D Peltan
- Department of Medicine, Intermountain Medical Center, Murray, Utah and University of Utah, Salt Lake City
| | - Samuel M Brown
- Department of Medicine, Intermountain Medical Center, Murray, Utah and University of Utah, Salt Lake City
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
| | - Amanda Martinez
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
| | | | - Kevin W Gibbs
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David N Hager
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Harith Ali
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Michelle N Gong
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Amira Mohamed
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Nicholas J Johnson
- Department of Emergency Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
| | | | - Jay S Steingrub
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts
| | - Aleda M Leis
- School of Public Health, University of Michigan, Ann Arbor
| | - Akram Khan
- Department of Medicine, Oregon Health and Sciences University, Portland
| | - Catherine L Hough
- Department of Medicine, Oregon Health and Sciences University, Portland
| | | | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Emily E Bendall
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor
| | - Jennifer G Wilson
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Nida Qadir
- Department of Medicine, University of California, Los Angeles
| | - Steven Y Chang
- Department of Medicine, University of California, Los Angeles
| | | | - Jennie H Kwon
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Cristie Columbus
- Baylor Scott &White Health, Dallas, Texas
- Texas A&M University College of Medicine, Dallas
| | - Ivana A Vaughn
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan
| | - Mayur Ramesh
- Division of Infectious Diseases, Henry Ford Health, Detroit, Michigan
| | - Jarrod M Mosier
- Department of Emergency Medicine, University of Arizona, Tucson
| | - Basmah Safdar
- Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan D Casey
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - H Keipp Talbot
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W Rice
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Natasha Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James D Chappell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adrienne Baughman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelsey N Womack
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sydney A Swan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cassandra A Johnson
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cara T Lwin
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nathaniel M Lewis
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sascha Ellington
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Meredith L McMorrow
- Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Emily T Martin
- School of Public Health, University of Michigan, Ann Arbor
| | - Wesley H Self
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
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7
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Mohr NM, Young T, Vakkalanka JP, Carter KD, Shane DM, Ullrich F, Schuette AR, Mack LJ, DeJong K, Bell A, Pals M, Camargo CA, Zachrison KS, Boggs KM, Skibbe A, Ward MM. Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments. Acad Emerg Med 2024; 31:326-338. [PMID: 38112033 DOI: 10.1111/acem.14857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs. METHODS Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions. RESULTS In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar. CONCLUSIONS Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.
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Affiliation(s)
- Nicholas M Mohr
- Departments of Emergency Medicine, Anesthesia, and Epidemiology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Tracy Young
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - J Priyanka Vakkalanka
- Departments of Emergency Medicine and Epidemiology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Knute D Carter
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Dan M Shane
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Fred Ullrich
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | | | - Luke J Mack
- Department of Family Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
- Avel eCARE, Sioux Falls, South Dakota, USA
| | | | | | - Mark Pals
- Avel eCARE, Sioux Falls, South Dakota, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Krislyn M Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adam Skibbe
- Department of Geography, University of Iowa College of Liberal Arts and Sciences, Iowa City, Iowa, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
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8
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Baymon DE, Vakkalanka JP, Krishnadasan A, Mohr NM, Talan DA, Hagen MB, Wallace K, Harland KK, Aisiku IP, Hou PC. Race, Ethnicity, and Delayed Time to COVID-19 Testing Among US Health Care Workers. JAMA Netw Open 2024; 7:e245697. [PMID: 38598239 PMCID: PMC11007575 DOI: 10.1001/jamanetworkopen.2024.5697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/12/2024] [Indexed: 04/11/2024] Open
Abstract
Importance Access to COVID-19 testing is critical to reducing transmission and supporting early treatment decisions; when made accessible, the timeliness of testing may also be an important metric in mitigating community spread of the infection. While disparities in transmission and outcomes of COVID-19 have been well documented, the extent of timeliness of testing and the association with demographic factors is unclear. Objectives To evaluate demographic factors associated with delayed COVID-19 testing among health care personnel (HCP) during the COVID-19 pandemic. Design, Setting, and Participants This cross-sectional study used data from the Preventing Emerging Infections Through Vaccine Effectiveness Testing study, a multicenter, test-negative, case-control vaccine effectiveness study that enrolled HCP who had COVID-19 symptoms and testing between December 2020 and April 2022. Data analysis was conducted from March 2022 to Junne 2023. Exposure Displaying COVID-19-like symptoms and polymerase chain reaction testing occurring from the first day symptoms occurred up to 14 days after symptoms occurred. Main Outcomes and Measures Variables of interest included patient demographics (sex, age, and clinical comorbidities) and COVID-19 characteristics (vaccination status and COVID-19 wave). The primary outcome was time from symptom onset to COVID-19 testing, which was defined as early testing (≤2 days) or delayed testing (≥3 days). Associations of demographic characteristics with delayed testing were measured while adjusting for clinical comorbidities, COVID-19 characteristics, and test site using multivariable modeling to estimate relative risks and 95% CIs. Results A total of 5551 HCP (4859 female [82.9%]; 1954 aged 25-34 years [35.2%]; 4233 non-Hispanic White [76.3%], 370 non-Hispanic Black [6.7%], and 324 non-Hispanic Asian [5.8%]) were included in the final analysis. Overall, 2060 participants (37.1%) reported delayed testing and 3491 (62.9%) reported early testing. Compared with non-Hispanic White HCP, delayed testing was higher among non-Hispanic Black HCP (adjusted risk ratio, 1.18; 95%CI, 1.10-1.27) and for non-Hispanic HCP of other races (adjusted risk ratio, 1.17; 95% CI, 1.03-1.33). Sex and age were not associated with delayed testing. Compared with clinical HCP with graduate degrees, all other professional and educational groups had significantly delayed testing. Conclusions and Relevance In this cross-sectional study of HCP, compared with non-Hispanic White HCP and clinical HCP with graduate degrees, non-Hispanic Black HCP, non-Hispanic HCP of other races, and HCP all other professional and education backgrounds were more likely to have delayed COVID-19 testing. These findings suggest that time to testing may serve as a valuable metric in evaluating sociodemographic disparities in the response to COVID-19 and future health mitigation strategies.
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Affiliation(s)
- DaMarcus E. Baymon
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - J. Priyanka Vakkalanka
- Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City
| | - Anusha Krishnadasan
- Olive View-University of California, Los Angeles Education and Research Institute, Los Angeles
| | - Nicholas M. Mohr
- Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City
- Department of Anesthesia Critical Care, Carver College of Medicine, University of Iowa, Iowa City
| | - David A. Talan
- Olive View-University of California, Los Angeles Education and Research Institute, Los Angeles
- David Geffen School of Medicine, University of California, Los Angeles
| | - Melissa Briggs Hagen
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control & Prevention, Atlanta, Georgia
| | - Kelli Wallace
- University of Iowa Holden Comprehensive Cancer Center, University of Iowa, Iowa City
| | - Karisa K. Harland
- Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City
| | - Imoigele P. Aisiku
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Peter C. Hou
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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9
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Weber KD, Mower W, Krishnadasan A, Mohr NM, Montoy JC, Rodriguez RM, Giordano PA, Eyck PT, Harland KK, Wallace K, McDonald LC, Kutty PK, Hesse EM, Talan DA. Coronavirus Disease 2019 Infections Among Emergency Health Care Personnel: Impact on Delivery of United States Emergency Medical Care, 2020. Ann Emerg Med 2024:S0196-0644(24)00035-0. [PMID: 38493375 DOI: 10.1016/j.annemergmed.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/04/2024] [Accepted: 01/18/2024] [Indexed: 03/18/2024]
Abstract
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.
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Affiliation(s)
- Kurt D Weber
- Department of Emergency Medicine, Orlando Health, Orlando, FL.
| | - William Mower
- Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, the David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City, IA
| | - Juan Carlos Montoy
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
| | | | - Patrick Ten Eyck
- Department of Emergency Medicine, University of Iowa, Iowa City, IA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa, Iowa City, IA
| | - Kelli Wallace
- Department of Emergency Medicine, University of Iowa, Iowa City, IA
| | | | - Preeta K Kutty
- Division of Healthcare Quality Promotion Centers for Disease Control and Prevention, Atlanta, GA; Division of Preparedness and Emerging Infections Centers for Disease Control and Prevention, Atlanta, GA
| | - Elisabeth M Hesse
- Division of Preparedness and Emerging Infections Centers for Disease Control and Prevention, Atlanta, GA
| | - David A Talan
- Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, the David Geffen School of Medicine at UCLA, Los Angeles, CA; Olive View-UCLA Education and Research Institute, Los Angeles, CA
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10
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Schneider K, Williams M, Mohr NM, Ahmed A. Rural Emergency Medical Services Clinicians' Perceptions and Preferences in Receiving Clinical Feedback From Hospitals: A Qualitative Needs Assessment. PREHOSP EMERG CARE 2024:1-10. [PMID: 38416871 DOI: 10.1080/10903127.2024.2324970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 02/18/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Emergency medical services (EMS) clinicians experience dissatisfaction with the quality and quantity of clinical feedback from hospitals. Satisfaction is further diminished by the lack of a standardized systems approach. The purpose of this study was to identify rural clinicians' perceptions and preferences regarding clinical feedback received from hospitals, the delivery mechanisms, and its impact on their relationships with health care organizations. METHODS This was a qualitative study focused on EMS clinicians involved in rural prehospital care at a single Midwestern academic medical center. Using a phenomenological framework, semi-structured interviews were conducted with medical directors, service directors, fire captains, air medical personnel, emergency medical responders, emergency medical technicians, advanced emergency medical technicians, and paramedics, all of whom were selected through purposive sampling. Interviews were recorded, transcribed, and independently coded by two trained reviewers. RESULTS Twenty participants (11 frontline clinicians and 9 administrative staff members) with a wide range of clinical experience from 14 air and ground EMS agencies were interviewed. Emerging themes included: (1) the value or usefulness of feedback; (2) desired feedback system characteristics; (3) barriers to receiving feedback; (4) utilization and application of feedback; and (5) the feedback's impact on the relationship with health care organizations. Participants felt that clinical feedback from hospitals was especially important as a method of improving quality of care, though was rarely provided. Professional development was seen as a major benefit of receiving clinical feedback from hospitals. CONCLUSION Our results suggest that consistent clinical feedback provided by hospitals was valued. Establishing a culture of providing organized feedback to practicing rural EMS clinicians is important for professional development and can strengthen the relationships between EMS clinicians and hospitals. These study findings can assist in the development and implementation of a standardized feedback instrument to benefit rural EMS clinicians, patients, and the health care system as a whole.
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Affiliation(s)
- Katherine Schneider
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Mimi Williams
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
- Divison of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Management and Entrepreneurship, University of Iowa Tippie College of Business, Iowa City, Iowa
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11
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DeCuir J, Payne AB, Self WH, Rowley EA, Dascomb K, DeSilva MB, Irving SA, Grannis SJ, Ong TC, Klein NP, Weber ZA, Reese SE, Ball SW, Barron MA, Naleway AL, Dixon BE, Essien I, Bride D, Natarajan K, Fireman B, Shah AB, Okwuazi E, Wiegand R, Zhu Y, Lauring AS, Martin ET, Gaglani M, Peltan ID, Brown SM, Ginde AA, Mohr NM, Gibbs KW, Hager DN, Prekker M, Mohamed A, Srinivasan V, Steingrub JS, Khan A, Busse LW, Duggal A, Wilson JG, Chang SY, Mallow C, Kwon JH, Exline MC, Columbus C, Vaughn IA, Safdar B, Mosier JM, Harris ES, Casey JD, Chappell JD, Grijalva CG, Swan SA, Johnson C, Lewis NM, Ellington S, Adams K, Tenforde MW, Paden CR, Dawood FS, Fleming-Dutra KE, Surie D, Link-Gelles R. Interim Effectiveness of Updated 2023-2024 (Monovalent XBB.1.5) COVID-19 Vaccines Against COVID-19-Associated Emergency Department and Urgent Care Encounters and Hospitalization Among Immunocompetent Adults Aged ≥18 Years - VISION and IVY Networks, September 2023-January 2024. MMWR Morb Mortal Wkly Rep 2024; 73:180-188. [PMID: 38421945 PMCID: PMC10907041 DOI: 10.15585/mmwr.mm7308a5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
In September 2023, CDC's Advisory Committee on Immunization Practices recommended updated 2023-2024 (monovalent XBB.1.5) COVID-19 vaccination for all persons aged ≥6 months to prevent COVID-19, including severe disease. However, few estimates of updated vaccine effectiveness (VE) against medically attended illness are available. This analysis evaluated VE of an updated COVID-19 vaccine dose against COVID-19-associated emergency department (ED) or urgent care (UC) encounters and hospitalization among immunocompetent adults aged ≥18 years during September 2023-January 2024 using a test-negative, case-control design with data from two CDC VE networks. VE against COVID-19-associated ED/UC encounters was 51% (95% CI = 47%-54%) during the first 7-59 days after an updated dose and 39% (95% CI = 33%-45%) during the 60-119 days after an updated dose. VE estimates against COVID-19-associated hospitalization from two CDC VE networks were 52% (95% CI = 47%-57%) and 43% (95% CI = 27%-56%), with a median interval from updated dose of 42 and 47 days, respectively. Updated COVID-19 vaccine provided increased protection against COVID-19-associated ED/UC encounters and hospitalization among immunocompetent adults. These results support CDC recommendations for updated 2023-2024 COVID-19 vaccination. All persons aged ≥6 months should receive updated 2023-2024 COVID-19 vaccine.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - CDC COVID-19 Vaccine Effectiveness Collaborators
- Coronavirus and Other
Respiratory Viruses Division, National Center for Immunization and Respiratory
Diseases, CDC; Vanderbilt University Medical Center, Nashville,
Tennessee; Westat,
Rockville, Maryland; Division of Infectious Diseases and Clinical Epidemiology,
Intermountain Healthcare, Salt Lake City, Utah; HealthPartners Institute,
Minneapolis, Minnesota; Kaiser Permanente Center for Health Research,
Portland, Oregon; Indiana University School of Medicine, Indianapolis,
Indiana; Regenstrief
Institute Center for Biomedical Informatics, Indianapolis, Indiana; University of Colorado
School of Medicine, Aurora, Colorado; Kaiser Permanente Vaccine Study Center, Kaiser
Permanente Northern California Division of Research, Oakland, California;
Department of
Biomedical Informatics, Columbia University Irving Medical Center, New York, New
York; New
York-Presbyterian Hospital, New York, New York; General Dynamics Information
Technology, Falls Church, Virginia; University of Michigan, Ann Arbor, Michigan;
Baylor Scott
& White Health, Texas; Baylor College of Medicine, Temple, Texas; Intermountain Medical
Center, Murray, Utah; University of Utah, Salt Lake City, Utah; University of Iowa, Iowa
City, Iowa; Wake
Forest School of Medicine, Winston-Salem, North Carolina; Johns Hopkins University School of
Medicine, Baltimore, Maryland; Hennepin County Medical Center, Minneapolis,
Minnesota; Montefiore
Medical Center, Albert Einstein College of Medicine, New York, New York; University of Washington,
Seattle, Washington; Baystate Medical Center, Springfield, Massachusetts;
Oregon Health
& Science University, Portland, Oregon; Emory University, Atlanta, Georgia; Cleveland Clinic,
Cleveland, Ohio; Stanford University School of Medicine, Stanford,
California; Ronald
Reagan UCLA Medical Center, Los Angeles, California; University of Miami, Miami, Florida;
Washington
University in St. Louis, St. Louis, Missouri; The Ohio State University, Columbus,
Ohio; Texas A&M
University College of Medicine, Dallas, Texas; Henry Ford Health, Detroit,
Michigan; Yale
University School of Medicine, New Haven, Connecticut; University of Arizona, Tucson,
Arizona; Influenza
Division, National Center for Immunization and Respiratory Diseases, CDC
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12
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Vakkalanka JP, Gadag K, Lavin L, Ternes S, Healy HS, Merchant KAS, Scott W, Wiggins W, Ward MM, Mohr NM. Telehealth Use and Health Equity for Mental Health and Substance Use Disorder During the COVID-19 Pandemic: A Systematic Review. Telemed J E Health 2024. [PMID: 38227387 DOI: 10.1089/tmj.2023.0588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
Background: As a result of the COVID-19 public health emergency (PHE), telehealth utilization accelerated to facilitate health care management and minimize risk. However, those with mental health conditions and substance use disorders (SUD)-who represent a vulnerable population, and members of underrepresented minorities (e.g., rural, racial/ethnic minorities, the elderly)-may not benefit from telehealth equally. Objective: To evaluate health equality in clinical effectiveness and utilization measures associated with telehealth for clinical management of mental health disorders and SUD to identify emerging patterns for underrepresented groups stratified by race/ethnicity, gender, age, rural status, insurance, sexual minorities, and social vulnerability. Methods: We performed a systematic review in PubMed, Embase, Cochrane Central Register of Controlled Trials, and CINAHL through November 2022. Studies included those with telehealth, COVID-19, health equity, and mental health or SUD treatment/care concepts. Our outcomes included general clinical measures, mental health or SUD clinical measures, and operational measures. Results: Of the 2,740 studies screened, 25 met eligibility criteria. The majority of studies (n = 20) evaluated telehealth for mental health conditions, while the remaining five studies evaluated telehealth for opioid use disorder/dependence. The most common study outcomes were utilization measures (n = 19) or demographic predictors of telehealth utilization (n = 3). Groups that consistently demonstrated less telehealth utilization during the PHE included rural residents, older populations, and Black/African American minorities. Conclusions: We observed evidence of inequities in telehealth utilization among several underrepresented groups. Future efforts should focus on measuring the contribution of utilization disparities on outcomes and strategies to mitigate disparities in implementation.
