Strain on Scarce Intensive Care Beds Drives Reduced Patient Volumes, Patient Selection, and Worse Outcome: A National Cohort Study

OBJECTIVES

Strain on ICUs during the COVID-19 pandemic required stringent triage at the ICU to distribute resources appropriately. This could have resulted in reduced patient volumes, patient selection, and worse outcome of non-COVID-19 patients, especially during the pandemic peaks when the strain on ICUs was extreme. We analyzed this potential impact on the non-COVID-19 patients.

DESIGN

A national cohort study.

SETTING

Data of 71 Dutch ICUs.

PARTICIPANTS

A total of 120,393 patients in the pandemic non-COVID-19 cohort (from March 1, 2020 to February 28, 2022) and 164,737 patients in the prepandemic cohort (from January 1, 2018 to December 31, 2019).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Volume, patient characteristics, and mortality were compared between the pandemic non-COVID-19 cohort and the prepandemic cohort, focusing on the pandemic period and its peaks, with attention to strata of specific admission types, diagnoses, and severity. The number of admitted non-COVID-19 patients during the pandemic period and its peaks were, respectively, 26.9% and 34.2% lower compared with the prepandemic cohort. The pandemic non-COVID-19 cohort consisted of fewer medical patients (48.1% vs. 50.7%), fewer patients with comorbidities (36.5% vs. 40.6%), and more patients on mechanical ventilation (45.3% vs. 42.4%) and vasoactive medication (44.7% vs. 38.4%) compared with the prepandemic cohort. Case-mix adjusted mortality during the pandemic period and its peaks was higher compared with the prepandemic period, odds ratios were, respectively, 1.08 (95% CI, 1.05-1.11) and 1.10 (95% CI, 1.07-1.13).

CONCLUSIONS

In non-COVID-19 patients the strain on healthcare has driven lower patient volume, selection of fewer comorbid patients who required more intensive support, and a modest increase in the case-mix adjusted mortality.

Critical care and pandemic preparedness and response

Critical care was established partially in response to a polio epidemic in the 1950s. In the intervening 70 yr, several epidemics and pandemics have placed critical care and allied services under extreme pressure. Pandemics cause wholesale changes to accepted standards of practice, require reallocation and retargeting of resources and goals of care. In addition to clinical acumen, mounting an effective critical care response to a pandemic requires local, national, and international coordination in a diverse array of fields from research collaboration and governance to organisation of critical care networks and applied biomedical ethics in the eventuality of triage situations. This review provides an introduction to an array of topics that pertain to different states of pandemic acuity: interpandemic preparedness, alert, surge activity, recovery and relapse through the literature and experience of recent pandemics including COVID-19, H1N1, Ebola, and SARS.

Renal tubular SGK1 is required to achieve blood pressure surge and circadian rhythm

Blood pressure (BP) follows a circadian pattern that rises during the active phase of the day (morning surge) and decreases during the inactive (night dipping) phase of the day. The morning surge coincides with increased circulating glucocorticoids and aldosterone, ligands for glucocorticoid receptors and mineralocorticoid receptors, respectively. Serum- and glucocorticoid-induced kinase 1 (SGK1), a clock-controlled and glucocorticoid receptor- and mineralocorticoid receptor-induced gene, plays a role in BP regulation in human and animal models. However, the role of SGK1 in BP circadian regulation has not yet been demonstrated. Using telemetry, we analyzed BP in the inducible renal tubule-specific Sgk1Pax8/LC1 model under basal K+ diet (1% K+) and high-K+ diet (HKD; 5% K+). Our data revealed that, under basal conditions, renal SGK1 plays a minor role in BP regulation; however, after 1 wk of HKD, Sgk1Pax8/LC1 mice exhibited significant defects in diastolic BP (DBP), including a blunted surge, a decreased amplitude, and reduced day/night differences. After prolonged HKD (7 wk), Sgk1Pax8/LC1 mice had lower BP than control mice and exhibited reduced DBP amplitude, together with decreased DBP day/night differences and midline estimating statistic of rhythm (MESOR). Interestingly, renal SGK1 deletion increased pulse pressure, likely secondary to an increase in circulating aldosterone. Taken together, our data suggest that 1) the kidney plays a significant role in setting the BP circadian rhythm; 2) renal tubule SGK1 mediates the BP surge and, thus, the day/night BP difference; 3) long-term renal SGK1 deletion results in lower BP in mutant compared with control mice; and 4) renal SGK1 indirectly regulates pulse pressure due to compensatory alterations in aldosterone levels.NEW & NOTEWORTHY Dysregulation of blood pressure (BP) circadian rhythm is associated with metabolic, cardiovascular, and kidney diseases. Our study provides experimental evidence demonstrating, for the first time, that renal tubule serum- and glucocorticoid-induced kinase 1 (SGK1) plays an essential role in inducing the BP surge. Inhibitors and activators of SGK1 signaling are parts of several therapeutic strategies. Our findings highlight the importance of the drug intake timing to be in phase with SGK1 function to avoid dysregulation of BP circadian rhythm.

