An Outbreak of Parvovirus B19 in Israel

Human parvovirus B19 (B19V) has a wide clinical spectrum, ranging from an asymptomatic infection to a life threatening one. During pregnancy, it can lead to fetal loss and hydrops fetalis. This retrospective study examined the incidence rates of B19V in Israel, analyzing anonymized electronic medical records of 2.7 million individuals between January 2015 and September 2023. A generalized linear model with a Poisson distribution was fit to the data, adjusting for potential confounders. A marked increase in B19V was observed in 2023, with an adjusted incidence rate ratio (IRR) of 6.6 (95% CI 6.33-6.89) when comparing 2023 to previous years. When specifically comparing 2023 to COVID-19 years (2020-2022), adjusted IRR climbs to 9.21 (8.66-9.80). Moreover, in 2023, previously existing seasonality has largely disappeared. High SES characterized most infected individuals with a marked discrepancy in social sectors; the Arab population was significantly less likely to be found B19V positive, even when adjusting for SES. Most infections occurred in school-aged children (6-11 years old). Pregnant women experienced the most significant rise in B19V, with an adjusted IRR of 11.47 (9.44-13.97) in 2023 compared to previous years; most cases were diagnosed in the first trimester. This study demonstrates that Israel is currently experiencing the largest and longest reported outbreak of B19V to date. Policymakers should consider setting screening policies in place, at least for populations at risk, while specifically studying and potentially targeting low socioeconomic populations and specific social sectors to avoid health inequalities.

Resilience of hospital staff facing COVID-19 pandemic: Lessons from Israel

Introduction

The COVID-19 pandemic has placed additional burden on already strained healthcare systems worldwide, intensifying the responsibility and burden of healthcare workers. Although most hospital staff continued working during this stressful and challenging unprecedented pandemic, differences in the characteristics and attributes were noted between sectors and hospital departments. Israeli healthcare workers are trained and experienced in coping with national emergencies, but the pandemic has exposed variations in staff reactions. Understanding the intrinsic differences between sectors and departments is a key factor in staff and hospital preparedness for unexpected events, better resource utilization for timely interventions to mitigate risk and improve staff wellbeing.

Objective

To identify and compare the level of resilience, secondary traumatization and burnout among hospital workers, between different sectors and hospital departments, during the COVID-19 pandemic.

Methods

Cross-sectional research to assess the resiliency, secondary traumatization and burnout of healthcare workers at a large general public hospital in central Israel. The sample consisted of 655 participants across various hospital units exposed to COVID-19 patients.

Results

Emergency department physicians had higher rates of resilience and lower rates of burnout and secondary traumatization than staff in other hospital departments. In contrast, staff from internal medicine departments demonstrated the highest levels of burnout (4.29). Overall, physicians demonstrated higher levels of resilience (7.26) and lower levels of burnout compared to other workers.

Conclusion

Identifying resilience characteristics across hospital staff, sectors and departments can guide hospital management in education, preparation and training of healthcare workers for future large-scale health emergencies such as pandemics, natural disasters, and war.

Real-time prediction of patient disposition and the impact of reporter confidence on mid-level triage accuracies: an observational study in Israel

AIM

The emergency department (ED) is the first port-of-call for most patients receiving hospital care and as such acts as a gatekeeper to the wards, directing patient flow through the hospital. ED overcrowding is a well-researched field and negatively affects patient outcome, staff well-being and hospital reputation. An accurate, real-time model capable of predicting ED overcrowding has obvious merit in a world becoming increasingly computational, although the complicated dynamics of the department have hindered international efforts to design such a model. Triage nurses' assessments have been shown to be accurate predictors of patient disposition and could, therefore, be useful input for overcrowding and patient flow models.

METHODS

In this study, we assess the prediction capabilities of triage nurses in a level 1 urban hospital in central Israeli. ED settings included both acute and ambulatory wings. Nurses were asked to predict admission or discharge for each patient over a 3-month period as well as exact admission destination. Prediction confidence was used as an optimisation variable.

RESULT

Triage nurses accurately predicted whether the patient would be admitted or discharged in 77% of patients in the acute wing, rising to 88% when their prediction certainty was high. Accuracies were higher still for patients in the ambulatory wing. In particular, negative predictive values for admission were highly accurate at 90%, irrespective of area or certainty levels.

CONCLUSION

Nurses prediction of disposition should be considered for input for real-time ED models.

Syncope and undifferentiated shock

Ventricular free wall rupture is a rare post myocardial complication with a high associated mortality. In this article we discuss the case of an elderly patient who presented to our emergency department in shock after an episode of syncope. Using Point Of Care Ultrasound (POCUS), identification of cardiac tamponade and pericardial thrombus was possible, signs indicating a diagnosis of free wall rupture. Early initiation of transfer proceedings to a tertiary cardio-thoracic unit was therefore possible, resulting in a positive patient outcome.

Do automatic push notifications improve patient flow in the emergency department? analysis of an ED in a large medical center in Israel

Introduction

Congestion in emergency departments [ED] is a significant challenge worldwide. Any delay in the timely and immediate medical care provided in the ED can affect patient morbidity and mortality. Our research analyzed the use of an innovative platform to improve patient navigation in the ED, as well as provide updated information about their care. Our hope is that this can improve ED efficiency and improve overall patient care.

Objective

The primary objective of our study was to determine whether the use of an automatic push notification system can shorten ‘length of stay’ (LOS) in the ED, improve patient flow, and decrease ED patient load.

Methods

This was a prospective cohort study utilizing data extrapolated from the electronic medical records of 2972 patients who visited the walk-in ED of a large-scale central hospital in Israel from January 17, 2021 to March 15, 2021. During this period, the automatic push text notification system was activated on a week-on week-off basis. We compared data from our experimental group with the control group.