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Affiliation(s)
- J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Khyathi Gadag
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Lauren Lavin
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Sara Ternes
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Heather S Healy
- Hardin Library for the Health Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Kimberly A S Merchant
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Wakina Scott
- Office for the Advancement of Telehealth, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland, USA
| | - Whitney Wiggins
- Office for the Advancement of Telehealth, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
- Department of Anesthesia and Critical Care, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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13
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Vakkalanka JP, Holcombe A, Ward MM, Carter KD, McCoy KD, Clark HM, Gutierrez JT, Merchant KAS, Mohr NM. Chronic Disease Management through Clinical Video Telehealth on Health Care Utilization, and Mortality in the Veterans Health Administration: A Retrospective Cohort Study. Telemed J E Health 2024. [PMID: 38206653 DOI: 10.1089/tmj.2023.0285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Background: Chronic health diseases such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM) affect 6 in 10 Americans and contribute to 90% of the $4.1 trillion health care expenditures. The objective of this study was to measure the effect of clinical video telehealth (CVT) on health care utilization and mortality. A retrospective cohort study of Veterans ≥65 years with CHF, COPD, or DM was conducted. Measures: Veterans using CVT were matched 1:3 on demographic characteristics to Veterans who did not use CVT. Outcomes included 1-year incidence of ED visits, inpatient admissions, and mortality, reported as adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results: Final analytical cohorts included 22,280 Veterans with CHF, 51,872 Veterans with COPD, and 170,605 Veterans with DM. CVT utilization was associated with increased ED visits for CHF (aOR: 1.24; 95% CI: 1.15-1.34), COPD (aOR: 1.20; 95% CI: 1.14-1.26), and DM (aOR: 1.07; 95% CI: 1.00-1.10). For CHF, there was no difference between CVT utilization and inpatient admissions (aOR: 0.98; 95% CI 0.91-1.05) or mortality (aOR: 1.03; 95% CI: 0.93-1.15). For COPD, CVT was associated with increased inpatient admissions (aOR: 1.08; 95% CI: 1.02-1.13) and mortality (aOR: 1.36; 95% CI: 1.25-1.48). For DM, CVT utilization was associated with lower risk of inpatient admissions (aOR: 0.83; 95% CI: 0.80-0.86) and mortality (aOR: 0.89; 95% CI: 0.84-0.95). Conclusions: CVT use as an alternative care site might serve as an early warning system, such that this mechanism may indicate when an in-person assessment is needed for potential exacerbation of conditions. Although inpatient and mortality varied, ED utilization was higher with CVT. Exploring pathways accessing clinical care through CVT, and how CVT is directly or indirectly associated with immediate and long-term clinical outcomes would be valuable.
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Affiliation(s)
- J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Andrea Holcombe
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Knute D Carter
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Kimberly D McCoy
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Heidi M Clark
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Jeydith T Gutierrez
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Kimberly A S Merchant
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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14
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Mohr NM, Plumb ID, Santos León E, Harland KK, Krishnadasan A, Nandi U, Hoth KF, Smithline HA, Talan DA. Factors associated with the decision to receive bivalent COVID-19 booster vaccination among health care personnel. Hum Vaccin Immunother 2023; 19:2284471. [PMID: 37994545 PMCID: PMC10760319 DOI: 10.1080/21645515.2023.2284471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
COVID-19 vaccination is effective at reducing SARS-CoV-2 complications, but uptake has been low. Our objective in this study was to compare the importance of factors reported to influence the decision to receive a bivalent COVID-19 booster vaccine among health care personnel (HCP) tested for SARS-CoV-2 between October 2022 and April 2023 in a 20-hospital vaccine effectiveness study in the United States (n = 1656). Compared with those who had not received the booster, the factors most likely to be reported to be important were concerns about contracting COVID-19 (84.0% of those who had received the bivalent booster vs. 47.5% of those who had not, difference 36.6% points (PP), 95% confidence interval [CI] 32.1 to 41.1%), spreading infection to family members (89.2% vs. 62.8%, difference 26.3 PP, 95% CI 22.3 to 30.4%), and spreading infection to colleagues at work (85.5% vs. 59.4%, difference 26.1 PP, 95% CI 21.7 to 30.5%). HCP who had received the booster more frequently cited the primary literature (61.7% vs. 31.8%, difference 29.9 PP, 95% CI 24.6 to 35.2%) and employer recommendations (48.3% vs. 29.8%, difference 18.5 PP, 95% CI 13.2 to 23.9%) as influencing their decision. This analysis provides insight into factors for targeting future vaccine messaging.
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Affiliation(s)
- Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Ian D. Plumb
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eliezer Santos León
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Karisa K. Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Anusha Krishnadasan
- Olive View-UCLA Education and Research Institute, Olive View-UCLA Medical Center, Los Angeles, CA, USA
| | - Utsav Nandi
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Karin F. Hoth
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Howard A. Smithline
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Springfield, MA, USA
| | - David A. Talan
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA, USA
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15
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Bonfanti NP, Mohr NM, Willms DC, Bedimo RJ, Gundert E, Goff KL, Kulstad EB, Drewry AM. Core Warming of Coronavirus Disease 2019 Patients Undergoing Mechanical Ventilation: A Pilot Study. Ther Hypothermia Temp Manag 2023; 13:225-229. [PMID: 37527424 DOI: 10.1089/ther.2023.0030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
Fever is a recognized protective factor in patients with sepsis, and growing data suggest beneficial effects on outcomes in sepsis with elevated temperature, with a recent pilot randomized controlled trial (RCT) showing lower mortality by warming afebrile sepsis patients in the intensive care unit (ICU). The objective of this prospective single-site RCT was to determine if core warming improves respiratory physiology of mechanically ventilated patients with coronavirus disease 2019 (COVID-19), allowing earlier weaning from ventilation, and greater overall survival. A total of 19 patients with mean age of 60.5 (±12.5) years, 37% female, mean weight 95.1 (±18.6) kg, and mean body mass index 34.5 (±5.9) kg/m2 with COVID-19 requiring mechanical ventilation were enrolled from September 2020 to February 2022. Patients were randomized 1:1 to standard of care or to receive core warming for 72 hours through an esophageal heat exchanger commonly utilized in critical care and surgical patients. The maximum target temperature was 39.8°C. A total of 10 patients received usual care and 9 patients received esophageal core warming. After 72 hours of warming, the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratios were 197 (±32) and 134 (±13.4), cycle thresholds were 30.8 (±6.4) and 31.4 (±3.2), ICU mortalities were 40% and 44%, 30-day mortalities were 30% and 22%, and mean 30-day ventilator-free days were 11.9 (±12.6) and 6.8 (±10.2) for standard of care and warmed patients, respectively (p = NS). This pilot study suggests that core warming of patients with COVID-19 undergoing mechanical ventilation is feasible and appears safe. Optimizing time to achieve febrile-range temperature may require a multimodal temperature management strategy to further evaluate effects on outcome. ClinicalTrials.gov Identifier: NCT04494867.
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Affiliation(s)
- Nathaniel P Bonfanti
- Department of Emergency Medicine, University of Texas at Southwestern Medical Center, Dallas, Texas, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - David C Willms
- Department of Critical Care, Sharp Memorial Hospital, San Diego, California, USA
| | - Roger J Bedimo
- Department of Internal Medicine, Division of Infectious Disease, VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emily Gundert
- Department of Emergency Medicine, University of Texas at Southwestern Medical Center, Dallas, Texas, USA
| | - Kristina L Goff
- Department of Anesthesiology, University of Texas at Southwestern Medical Center, Dallas, Texas, USA
| | - Erik B Kulstad
- Department of Emergency Medicine, University of Texas at Southwestern Medical Center, Dallas, Texas, USA
| | - Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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16
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Fuller BM, Driver BE, Roberts MB, Schorr CA, Thompson K, Faine B, Yeary J, Mohr NM, Pappal RD, Stephens RJ, Yan Y, Johnson NJ, Roberts BW. Awareness with paralysis and symptoms of post-traumatic stress disorder among mechanically ventilated emergency department survivors (ED-AWARENESS-2 Trial): study protocol for a pragmatic, multicenter, stepped wedge cluster randomized trial. Trials 2023; 24:753. [PMID: 38001507 PMCID: PMC10675941 DOI: 10.1186/s13063-023-07764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Awareness with paralysis (AWP) is memory recall during neuromuscular blockade (NMB) and can cause significant psychological harm. Decades of effort and rigorous trials have been conducted to prevent AWP in the operating room, where prevalence is 0.1-0.2%. By contrast, AWP in mechanically ventilated emergency department (ED) patients is common, with estimated prevalence of 3.3-7.4% among survivors given NMB. Longer-acting NMB use is a critical risk for AWP, and we have shown an association between ED rocuronium use and increased AWP prevalence. As NMB are given to more than 90% of ED patients during tracheal intubation, this trial provides a platform to test an intervention aimed at reducing AWP. The overall objective is to test the hypothesis that limiting ED rocuronium exposure will significantly reduce the proportion of patients experiencing AWP. METHODS This is a pragmatic, stepped wedge cluster randomized trial conducted in five academic EDs, and will enroll 3090 patients. Per the design, all sites begin in a control phase, under observational conditions. At 6-month intervals, sites sequentially enter a 2-month transition phase, during which we will implement the multifaceted intervention, which will rely on use of nudges and defaults to change clinician decisions regarding ED NMB use. During the intervention phase, succinylcholine will be the default NMB over rocuronium. The primary outcome is AWP, assessed with the modified Brice questionnaire, adjudicated by three independent, blinded experts. The secondary outcome is the proportion of patients developing clinically significant symptoms of post-traumatic stress disorder at 30 and 180 days after hospital discharge. We will also assess for symptoms of depression and anxiety, and health-related quality of life. A generalized linear model, adjusted for time and cluster interactions, will be used to compare AWP in control versus intervention phases, analyzed by intention-to-treat. DISCUSSION The ED-AWARENESS-2 Trial will be the first ED-based trial aimed at preventing AWP, a critical threat to patient safety. Results could shape clinical use of NMB in the ED and prevent more than 10,000 annual cases of AWP related to ED care. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT05534243 . Registered 06, September 2022.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, 63110, USA.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, 55415, USA
| | - Michael B Roberts
- Department of Institutional Research, Department of Psychology, Philadelphia College of Osteopathic Medicine, Rowland Hall, 514B, 4190 City Avenue, Philadelphia, PA, 19131, USA
| | - Christa A Schorr
- Cooper Research Institute, Cooper University Health Care, One Cooper Plaza, Dorrance, Camden, NJ, 08103, USA
| | - Kathryn Thompson
- Department of Emergency Medicine, University of Washington/Harborview Medical Center, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Brett Faine
- Departments of Emergency Medicine and Pharmacy, Roy J. and Lucille A. Carver College of Medicine, University of Iowa College of Pharmacy, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA
| | - Julianne Yeary
- Emergency Department, Charles F. Knight Emergency and Trauma Center, Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza, St. Louis, MO, 63110, USA
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA
| | - Ryan D Pappal
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Robert J Stephens
- Department of Medicine, Division of Critical Care Medicine, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, 418E, 2Nd Floor, 600 South Taylor Ave., St. Louis, MO, 63110, USA
| | - Nicholas J Johnson
- Departments of Emergency Medicine and Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington/Harborview Medical Center, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, NJ, 08103, USA
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17
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Ofoma UR, Deych E, Mohr NM, Walkey A, Kollef M, Wan F, Joynt Maddox KE. The Relationship Between Hospital Capability and Mortality in Sepsis: Development of a Sepsis-Related Hospital Capability Index. Crit Care Med 2023; 51:1479-1491. [PMID: 37338282 PMCID: PMC10615795 DOI: 10.1097/ccm.0000000000005973] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVES Regionalized sepsis care could improve sepsis outcomes by facilitating the interhospital transfer of patients to higher-capability hospitals. There are no measures of sepsis capability to guide the identification of such hospitals, although hospital case volume of sepsis has been used as a proxy. We evaluated the performance of a novel hospital sepsis-related capability (SRC) index as compared with sepsis case volume. DESIGN Principal component analysis (PCA) and retrospective cohort study. SETTING A total of 182 New York (derivation) and 274 Florida and Massachusetts (validation) nonfederal hospitals, 2018. PATIENTS A total of 89,069 and 139,977 adult patients (≥ 18 yr) with sepsis were directly admitted into the derivation and validation cohort hospitals, respectively. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We derived SRC scores by PCA of six hospital resource use characteristics (bed capacity, annual volumes of sepsis, major diagnostic procedures, renal replacement therapy, mechanical ventilation, and major therapeutic procedures) and classified hospitals into capability score tertiles: high, intermediate, and low. High-capability hospitals were mostly urban teaching hospitals. Compared with sepsis volume, the SRC score explained more variation in hospital-level sepsis mortality in the derivation (unadjusted coefficient of determination [ R2 ]: 0.25 vs 0.12, p < 0.001 for both) and validation (0.18 vs 0.05, p < 0.001 for both) cohorts; and demonstrated stronger correlation with outward transfer rates for sepsis in the derivation (Spearman coefficient [ r ]: 0.60 vs 0.50) and validation (0.51 vs 0.45) cohorts. Compared with low-capability hospitals, patients with sepsis directly admitted into high-capability hospitals had a greater number of acute organ dysfunctions, a higher proportion of surgical hospitalizations, and higher adjusted mortality (odds ratio [OR], 1.55; 95% CI, 1.25-1.92). In stratified analysis, worse mortality associated with higher hospital capability was only evident among patients with three or more organ dysfunctions (OR, 1.88 [1.50-2.34]). CONCLUSIONS The SRC score has face validity for capability-based groupings of hospitals. Sepsis care may already be de facto regionalized at high-capability hospitals. Low-capability hospitals may have become more adept at treating less complicated sepsis.