The Effects of COVID-19 Surges on Otolaryngology Consults

Objectives We aimed to evaluate the effects COVID-19 surges had on an otolaryngology service's consultation data. Methods After obtaining Upstate University Hospital institutional review board exemption to perform this research, a retrospective review analyzing otolaryngology consults at a single institution during COVID-19 surges in the years 2020 to 2021 was performed. The total consult volume and emergency department, inpatient, pediatric, adult, weekday, night, and weekend consults were assessed. Statistical analysis was used to compare these findings to the otolaryngology consult volumes and characteristics during the same time frames as the COVID-19 surges in the years 2014 to 2019. Results Based on bivariate analysis, an upward trend in otolaryngology consult volume was found over the study period. Although there was not a significant difference in consult volume during COVID-19 surges compared to historical data (p = 0.718, p = 0.695), both surge periods had significantly lower proportions of emergency department and pediatric consults (p < 0.001 for both). Conclusion Our study demonstrated that despite increasing cases of COVID-19 infection, otolaryngology consult volume remained high during surges. It was found that there has been an increase in otolaryngology consult volume at our academic center from the year 2014 to the present, a finding that was also seen in previous studies from our institution. Interestingly, consult parameters that changed when compared to the historical data included a decreased percentage of emergency department and pediatric consults during COVID-19 surges. The summation of these findings can be used to provide insight into how hospitals and otolaryngology services can prepare for the anticipated fluctuations in COVID-19 cases and associated hospitalizations.

Role of air pollutants in dengue fever incidence: evidence from two southern cities in Taiwan

Air pollution may be involved in spreading dengue fever (DF) besides rainfalls and warmer temperatures. While particulate matter (PM), especially those with diameter of 10 μm (PM10) or 2.5 μm or less (PM25), and NO2 increase the risk of coronavirus 2 infection, their roles in triggering DF remain unclear. We explored if air pollution factors predict DF incidence in addition to the classic climate factors. Public databases and DF records of two southern cities in Taiwan were used in regression analyses. Month order, PM10 minimum, PM2.5 minimum, and precipitation days were retained in the enter mode model, and SO2 minimum, O3 maximum, and CO minimum were retained in the stepwise forward mode model in addition to month order, PM10 minimum, PM2.5 minimum, and precipitation days. While PM2.5 minimum showed a negative contribution to the monthly DF incidence, other variables showed the opposite effects. The sustain of month order, PM10 minimum, PM2.5 minimum, and precipitation days in both regression models confirms the role of classic climate factors and illustrates a potential biological role of the air pollutants in the life cycle of mosquito vectors and dengue virus and possibly human immune status. Future DF prevention should concern the contribution of air pollution besides the classic climate factors.

Ovulation and birth after administration of progesterone trigger-two case reports

PURPOSE

To determine whether using progesterone as a trigger of a gonadotropin surge will induce ovulation and a competent corpus luteum.

METHODS

Patients were administered 5 or 10 mg of progesterone intramuscularly when the leading follicle reached preovulatory size.

RESULTS

We demonstrate that progesterone injections result in classical ultrasonographic hallmarks of ovulation about 48 h later and the formation of a corpus luteum competent to support pregnancy.

CONCLUSION

Our results support further exploration of using progesterone to trigger a gonadotropin surge in assisted human reproduction.

Arizona Surge Line: An emergent statewide COVID-19 transfer service with equity as an outcome

Introduction

The Arizona Surge Line was an emergent initiative during the COVID-19 pandemic to facilitate COVID-19 patient transfers and load-level hospitals on a statewide level. It was designed and implemented by the Arizona Department of Health Services in preparation for the first hospital surge due to COVID-19, recognizing the disproportionate impact that hospital surge would have on rural and tribal populations.

Methods

We analyzed the Arizona Surge Line transfer data for the state's first two COVID-19 surges (4/16/2020-3/6/2021). Transfer data included transfer request characteristics, patient demographics and participating hospital characteristics. When applicable, we compared this data with Arizona census data, COVID-19 case data, and the CDC/ATSDR Social Vulnerability Index. The primary outcomes studied were the proportion of COVID-19 patient requests being successfully transferred, the median transfer time, and the proportion of vulnerable populations impacted.

Results

During the period of study, 160 hospitals in Arizona made 6,732 requests for transfer of COVID-19 patients. The majority of these patients (84%, 95% CI: 83-85%) were placed successfully with a median transfer time of 59 min (inter-quartile range 33-116). Of all transfer requests, 58% originated from rural hospitals, 53% were for patients of American Indian/Alaska Native ethnicity, and 73% of patients originated from highly vulnerable areas. The majority (98%) of receiving facilities were in urban areas. The Arizona Surge Line matched the number of transfers with licensed market shares during the period of study.

Conclusions

The Arizona Surge Line is an equity-enhancing initiative that disproportionately benefited vulnerable populations. This statewide transfer infrastructure could become a standard public health mechanism to manage hospital surges and enhance access to care during a health emergency.

Reduction in Hospital Transfers at a US COVID-19 Alternate Care Site: Maintaining Surge Capacity Support in Imperial County, California

OBJECTIVE

The transfer rate for patients from an Alternate Care Site (ACS) back to a hospital may serve as a metric of appropriate patient selection and the ability of an ACS to treat moderate to severely ill patients accepted from overwhelmed health-care systems. During the coronavirus infectious disease 2019 (COVID-19) pandemic, hospitals worldwide experienced acute surges of patients presenting with acute respiratory failure.