Results

The results of this study indicate that the use of an automatic push notification system had a minimal impact on specific parameters of ED patient flow. Apart from a few significant reductions of specific timed-intervals during patients’ ED visit, the majority of results were not statistically significant.

Conclusion

This study concluded that the anticipated benefits of a push text notification system in the ED do not, at this stage, justify the system’s additional cost. We recommend a follow-up study to further investigate other possible benefits.

The green man enigma: Unique presentation of toxicology in the emergency department

We describe a case report of hypertensive crisis induced by a combination of amphetamine and Marwitt's Kidney Pills. Diagnosis was delayed because of nonspecific physical findings including chest pain, abdominal pain, coughing, and diarrhea. This was confounded by puzzling physical examination findings, including green-colored urine and fingernails. Diagnosis was aided with point-of-care ultrasound, which presented a picture of acute cardiac insufficiency, pulmonary congestion, and bilateral effusions. Laboratory values on admission indicated acute multiorgan injury. Detailed patient history revealed chronic consumption of "Kidney," an over-the-counter drug available in Thailand with the primary ingredient methylene blue and used for a myriad of renal and genitourinary conditions. The patient also had a history of amphetamine use, which ultimately initiated his acute presentation.

Cardiopulmonary Resuscitation in Adults Over 80: Outcome and the Perception of Appropriateness by Clinicians

OBJECTIVES

To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out-of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome.

DESIGN

Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE).

SETTING

Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older.

PARTICIPANTS

A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics.

RESULTS AND MEASUREMENTS

The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the "appropriate" subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the "uncertain" subgroup, and 2 of 107 (1.9%) in the "inappropriate" subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate.

CONCLUSION

Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39-45, 2019.

Perception of inappropriate cardiopulmonary resuscitation by clinicians working in emergency departments and ambulance services: The REAPPROPRIATE international, multi-centre, cross sectional survey

INTRODUCTION

Cardiopulmonary resuscitation (CPR) is often started irrespective of comorbidity or cause of arrest. We aimed to determine the prevalence of perception of inappropriate CPR of the last cardiac arrest encountered by clinicians working in emergency departments and out-of-hospital, factors associated with perception, and its relation to patient outcome.

METHODS

A cross-sectional survey was conducted in 288 centres in 24 countries. Factors associated with perception of CPR and outcome were analyzed by Cochran-Mantel-Haenszel tests and conditional logistic models.

RESULTS

Of the 4018 participating clinicians, 3150 (78.4%) perceived their last CPR attempt as appropriate, 548 (13.6%) were uncertain about its appropriateness and 320 (8.0%) perceived inappropriateness; survival to hospital discharge was 370/2412 (15.3%), 8/481 (1.7%) and 8/294 (2.7%) respectively. After adjusting for country, team and clinician's characteristics, the prevalence of perception of inappropriate CPR was higher for a non-shockable initial rhythm (OR 3.76 [2.13-6.64]; P < .0001), a non-witnessed arrest (2.68 [1.89-3.79]; P < .0001), in older patients (2.94 [2.18-3.96]; P < .0001, for patients >79 years) and in case of a "poor" first physical impression of the patient (3.45 [2.36-5.05]; P < .0001). In accordance, non-shockable and non-witnessed arrests were both associated with lower survival to hospital discharge (0.33 [0.26-0.41]; P < 0.0001 and 0.25 [0.15-0.41]; P < 0.0001, respectively), as were older patient age (0.25 [0.14-0.44]; P < 0.0001 for patients >79 years) and a "poor" first physical impression (0.26 [0.19-0.35]; P < 0.0001).

CONCLUSIONS

The perception of inappropriate CPR increased when objective indicators of poor prognosis were present and was associated with a low survival to hospital discharge. Factoring clinical judgment into the decision to (not) attempt CPR may reduce harm inflicted by excessive resuscitation attempts.

Predictors of long-term survival after out-of-hospital cardiac arrest: the impact of Activities of Daily Living and Cerebral Performance Category scores

BACKGROUND

Current focus on immediate survival from out-of-hospital cardiac arrest (OHCA) has diverted attention away from the variables potentially affecting long-term survival.

AIM

To determine the relationship between neurological and functional status at hospital discharge and long-term survival after OHCA.

METHODS

Prospective data collection for all OHCA patients aged >18 years in the Jerusalem district (n=1043, 2008-2009).

PRIMARY OUTCOME MEASURE

Length of survival after OHCA. Potential predictors: Activities of Daily Living (ADL) and Cerebral Performance Category (CPC) scores at hospital discharge, age and sex.

RESULTS

There were 52/279 (18.6%) survivors to hospital discharge. Fourteen were discharged on mechanical ventilation (27%). Interviews with survivors and/or their legal guardians were sought 2.8±0.6 years post-arrest. Eighteen died before long-term follow-up (median survival 126 days, IQR 94-740). Six improved their ADL and CPC scores between discharge and follow-up. Long-term survival was positively related with lower CPC scores (p=0.002) and less deterioration in ADL from before the arrest to hospital discharge (p=0.001). For each point increment in ADL at hospital discharge, the hazard ratio of death was 1.31 (95%CI 1.12, 1.53, p=0.001); this remained unchanged after adjustment for age and sex (HR 1.26, 95%CI 0.07, 1.48, p=0.005).

CONCLUSIONS

One-third of the patients discharged from hospital after OHCA died within 30 months of the event. Long-term survival was associated both with better neurological and functional level at hospital discharge and a smaller decrease in functional limitation from before to after the arrest, yet some patients with a poor neurological outcome survived prolonged periods after hospital discharge.