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Affiliation(s)
- Uchenna R. Ofoma
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis, St. Louis MO, USA
| | - Elena Deych
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis MO, USA
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia, and Epidemiology, University of Iowa Carver College of Medicine, Iowa City IA, USA
| | - Allan Walkey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, MA
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St. Louis, St. Louis MO, USA
| | - Fei Wan
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis MO, USA
| | - Karen E Joynt Maddox
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis MO, USA
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18
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Mohr NM, Vakkalanka JP, Holcombe A, Carter KD, McCoy KD, Clark HM, Gutierrez J, Merchant KAS, Bailey GJ, Ward MM. Effect of Chronic Disease Home Telehealth Monitoring in the Veterans Health Administration on Healthcare Utilization and Mortality. J Gen Intern Med 2023; 38:3313-3320. [PMID: 37157039 PMCID: PMC10682298 DOI: 10.1007/s11606-023-08220-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND The high prevalence of chronic diseases, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM), accounts for a large burden of cost and poor health outcomes in US hospitals, and home telehealth (HT) monitoring has been proposed to improve outcomes. OBJECTIVE To measure the association between HT initiation and 12-month inpatient hospitalizations, emergency department (ED) visits, and mortality in veterans with CHF, COPD, or DM. DESIGN Comparative effectiveness matched cohort study. PATIENTS Veterans aged 65 years and older treated for CHF, COPD, or DM. MAIN MEASURES We matched veterans initiating HT with veterans with similar demographics who did not use HT (1:3). Our outcome measures included a 12-month risk of inpatient hospitalization, ED visits, and all-cause mortality. KEY RESULTS A total of 139,790 veterans with CHF, 65,966 with COPD, and 192,633 with DM were included in this study. In the year after HT initiation, the risk of hospitalization was not different in those with CHF (adjusted odds ratio [aOR] 1.01, 95% confidence interval [95%CI] 0.98-1.05) or DM (aOR 1.00, 95%CI 0.97-1.03), but it was higher in those with COPD (aOR 1.15, 95%CI 1.09-1.21). The risk of ED visits was higher among HT users with CHF (aOR 1.09, 95%CI 1.05-1.13), COPD (1.24, 95%CI 1.18-1.31), and DM (aOR 1.03, 95%CI 1.00-1.06). All-cause 12-month mortality was lower in those initiating HT monitoring with CHF (aOR 0.70, 95%CI 0.67-0.73) and DM (aOR 0.79, 95%CI 0.75-0.83), but higher in COPD (aOR 1.08, 95%CI 1.00-1.16). CONCLUSIONS The initiation of HT was associated with increased ED visits, no change in hospitalizations, and lower all-cause mortality in patients with CHF or DM, while those with COPD had both higher healthcare utilization and all-cause mortality.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA.
| | - J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Andrea Holcombe
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Knute D Carter
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Kimberly D McCoy
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Heidi M Clark
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Jeydith Gutierrez
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Kimberly A S Merchant
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA
| | - George J Bailey
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA
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Surie D, Yuengling KA, DeCuir J, Zhu Y, Gaglani M, Ginde AA, Talbot HK, Casey JD, Mohr NM, Ghamande S, Gibbs KW, Files DC, Hager DN, Ali H, Prekker ME, Gong MN, Mohamed A, Johnson NJ, Steingrub JS, Peltan ID, Brown SM, Leis AM, Khan A, Hough CL, Bender WS, Duggal A, Wilson JG, Qadir N, Chang SY, Mallow C, Kwon JH, Exline MC, Lauring AS, Shapiro NI, Columbus C, Vaughn IA, Ramesh M, Safdar B, Halasa N, Chappell JD, Grijalva CG, Baughman A, Rice TW, Womack KN, Han JH, Swan SA, Mukherjee I, Lewis NM, Ellington S, McMorrow ML, Martin ET, Self WH. Disease Severity of Respiratory Syncytial Virus Compared with COVID-19 and Influenza Among Hospitalized Adults Aged ≥60 Years - IVY Network, 20 U.S. States, February 2022-May 2023. MMWR Morb Mortal Wkly Rep 2023; 72:1083-1088. [PMID: 37796753 PMCID: PMC10564326 DOI: 10.15585/mmwr.mm7240a2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
On June 21, 2023, CDC's Advisory Committee on Immunization Practices recommended respiratory syncytial virus (RSV) vaccination for adults aged ≥60 years, offered to individual adults using shared clinical decision-making. Informed use of these vaccines requires an understanding of RSV disease severity. To characterize RSV-associated severity, 5,784 adults aged ≥60 years hospitalized with acute respiratory illness and laboratory-confirmed RSV, SARS-CoV-2, or influenza infection were prospectively enrolled from 25 hospitals in 20 U.S. states during February 1, 2022-May 31, 2023. Multivariable logistic regression was used to compare RSV disease severity with COVID-19 and influenza severity on the basis of the following outcomes: 1) standard flow (<30 L/minute) oxygen therapy, 2) high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV), 3) intensive care unit (ICU) admission, and 4) invasive mechanical ventilation (IMV) or death. Overall, 304 (5.3%) enrolled adults were hospitalized with RSV, 4,734 (81.8%) with COVID-19 and 746 (12.9%) with influenza. Patients hospitalized with RSV were more likely to receive standard flow oxygen, HFNC or NIV, and ICU admission than were those hospitalized with COVID-19 or influenza. Patients hospitalized with RSV were more likely to receive IMV or die compared with patients hospitalized with influenza (adjusted odds ratio = 2.08; 95% CI = 1.33-3.26). Among hospitalized older adults, RSV was less common, but was associated with more severe disease than COVID-19 or influenza. High disease severity in older adults hospitalized with RSV is important to consider in shared clinical decision-making regarding RSV vaccination.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - IVY Network
- Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, CDC; Vanderbilt University Medical Center, Nashville, Tennessee; Baylor Scott & White Health, Temple, Texas; Texas A&M University College of Medicine, Temple, Texas; Baylor, Scott & White Health, Dallas, Texas; University of Colorado School of Medicine, Aurora, Colorado; University of Iowa, Iowa City, Iowa; Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina; Johns Hopkins Hospital, Baltimore, Maryland; Hennepin County Medical Center, Minneapolis, Minnesota; Montefiore Healthcare Center, Albert Einstein College of Medicine, New York, New York; University of Washington School of Medicine, Seattle, Washington; Baystate Medical Center, Springfield, Massachusetts; Intermountain Medical Center and University of Utah, Salt Lake City, Utah; University of Michigan School of Public Health, Ann Arbor, Michigan; Oregon Health & Science University Hospital, Portland, Oregon; Emory University School of Medicine, Atlanta, Georgia; Cleveland Clinic, Cleveland, Ohio; Stanford University School of Medicine, Stanford, California; Ronald Reagan-UCLA Medical Center, Los Angeles, California; University of Miami, Miami, Florida; Washington University, St. Louis, Missouri; The Ohio State University Wexner Medical Center, Columbus, Ohio; University of Michigan School of Medicine, Ann Arbor, Michigan; Beth Israel Deaconess Medical Center, Boston, Massachusetts; Henry Ford Health, Detroit, Michigan; Yale University School of Medicine, New Haven, Connecticut; Influenza Division, National Center for Immunization and Respiratory Diseases, CDC
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20
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Plumb ID, Mohr NM, Hagen M, Wiegand R, Dumyati G, Harland KK, Krishnadasan A, Gist JJ, Abedi G, Fleming-Dutra KE, Chea N, Lee J, Barter D, Brackney M, Fridkin SK, Wilson LE, Lovett SA, Ocampo V, Phipps EC, Marcus TM, Smithline HA, Hou PC, Lee LC, Moran GJ, Krebs E, Steele MT, Lim SC, Schrading WA, Chinnock B, Beiser DG, Faine B, Haran JP, Nandi U, Chipman AK, LoVecchio F, Talan DA, Pilishvili T. Effectiveness of a Messenger RNA Vaccine Booster Dose Against Coronavirus Disease 2019 Among US Healthcare Personnel, October 2021-July 2022. Open Forum Infect Dis 2023; 10:ofad457. [PMID: 37799130 PMCID: PMC10549208 DOI: 10.1093/ofid/ofad457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 09/06/2023] [Indexed: 10/07/2023] Open
Abstract
Background Protection against symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease 2019 [COVID-19]) can limit transmission and the risk of post-COVID conditions, and is particularly important among healthcare personnel. However, lower vaccine effectiveness (VE) has been reported since predominance of the Omicron SARS-CoV-2 variant. Methods We evaluated the VE of a monovalent messenger RNA (mRNA) booster dose against COVID-19 from October 2021 to June 2022 among US healthcare personnel. After matching case-participants with COVID-19 to control-participants by 2-week period and site, we used conditional logistic regression to estimate the VE of a booster dose compared with completing only 2 mRNA doses >150 days previously, adjusted for multiple covariates. Results Among 3279 case-participants and 3998 control-participants who had completed 2 mRNA doses, we estimated that the VE of a booster dose against COVID-19 declined from 86% (95% confidence interval, 81%-90%) during Delta predominance to 65% (58%-70%) during Omicron predominance. During Omicron predominance, VE declined from 73% (95% confidence interval, 67%-79%) 14-60 days after the booster dose, to 32% (4%-52%) ≥120 days after a booster dose. We found that VE was similar by age group, presence of underlying health conditions, and pregnancy status on the test date, as well as among immunocompromised participants. Conclusions A booster dose conferred substantial protection against COVID-19 among healthcare personnel. However, VE was lower during Omicron predominance, and waning effectiveness was observed 4 months after booster dose receipt during this period. Our findings support recommendations to stay up to date on recommended doses of COVID-19 vaccines for all those eligible.
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Affiliation(s)
- Ian D Plumb
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Melissa Hagen
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ryan Wiegand
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ghinwa Dumyati
- New York State Emerging Infections Program, University of Rochester Medical Center, Rochester, New York, USA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Anusha Krishnadasan
- Department of Emergency Medicine, Olive View–UCLA Education and Research Institute, Los Angeles, California, USA
| | - Jade James Gist
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Glen Abedi
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine E Fleming-Dutra
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nora Chea
- National Center for Emerging and Zoonotic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jane Lee
- Healthcare-Associated Infections, California Emerging Infections Program, Oakland, California, USA
| | - Devra Barter
- Healthcare-associated Infections / Antimicrobial Resistance Program, Colorado Department of Public Health & Environment, Denver, Colorado, USA
| | - Monica Brackney
- Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, Connecticut, USA
| | - Scott K Fridkin
- Georgia Emerging Infections Program and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lucy E Wilson
- Maryland Emerging Infections Program, Maryland Department of Health, and University of Maryland,Baltimore County, Baltimore, Maryland, USA
| | - Sara A Lovett
- Infectious Disease Epidemiology, Prevention and Control Divison, Minnesota Department of Health, St. Paul, Minnesota, USA
| | - Valerie Ocampo
- Public Health Division, Oregon Health Authority, Portland, Oregon, USA
| | - Erin C Phipps
- New Mexico Emerging Infections Program, University of New Mexico, Albuquerque, New Mexico, USA
| | - Tiffanie M Marcus
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Howard A Smithline
- Department of Emergency Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield, Massachusetts, USA
| | - Peter C Hou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lilly C Lee
- Emergency Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | - Gregory J Moran
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Elizabeth Krebs
- Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mark T Steele
- Department of Emergency Medicine, University of Missouri–Kansas City, Kansas City, Missouri, USA
| | - Stephen C Lim
- Section of Emergency Medicine, University Medical Center New Orleans, LSU Health Sciences Center, New Orleans, Louisiana, USA
| | - Walter A Schrading
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brian Chinnock
- Department of Emergency Medicine, University of California San Francisco, Fresno, California, USA
| | - David G Beiser
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois, USA
| | - Brett Faine
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | - John P Haran
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Utsav Nandi
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Anne K Chipman
- Emergency Department, University of Washington, Seattle, Washington, USA
| | - Frank LoVecchio
- Emergency Medicine, Valleywise Health Medical Center, Phoenix, Arizona, USA
| | - David A Talan
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Tamara Pilishvili
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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21
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Glass NE, Salvi A, Wei R, Lin A, Malveau S, Cook JNB, Mann NC, Burd RS, Jenkins PC, Hansen M, Mohr NM, Stephens C, Fallat ME, Lerner EB, Carr BG, Wall SP, Newgard CD. Association of Transport Time, Proximity, and Emergency Department Pediatric Readiness With Pediatric Survival at US Trauma Centers. JAMA Surg 2023; 158:1078-1087. [PMID: 37556154 PMCID: PMC10413216 DOI: 10.1001/jamasurg.2023.3344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/25/2023] [Indexed: 08/10/2023]
Abstract
Importance Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear. Objective To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children. Design, Setting, and Participants This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022. Exposures Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]). Main Outcomes and Measures In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality. Results This study included 212 689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136 538 (64.2%) were male, and 127 885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105 871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36 330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives). Conclusions and Relevance These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.
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Affiliation(s)
- Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Apoorva Salvi
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Ran Wei
- School of Public Policy, University of California, Riverside
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Center for Surgical Care, Children’s National Hospital, Washington, DC
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City
| | | | - Mary E. Fallat
- Department of Surgery, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, Kentucky
| | - E. Brooke Lerner
- Department of Emergency Medicine, University at Buffalo, Buffalo, New York
| | - Brendan G. Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephen P. Wall
- Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York
| | - Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
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22
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Kojima N, Adams K, Self WH, Gaglani M, McNeal T, Ghamande S, Steingrub JS, Shapiro NI, Duggal A, Busse LW, Prekker ME, Peltan ID, Brown SM, Hager DN, Ali H, Gong MN, Mohamed A, Exline MC, Khan A, Wilson JG, Qadir N, Chang SY, Ginde AA, Withers CA, Mohr NM, Mallow C, Martin ET, Lauring AS, Johnson NJ, Casey JD, Stubblefield WB, Gibbs KW, Kwon JH, Baughman A, Chappell JD, Hart KW, Jones ID, Rhoads JP, Swan SA, Womack KN, Zhu Y, Surie D, McMorrow ML, Patel MM, Tenforde MW. Changing Severity and Epidemiology of Adults Hospitalized With Coronavirus Disease 2019 (COVID-19) in the United States After Introduction of COVID-19 Vaccines, March 2021-August 2022. Clin Infect Dis 2023; 77:547-557. [PMID: 37255285 PMCID: PMC10526883 DOI: 10.1093/cid/ciad276] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Indexed: 06/01/2023] Open
Abstract
INTRODUCTION Understanding the changing epidemiology of adults hospitalized with coronavirus disease 2019 (COVID-19) informs research priorities and public health policies. METHODS Among adults (≥18 years) hospitalized with laboratory-confirmed, acute COVID-19 between 11 March 2021, and 31 August 2022 at 21 hospitals in 18 states, those hospitalized during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron-predominant period (BA.1, BA.2, BA.4/BA.5) were compared to those from earlier Alpha- and Delta-predominant periods. Demographic characteristics, biomarkers within 24 hours of admission, and outcomes, including oxygen support and death, were assessed. RESULTS Among 9825 patients, median (interquartile range [IQR]) age was 60 years (47-72), 47% were women, and 21% non-Hispanic Black. From the Alpha-predominant period (Mar-Jul 2021; N = 1312) to the Omicron BA.4/BA.5 sublineage-predominant period (Jun-Aug 2022; N = 1307): the percentage of patients who had ≥4 categories of underlying medical conditions increased from 11% to 21%; those vaccinated with at least a primary COVID-19 vaccine series increased from 7% to 67%; those ≥75 years old increased from 11% to 33%; those who did not receive any supplemental oxygen increased from 18% to 42%. Median (IQR) highest C-reactive protein and D-dimer concentration decreased from 42.0 mg/L (9.9-122.0) to 11.5 mg/L (2.7-42.8) and 3.1 mcg/mL (0.8-640.0) to 1.0 mcg/mL (0.5-2.2), respectively. In-hospital death peaked at 12% in the Delta-predominant period and declined to 4% during the BA.4/BA.5-predominant period. CONCLUSIONS Compared to adults hospitalized during early COVID-19 variant periods, those hospitalized during Omicron-variant COVID-19 were older, had multiple co-morbidities, were more likely to be vaccinated, and less likely to experience severe respiratory disease, systemic inflammation, coagulopathy, and death.