METHODS

An ACS in Imperial County, California was re-established in November 2020 to help decompress 2 local hospitals experiencing surges of COVID-19 cases. The patients treated often had multiple comorbid illnesses and required a median supplemental oxygen of 3 L/min (LPM) on admission. Numerous interventions were initiated during a 2-wk period to improve clinical care delivery.

RESULTS

The objectives of this retrospective observational study are to evaluate the impact of these clinical and staff interventions at an ACS on the transfer rate and to provide issues to consider for future ACS sites managing COVID-19 patients.

CONCLUSIONS

The data suggest that continuous, real-time process-improvement interventions helped reduce the transfer rate back to hospitals from 36.7% to 14.5% and that an ACS is a viable option for managing symptomatic COVID-19 positive patients requiring hospital-level care when hospitals are overburdened.

Perceptions of Critical Care Shortages, Resource Use, and Provider Well-being During the COVID-19 Pandemic: A Survey of 1,985 Health Care Providers in Brazil

BACKGROUND

Brazil has been disproportionately affected by COVID-19, placing a high burden on ICUs.

RESEARCH QUESTION

Are perceptions of ICU resource availability associated with end-of-life decisions and burnout among health care providers (HCPs) during COVID-19 surges in Brazil?

STUDY DESIGN AND METHODS

We electronically administered a survey to multidisciplinary ICU HCPs during two 2-week periods (in June 2020 and March 2021) coinciding with COVID-19 surges. We examined responses across geographical regions and performed multivariate regressions to explore factors associated with reports of: (1) families being allowed less input in decisions about maintaining life-sustaining treatments for patients with COVID-19 and (2) emotional distress and burnout.

RESULTS

We included 1,985 respondents (57% physicians, 14% nurses, 12% respiratory therapists, 16% other HCPs). More respondents reported shortages during the second surge compared with the first (P < .05 for all comparisons), including lower availability of intensivists (66% vs 42%), ICU nurses (53% vs 36%), ICU beds (68% vs 22%), and ventilators for patients with COVID-19 (80% vs 70%); shortages were highest in the North. One-quarter of HCPs reported that families were allowed less input in decisions about maintaining life-sustaining treatments for patients with COVID-19, which was associated with lack of intensivists (adjusted relative risk [aRR], 1.37; 95% CI, 1.05-1.80) and ICU beds (aRR, 1.71; 95% CI, 1.16-2.62) during the first surge and lack of N95 masks (aRR, 1.43; 95% CI, 1.10-1.85), noninvasive positive pressure ventilation (aRR, 1.56; 95% CI, 1.18-2.07), and oxygen concentrators (aRR, 1.50; 95% CI, 1.13-2.00) during the second surge. Burnout was higher during the second surge (60% vs 71%; P < .001), associated with witnessing colleagues at one's hospital contract COVID-19 during both surges (aRR, 1.55 [95% CI, 1.25-1.93] and 1.31 [95% CI, 1.11-1.55], respectively), as well as worries about finances (aRR, 1.28; 95% CI, 1.02-1.61) and lack of ICU nurses (aRR, 1.25; 95% CI, 1.02-1.53) during the first surge.

INTERPRETATION

During the COVID-19 pandemic, ICU HCPs in Brazil experienced substantial resource shortages, health care disparities between regions, changes in end-of-life care associated with resource shortages, and high proportions of burnout.

COVID-19 in a region of Cameroon hit by armed conflict

Introduction

the emergence of more transmissible SARS-CoV-2 variants like Delta and Omicron have triggered the next wave of COVID-19 in many parts of the world. Here we report a surge in COVID-19 cases and deaths in the Northwest (NW) Region of Cameroon, which is plagued with low immunization coverage and armed conflict.

Methods

a cross-sectional study was conducted in September 2021 and data on COVID-19 cases and vaccination were reviewed from the Ministry of Health database from January 1^st, 2020 to September 4^th, 2021. The security situation of the region was obtained from the districts and regional health managers. Data were analyzed with MS Excel and results presented as trends and proportions.

Results

since the onset of COVID-19 pandemic, there is an increasing prevalence in cases in the NW. Between epidemiological week 34-35 of 2021, there was a surge in COVID-19 cases in the NW. More than 70% of all COVID-19 related deaths reported in the country during epidemiological week-35 were recorded in this region. Despite this high mortality, COVID-19 vaccine uptake remains very low in the region. Indeed, just 0.6% of the 962,036-target population 18-years and above are fully immunized after 6-months of vaccination.

Conclusion

though the country´s epi-curve does not suggest a third wave currently, the NW is experiencing a steady COVID-19 case surge amid insecurity and the circulation of the Delta variant. There is therefore a need to adopt innovative strategies to improve immunization and strengthen other SARS-CoV-2 preventive measures in this region.

