Calvert Memorial Hospital

The American healthcare system is amid a burnout epidemic, worsened by COVID, that must be addressed expeditiously and with high priority. The burden Emergency Physicians encountered before and during the pandemic is well known, with countless healthcare workers exiting the work force. A Chief Wellness Officer (CWO) is a senior leader who works primarily to cultivate organisational wellness and to foster and promote a culture of well-being throughout an institution. Specifically, the CWO assists the health system leadership promote clinician engagement and address clinician burnout. This paper explores the status of existing CWOs, and cites the benefits, impacts, and barriers to implementation of a CWO, with focus on the field of Emergency Medicine (EM). A steering committee of wellness experts was formed from a national EM organisation. A purposive search and literature review using search terms relating to CWOs was completed. Publications were examined for relevance and recency. The committee created an online questionnaire surveying current US CWOs, conducted personal interviews, and met through regular focused meetings. A framework delineating the role of a CWO as an organisation evolves from instituting novice wellness interventions to expert organisational innovations was created. Despite their title, CWOs are not regularly included in c-suite decisions. Barriers to instituting a CWO include perceived financial cost, the medical system itself, and physician resistance. Defining and measuring objective return on investment may be a solution to overcoming barriers. CWOs who create comprehensive institutional wellness innovations bring organisations to the highest proficient and expert levels of wellness practices, positively affecting physician engagement and deflecting burnout. CWOs instituting novice and beginner levels of wellness interventions, especially in EM, only modestly impact individual wellness practices. A CWO and team with an organisational voice and a C-suite stakeholder's seat are essential to centralising and leading effective wellness efforts and innovations in EM and other specialities. This team will improve the work environment and culture and begin to fix our broken healthcare system and providers.

There is significant interest in the potential for nebulised unfractionated heparin (UFH), as a novel therapy for patients with COVID‐19 induced acute hypoxaemic respiratory failure requiring invasive ventilation. The scientific and biological rationale for nebulised heparin stems from the evidence for extensive activation of coagulation resulting in pulmonary microvascular thrombosis in COVID‐19 pneumonia. Nebulised delivery of heparin to the lung may limit alveolar fibrin deposition and thereby limit progression of lung injury. Importantly, laboratory studies show that heparin can directly inactivate the SARS‐CoV‐2 virus, thereby prevent its entry into and infection of mammalian cells. UFH has additional anti‐inflammatory and mucolytic properties that may be useful in this context.Methods and interventionThe Can nebulised HepArin Reduce morTality and time to Extubation in Patients with COVID‐19 Requiring invasive ventilation Meta‐Trial (CHARTER‐MT) is a collaborative prospective individual patient data analysis of on‐going randomised controlled clinical trials across several countries in five continents, examining the effects of inhaled heparin in patients with COVID‐19 requiring invasive ventilation on various endpoints.Each constituent study will randomise patients with COVID‐19 induced respiratory failure requiring invasive ventilation. Patients are randomised to receive nebulised heparin or standard care (open label studies) or placebo (blinded placebo‐controlled studies) while under invasive ventilation. Each participating study collect a pre‐defined minimum dataset. The primary outcome for the meta‐trial is the number of ventilator‐free days up to day 28 day, defined as days alive and free from invasive ventilation.