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Affiliation(s)
- Noah Kojima
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine Adams
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Wesley H Self
- Department of Emergency Medicine and Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Manjusha Gaglani
- Department of Pediatrics, Baylor Scott & White Health and Texas A&M University College of Medicine, Temple and Dallas, Texas, USA
| | - Tresa McNeal
- Department of Medical Education, Baylor Scott & White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Shekhar Ghamande
- Department of Medical Education, Baylor Scott & White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Jay S Steingrub
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Matthew E Prekker
- Department of Emergency Medicine and Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Ithan D Peltan
- Department of Medicine, Intermountain Medical Center, Murray, Utah and University of Utah, Salt Lake City, Utah, USA
| | - Samuel M Brown
- Department of Medicine, Intermountain Medical Center, Murray, Utah and University of Utah, Salt Lake City, Utah, USA
| | - David N Hager
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Harith Ali
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michelle N Gong
- Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Amira Mohamed
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Matthew C Exline
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Akram Khan
- Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Jennifer G Wilson
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nida Qadir
- Department of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Steven Y Chang
- Department of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cori A Withers
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | | | - Emily T Martin
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Adam S Lauring
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine and Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Jonathan D Casey
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin W Gibbs
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jennie H Kwon
- Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Adrienne Baughman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James D Chappell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kimberly W Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ian D Jones
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jillian P Rhoads
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sydney A Swan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelsey N Womack
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Diya Surie
- Coronavirus and Other Respiratory Viruses Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Meredith L McMorrow
- Coronavirus and Other Respiratory Viruses Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Manish M Patel
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mark W Tenforde
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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23
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Dimcheff DE, Blair CN, Zhu Y, Chappell JD, Gaglani M, McNeal T, Ghamande S, Steingrub JS, Shapiro NI, Duggal A, Busse LW, Frosch AEP, Peltan ID, Hager DN, Gong MN, Exline MC, Khan A, Wilson JG, Qadir N, Ginde AA, Douin DJ, Mohr NM, Mallow C, Martin ET, Johnson NJ, Casey JD, Stubblefield WB, Gibbs KW, Kwon JH, Talbot HK, Halasa N, Grijalva CG, Baughman A, Womack KN, Hart KW, Swan SA, Surie D, Thornburg NJ, McMorrow ML, Self WH, Lauring AS. Total and Subgenomic RNA Viral Load in Patients Infected With SARS-CoV-2 Alpha, Delta, and Omicron Variants. J Infect Dis 2023; 228:235-244. [PMID: 36883903 PMCID: PMC10420395 DOI: 10.1093/infdis/jiad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genomic and subgenomic RNA levels are frequently used as a correlate of infectiousness. The impact of host factors and SARS-CoV-2 lineage on RNA viral load is unclear. METHODS Total nucleocapsid (N) and subgenomic N (sgN) RNA levels were measured by quantitative reverse transcription polymerase chain reaction (RT-qPCR) in specimens from 3204 individuals hospitalized with coronavirus disease 2019 (COVID-19) at 21 hospitals. RT-qPCR cycle threshold (Ct) values were used to estimate RNA viral load. The impact of time of sampling, SARS-CoV-2 variant, age, comorbidities, vaccination, and immune status on N and sgN Ct values were evaluated using multiple linear regression. RESULTS Mean Ct values at presentation for N were 24.14 (SD 4.53) for non-variants of concern, 25.15 (SD 4.33) for Alpha, 25.31 (SD 4.50) for Delta, and 26.26 (SD 4.42) for Omicron. N and sgN RNA levels varied with time since symptom onset and infecting variant but not with age, comorbidity, immune status, or vaccination. When normalized to total N RNA, sgN levels were similar across all variants. CONCLUSIONS RNA viral loads were similar among hospitalized adults, irrespective of infecting variant and known risk factors for severe COVID-19. Total N and subgenomic RNA N viral loads were highly correlated, suggesting that subgenomic RNA measurements add little information for the purposes of estimating infectivity.
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Affiliation(s)
- Derek E Dimcheff
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher N Blair
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James D Chappell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Manjusha Gaglani
- Baylor Scott and White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Tresa McNeal
- Baylor Scott and White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Shekhar Ghamande
- Baylor Scott and White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Jay S Steingrub
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Anne E P Frosch
- Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Ithan D Peltan
- Department of Medicine, Intermountain Medical Center, Murray, Utah, USA
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - David N Hager
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michelle N Gong
- Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Matthew C Exline
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Akram Khan
- Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Jennifer G Wilson
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nida Qadir
- Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | | | - Emily T Martin
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine and Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Jonathan D Casey
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin W Gibbs
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jennie H Kwon
- Department of Medicine, Washington University, St Louis, Missouri, USA
| | - H Keipp Talbot
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Natasha Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adrienne Baughman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelsey N Womack
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kimberly W Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sydney A Swan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Diya Surie
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Natalie J Thornburg
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Meredith L McMorrow
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adam S Lauring
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
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24
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Colgan A, Swanson MB, Ahmed A, Harland K, Mohr NM. Documented Use of Emergency Medical Dispatch Protocols is Associated with Improved Survival in Out of Hospital Cardiac Arrest. PREHOSP EMERG CARE 2023; 28:160-167. [PMID: 37471458 DOI: 10.1080/10903127.2023.2239363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE There are over 300,000 out-of-hospital cardiac arrests (OHCA) annually in the United States (US) and despite many scientific advances in the field, the survival rate remains low. We seek to determine if return of spontaneous circulation (ROSC) is higher when use of emergency medical dispatch (EMD) protocols is documented for OHCA calls compared to when no EMD protocol use is documented. We also seek identify care-related processes that differ in calls that use EMD protocols. METHODS This is a retrospective cohort study of U.S. adults with OHCA prior to emergency medical services (EMS) arrival using 2019 National EMS Information System data. The primary exposure was EMD usage during EMS call. The primary outcome was prehospital ROSC, and secondary outcomes included automated external defibrillator (AED) use before EMS arrival, bystander CPR, and end-of-event EMS survival (survival to the end of the EMS care at transport destination). Multivariable logistic regression adjusted for age, sex, race/ethnicity, primary insurance, rurality, initial rhythm, arrest etiology, and witnessed arrest. RESULTS Of the 96,269 OHCA cases included, EMD use was documented in 73%. Overall, 26% of subjects achieved ROSC in EMS care. EMD subjects were more likely to achieve ROSC (27.2% vs. 23.5%, uOR 1.22, 95%CI 1.18 - 1.26) even after adjusting for subject and arrest characteristics (aOR 1.13, 95%CI 1.08 - 1.17). EMD subjects also had higher end-of-event survival (19.1% vs. 16.4%, aOR 1.20, 95%CI 1.15 - 1.25). AED use before EMS arrival was more common in the EMD group (28.3% vs. 26.3% %diff 2.0, 95%CI 1.4 to 2.6), as was CPR before EMS arrival (63.8% vs. 55.1%, difference 8.6%, 95%CI 7.9 to 9.3%). CONCLUSIONS In this retrospective analysis, the rate of ROSC was higher in adult OHCA patients when EMD protocol use was reported compared to when it was not reported. The group with documented EMD use also experienced higher rates of bystander AED use, bystander CPR, and end-of-event survival.
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Affiliation(s)
- Alexander Colgan
- Department of Emergency Medicine, Banner Wyoming Medical Center, Casper, Wyoming
| | - Morgan B Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Kari Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
- Divison of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Vakkalanka JP, Nataliansyah MM, Merchant KAS, Mack LJ, Parsons S, Mohr NM, Ward MM. Evaluation of Telepsychiatry Services Implementation in Medical and Psychiatric Inpatient Settings: A Mixed-Methods Study. Telemed J E Health 2023; 29:1224-1232. [PMID: 36595509 DOI: 10.1089/tmj.2022.0436] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Introduction: Telepsychiatry consultation for rural providers may help address local staffing needs while ensuring timely and appropriate care from behavioral health experts. The purpose of this study was to assess the implementation of a telepsychiatry consultation service within medical and psychiatry inpatient units of hospitals serving predominantly rural areas. Methods: A mixed-methods study with qualitative interviews of site personnel and quantitative assessment of electronic health record data was conducted across 6 facilities in 3 U.S. states between June 2019 and May 2021. We interviewed 15 health care professionals 6 months after telepsychiatry was implemented, and we identified emerging themes related to the inpatient telepsychiatry service implementation and utilization through an inductive qualitative analysis approach. We then applied the themes emerging from this study to existing implementation science theoretical frameworks. Results: Telepsychiatry consultation was utilized for 437 medical inpatient cases and 531 psychiatric inpatient units. Average encounters by site ranged from 1 to 20 per month. The three main domains from the qualitative assessment included the impact on the care process (the partnership between inpatient units and the telehealth hub, and logistical dynamics), the care provider (resource availability in inpatient units and changes in inpatient units' capability), and the patient (impact on patient safety and care). Discussion: Implementation of a telepsychiatry service in the inpatient setting holds the promise of being beneficial to the patient, local hospital, and the rural community. In this study, we found that implementing this telepsychiatry service improved the clinical care processes, while addressing both the providers' and patients' needs.
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Affiliation(s)
- J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - M Muska Nataliansyah
- Division of Surgical Oncology, Department of Surgery, Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kimberly A S Merchant
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Luke J Mack
- Avel eCare, Sioux Falls, South Dakota, USA
- Department of Family Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Seth Parsons
- Avel eCare, Sioux Falls, South Dakota, USA
- Department of Psychiatry, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
- Department of Anesthesia Critical Care, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
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Wessman BT, Mohr NM. Right Care, Right Now: Bringing More Critical Care to Boarding Patients in the Emergency Department. Crit Care Med 2023; 51:833-835. [PMID: 37199552 DOI: 10.1097/ccm.0000000000005859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Brian T Wessman
- Department of Anesthesiology and Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Nicholas M Mohr
- Departments of Emergency Medicine, Anesthesia Critical Care, and Epidemiology, University of Iowa Carver College of Medicine, Iowa City, IA
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Surie D, Bonnell LN, DeCuir J, Gaglani M, McNeal T, Ghamande S, Steingrub JS, Shapiro NI, Busse LW, Prekker ME, Peltan ID, Brown SM, Hager DN, Ali H, Gong MN, Mohamed A, Khan A, Wilson JG, Qadir N, Chang SY, Ginde AA, Huynh D, Mohr NM, Mallow C, Martin ET, Lauring AS, Johnson NJ, Casey JD, Gibbs KW, Kwon JH, Baughman A, Chappell JD, Hart KW, Grijalva CG, Rhoads JP, Swan SA, Keipp Talbot H, Womack KN, Zhu Y, Tenforde MW, Adams K, Self WH, McMorrow ML. Comparison of mRNA vaccine effectiveness against COVID-19-associated hospitalization by vaccination source: Immunization information systems, electronic medical records, and self-report-IVY Network, February 1-August 31, 2022. Vaccine 2023:S0264-410X(23)00567-4. [PMID: 37301704 DOI: 10.1016/j.vaccine.2023.05.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Accurate determination of COVID-19 vaccination status is necessary to produce reliable COVID-19 vaccine effectiveness (VE) estimates. Data comparing differences in COVID-19 VE by vaccination sources (i.e., immunization information systems [IIS], electronic medical records [EMR], and self-report) are limited. We compared the number of mRNA COVID-19 vaccine doses identified by each of these sources to assess agreement as well as differences in VE estimates using vaccination data from each individual source and vaccination data adjudicated from all sources combined. METHODS Adults aged ≥18 years who were hospitalized with COVID-like illness at 21 hospitals in 18 U.S. states participating in the IVY Network during February 1-August 31, 2022, were enrolled. Numbers of COVID-19 vaccine doses identified by IIS, EMR, and self-report were compared in kappa agreement analyses. Effectiveness of mRNA COVID-19 vaccines against COVID-19-associated hospitalization was estimated using multivariable logistic regression models to compare the odds of COVID-19 vaccination between SARS-CoV-2-positive case-patients and SARS-CoV-2-negative control-patients. VE was estimated using each source of vaccination data separately and all sources combined. RESULTS A total of 4499 patients were included. Patients with ≥1 mRNA COVID-19 vaccine dose were identified most frequently by self-report (n = 3570, 79 %), followed by IIS (n = 3272, 73 %) and EMR (n = 3057, 68 %). Agreement was highest between IIS and self-report for 4 doses with a kappa of 0.77 (95 % CI = 0.73-0.81). VE point estimates of 3 doses against COVID-19 hospitalization were substantially lower when using vaccination data from EMR only (VE = 31 %, 95 % CI = 16 %-43 %) than when using all sources combined (VE = 53 %, 95 % CI = 41 %-62%). CONCLUSION Vaccination data from EMR only may substantially underestimate COVID-19 VE.
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Affiliation(s)
- Diya Surie
- Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States.
| | - Levi N Bonnell
- Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States; General Dynamics Information Technology, Falls Church, VA, United States
| | - Jennifer DeCuir
- Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Manjusha Gaglani
- Baylor Scott & White Health and Texas A&M University College of Medicine, Temple, TX, United States
| | - Tresa McNeal
- Baylor Scott & White Health and Texas A&M University College of Medicine, Temple, TX, United States
| | - Shekhar Ghamande
- Baylor Scott & White Health and Texas A&M University College of Medicine, Temple, TX, United States
| | - Jay S Steingrub
- Department of Medicine, Baystate Medical Center, Springfield, MA, United States
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Laurence W Busse
- Department of Medicine, Emory University, Atlanta, GA, United States
| | - Matthew E Prekker
- Department of Emergency Medicine and Medicine, Hennepin County Medical Center, Minneapolis, MN, United States
| | - Ithan D Peltan
- Department of Medicine, Intermountain Medical Center, Murray, UT and University of Utah, Salt Lake City, UT, United States
| | - Samuel M Brown
- Department of Medicine, Intermountain Medical Center, Murray, UT and University of Utah, Salt Lake City, UT, United States
| | - David N Hager
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Harith Ali
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michelle N Gong
- Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Amira Mohamed
- Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Akram Khan
- Department of Medicine, Oregon Health and Sciences University, Portland, OR, United States
| | - Jennifer G Wilson
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Nida Qadir
- Department of Medicine, University of California-Los Angeles, Los Angeles, CA, United States
| | - Steven Y Chang
- Department of Medicine, University of California-Los Angeles, Los Angeles, CA, United States
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - David Huynh
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, United States
| | | | - Emily T Martin
- School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Adam S Lauring
- Departments of Internal Medicine and Microbiology and Immunology, University of Michigan, Ann Arbor, MI, United States
| | - Nicholas J Johnson
- Department of Emergency Medicine and Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States
| | - Jonathan D Casey
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kevin W Gibbs
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jennie H Kwon
- Department of Medicine, Washington University, St. Louis, MO, United States
| | - Adrienne Baughman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - James D Chappell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kimberly W Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jillian P Rhoads
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sydney A Swan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - H Keipp Talbot
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kelsey N Womack
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Mark W Tenforde
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Katherine Adams
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Meredith L McMorrow
- Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
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DeCuir J, Surie D, Zhu Y, Gaglani M, Ginde AA, Douin DJ, Talbot HK, Casey JD, Mohr NM, McNeal T, Ghamande S, Gibbs KW, Files DC, Hager DN, Phan M, Prekker ME, Gong MN, Mohamed A, Johnson NJ, Steingrub JS, Peltan ID, Brown SM, Martin ET, Monto AS, Khan A, Bender WS, Duggal A, Wilson JG, Qadir N, Chang SY, Mallow C, Kwon JH, Exline MC, Lauring AS, Shapiro NI, Columbus C, Gottlieb R, Vaughn IA, Ramesh M, Lamerato LE, Safdar B, Halasa N, Chappell JD, Grijalva CG, Baughman A, Womack KN, Rhoads JP, Hart KW, Swan SA, Lewis N, McMorrow ML, Self WH. Effectiveness of Monovalent mRNA COVID-19 Vaccination in Preventing COVID-19-Associated Invasive Mechanical Ventilation and Death Among Immunocompetent Adults During the Omicron Variant Period - IVY Network, 19 U.S. States, February 1, 2022-January 31, 2023. MMWR Morb Mortal Wkly Rep 2023; 72:463-468. [PMID: 37104244 DOI: 10.15585/mmwr.mm7217a3] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
As of April 2023, the COVID-19 pandemic has resulted in 1.1 million deaths in the United States, with approximately 75% of deaths occurring among adults aged ≥65 years (1). Data on the durability of protection provided by monovalent mRNA COVID-19 vaccination against critical outcomes of COVID-19 are limited beyond the Omicron BA.1 lineage period (December 26, 2021-March 26, 2022). In this case-control analysis, the effectiveness of 2-4 monovalent mRNA COVID-19 vaccine doses was evaluated against COVID-19-associated invasive mechanical ventilation (IMV) and in-hospital death among immunocompetent adults aged ≥18 years during February 1, 2022-January 31, 2023. Vaccine effectiveness (VE) against IMV and in-hospital death was 62% among adults aged ≥18 years and 69% among those aged ≥65 years. When stratified by time since last dose, VE was 76% at 7-179 days, 54% at 180-364 days, and 56% at ≥365 days. Monovalent mRNA COVID-19 vaccination provided substantial, durable protection against IMV and in-hospital death among adults during the Omicron variant period. All adults should remain up to date with recommended COVID-19 vaccination to prevent critical COVID-19-associated outcomes.