Utilization of Alternate Care Sites During the COVID-19 Surge and Mass Care: California, 2020-2021

The coronavirus disease (COVID-19) pandemic caused critical hospital bed and staffing shortages in parts of California for most of 2020 and 2021. Alternate Care Sites (ACS) were established in several regions to alleviate the hospital patient surge and to maximize staffed bed capacity. Over 1900 patients were successfully provided medical care (with physician, nursing, respiratory therapy, oxygen, and pharmacy services) in relatively austere settings. This paper examines the challenges faced at these ACS facilities and how adaptations were incorporated according to the changing dynamics of the COVID-19 pandemic to successfully manage higher acuity patients. ACS facilities were 1 approach to California's surge of COVID-19 patients, despite limited medical supplies and staffing.

Comparison of Empirical Mode Decomposition and Singular Spectrum Analysis for Quick and Robust Detection of Aerodynamic Instabilities in Centrifugal Compressors

Aerodynamic instabilities in centrifugal compressors are dangerous phenomena affecting machine efficiency and in severe cases leading to failure of the compressing system. Quick and robust instability detection during compressor operation is a challenge of utmost importance from an economical and safety point of view. Rapid indication of instabilities can be obtained using a pressure signal from the compressor. Detection of aerodynamic instabilities using pressure signal results in specific challenges, as the signal is often highly contaminated with noise, which can influence the performance of detection methods. The aim of this study is to investigate and compare the performance of two non-linear signal processing methods-Empirical Mode Decomposition (EMD) and Singular Spectrum Analysis (SSA)-for aerodynamic instability detection. Two instabilities of different character, local-inlet recirculation and global-surge, are considered. The comparison focuses on the robustness, sensitivity and pace of detection-crucial parameters for a successful detection method. It is shown that both EMD and SSA perform similarly for the analysed machine, despite different underlying principles of the methods. Both EMD and SSA have great potential for instabilities detection, but tuning of their parameters is important for robust detection.

Association of Surge Conditions with Mortality Among Critically Ill Patients with COVID-19

Objective

To determine whether surge conditions were associated with increased mortality.

Design

Multicenter cohort study.

Setting

U.S. ICUs participating in STOP-COVID.

Patients

Consecutive adults with COVID-19 admitted to participating ICUs between March 4 and July 1, 2020.

Interventions

None

Measurements and Main Results

The main outcome was 28-day in-hospital mortality. To assess the association between admission to an ICU during a surge period and mortality, we used two different strategies: (1) an inverse probability weighted difference-in-differences model limited to appropriately matched surge and non-surge patients and (2) a meta-regression of 50 multivariable difference-in-differences models (each based on sets of randomly matched surge- and non-surge hospitals). In the first analysis, we considered a single surge period for the cohort (March 23 – May 6). In the second, each surge hospital had its own surge period (which was compared to the same time periods in matched non-surge hospitals).

Our cohort consisted of 4342 ICU patients (average age 60.8 [sd 14.8], 63.5% men) in 53 U.S. hospitals. Of these, 13 hospitals encountered surge conditions. In analysis 1, the increase in mortality seen during surge was not statistically significant (odds ratio [95% CI]: 1.30 [0.47-3.58], p = .6). In analysis 2, surge was associated with an increased odds of death (odds ratio 1.39 [95% CI, 1.34-1.43], p < .001).

Conclusions

Admission to an ICU with COVID-19 in a hospital that is experiencing surge conditions may be associated with an increased odds of death. Given the high incidence of COVID-19, such increases would translate into substantial excess mortality.

Mass Critical Care Surge Response During COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings From the Task Force for Mass Critical Care

Background

After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world.

Research Question

A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality.

Study Design and Methods

TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, “gray” evidence from lay media sources, and anecdotal experiential evidence.

Results

Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs.

Interpretation

A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.

High proportion of low cycle threshold value as an early indicator of COVID-19 surge

Many countries in the world are experiencing a recent surge in COVID‐19 cases. This is mainly attributed to the emergence of new SARS‐CoV‐2 variants. Genome sequencing is the only means to detect the evolving virus mutants and emerging variants. Cycle threshold values have an inverse relationship with viral load and lower Ct values are also found to be associated with increased infectivity. In this study, we propose to use Ct values as an early indicator for upcoming COVID‐19 waves. A retrospective cross‐sectional study was carried out to analyze the Ct values of positive samples reported during the first wave and second wave (April 2020–May 2021). Median Ct values of confirmatory genes were taken into consideration for comparison. Ct values below 25, >25–30, and >30 were categorized as high, moderate, and low viral load respectively. Our study found a significantly higher proportion of positive samples with a low Ct value (<25) across age groups and gender during the second wave of the COVID‐19 pandemic. A higher proportion of positive samples with a low Ct value (high viral load) may act as an early indicator of an upcoming surge.

A surge in COVID‐19 cases is predominantly due to emergence of new SARS‐CoV‐2 variants.

Cycle threshold values have an inverse relationship with viral load and also associated with infectivity.

Our study found a significantly higher proportion of positive samples with low Ct value (<25) across age groups and gender during the second wave of COVID‐19 pandemic.

Higher proportion of positive samples with low Ct value (high viral load) may act as an early indicator of an upcoming surge.