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Abstract
OBJECTIVES Sepsis is associated with significant mortality. Telehealth may improve the quality of early sepsis care, but the use and impact of telehealth applications for sepsis remain unclear. We aim to describe the telehealth interventions that have been used to facilitate sepsis care, and to summarize the reported effect of telehealth on sepsis outcomes. DATA SOURCES We identified articles reporting telehealth use for sepsis using an English-language search of PubMed, CINAHL Plus (EBSCO), Academic Search Ultimate (EBSCO), APA PsycINFO (EBSCO), Public Health (ProQuest), and Web of Science databases with no restrictions on publication date. STUDY SELECTION Included studies described the use of telehealth as an intervention for treating sepsis. Only comparative effectiveness analyses were included. DATA EXTRACTION AND SYNTHESIS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines, two investigators independently selected articles for inclusion and abstracted data. A random-effects subgroup analysis was conducted on patient survival treated with and without telehealth. RESULTS A total of 15 studies were included, involving 188,418 patients with sepsis. Thirteen studies used observational study designs, and the most common telehealth applications were provider-to-provider telehealth consultation and intensive care unit telehealth. Clinical and methodological heterogeneity was significantly high. Telehealth use was associated with higher survival, especially in settings with low control group survival. The effect of telehealth on other care processes and outcomes were more varied and likely dependent on hospital-level factors. CONCLUSIONS Telehealth has been used in diverse applications for sepsis care, and it may improve patient outcomes in certain contexts. Additional interventional trials and cost-based analyses would clarify the causal role of telehealth in improving sepsis outcomes.
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Affiliation(s)
- Kevin J Tu
- Department of Cell Biology and Molecular Genetics, University of Maryland, College Park, MD, USA
| | - Cole Wymore
- Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Nedelina Tchangalova
- Research and Academic Services, University of Maryland Libraries, College Park, MD, USA
| | - Brian M Fuller
- Division of Critical Care, Department of Anesthesiology, Department of Emergency Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Nicholas M Mohr
- Departments of Emergency Medicine, Anesthesia Critical Care, and Epidemiology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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Tenforde MW, Patel MM, Lewis NM, Adams K, Gaglani M, Steingrub JS, Shapiro NI, Duggal A, Prekker ME, Peltan ID, Hager DN, Gong MN, Exline MC, Ginde AA, Mohr NM, Mallow C, Martin ET, Talbot HK, Gibbs KW, Kwon JH, Chappell JD, Halasa N, Lauring AS, Lindsell CJ, Swan SA, Hart KW, Womack KN, Baughman A, Grijalva CG, Self WH. Vaccine Effectiveness Against Influenza A(H3N2)-Associated Hospitalized Illness: United States, 2022. Clin Infect Dis 2023; 76:1030-1037. [PMID: 36327388 PMCID: PMC10226741 DOI: 10.1093/cid/ciac869] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic was associated with historically low influenza circulation during the 2020-2021 season, followed by an increase in influenza circulation during the 2021-2022 US season. The 2a.2 subgroup of the influenza A(H3N2) 3C.2a1b subclade that predominated was antigenically different from the vaccine strain. METHODS To understand the effectiveness of the 2021-2022 vaccine against hospitalized influenza illness, a multistate sentinel surveillance network enrolled adults aged ≥18 years hospitalized with acute respiratory illness and tested for influenza by a molecular assay. Using the test-negative design, vaccine effectiveness (VE) was measured by comparing the odds of current-season influenza vaccination in influenza-positive case-patients and influenza-negative, SARS-CoV-2-negative controls, adjusting for confounders. A separate analysis was performed to illustrate bias introduced by including SARS-CoV-2-positive controls. RESULTS A total of 2334 patients, including 295 influenza cases (47% vaccinated), 1175 influenza- and SARS-CoV-2-negative controls (53% vaccinated), and 864 influenza-negative and SARS-CoV-2-positive controls (49% vaccinated), were analyzed. Influenza VE was 26% (95% CI: -14% to 52%) among adults aged 18-64 years, -3% (-54% to 31%) among adults aged ≥65 years, and 50% (15-71%) among adults aged 18-64 years without immunocompromising conditions. Estimated VE decreased with inclusion of SARS-CoV-2-positive controls. CONCLUSIONS During a season where influenza A(H3N2) was antigenically different from the vaccine virus, vaccination was associated with a reduced risk of influenza hospitalization in younger immunocompetent adults. However, vaccination did not provide protection in adults ≥65 years of age. Improvements in vaccines, antivirals, and prevention strategies are warranted.
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Affiliation(s)
- Mark W Tenforde
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Manish M Patel
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nathaniel M Lewis
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine Adams
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Manjusha Gaglani
- Baylor Scott and White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Jay S Steingrub
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew E Prekker
- Departments of Emergency Medicine and Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Ithan D Peltan
- Department of Medicine, Intermountain Medical Center, Murray, Utah and University of Utah, Salt Lake City, Utah, USA
| | - David N Hager
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michelle N Gong
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Matthew C Exline
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | | | - Emily T Martin
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - H Keipp Talbot
- Departments of Medicine and Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin W Gibbs
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jennie H Kwon
- Department of Medicine, Washington University, St Louis, Missouri, USA
| | - James D Chappell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Natasha Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adam S Lauring
- Departments of Internal Medicine and Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sydney A Swan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kimberly W Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelsey N Womack
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adrienne Baughman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wesley H Self
- Vanderbilt Institute for Clinical and Translational Research and Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Tenforde MW, Self WH, Zhu Y, Naioti EA, Gaglani M, Ginde AA, Jensen K, Talbot HK, Casey JD, Mohr NM, Zepeski A, McNeal T, Ghamande S, Gibbs KW, Files DC, Hager DN, Shehu A, Prekker ME, Erickson HL, Gong MN, Mohamed A, Johnson NJ, Srinivasan V, Steingrub JS, Peltan ID, Brown SM, Martin ET, Monto AS, Khan A, Hough CL, Busse LW, Lohuis CT, Duggal A, Wilson JG, Qadir N, Chang SY, Mallow C, Rivas C, Babcock HM, Kwon JH, Exline MC, Botros MM, Lauring AS, Shapiro NI, Halasa N, Chappell JD, Grijalva CG, Rice TW, Jones ID, Stubblefield WB, Baughman A, Womack KN, Rhoads JP, Lindsell CJ, Hart KW, Turbyfill C, Olson S, Murray N, Adams K, Patel MM. Protection of Messenger RNA Vaccines Against Hospitalized Coronavirus Disease 2019 in Adults Over the First Year Following Authorization in the United States. Clin Infect Dis 2023; 76:e460-e468. [PMID: 35580849 PMCID: PMC9129194 DOI: 10.1093/cid/ciac381] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/29/2022] [Accepted: 05/12/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) messenger RNA (mRNA) vaccines were authorized in the United States in December 2020. Although vaccine effectiveness (VE) against mild infection declines markedly after several months, limited understanding exists on the long-term durability of protection against COVID-19-associated hospitalization. METHODS Case-control analysis of adults (≥18 years) hospitalized at 21 hospitals in 18 states 11 March-15 December 2021, including COVID-19 case patients and reverse transcriptase-polymerase chain reaction-negative controls. We included adults who were unvaccinated or vaccinated with 2 doses of a mRNA vaccine before the date of illness onset. VE over time was assessed using logistic regression comparing odds of vaccination in cases versus controls, adjusting for confounders. Models included dichotomous time (<180 vs ≥180 days since dose 2) and continuous time modeled using restricted cubic splines. RESULTS A total of 10 078 patients were included, 4906 cases (23% vaccinated) and 5172 controls (62% vaccinated). Median age was 60 years (interquartile range, 46-70), 56% were non-Hispanic White, and 81% had ≥1 medical condition. Among immunocompetent adults, VE <180 days was 90% (95% confidence interval [CI], 88-91) versus 82% (95% CI, 79-85) at ≥180 days (P < .001). VE declined for Pfizer-BioNTech (88% to 79%, P < .001) and Moderna (93% to 87%, P < .001) products, for younger adults (18-64 years) (91% to 87%, P = .005), and for adults ≥65 years of age (87% to 78%, P < .001). In models using restricted cubic splines, similar changes were observed. CONCLUSIONS In a period largely predating Omicron variant circulation, effectiveness of 2 mRNA doses against COVID-19-associated hospitalization was largely sustained through 9 months.
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Affiliation(s)
| | - Wesley H Self
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yuwei Zhu
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Manjusha Gaglani
- Baylor Scott & White Health, Temple, Texas, USA.,Texas A&M University College of Medicine, Temple, Texas, USA
| | - Adit A Ginde
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kelly Jensen
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - H Keipp Talbot
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | | - Tresa McNeal
- Baylor Scott & White Health, Temple, Texas, USA.,Texas A&M University College of Medicine, Temple, Texas, USA
| | - Shekhar Ghamande
- Baylor Scott & White Health, Temple, Texas, USA.,Texas A&M University College of Medicine, Temple, Texas, USA
| | - Kevin W Gibbs
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - D Clark Files
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | - Arber Shehu
- Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | | | - Michelle N Gong
- Montefiore Healthcare Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Amira Mohamed
- Montefiore Healthcare Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | | | | | - Ithan D Peltan
- Intermountain Medical Center and University of Utah, Salt Lake City, Utah, USA
| | - Samuel M Brown
- Intermountain Medical Center and University of Utah, Salt Lake City, Utah, USA
| | - Emily T Martin
- University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Arnold S Monto
- University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Akram Khan
- Oregon Health & Science University Hospital, Portland, Oregon, USA
| | | | | | | | | | | | - Nida Qadir
- Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA
| | - Steven Y Chang
- Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA
| | | | | | | | | | - Matthew C Exline
- Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mena M Botros
- Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adam S Lauring
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Nathan I Shapiro
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Natasha Halasa
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Todd W Rice
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ian D Jones
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Kelsey N Womack
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Kimberly W Hart
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Nancy Murray
- CDC COVID-19 Response Team, Atlanta, Georgia, USA
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Mohr NM, Plumb ID, Harland KK, Pilishvili T, Fleming-Dutra KE, Krishnadasan A, Hoth KF, Saydah SH, Mankoff Z, Haran JP, Briggs-Hagen M, León ES, Talan DA. Presence of symptoms 6 weeks after COVID-19 among vaccinated and unvaccinated US healthcare personnel: a prospective cohort study. BMJ Open 2023; 13:e063141. [PMID: 36731936 PMCID: PMC9895915 DOI: 10.1136/bmjopen-2022-063141] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 01/12/2023] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Although COVID-19 vaccines offer protection against infection and severe disease, there is limited information on the effect of vaccination on prolonged symptoms following COVID-19. Our objective was to determine differences in prevalence of prolonged symptoms 6 weeks after onset of COVID-19 among healthcare personnel (HCP) by vaccination status, and to assess differences in timing of return to work. DESIGN Cohort analysis of HCP with COVID-19 enrolled in a multicentre vaccine effectiveness study. HCP with COVID-19 between December 2020 and August 2021 were followed up 6 weeks after illness onset. SETTING Health systems in 12 US states. PARTICIPANTS HCP participating in a vaccine effectiveness study were eligible for inclusion if they had laboratory-confirmed symptomatic SARS-CoV-2 with mRNA vaccination (symptom onset ≥14 days after two doses) or no prior vaccination. Among 681 eligible participants, 419 (61%) completed a follow-up survey to assess symptoms reported 6 weeks after illness onset. EXPOSURES Two doses of a COVID-19 mRNA vaccine compared with no COVID-19 vaccine. MAIN OUTCOME MEASURES Prevalence of symptoms 6 weeks after onset of COVID-19 illness and days to return to work. RESULTS Among 419 HCP with COVID-19, 298 (71%) reported one or more COVID-like symptoms 6 weeks after illness onset, with a lower prevalence among vaccinated participants compared with unvaccinated participants (60.6% vs 79.1%; adjusted risk ratio 0.70, 95% CI 0.58 to 0.84). Following their illness, vaccinated HCP returned to work a median 2.0 days (95% CI 1.0 to 3.0) sooner than unvaccinated HCP (adjusted HR 1.37, 95% CI 1.04 to 1.79). CONCLUSIONS Receipt of two doses of a COVID-19 mRNA vaccine among HCP with COVID-19 illness was associated with decreased prevalence of COVID-like symptoms at 6 weeks and earlier return to work.
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Affiliation(s)
- Nicholas M Mohr
- Emergency Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa, Iowa, USA
- Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ian D Plumb
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kari K Harland
- Emergency Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa, Iowa, USA
| | - Tamara Pilishvili
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Anusha Krishnadasan
- Olive View and Ronald Reagan-UCLA Medical Center Emergency Medicine, University of California - Los Angeles, Los Angeles, California, USA
| | - Karin F Hoth
- Internal Medicine, University of Iowa Carver College of Medicine, Iowa CIty, Iowa, USA
| | - Sharon H Saydah
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Zachary Mankoff
- Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John P Haran
- Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Melissa Briggs-Hagen
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Eliezer Santos León
- Emergency Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa, Iowa, USA
| | - David A Talan
- Olive View and Ronald Reagan-UCLA Medical Center Emergency Medicine, University of California - Los Angeles, Los Angeles, California, USA
- Internal Medicine Division of Infectious Diseases, University of California - Los Angeles, Los Angeles, California, USA
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Mohr NM, Santos Leon E, Carlson JN, Driver B, Krishnadasan A, Harland KK, Ten Eyck P, Mower WR, Foley TM, Wallace K, McDonald LC, Kutty PK, Santibanez S, Talan DA. Endotracheal Intubation Strategy, Success, and Adverse Events Among Emergency Department Patients During the COVID-19 Pandemic. Ann Emerg Med 2023; 81:145-157. [PMID: 36336542 PMCID: PMC9633323 DOI: 10.1016/j.annemergmed.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/09/2022] [Accepted: 09/19/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa College of Public Health, Iowa City, IA; Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA.
| | - Eliezer Santos Leon
- Department of Emergency Medicine, University of Iowa College of Public Health, Iowa City, IA
| | - Jestin N Carlson
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Brian Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Anusha Krishnadasan
- Olive View-University of California Los Angeles Education and Research Institute, Los Angeles, CA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa College of Public Health, Iowa City, IA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Sciences, University of Iowa, Iowa City, IA
| | - William R Mower
- University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA
| | - Tyler M Foley
- Department of Internal Medicine, University of Virginia, Charlottesville, VA
| | - Kelli Wallace
- Department of Emergency Medicine, University of Iowa College of Public Health, Iowa City, IA
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, Division of Preparedness and Emerging Infections, Atlanta, GA
| | - Preeta K Kutty
- Division of Healthcare Quality Promotion, Division of Preparedness and Emerging Infections, Atlanta, GA
| | - Scott Santibanez
- Division of Preparedness and Emerging Infections, Centers for Disease Control and Prevention, Atlanta, GA
| | - David A Talan
- Department of Emergency Medicine, University of Iowa College of Public Health, Iowa City, IA; Olive View-University of California Los Angeles Education and Research Institute, Los Angeles, CA; University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA
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Fuller BM, Mohr NM, Ablordeppey E, Roman O, Mittauer D, Yan Y, Kollef MH, Carpenter CR, Roberts BW. The Practice Change and Clinical Impact of Lung-Protective Ventilation Initiated in the Emergency Department: A Secondary Analysis of Individual Patient-Level Data From Prior Clinical Trials and Cohort Studies. Crit Care Med 2023; 51:279-290. [PMID: 36374044 PMCID: PMC10907984 DOI: 10.1097/ccm.0000000000005717] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Mechanically ventilated emergency department (ED) patients experience high morbidity and mortality. In a prior trial at our center, ED-based lung-protective ventilation was associated with improved care delivery and outcomes. Whether this strategy has persisted in the years after the trial remains unclear. The objective was to assess practice change and clinical outcomes associated with ED lung-protective ventilation. DESIGN Secondary analysis of individual patient-level data from prior clinical trials and cohort studies. SETTING ED and ICUs of a single academic center. PATIENTS Mechanically ventilated adults. INTERVENTIONS A lung-protective ventilator protocol used as the default approach in the ED. MEASUREMENTS AND MAIN RESULTS The primary ventilator-related outcome was tidal volume, and the primary clinical outcome was hospital mortality. Secondary outcomes included ventilator-, hospital-, and ICU-free days. Multivariable logistic regression, propensity score (PS)-adjustment, and multiple a priori subgroup analyses were used to evaluate outcome as a function of the intervention. A total of 1,796 patients in the preintervention period and 1,403 patients in the intervention period were included. In the intervention period, tidal volume was reduced from 8.2 mL/kg predicted body weight (PBW) (7.3-9.1) to 6.5 mL/kg PBW (6.1-7.1), and low tidal volume ventilation increased from 46.8% to 96.2% ( p < 0.01). The intervention period was associated with lower mortality (35.9% vs 19.1%), remaining significant after multivariable logistic regression analysis (adjusted odds ratio [aOR], 0.43; 95% CI, 0.35-0.53; p < 0.01). Similar results were seen after PS adjustment and in subgroups. The intervention group had more ventilator- (18.8 [10.1] vs 14.1 [11.9]; p < 0.01), hospital- (12.2 [9.6] vs 9.4 [9.5]; p < 0.01), and ICU-free days (16.6 [10.1] vs 13.1 [11.1]; p < 0.01). CONCLUSIONS ED lung-protective ventilation has persisted in the years since implementation and was associated with improved outcomes. These data suggest the use of ED-based lung-protective ventilation as a means to improve outcome.
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Affiliation(s)
- Brian M Fuller
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Enyo Ablordeppey
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Olivia Roman
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Dylan Mittauer
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - Marin H Kollef
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian W Roberts
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
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Lewis NM, Murray N, Adams K, Surie D, Gaglani M, Ginde AA, McNeal T, Ghamande S, Douin DJ, Talbot HK, Casey JD, Mohr NM, Zepeski A, Shapiro NI, Gibbs KW, Files DC, Hager DN, Ali H, Prekker ME, Frosch AE, Exline MC, Gong MN, Mohamed A, Johnson NJ, Srinivasan V, Steingrub JS, Peltan ID, Brown SM, Martin ET, Monto AS, Lauring AS, Khan A, Hough CL, Busse LW, Bender W, Duggal A, Wilson JG, Gordon AJ, Qadir N, Chang SY, Mallow C, Rivas C, Babcock HM, Kwon JH, Chappell JD, Halasa N, Grijalva CG, Rice TW, Stubblefield WB, Baughman A, Lindsell CJ, Hart KW, Rhoads JP, McMorrow ML, Tenforde MW, Self WH, Patel MM. Absolute and Relative Vaccine Effectiveness of Primary and Booster Series of COVID-19 Vaccines (mRNA and Adenovirus Vector) Against COVID-19 Hospitalizations in the United States, December 2021-April 2022. Open Forum Infect Dis 2023; 10:ofac698. [PMID: 36695662 PMCID: PMC9868348 DOI: 10.1093/ofid/ofac698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/29/2022] [Indexed: 01/01/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) vaccine effectiveness (VE) studies are increasingly reporting relative VE (rVE) comparing a primary series plus booster doses with a primary series only. Interpretation of rVE differs from traditional studies measuring absolute VE (aVE) of a vaccine regimen against an unvaccinated referent group. We estimated aVE and rVE against COVID-19 hospitalization in primary-series plus first-booster recipients of COVID-19 vaccines. Methods Booster-eligible immunocompetent adults hospitalized at 21 medical centers in the United States during December 25, 2021-April 4, 2022 were included. In a test-negative design, logistic regression with case status as the outcome and completion of primary vaccine series or primary series plus 1 booster dose as the predictors, adjusted for potential confounders, were used to estimate aVE and rVE. Results A total of 2060 patients were analyzed, including 1104 COVID-19 cases and 956 controls. Relative VE against COVID-19 hospitalization in boosted mRNA vaccine recipients versus primary series only was 66% (95% confidence interval [CI], 55%-74%); aVE was 81% (95% CI, 75%-86%) for boosted versus 46% (95% CI, 30%-58%) for primary. For boosted Janssen vaccine recipients versus primary series, rVE was 49% (95% CI, -9% to 76%); aVE was 62% (95% CI, 33%-79%) for boosted versus 36% (95% CI, -4% to 60%) for primary. Conclusions Vaccine booster doses increased protection against COVID-19 hospitalization compared with a primary series. Comparing rVE measures across studies can lead to flawed interpretations of the added value of a new vaccination regimen, whereas difference in aVE, when available, may be a more useful metric.
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Affiliation(s)
| | - Nancy Murray
- CDC COVID-19 Response Team, Atlanta, Georgia, USA
| | | | - Diya Surie
- CDC COVID-19 Response Team, Atlanta, Georgia, USA
| | - Manjusha Gaglani
- Baylor Scott and White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tresa McNeal
- Baylor Scott and White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Shekhar Ghamande
- Baylor Scott and White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - H Keipp Talbot
- Departments of Medicine and Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan D Casey
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Anne Zepeski
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kevin W Gibbs
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - D Clark Files
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David N Hager
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Harith Ali
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew E Prekker
- Department of Emergency Medicine and Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Anne E Frosch
- Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Matthew C Exline
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Michelle N Gong
- Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Amira Mohamed
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine and Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Jay S Steingrub
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Ithan D Peltan
- Department of Medicine, Intermountain Medical Center, Murray, Utah and University of Utah, Salt Lake City, Utah, USA
| | - Samuel M Brown
- Department of Medicine, Intermountain Medical Center, Murray, Utah and University of Utah, Salt Lake City, Utah, USA
| | - Emily T Martin
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Arnold S Monto
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Adam S Lauring
- Departments of Internal Medicine and Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Akram Khan
- Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Catherine L Hough
- Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | | | - William Bender
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jennifer G Wilson
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Alexandra June Gordon
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nida Qadir
- Department of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Steven Y Chang
- Department of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | | | - Carolina Rivas
- Department of Medicine, University of Miami, Miami, Florida, USA
| | - Hilary M Babcock
- Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Jennie H Kwon
- Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - James D Chappell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Natasha Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd W Rice
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adrienne Baughman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kimberly W Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jillian P Rhoads
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Wesley H Self
- Department of Emergency Medicine and Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Mohr NM, Okoro U, Harland KK, Fuller BM, Campbell K, Swanson MB, Wymore C, Faine B, Zepeski A, Parker EA, Mack L, Bell A, DeJong K, Mueller K, Chrischilles E, Carpenter CR, Wallace K, Jones MP, Ward MM. Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study. Ann Emerg Med 2023; 81:1-13. [PMID: 36253295 PMCID: PMC9780149 DOI: 10.1016/j.annemergmed.2022.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/07/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA.
| | - Uche Okoro
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Brian M Fuller
- Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO; Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO
| | - Kalyn Campbell
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Surgery, Hennepin County Medical Center, Minneapolis, MN
| | - Morgan B Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Cole Wymore
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Brett Faine
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Pharmaceutical Practice, College of Pharmacy, University of Iowa, Iowa City, IA
| | - Anne Zepeski
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Edith A Parker
- Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City, IA
| | - Luke Mack
- Avel eCare, Sioux Falls, SD; Department of Family Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD
| | | | | | - Keith Mueller
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
| | | | | | - Kelli Wallace
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Michael P Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
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Surie D, DeCuir J, Zhu Y, Gaglani M, Ginde AA, Douin DJ, Talbot HK, Casey JD, Mohr NM, Zepeski A, McNeal T, Ghamande S, Gibbs KW, Files DC, Hager DN, Ali H, Taghizadeh L, Gong MN, Mohamed A, Johnson NJ, Steingrub JS, Peltan ID, Brown SM, Martin ET, Khan A, Bender WS, Duggal A, Wilson JG, Qadir N, Chang SY, Mallow C, Kwon JH, Exline MC, Lauring AS, Shapiro NI, Columbus C, Halasa N, Chappell JD, Grijalva CG, Rice TW, Stubblefield WB, Baughman A, Womack KN, Rhoads JP, Hart KW, Swan SA, Lewis NM, McMorrow ML, Self WH. Early Estimates of Bivalent mRNA Vaccine Effectiveness in Preventing COVID-19-Associated Hospitalization Among Immunocompetent Adults Aged ≥65 Years - IVY Network, 18 States, September 8-November 30, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:1625-1630. [PMID: 36580424 PMCID: PMC9812444 DOI: 10.15585/mmwr.mm715152e2] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Monovalent COVID-19 mRNA vaccines, designed against the ancestral strain of SARS-CoV-2, successfully reduced COVID-19-related morbidity and mortality in the United States and globally (1,2). However, vaccine effectiveness (VE) against COVID-19-associated hospitalization has declined over time, likely related to a combination of factors, including waning immunity and, with the emergence of the Omicron variant and its sublineages, immune evasion (3). To address these factors, on September 1, 2022, the Advisory Committee on Immunization Practices recommended a bivalent COVID-19 mRNA booster (bivalent booster) dose, developed against the spike protein from ancestral SARS-CoV-2 and Omicron BA.4/BA.5 sublineages, for persons who had completed at least a primary COVID-19 vaccination series (with or without monovalent booster doses) ≥2 months earlier (4). Data on the effectiveness of a bivalent booster dose against COVID-19 hospitalization in the United States are lacking, including among older adults, who are at highest risk for severe COVID-19-associated illness. During September 8-November 30, 2022, the Investigating Respiratory Viruses in the Acutely Ill (IVY) Network§ assessed effectiveness of a bivalent booster dose received after ≥2 doses of monovalent mRNA vaccine against COVID-19-associated hospitalization among immunocompetent adults aged ≥65 years. When compared with unvaccinated persons, VE of a bivalent booster dose received ≥7 days before illness onset (median = 29 days) against COVID-19-associated hospitalization was 84%. Compared with persons who received ≥2 monovalent-only mRNA vaccine doses, relative VE of a bivalent booster dose was 73%. These early findings show that a bivalent booster dose provided strong protection against COVID-19-associated hospitalization in older adults and additional protection among persons with previous monovalent-only mRNA vaccination. All eligible persons, especially adults aged ≥65 years, should receive a bivalent booster dose to maximize protection against COVID-19 hospitalization this winter season. Additional strategies to prevent respiratory illness, such as masking in indoor public spaces, should also be considered, especially in areas where COVID-19 community levels are high (4,5).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - IVY Network
- National Center for Immunization and Respiratory Diseases, CDC; Vanderbilt University Medical Center, Nashville, Tennessee; Baylor Scott & White Health – Baylor Scott & White Medical Center, Temple, Texas; Texas A&M University College of Medicine, Temple, Texas; University of Colorado School of Medicine, Aurora, Colorado; University of Iowa, Iowa City, Iowa; Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina; Johns Hopkins Hospital, Baltimore, Maryland; Hennepin County Medical Center, Minneapolis, Minnesota; Montefiore Healthcare Center, Albert Einstein College of Medicine, New York, New York; University of Washington School of Medicine, Seattle, Washington; Baystate Medical Center, Springfield, Massachusetts; Intermountain Medical Center and University of Utah, Salt Lake City, Utah; University of Michigan School of Public Health, Ann Arbor, Michigan; Oregon Health & Science University Hospital, Portland, Oregon; Emory University School of Medicine, Atlanta, Georgia; Cleveland Clinic, Cleveland, Ohio; Stanford University School of Medicine, Stanford, California; Ronald Reagan-UCLA Medical Center, Los Angeles, California; University of Miami, Miami, Florida; Washington University, St. Louis, Missouri; The Ohio State University Wexner Medical Center, Columbus, Ohio; University of Michigan School of Medicine, Ann Arbor, Michigan; Beth Israel Deaconess Medical Center, Boston, Massachusetts; Baylor Scott & White Health – Baylor University Medical Center, Dallas, Texas
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Wessman BT, Mohr NM. The authors reply. Crit Care Med 2022; 50:e817-e818. [PMID: 36394413 DOI: 10.1097/ccm.0000000000005696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Brian T Wessman
- Department of Anesthesiology and Department of Emergency Medicine, Washington University in St. Louis, School of Medicine, St. Louis, MO
| | - Nicholas M Mohr
- Department of Emergency Medicine and Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
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Bolte TB, Swanson MB, Kaldjian AM, Mohr NM, McDanel J, Ahmed A. Hospitals That Report Severe Sepsis and Septic Shock Bundle Compliance Have More Structured Sepsis Performance Improvement. J Patient Saf 2022; 18:e1231-e1236. [PMID: 35858483 PMCID: PMC9722504 DOI: 10.1097/pts.0000000000001062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Sepsis is a common cause of death. The Centers for Medicare and Medicaid Services severe sepsis/septic shock (SEP-1) bundle is focused on improving sepsis outcomes, but it is unknown which quality improvement (QI) practices are associated with SEP-1 compliance and reduced sepsis mortality. The objectives of this study were to compare sepsis QI practices in SEP-1 reporting and nonreporting hospitals and to measure the association between sepsis QI processes, SEP-1 performance, and sepsis mortality. MATERIALS AND METHODS This study linked survey data on QI practices from Iowa hospitals to SEP-1 performance data and mortality. Characteristics of hospitals and sepsis QI practices were compared by SEP-1 reporting status. Univariable and multivariable logistic and linear regression estimated the association of QI practices with SEP-1 performance and observed-to-expected sepsis mortality ratios. RESULTS One hundred percent of Iowa's 118 hospitals completed the survey. SEP-1 reporting hospitals were more likely to have sepsis QI practices, including reporting sepsis quality to providers (64% versus 38%, P = 0.026) and using the case review process to develop sepsis care plans (87% versus 64%, P = 0.013). Sepsis QI practices were not associated with increased SEP-1 scores. A sepsis registry was associated with decreased odds of being in the bottom quartile of sepsis mortality (odds ratio, 0.37; 95% confidence interval, 0.14 to 0.96, P = 0.041), and presence of a sepsis committee was associated with lower hospital-specific mortality (observed-to-expected ratio, -0.11; 95% confidence interval, -0.20 to 0.01). CONCLUSIONS Hospitals reporting SEP-1 compliance conduct more sepsis QI practices. Most QI practices are not associated with increased SEP-1 performance or decreased sepsis mortality. Future work could explore how to implement these performance improvement practices in hospitals not reporting SEP-1 compliance.