Oxygen and Ventilator Logistics During California's COVID-19 Surge: When Oxygen Becomes a Scarce Resource

The state of California, in the United States of America, has a population of nearly 40 million people and is the 5th largest economy in the world. During the coronavirus disease 2019 (COVID-19) pandemic in 2020-2021, the state experienced a medical surge that stressed its sophisticated health-care and public health system. During this period, ventilators, oxygen, and other equipment necessary for providing ventilatory support became a scarce resource in many health-care settings. When demand overwhelms supply, creative solutions are required at all levels of disaster management and health care. This study describes the disaster response by the state of California to mitigate the emergency demands for oxygen delivery resources.

Symptoms of Mental Health Disorders in Critical Care Physicians Facing the Second COVID-19 Wave: A Cross-Sectional Study

BACKGROUND

Working in the ICU during the first COVID-19 wave was associated with high levels of mental health disorders.

RESEARCH QUESTION

What are the mental health symptoms in health-care providers (HCPs) facing the second wave?

STUDY DESIGN AND METHODS

A cross-sectional study (October 30-December 1, 2020) was conducted in 16 ICUs during the second wave in France. HCPs completed the Hospital Anxiety and Depression Scale, the Impact of Event Scale-Revised (for post-traumatic stress disorder), and the Maslach Burnout Inventory.

RESULTS

Of 1,203 HCPs, 845 responded (70%) (66% nursing staff, 32% medical staff, 2% other professionals); 487 (57.6%) had treated more than 10 new patients with COVID-19 in the previous week. Insomnia affected 320 (37.9%), and 7.7% were taking a psychotropic drug daily. Symptoms of anxiety, depression, post-traumatic stress disorder, and burnout were reported in 60.0% (95% CI, 56.6%-63.3%), 36.1% (95% CI, 32.9%-39.5%), 28.4% (95% CI, 25.4%-31.6%), and 45.1% (95% CI, 41.7%-48.5%) of respondents, respectively. Independent predictors of such symptoms included respondent characteristics (sex, profession, experience, personality traits), work organization (ability to rest and to care for family), and self-perceptions (fear of becoming infected or of infecting family and friends, feeling pressure related to the surge, intention to leave the ICU, lassitude, working conditions, feeling they had a high-risk profession, and "missing the clapping"). The number of patients with COVID-19 treated in the first wave or over the last week was not associated with symptoms of mental health disorders.

INTERPRETATION

The prevalence of symptoms of mental health disorders is high in ICU HCPs managing the second COVID-19 surge. The highest tiers of hospital management urgently need to provide psychological support, peer-support groups, and a communication structure that ensure the well-being of HCPs.

Implementing Paper Documentation During an Influenza Surge in a Pediatric Emergency Department

OBJECTIVE

We hypothesized that a paper documentation and discharge bundle can expedite patient care during an influenza-related surge.

METHODS

Retrospective cohort study of low-acuity patients younger than 21 years surging into a pediatric emergency department between January and March 2018 with influenza-like illness. Patient visits documented using a paper bundle were compared with those documented in the electronic medical record on the same date of visit. The primary outcome of interest was time from physician evaluation to discharge for patient visits documented using the paper bundle compared with those documented in the electronic medical record. Secondary outcome was difference in return visits within 72 hours. We identified patient and visit level factors associated with emergency department length of stay.

RESULTS

A total of 1591 patient visits were included, 1187 documented in the electronic health record and 404 documented using the paper bundle. Patient visits documented using the paper bundle had a 21% shortened median time from physician evaluation to discharge (41 minutes; interquartile range, 27-62.8 minutes) as compared with patient visits documented in the electronic health record (52 minutes; interquartile range, 35-61 minutes; P < 0.001). There was no difference in return visits (odds ratio, 0.7; 95% confidence interval, 0.2, 2.2).

CONCLUSIONS

Implementation of paper charting during an influenza-related surge was associated with shorter physician to discharge times when compared with patient visits documented in the electronic health record. A paper bundle may improve patient throughput and decrease emergency department overcrowding during influenza or coronavirus disease-related surge.

The Impact of Process Conditions on Surge Current Capability of 1.2 kV SiC JBS and MPS Diodes

This paper demonstrated the impact of process conditions on the surge current capability of 1.2 kV SiC junction barrier Schottky diode (JBS) and merged PiN Schottky diode (MPS). The influence of ohmic contact and defect density produced by implantation was studied in the simulation. The device fabricated with high temperature implantation had less defect density in the implant region compared with room temperature implantation, which contributed to higher hole injection in surge current mode and 20% surge capability improvement. In addition, with lower P+ ohmic contact resistance, the device had higher surge capability. When compared to device fabrication with a single Schottky metal layer in the device active area, adding additional P+ ohmic contact on top of the P+ regions in the device active area resulted in the pn junctions sharing a greater portion of surge current, and improved the devices’ surge capability by ~10%.