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Affiliation(s)
- Ty B. Bolte
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Morgan B. Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Anna M. Kaldjian
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
- Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine
| | - Jennifer McDanel
- Clinical Quality, Safety & Performance Improvement, University of Iowa Hospitals and Clinics
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
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Linderman SL, Lai L, Bocangel Gamarra EL, Lau MS, Edupuganti S, Surie D, Tenforde MW, Chappell JD, Mohr NM, Gibbs KW, Steingrub JS, Exline MC, Shapiro NI, Frosch AE, Qadir N, Davis-Gardner ME, McElrath MJ, Lauring AS, Suthar MS, Patel MM, Self WH, Ahmed R. Neutralizing antibody responses in patients hospitalized with SARS-CoV-2 Delta or Omicron infection. J Clin Invest 2022; 132:164303. [PMID: 36256473 PMCID: PMC9711871 DOI: 10.1172/jci164303] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
| | - Lilin Lai
- Emory Vaccine Center,,Department of Pediatrics
| | | | - Max S.Y. Lau
- Department of Biostatistics and Bioinformatics, and
| | | | | | | | - James D. Chappell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Kevin W. Gibbs
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jay S. Steingrub
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Matthew C. Exline
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Nathan I. Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anne E. Frosch
- Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Nida Qadir
- Department of Medicine, UCLA, Los Angeles, California, USA
| | | | - M. Juliana McElrath
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Adam S. Lauring
- Departments of Medicine and of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mehul S. Suthar
- Emory Vaccine Center,,Department of Microbiology and Immunology,,Department of Pediatrics
| | | | - Wesley H. Self
- Department of Emergency Medicine and Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rafi Ahmed
- Emory Vaccine Center,,Department of Microbiology and Immunology
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Stephenson M, Olson SM, Self WH, Ginde AA, Mohr NM, Gaglani M, Shapiro NI, Gibbs KW, Hager DN, Prekker ME, Gong MN, Steingrub JS, Peltan ID, Martin ET, Reddy R, Busse LW, Duggal A, Wilson JG, Qadir N, Mallow C, Kwon JH, Exline MC, Chappell JD, Lauring AS, Baughman A, Lindsell CJ, Hart KW, Lewis NM, Patel MM, Tenforde MW. Ascertainment of vaccination status by self-report versus source documentation: Impact on measuring COVID-19 vaccine effectiveness. Influenza Other Respir Viruses 2022; 16:1101-1111. [PMID: 35818721 PMCID: PMC9350035 DOI: 10.1111/irv.13023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/06/2022] [Accepted: 05/12/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND During the COVID-19 pandemic, self-reported COVID-19 vaccination might facilitate rapid evaluations of vaccine effectiveness (VE) when source documentation (e.g., immunization information systems [IIS]) is not readily available. We evaluated the concordance of COVID-19 vaccination status ascertained by self-report versus source documentation and its impact on VE estimates. METHODS Hospitalized adults (≥18 years) admitted to 18 U.S. medical centers March-June 2021 were enrolled, including COVID-19 cases and SARS-CoV-2 negative controls. Patients were interviewed about COVID-19 vaccination. Abstractors simultaneously searched IIS, medical records, and other sources for vaccination information. To compare vaccination status by self-report and documentation, we estimated percent agreement and unweighted kappa with 95% confidence intervals (CIs). We then calculated VE in preventing COVID-19 hospitalization of full vaccination (2 doses of mRNA product ≥14 days prior to illness onset) independently using data from self-report or source documentation. RESULTS Of 2520 patients, 594 (24%) did not have self-reported vaccination information to assign vaccination group; these patients tended to be more severely ill. Among 1924 patients with both self-report and source documentation information, 95.0% (95% CI: 93.9-95.9%) agreement was observed, with a kappa of 0.9127 (95% CI: 0.9109-0.9145). VE was 86% (95% CI: 81-90%) by self-report data only and 85% (95% CI: 81-89%) by source documentation data only. CONCLUSIONS Approximately one-quarter of hospitalized patients could not provide self-report COVID-19 vaccination status. Among patients with self-report information, there was high concordance with source documented status. Self-report may be a reasonable source of COVID-19 vaccination information for timely VE assessment for public health action.
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Affiliation(s)
| | | | - Wesley H. Self
- Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Adit A. Ginde
- University of Colorado School of MedicineAuroraColoradoUSA
| | | | - Manjusha Gaglani
- Baylor Scott & White HealthTempleTexasUSA
- Texas A&M University College of MedicineTempleTexasUSA
| | | | - Kevin W. Gibbs
- Wake Forest University Baptist Medical CenterWinston‐SalemNorth CarolinaUSA
| | | | | | - Michelle N. Gong
- Montefiore Healthcare CenterAlbert Einstein College of MedicineBronxNew YorkUSA
| | | | - Ithan D. Peltan
- Intermountain Medical Center and University of UtahSalt Lake CityUtahUSA
| | - Emily T. Martin
- University of Michigan School of Public HealthAnn ArborMichiganUSA
| | - Raju Reddy
- Oregon Health & Science University HospitalPortlandOregonUSA
| | | | | | | | - Nida Qadir
- Ronald Reagan‐UCLA Medical CenterLos AngelesCaliforniaUSA
| | | | | | | | | | - Adam S. Lauring
- University of Michigan School of MedicineAnn ArborMichiganUSA
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Surie D, Bonnell L, Adams K, Gaglani M, Ginde AA, Douin DJ, Talbot HK, Casey JD, Mohr NM, Zepeski A, McNeal T, Ghamande S, Gibbs KW, Files DC, Hager DN, Shehu A, Frosch AP, Erickson HL, Gong MN, Mohamed A, Johnson NJ, Srinivasan V, Steingrub JS, Peltan ID, Brown SM, Martin ET, Khan A, Bender WS, Duggal A, Wilson JG, Qadir N, Chang SY, Mallow C, Rivas C, Kwon JH, Exline MC, Lauring AS, Shapiro NI, Halasa N, Chappell JD, Grijalva CG, Rice TW, Stubblefield WB, Baughman A, Womack KN, Hart KW, Swan SA, Zhu Y, DeCuir J, Tenforde MW, Patel MM, McMorrow ML, Self WH. Effectiveness of Monovalent mRNA Vaccines Against COVID-19-Associated Hospitalization Among Immunocompetent Adults During BA.1/BA.2 and BA.4/BA.5 Predominant Periods of SARS-CoV-2 Omicron Variant in the United States - IVY Network, 18 States, December 26, 2021-August 31, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:1327-1334. [PMID: 36264830 PMCID: PMC9590291 DOI: 10.15585/mmwr.mm7142a3] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Fuller BM, Pappal RD, Mohr NM, Roberts BW, Faine B, Yeary J, Sewatsky T, Johnson NJ, Driver BE, Ablordeppey E, Drewry AM, Wessman BT, Yan Y, Kollef MH, Carpenter CR, Avidan MS. Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study. Crit Care Med 2022; 50:1449-1460. [PMID: 35866657 PMCID: PMC10040234 DOI: 10.1097/ccm.0000000000005626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence. DESIGN An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial. SETTING The ED of three academic medical centers. PATIENTS Mechanically ventilated adult patients that received neuromuscular blockers. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01). CONCLUSIONS AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.
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Affiliation(s)
- Brian M Fuller
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Ryan D Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Brett Faine
- Departments of Emergency Medicine and Pharmacy, Roy J. and Lucille A. Carver College of Medicine, University of Iowa College of Pharmacy, Iowa City, IA
| | - Julianne Yeary
- Emergency Department, Charles F. Knight Emergency and Trauma Center, Barnes Jewish Hospital, St. Louis, MO
| | - Thomas Sewatsky
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Nicholas J Johnson
- Departments of Emergency Medicine and Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington/Harborview Medical Center, Seattle, WA
| | - Brian E Driver
- Department of Emergency Medicine, University of Minnesota School of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Enyo Ablordeppey
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian T Wessman
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO
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Kwon JH, Tenforde MW, Gaglani M, Talbot HK, Ginde AA, McNeal T, Ghamande S, Douin DJ, Casey JD, Mohr NM, Zepeski A, Shapiro NI, Gibbs KW, Files DC, Hager DN, Shehu A, Prekker ME, Caspers SD, Exline MC, Botros M, Gong MN, Li A, Mohamed A, Johnson NJ, Srinivasan V, Steingrub JS, Peltan ID, Brown SM, Martin ET, Khan A, Hough CL, Busse LW, Duggal A, Wilson JG, Perez C, Chang SY, Mallow C, Rovinski R, Babcock HM, Lauring AS, Felley L, Halasa N, Chappell JD, Grijalva CG, Rice TW, Womack KN, Lindsell CJ, Hart KW, Baughman A, Olson SM, Schrag S, Kobayashi M, Verani JR, Patel MM, Self WH. mRNA Vaccine Effectiveness Against Coronavirus Disease 2019 Hospitalization Among Solid Organ Transplant Recipients. J Infect Dis 2022; 226:797-807. [PMID: 35385875 PMCID: PMC9047160 DOI: 10.1093/infdis/jiac118] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/31/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The study objective was to evaluate 2- and 3-dose coronavirus disease 2019 (COVID-19) mRNA vaccine effectiveness (VE) in preventing COVID-19 hospitalization among adult solid organ transplant (SOT) recipients. METHODS We conducted a 21-site case-control analysis of 10 425 adults hospitalized in March to December 2021. Cases were hospitalized with COVID-19; controls were hospitalized for an alternative diagnosis (severe acute respiratory syndrome coronavirus 2-negative). Participants were classified as follows: SOT recipient (n = 440), other immunocompromising condition (n = 1684), or immunocompetent (n = 8301). The VE against COVID-19-associated hospitalization was calculated as 1-adjusted odds ratio of prior vaccination among cases compared with controls. RESULTS Among SOT recipients, VE was 29% (95% confidence interval [CI], -19% to 58%) for 2 doses and 77% (95% CI, 48% to 90%) for 3 doses. Among patients with other immunocompromising conditions, VE was 72% (95% CI, 64% to 79%) for 2 doses and 92% (95% CI, 85% to 95%) for 3 doses. Among immunocompetent patients, VE was 88% (95% CI, 87% to 90%) for 2 doses and 96% (95% CI, 83% to 99%) for 3 doses. CONCLUSIONS Effectiveness of COVID-19 mRNA vaccines was lower for SOT recipients than immunocompetent adults and those with other immunocompromising conditions. Among SOT recipients, vaccination with 3 doses of an mRNA vaccine led to substantially greater protection than 2 doses.
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Affiliation(s)
- Jennie H Kwon
- Department of Medicine, Washington University, St. Louis, Missouri, USA
| | | | - Manjusha Gaglani
- Baylor Scott and White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - H Keipp Talbot
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tresa McNeal
- Baylor Scott and White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Shekhar Ghamande
- Baylor Scott and White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jonathan D Casey
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Anne Zepeski
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kevin W Gibbs
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - D Clark Files
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David N Hager
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Arber Shehu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew E Prekker
- Department of Emergency Medicine and Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Sean D Caspers
- Department of Emergency Medicine and Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Matthew C Exline
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Mena Botros
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Michelle N Gong
- Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alex Li
- Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Amira Mohamed
- Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine and Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Jay S Steingrub
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Ithan D Peltan
- Department of Medicine, Intermountain Medical Center, Murray, Utah and University of Utah, Salt Lake City, Utah, USA
| | - Samuel M Brown
- Department of Medicine, Intermountain Medical Center, Murray, Utah and University of Utah, Salt Lake City, Utah, USA
| | - Emily T Martin
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Akram Khan
- Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Catherine L Hough
- Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | | | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jennifer G Wilson
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Cynthia Perez
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Steven Y Chang
- Department of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Christopher Mallow
- Department of Medicine, University of Miami and Jackson Memorial Health System, Miami, Florida, USA
| | - Randal Rovinski
- Department of Medicine, University of Miami and Jackson Memorial Health System, Miami, Florida, USA
| | - Hilary M Babcock
- Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Adam S Lauring
- Departments of Internal Medicine and Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Laura Felley
- Departments of Internal Medicine and Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Natasha Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James D Chappell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd W Rice
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelsey N Womack
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kimberly W Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adrienne Baughman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | | | | | | - Wesley H Self
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Mohr NM, Krishnadasan A, Harland KK, Ten Eyck P, Mower WR, Schrading WA, Montoy JCC, McDonald LC, Kutty PK, Hesse E, Santibanez S, Weissman DN, Slev P, Talan DA. Emergency department personnel patient care-related COVID-19 risk. PLoS One 2022; 17:e0271597. [PMID: 35867681 PMCID: PMC9307202 DOI: 10.1371/journal.pone.0271597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/04/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Emergency department (ED) health care personnel (HCP) are at risk of exposure to SARS-CoV-2. The objective of this study was to determine the attributable risk of SARS-CoV-2 infection from providing ED care, describe personal protective equipment use, and identify modifiable ED risk factors. We hypothesized that providing ED patient care increases the probability of acquiring SARS-CoV-2 infection. METHODS We conducted a multicenter prospective cohort study of 1,673 ED physicians, advanced practice providers (APPs), nurses, and nonclinical staff at 20 U.S. centers over 20 weeks (May to December 2020; before vaccine availability) to detect a four-percentage point increased SARS-CoV-2 incidence among HCP related to direct patient care. Participants provided monthly nasal and serology specimens and weekly exposure and procedure information. We used multivariable regression and recursive partitioning to identify risk factors. RESULTS Over 29,825 person-weeks, 75 participants (4.5%) acquired SARS-CoV-2 infection (31 were asymptomatic). Physicians/APPs (aOR 1.07; 95% CI 0.56-2.03) did not have higher risk of becoming infected compared to nonclinical staff, but nurses had a marginally increased risk (aOR 1.91; 95% CI 0.99-3.68). Over 99% of participants used CDC-recommended personal protective equipment (PPE), but PPE lapses occurred in 22.1% of person-weeks and 32.1% of SARS-CoV-2-infected patient intubations. The following factors were associated with infection: household SARS-CoV-2 exposure; hospital and community SARS-CoV-2 burden; community exposure; and mask non-use in public. SARS-CoV-2 intubation was not associated with infection (attributable risk fraction 13.8%; 95% CI -2.0-38.2%), and nor were PPE lapses. CONCLUSIONS Among unvaccinated U.S. ED HCP during the height of the pandemic, the risk of SARS-CoV-2 infection was similar in nonclinical staff and HCP engaged in direct patient care. Many identified risk factors were related to community exposures.
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Affiliation(s)
- Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
- * E-mail:
| | - Anusha Krishnadasan
- Olive View-UCLA Education and Research Institute, Los Angeles, California, United States of America
| | - Karisa K. Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
| | - William R. Mower
- Department of Emergency Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, California, United States of America
| | - Walter A. Schrading
- Department of Emergency Medicine, University of Alabama and Birmingham, Birmingham, Alabama, United States of America
| | - Juan Carlos C. Montoy
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, California, United States of America
| | - L. Clifford McDonald
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Preeta K. Kutty
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Elisabeth Hesse
- Division of Preparedness and Emerging Infections, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Scott Santibanez
- Division of Preparedness and Emerging Infections, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - David N. Weissman
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, United States of America
| | - Patricia Slev
- ARUP Laboratories, Salt Lake City, Utah, United States of America
| | - David A. Talan
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America
- Olive View-UCLA Education and Research Institute, Los Angeles, California, United States of America
- Department of Emergency Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, California, United States of America
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Nataliansyah MM, Merchant KAS, Croker JA, Zhu X, Mohr NM, Marcin JP, Rahmouni H, Ward MM. Managing innovation: a qualitative study on the implementation of telehealth services in rural emergency departments. BMC Health Serv Res 2022; 22:852. [PMID: 35780165 PMCID: PMC9250734 DOI: 10.1186/s12913-022-08271-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Telehealth studies have highlighted the positive benefits of having the service in rural areas. However, there is evidence of limited adoption and utilization. Our objective was to evaluate this gap by exploring U.S. healthcare systems' experience in implementing telehealth services in rural hospital emergency departments (TeleED) and by analyzing factors influencing its implementation and sustainability. METHODS We conducted semi-structured interviews with 18 key informants from six U.S. healthcare systems (hub sites) that provided TeleED services to 65 rural emergency departments (spoke sites). All used synchronous high-definition video to provide the service. We applied an inductive qualitative analysis approach to identify relevant quotes and themes related to TeleED service uptake facilitators and barriers. RESULTS We identified three stages of implementation: 1) the start-up stage; 2) the utilization stage; and 3) the sustainment stage. At each stage, we identified emerging factors that can facilitate or impede the process. We categorized these factors into eight domains: 1) strategies; 2) capability; 3) relationships; 4) financials; 5) protocols; 6) environment; 7) service characteristics; and 8) accountability. CONCLUSIONS The implementation of healthcare innovation can be influenced by multiple factors. Our study contributes to the field by highlighting key factors and domains that play roles in specific stages of telehealth operation in rural hospitals. By appreciating and responding to these domains, healthcare systems may achieve more predictable and favorable implementation outcomes. Moreover, we recommend strategies to motivate the diffusion of promising innovations such as telehealth.
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Affiliation(s)
- Mochamad Muska Nataliansyah
- Department of Surgery, Division of Surgical Oncology, Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53005, USA.
| | - Kimberly A S Merchant
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
| | - James A Croker
- Cardiovascular Research Institute, University of California School of Medicine, San Francisco, CA, USA
| | - Xi Zhu
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - James P Marcin
- University of California Davis School of Medicine, Sacramento, CA, USA
| | - Hicham Rahmouni
- Richard G. Lugar Center for Rural Health, Union Health, Terre Haute, IN, USA
| | - Marcia M Ward
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
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Stephens RJ, Evans EM, Pajor MJ, Pappal RD, Egan HM, Wei M, Hayes H, Morris JA, Becker N, Roberts BW, Kollef MH, Mohr NM, Fuller BM. A dual-center cohort study on the association between early deep sedation and clinical outcomes in mechanically ventilated patients during the COVID-19 pandemic: The COVID-SED study. Crit Care 2022; 26:179. [PMID: 35705989 PMCID: PMC9198202 DOI: 10.1186/s13054-022-04042-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/25/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Mechanically ventilated patients have experienced greater periods of prolonged deep sedation during the coronavirus disease (COVID-19) pandemic. Multiple studies from the pre-COVID era demonstrate that early deep sedation is associated with worse outcome. Despite this, there is a lack of data on sedation depth and its impact on outcome for mechanically ventilated patients during the COVID-19 pandemic. We sought to characterize the emergency department (ED) and intensive care unit (ICU) sedation practices during the COVID-19 pandemic, and to determine if early deep sedation was associated with worse clinical outcomes. STUDY DESIGN AND METHODS Dual-center, retrospective cohort study conducted over 6 months (March-August, 2020), involving consecutive, mechanically ventilated adults. All sedation-related data during the first 48 h were collected. Deep sedation was defined as Richmond Agitation-Sedation Scale of - 3 to - 5 or Riker Sedation-Agitation Scale of 1-3. To examine impact of early sedation depth on hospital mortality (primary outcome), we used a multivariable logistic regression model. Secondary outcomes included ventilator-, ICU-, and hospital-free days. RESULTS 391 patients were studied, and 283 (72.4%) experienced early deep sedation. Deeply sedated patients received higher cumulative doses of fentanyl, propofol, midazolam, and ketamine when compared to light sedation. Deep sedation patients experienced fewer ventilator-, ICU-, and hospital-free days, and greater mortality (30.4% versus 11.1%) when compared to light sedation (p < 0.01 for all). After adjusting for confounders, early deep sedation remained significantly associated with higher mortality (adjusted OR 3.44; 95% CI 1.65-7.17; p < 0.01). These results were stable in the subgroup of patients with COVID-19. CONCLUSIONS The management of sedation for mechanically ventilated patients in the ICU has changed during the COVID pandemic. Early deep sedation is common and independently associated with worse clinical outcomes. A protocol-driven approach to sedation, targeting light sedation as early as possible, should continue to remain the default approach.
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Affiliation(s)
- Robert J. Stephens
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, Campus Box 8054, St. Louis, MO 63110 USA
| | - Erin M. Evans
- Division of Critical Care, Departments of Emergency Medicine and Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242 USA
| | - Michael J. Pajor
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, Campus Box 8054, St. Louis, MO 63110 USA
| | - Ryan D. Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
| | - Haley M. Egan
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Max Wei
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Hunter Hayes
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Jason A. Morris
- Department of Emergency Medicine, Harvard-Affiliated Emergency Medicine Residency, Mass General Brigham, Boston, MA 02115 USA
| | - Nicholas Becker
- Department of Emergency Medicine, Mount Sinai Morningside/West, New York, NY 10025 USA
| | - Brian W. Roberts
- Department of Emergency Medicine, Cooper University Hospital, One Cooper Plaza, Camden, NJ K152 USA
| | - Marin H. Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
| | - Nicholas M. Mohr
- Division of Critical Care, Departments of Emergency Medicine and Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242 USA
| | - Brian M. Fuller
- Division of Critical Care, Departments of Anesthesiology and Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
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Adams K, Rhoads JP, Surie D, Gaglani M, Ginde AA, McNeal T, Ghamande S, Huynh D, Talbot HK, Casey JD, Mohr NM, Zepeski A, Shapiro NI, Gibbs KW, Files DC, Hicks M, Hager DN, Ali H, Prekker ME, Frosch AE, Exline MC, Gong MN, Mohamed A, Johnson NJ, Srinivasan V, Steingrub JS, Peltan ID, Brown SM, Martin ET, Monto AS, Lauring AS, Khan A, Hough CL, Busse LW, Ten Lohuis CC, Duggal A, Wilson JG, Gordon AJ, Qadir N, Chang SY, Mallow C, Rivas C, Babcock HM, Kwon JH, Chappell JD, Halasa N, Grijalva CG, Rice TW, Stubblefield WB, Baughman A, Lindsell CJ, Hart KW, Lester SN, Thornburg NJ, Park S, McMorrow ML, Patel MM, Tenforde MW, Self WH. Vaccine Effectiveness of Primary Series and Booster Doses against Omicron Variant COVID-19-Associated Hospitalization in the United States. medRxiv 2022. [PMID: 35734090 DOI: 10.1101/2022.06.09.22276228] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives: To compare the effectiveness of a primary COVID-19 vaccine series plus a booster dose with a primary series alone for the prevention of Omicron variant COVID-19 hospitalization. Design: Multicenter observational case-control study using the test-negative design to evaluate vaccine effectiveness (VE). Setting: Twenty-one hospitals in the United States (US). Participants: 3,181 adults hospitalized with an acute respiratory illness between December 26, 2021 and April 30, 2022, a period of SARS-CoV-2 Omicron variant (BA.1, BA.2) predominance. Participants included 1,572 (49%) case-patients with laboratory confirmed COVID-19 and 1,609 (51%) control patients who tested negative for SARS-CoV-2. Median age was 64 years, 48% were female, and 21% were immunocompromised; 798 (25%) were vaccinated with a primary series plus booster, 1,326 (42%) were vaccinated with a primary series alone, and 1,057 (33%) were unvaccinated. Main Outcome Measures: VE against COVID-19 hospitalization was calculated for a primary series plus a booster and a primary series alone by comparing the odds of being vaccinated with each of these regimens versus being unvaccinated among cases versus controls. VE analyses were stratified by immune status (immunocompetent; immunocompromised) because the recommended vaccine schedules are different for these groups. The primary analysis evaluated all COVID-19 vaccine types combined and secondary analyses evaluated specific vaccine products. Results: Among immunocompetent patients, VE against Omicron COVID-19 hospitalization for a primary series plus one booster of any vaccine product dose was 77% (95% CI: 71-82%), and for a primary series alone was 44% (95% CI: 31-54%) (p<0.001). VE was higher for a boosted regimen than a primary series alone for both mRNA vaccines used in the US (BNT162b2: primary series plus booster VE 80% (95% CI: 73-85%), primary series alone VE 46% (95% CI: 30-58%) [p<0.001]; mRNA-1273: primary series plus booster VE 77% (95% CI: 67-83%), primary series alone VE 47% (95% CI: 30-60%) [p<0.001]). Among immunocompromised patients, VE for a primary series of any vaccine product against Omicron COVID-19 hospitalization was 60% (95% CI: 41-73%). Insufficient sample size has accumulated to calculate effectiveness of boosted regimens for immunocompromised patients. Conclusions: Among immunocompetent people, a booster dose of COVID-19 vaccine provided additional benefit beyond a primary vaccine series alone for preventing COVID-19 hospitalization due to the Omicron variant.
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Lewis NM, Self WH, Gaglani M, Ginde AA, Douin DJ, Keipp Talbot H, Casey JD, Mohr NM, Zepeski A, Ghamande SA, McNeal TA, Shapiro NI, Gibbs KW, Files DC, Hager DN, Shehu A, Prekker ME, Erickson HL, Gong MN, Mohamed A, Johnson NJ, Srinivasan V, Steingrub JS, Peltan ID, Brown SM, Martin ET, Monto AS, Khan A, Busse LW, ten Lohuis CC, Duggal A, Wilson JG, Gordon AJ, Qadir N, Chang SY, Mallow C, Rivas C, Babcock HM, Kwon JH, Exline MC, Lauring AS, Halasa N, Chappell JD, Grijalva CG, Rice TW, Rhoads JP, Jones ID, Stubblefield WB, Baughman A, Womack KN, Lindsell CJ, Hart KW, Zhu Y, Adams K, Patel MM, Tenforde MW. Effectiveness of the Ad26.COV2.S (Johnson & Johnson) Coronavirus Disease 2019 (COVID-19) Vaccine for Preventing COVID-19 Hospitalizations and Progression to High Disease Severity in the United States. Clin Infect Dis 2022; 75:S159-S166. [PMID: 35675695 PMCID: PMC9214149 DOI: 10.1093/cid/ciac439] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Indexed: 01/19/2023] Open
Abstract
Background . Adults in the United States (US) began receiving the adenovirus vector coronavirus disease 2019 (COVID-19) vaccine, Ad26.COV2.S (Johnson & Johnson [Janssen]), in February 2021. We evaluated Ad26.COV2.S vaccine effectiveness (VE) against COVID-19 hospitalization and high disease severity during the first 10 months of its use. Methods . In a multicenter case-control analysis of US adults (≥18 years) hospitalized 11 March to 15 December 2021, we estimated VE against susceptibility to COVID-19 hospitalization (VEs), comparing odds of prior vaccination with a single dose Ad26.COV2.S vaccine between hospitalized cases with COVID-19 and controls without COVID-19. Among hospitalized patients with COVID-19, we estimated VE against disease progression (VEp) to death or invasive mechanical ventilation (IMV), comparing odds of prior vaccination between patients with and without progression. Results . After excluding patients receiving mRNA vaccines, among 3979 COVID-19 case-patients (5% vaccinated with Ad26.COV2.S) and 2229 controls (13% vaccinated with Ad26.COV2.S), VEs of Ad26.COV2.S against COVID-19 hospitalization was 70% (95% confidence interval [CI]: 63-75%) overall, including 55% (29-72%) among immunocompromised patients, and 72% (64-77%) among immunocompetent patients, for whom VEs was similar at 14-90 days (73% [59-82%]), 91-180 days (71% [60-80%]), and 181-274 days (70% [54-81%]) postvaccination. Among hospitalized COVID-19 case-patients, VEp was 46% (18-65%) among immunocompetent patients. Conclusions . The Ad26.COV2.S COVID-19 vaccine reduced the risk of COVID-19 hospitalization by 72% among immunocompetent adults without waning through 6 months postvaccination. After hospitalization for COVID-19, vaccinated immunocompetent patients were less likely to require IMV or die compared to unvaccinated immunocompetent patients.
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Affiliation(s)
- Nathaniel M. Lewis
- Corresponding Author Nathaniel M. Lewis, Influenza Prevention and Control Team, Influenza Division, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop 46 24/7, Atlanta, Georgia, 30329 ()
| | - Wesley H. Self
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Manjusha Gaglani
- Baylor Scott & White Health, Temple, Texas, USA,Texas A&M University College of Medicine, Temple, Texas, USA
| | - Adit A. Ginde
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David J. Douin
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - H. Keipp Talbot
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | | | | | | | | - Kevin W. Gibbs
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - D. Clark Files
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | - Arber Shehu
- Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | | | - Michelle N. Gong
- Montefiore Healthcare Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Amira Mohamed
- Montefiore Healthcare Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | | | | | - Ithan D. Peltan
- Intermountain Medical Center and University of Utah, Salt Lake City, Utah, USA
| | - Samuel M. Brown
- Intermountain Medical Center and University of Utah, Salt Lake City, Utah, USA
| | - Emily T. Martin
- University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Arnold S. Monto
- University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Akram Khan
- University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | | | | | | | | | | | - Nida Qadir
- David Geffen School of Medicine at UCLA, Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA
| | - Steven Y. Chang
- David Geffen School of Medicine at UCLA, Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA
| | | | | | | | | | | | - Adam S. Lauring
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Natasha Halasa
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Todd W. Rice
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Ian D. Jones
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | | | | | | - Yuwei Zhu
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Moy HP, Nayman BD, Olvera D, Monnin KD, Pappal RD, Hayes JM, Mohr NM, Kollef MH, Palmer CM, Ablordeppey E, Roberts BW, Fuller BM. Mechanical Ventilation Practices and Low Tidal Volume Ventilation in Air Medical Transport Patients: The AIR-VENT Study. Respir Care 2022; 67:647-656. [PMID: 35440496 PMCID: PMC9994187 DOI: 10.4187/respcare.09824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The management of mechanical ventilation critically impacts outcome for patients with acute respiratory failure. Ventilator settings in the early post-intubation period may be especially influential on outcome. Low tidal volume ventilation in the prehospital setting has been shown to impact the provision of low tidal volume after admission and influence outcome. However, there is an overall paucity of data on mechanical ventilation for air medical transport patients. The objectives of this study were to characterize air medical transport ventilation practices and assess variables associated with nonprotective ventilation. METHODS This was a multi-center, nationwide (approximately 130 bases) retrospective cohort study conducted on consecutive, adult mechanically ventilated air medical transport patients treated in the prehospital environment. Descriptive statistics were used to assess the cohort; the chi-square test compared categorical variables, and continuous variables were compared using independent samples t test or Mann-Whitney U test. To assess for predictors of nonprotective ventilation, a multivariable logistic regression model was constructed to adjust for potentially confounding variables. Low tidal volume ventilation was defined as a tidal volume of ≤ 8 mL/kg predicted body weight (PBW). RESULTS A total of 68,365 subjects were studied. Height was documented in only 4,186 (6.1%) subjects. Significantly higher tidal volume/PBW (8.6 [8.3-9.2] mL vs 6.5 [6.1-7.0] mL) and plateau pressure (20.0 [16.5-25.0] cm H2O vs 18.0 [15.0-22.0] cm H2O) were seen in the nonpro-tective ventilation group (P < .001 for both). According to sex, females received higher tidal volume/PBW compared to males (7.4 [6.6-8.0] mL vs 6.4 [6.0-6.8] mL, P < .001) and composed 75% of those subjects with nonprotective ventilation compared to 25% male, P < .001. After multivariable logistic regression, female sex was an independent predictor of nonprotective ventilation (adjusted odds ratio 6.79 [95% CI 5.47-8.43], P < .001). CONCLUSIONS The overwhelming majority of air medical transport subjects had tidal volume set empirically, which may be exposing patients to nonprotective ventilator settings. Given a lack of PBW assessments, the frequency of low tidal volume use remains unknown. Performance improvement initiatives aimed at indexing tidal volume to PBW are easy targets to improve the delivery of mechanical ventilation in the prehospital arena, especially for females.
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Affiliation(s)
- Hawnwan P Moy
- Department of Emergency Medicine, Division of Emergency Medical Services, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | | | | | - Karlee De Monnin
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Ryan D Pappal
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Jane M Hayes
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Christopher M Palmer
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Enyo Ablordeppey
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, New Jersey
| | - Brian M Fuller
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri.
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