Where COVID-19 testing is challenging: a case series highlighting the role of thoracic imaging in resolving management dilemma posed by unusual presentation

The COVID-19 pandemic remains an evolving disease posing a challenge of incomplete understanding escalated by random atypical clinical presentations. Numerous challenges still exist with accessibility and availability of standard COVID-19 viral testing using real-time Polymerase Chain Reaction (RT-PCR), in low- and middle-income countries, especially in several hospital settings. The clinical information of three select patients at a major health facility in Southwestern Nigeria with unusual COVID-19 clinical presentation and clinical management dilemma related to challenges with COVID-19 viral laboratory testing, were retrospectively reviewed. The medical history in all three cases closely mimicked that of other medical conditions because of assumptions created by red herrings like an acute exacerbation of an underlying non-communicable disease (diaphragmatic eventration) in case 1, re-activation of a previously treated lung condition (tuberculosis) in case 2 and a sequalae of a previously diagnosed but poorly-managed chronic non-communicable disease (decompensated hypertensive heart disease). Also, viral testing was challenging in all cases due to reasons ranging from late turn-around time to inconsistent results. However, thoracic imaging was employed in all cases to heighten suspicion of COVID-19 infection, resolve management dilemma and limit intra-hospital spread. Thoracic imaging can play a major role within hospital settings in low-and middle-income countries in resolving diagnostic challenges of atypical COVID-19 clinical presentations, raising suspicion for early institution of intra-hospital disease containment measures, limiting exposure among hospital staff and guiding clinical case management of COVID-19; especially where challenges with confirmatory viral testing remain persistent.

The ongoing COVID-19 pandemic will create a disease surge among cancer patients

With major parts of the United States in lockdown, parts of Europe and the UK possibly going back on lockdown or expecting a second COVID-19 wave and rapidly rising rates elsewhere other than Asia, many people are forgoing regular cancer screenings and prevention services. More worrisome, some may be experiencing early signs or symptoms, yet they are not seeking evaluation, treatment or surveillance examinations. The long-term impact of this on patients, families and health care providers will be substantial. Not only will this strain sophisticated health systems in developed countries, but it will also overwhelm the health care infrastructure in developing countries.

Health-care executives, cancer center directors, oncologists and policy experts should focus now on serving this potential “third wave” of sick patients who have delayed treatment. Stopping COVID-19 is critical. However, it’s also essential to plan for the coming wave of patients who have delayed seeking care or don’t have access.

To evaluate the effect of COVID-19 pandemic and national lockdown on patient care at a tertiary-care ophthalmology institute

Purpose:

To evaluate the effect of COVID-19 pandemic and national lockdown on patient care at a tertiary-care ophthalmology institute.

Methods:

Records of all the patients who presented from March 25^th to May 3^rd, 2020 were scanned to evaluate the details regarding the presenting complaints, diagnosis, advised treatment and surgical interventions.

Results:

The number of outpatient department visits, retinal laser procedures, intravitreal injections and cataract surgeries during this lockdown decreased by 96.5%, 96.5%, 98.7% and 99.7% respectively compared from the corresponding time last year. Around 38.8% patients could be triaged as non-emergency cases based on history alone while 59.5% patients could be triaged as non-emergency cases after examination. Only eighty-four patients opted for video-consultation from April 15^th to May 3^rd, 2020. Nine patients presented with perforated corneal ulcer, but could not undergo penetrating keratoplasty due to the lack to available donor corneal tissue. One of these patients had to undergo evisceration due to disease progression. Two patients with open globe injury presented late after trauma and had to undergo enucleation. Around 9% patients could not undergo the advised urgent procedure due to logistical issues related to the lockdown.

Conclusion:

A significant number of patients could not get adequate treatment during the lockdown period. Hospitals need to build capacity to cater to the expected patient surge post-COVID-19-era, especially those requiring immediate in-person attention. A large number of patients can be classified as non-emergency cases. These patients need to be encouraged to follow-up via video-consultation to carve adequate in-person time for the high-risk patients.

From Concerts to COVID: Transforming the RI Convention Center into an Alternate Hospital Site in under a Month

Field hospitals have long been used to extend health care capabilities in times of crisis. In response to the pandemic and an anticipated surge in patients, Rhode Island Gov. Gina Raimondo announced a plan to create three field hospitals, or "alternate hospital sites" (AHS), totaling 1,000 beds, in order to expand the state's hospital capacity. Following China's Fangcang shelter hospital model, the Lifespan AHS (LAHS) planning group attempted to identify existing public venues that could support rapid conversion to a site for large numbers of patients at a reasonable cost. After discussions with many stakeholders - pharmacy, laboratory, healthcare providers, security, emergency medical services, and infection control - design and equipment recommendations were given to the architects during daily teleconferencing and site visits. Specific patient criteria for the LAHS were established, staffing was prioritized, and clinical protocols were designed to facilitate care. Simulations using 4 different scenarios were practiced in order to assure proper patient care and flow, pharmacy utilization, and staffing.

Resource Reallocation during the COVID-19 Pandemic in a Suburban Hospital System: Implications for Outpatient Hip and Knee Arthroplasty

The COVID pandemic of 2020 has emerged as a global threat to patients, health care providers, and to the global economy. Owing to this particular novel and highly infectious strain of coronavirus, the rapid community spread and clinical severity of the subsequent respiratory syndrome created a substantial strain on hospitals and health care systems around the world. The rapid surge of patients presenting over a small period for emergent clinical care, admission to the hospital, and intensive care units with many requiring mechanically assisted ventilators for respiratory support demonstrated the potential to overwhelm health care workers, hospitals, and health care systems. The purpose of this article is to describe an effective system for redeployment of health care supplies, resources, and personnel to hospitals within a suburban academic hospital system to optimize the care of COVID patients, while treating orthopedic patients in an equally ideal setting to maximize their surgical and clinical care. This article will provide a particular focus on the current and future role of a specialty hip and knee hospital and its partnering ambulatory surgery center in the context of an outpatient arthroplasty program.

Obtaining Information about Operation of Centrifugal Compressor from Pressure by Combining EEMD and IMFE

Based on entropy characteristics, some complex nonlinear dynamics of the dynamic pressure at the outlet of a centrifugal compressor are analyzed, as the centrifugal compressor operates in a stable and unstable state. First, the 800-kW centrifugal compressor is tested to gather the time sequence of dynamic pressure at the outlet by controlling the opening of the anti-surge valve at the outlet, and both the stable and unstable states are tested. Then, multi-scale fuzzy entropy and an improved method are introduced to analyze the gathered time sequence of dynamic pressure. Furthermore, the decomposed signals of dynamic pressure are obtained using ensemble empirical mode decomposition (EEMD), and are decomposed into six intrinsic mode functions and one residual signal, and the intrinsic mode functions with large correlation coefficients in the frequency domain are used to calculate the improved multi-scale fuzzy entropy (IMFE). Finally, the statistical reliability of the method is studied by modifying the original data. After analysis of the relationships between the dynamic pressure and entropy characteristics, some important intrinsic dynamics are captured. The entropy becomes the largest in the stable state, but decreases rapidly with the deepening of the unstable state, and it becomes the smallest in the surge. Compared with multi-scale fuzzy entropy, the curve of the improved method is smoother and could show the change of entropy exactly under different scale factors. For the decomposed signals, the unstable state is captured clearly for higher order intrinsic mode functions and residual signals, while the unstable state is not apparent for lower order intrinsic mode functions. In conclusion, it can be observed that the proposed method can be used to accurately identify the unstable states of a centrifugal compressor in real-time fault diagnosis.

Tropical cyclones and the organization of mangrove forests: a review

BACKGROUND

Many mangrove ecosystems are periodically exposed to high velocity winds and surge from tropical cyclones, and often recover with time and continue to provide numerous societal benefits in the wake of storm events.

SCOPE

This review focuses on the drivers and disturbance mechanisms (visible and functional) that tropical cyclones of various intensities have on mangrove ecosystem properties around the world, as well as the potential ecosystem services role offered by mangroves along storm-ravaged coastlines. When viewed together, studies describe repeatable types of impact and a variety of responses of mangroves that make them ecologically resilient to high velocity winds, and which have served to advance the notion that mangroves are disturbance-adapted ecosystems.

CONCLUSIONS

Studies have documented massive tree mortality and forest structural shifts as well as high variability of spatial effects associated with proximity and direction of the tropical cyclone trajectory that influence biogeochemical processes, recovery of individual trees, and forest regeneration and succession. Mangroves provide coastal protection through surge and wind suppression during tropical cyclones, and yet are able to overcome wind effects and often recover unless some alternative environmental stress is at play (e.g. hydrological alteration or sedimentation). Structural elements of mangroves are influenced by the legacies imposed by past tropical cyclone injury, which affect their current appearance, and presumably their function, at any point in time. However, much is yet to be discovered about the importance of the effects of tropical cyclones on these fascinating botanical ecosystems, including the role of storm-based sediment subsidies, and much more effort will be needed to predict future recovery patterns as the frequency and intensity of tropical cyclones potentially change.

Descriptions of Entropy with Fractal Dynamics and Their Applications to the Flow Pressure of Centrifugal Compressor

In this study, some important intrinsic dynamics have been captured after analyzing the relationships between the dynamic pressure at an outlet of centrifugal compressor and fractal characteristics, which is one of powerful descriptions in entropy to measure the disorder or complexity in the nonlinear dynamic system. In particular, the fractal dynamics of dynamic pressure of the flow is studied, as the centrifugal compressor is in surge state, resulting in the dynamic pressure of flow and becoming a serious disorder and complex. First, the dynamic pressure at outlet of a centrifugal compressor with 800 kW is tested and then obtained by controlling the opening of the anti-surge valve at the outlet, and both the stable state and surge are initially tested and analyzed. Subsequently, the fractal dynamics is introduced to study the intrinsic dynamics of dynamic pressure under various working conditions, in order to identify surge, which is one typical flow instability in centrifugal compressor. Following fractal dynamics, the Hurst exponent, autocorrelation functions, and variance in measure theories of entropy are studied to obtain the mono-fractal characteristics of the centrifugal compressor. Further, the multi-fractal spectrums are investigated in some detail, and their physical meanings are consequently explained. At last, the statistical reliability of multi-fractal spectrum by modifying the original data has been studied. The results show that a distinct relationship between the dynamic pressure and fractal characteristics exists, including mono-fractal and multi-fractal, and such fractal dynamics are intrinsic. As the centrifugal compressor is working under normal condition, its autocorrelation function curve demonstrates apparent stochastic characteristics, and its Hurst exponent and variance are lower. However, its autocorrelation function curve demonstrates an apparent heavy tail distribution, and its Hurst exponent and variance are higher, as it is working in an unstable condition, namely, surge. In addition, the results show that the multi-fractal spectrum parameters are closely related to the dynamic pressure. With the state of centrifugal compressor being changed from stable to unstable states, some multi-fractal spectrum parameters Δα, Δf(α), α_max, and f(α_min) become larger, but α_min in the multi-fractal spectrum show the opposite trend, and consistent properties are graphically shown for the randomly shuffled data. As a conclusion, the proposed method, as one measure method for entropy, can be used to feasibly identify the incipient surge of a centrifugal compressor and design its surge controller.

Fluid dynamics and intraocular pressure using venturi phacoemulsification machine in dogs ex vivo

OBJECTIVE

To optimize fluid dynamics through measuring intraocular pressure (IOP) in a venturi phacoemulsification machine in dogs.

PROCEDURES

In step I, flow and IOP of the test chamber were measured using a pressure transducer with the bottle height (BH) set at 50, 70, 100, and 120 cm and the vacuum from 30 to 450 mmHg. A 19-gauge phaco and a 0.3-mm irrigation/aspiration (I/A) handpiece were used. In step II, flow and IOP were measured in an enucleated canine eye with a 3.0- and a 3.2-mm clear corneal incision (CCI), respectively. IOP was measured using the pressure transducer at a 30-mmHg vacuum to allow corneal deformation, to define the fluidic parameters for preventing surge.

RESULTS

Flow was directly proportional to the BH and vacuum, whereas IOP was directly proportional to the BH and inversely to the vacuum. Flow with an I/A handpiece was significantly less than with a phaco handpiece, explaining why IOP with an I/A handpiece was significantly higher than with a phaco handpiece. With the I/A handpiece, vacuum parameters less than 450 mmHg did not result in corneal deformation. IOP with a 3.2-mm CCI was significantly lower than with a 3.0-mm CCI, with the 3.2-mm flow being greater than the 3.0-mm flow.

CONCLUSIONS

BH during the I/A stage could be reduced to avoid unnecessary stress on the canine eye when using a venturi system. Although phacoemulsification with a 3.2-mm CCI could induce lower IOP, a 3.0-mm CCI might lessen the irrigation flow stress on the eye.

10. Identification of needs

Needs are not directly assessed, but rather, the identification of needs is the result of a complex process that requires integration and synthesis of many factors, including the results from numerous assessments. The assessments synthesised into needs include: (1) the pre-event levels of function; (2) the amount and types of damage sustained initially and existing at the current time; current (3) levels of function and the levels of function detected by the last assessment; (4) the presence of a surge; (5) the demands of the population affected; (6) the culture in which the event occurred; (7) the climate in the affected area; (8) the geography and access to the affected area; and (9) politics. The process consumes resources (costs). The transformation process (synthesis) of these many factors requires that those charged with synthesis have knowledge, field experience, insight, and experience using the process.

Operation crash and surge: lessons learned from a region-wide exercise

The Homeland Security Exercise and Evaluation Program (HSEEP) provides base guidance for planning all levels of public safety exercises, from simple seminars to complex full-scale exercises. However, the recent emphasis placed on the Federal Emergency Response Agency Whole Community approach to emergency management involves broadening the spectrum of participants to include multiple community partners. The magnitude and complexity of these exercises necessitates the incorporation of additional planning strategies beyond HSEEP guidance. The objective of this paper is to offer insight on effectively planning, running and learning from a region-wide multi-agency, multi-discipline, full-scale exercise. This will be achieved by utilising a case study to outline the planning process and lessons learned from managing the interaction of components, with an emphasis on achieving common goals without compromising individual needs. Additionally, this article complements 'Plane down in the city: Operation Crash and Surge', written by Duane F. Kann and Thomas W. Draper, and published in Volume 7 Number 3 of this journal.

Public perceptions of hospital responsibilities to those presenting without medical injury or illness during a disaster

Background

During natural and manmade disasters, the hospital is perceived as a central rallying and care site for the public, for both those with and without emergency medical needs. The expectations of the public may outstrip hospital plans and abilities to provide nonmedical assistance.

Objective

Our objective was to determine the public expectations of the hospital during disasters regarding resource provision.

Methods

A survey was distributed to adult patients or family members at three emergency departments (EDs). Respondents were asked to evaluate hospital responsibility to provide nine resources to those without emergency medical needs, including vaccination, medication refill or replacement, food and water, grief/stress counseling, Federal Emergency Management Agency (FEMA) access assistance, short/long-term shelter, family reunification, and hospital. Additionally, respondents answered questions regarding prior disaster experience and demographics.

Results

There were 961 respondents (66.9% were female, 47.5% were white, and 44.6% were black). Respondents agreed or strongly agreed that the hospital should provide the following services: event-specific vaccination (84%), medication refill/replacement (76.5%), food and water (61%), grief or stress counseling (53%), FEMA access assistance (52%), short-term shelter (51%), family reunification (50%), long-term shelter (38%), and hospital transportation (29%). Those 36–45 years of age were less likely to expect services (p < 0.05) and non-whites and those with a family member with a medical condition requiring electricity were more likely to expect services (p < 0.001 and p < 0.05, respectively). There were no differences based on frequency of ED use, sex, income, or prior disaster experience.

Conclusion

There is a high public expectation that hospitals will provide significant nonmedical disaster relief. Understanding these expectations is essential to appropriate community disaster planning.