Inhaled nebulised unfractionated heparin (UFH) has a strong scientific and biological rationale that warrants urgent investigation of its therapeutic potential in patients with COVID-19. UFH has antiviral effects and prevents the SARS-CoV-2 virus' entry into mammalian cells. In addition, UFH has significant anti-inflammatory and anticoagulant properties, which limit progression of lung injury and vascular pulmonary thrombosis. The INHALEd nebulised unfractionated HEParin for the treatment of hospitalised patients with COVID-19 (INHALE-HEP) metatrial is a prospective individual patient data analysis of on-going randomised controlled trials and early phase studies. Individual studies are being conducted in multiple countries. Participating studies randomise adult patients admitted to the hospital with confirmed SARS-CoV-2 infection, who do not require immediate mechanical ventilation, to inhaled nebulised UFH or standard care. All studies collect a minimum core dataset. The primary outcome for the metatrial is intubation (or death, for patients who died before intubation) at day 28. The secondary outcomes are oxygenation, clinical worsening and mortality, assessed in time-to-event analyses. Individual studies may have additional outcomes. We use a Bayesian approach to monitoring, followed by analysing individual patient data, outcomes and adverse events. All analyses will follow the intention-to-treat principle, considering all participants in the treatment group to which they were assigned, except for cases lost to follow-up or withdrawn. The metatrial is registered at ClinicalTrials.gov ID NCT04635241. Each contributing study is individually registered and has received approval of the relevant ethics committee or institutional review board. Results of this study will be shared with the World Health Organisation, published in scientific journals and presented at scientific meetings.

Inhaled nebulised unfractionated heparin (UFH) has a strong scientific and biological rationale that warrants urgent investigation of its therapeutic potential in patients with COVID-19. UFH has antiviral effects and prevents the SARS-CoV-2 virus’ entry into mammalian cells. In addition, UFH has significant anti-inflammatory and anti-coagulant properties, which limit progression of lung injury and vascular pulmonary thrombosis. Methods and intervention The INHALEd nebulised unfractionated HEParin for the treatment of hospitalised patients with COVID-19 (INHALE-HEP) meta-trial is a prospective individual patient data analysis of on-going randomised controlled trials and early phase studies. Individual studies are being conducted in multiple countries. Participating studies randomise adult patients admitted to the hospital with confirmed SARS-CoV-2 infection, who do not require immediate mechanical ventilation, to inhaled nebulised UFH or standard care. All studies collect a minimum core dataset. The primary outcome for the meta-trial is intubation (or death, for patients who died before intubation) at day 28. The secondary outcomes are oxygenation, clinical worsening and mortality, assessed in time-to-event analyses. Individual studies may have additional outcomes. Analysis We use a Bayesian approach to monitoring, followed by analysing individual patient data, outcomes and adverse events. All analyses will follow the intention-to-treat principle, considering all participants in the treatment group to which they were assigned, except for cases lost to follow-up or withdrawn. Trial registration, ethics and dissemination The meta-trial is registered at ClinicalTrials.gov ID NCT04635241. Each contributing study is individually registered and has received approval of the relevant ethics committee or institutional review board.

In 2012, Frederick Memorial Hospital (FMH) revitalized their blood utilization guidelines to follow a more restrictive approach to blood product transfusions. With help from the American Red Cross and the American Association of Blood Banks, the blood utilization committee at FMH established a set of blood transfusion guidelines, and educated and enforced all ordering physicians to follow the new set of guidelines. Since the guidelines were established, the amount of red blood cell transfusions decreased by 34%, plasma transfusions decreased by 55%, and platelet transfusions decreased by 34%. These decreases have reduced the number of patients exposed to the possibility of transfusion-adverse reactions and related side effects. Reported transfusion reactions since 2012 decreased by 51%. By using a more restrictive set of guidelines the blood utilization committee was able to achieve their goals, which included 1) reducing the high cost associated with blood transfusion, 2) improving patient care, and 3) educating physicians regarding current transfusion protocols and techniques, while concurrently decreasing transfusion-related adverse events. The successful process used at FMH may be useful for other similar health care settings.

Mania is a mood disorder characteristic of certain psychiatric conditions and is exhibited by high energy, elevated mood, irritability, insomnia, and pressured speech. Though commonly attributed to bipolar and schizoaffective disorders, mania may be precipitated by other non-psychiatric conditions, including substance abuse, medications, metabolic disturbance, and organic brain pathology. Steroid-induced mania is not uncommon and may present with a number of psychiatric symptoms. Brain tumors presenting with predominantly psychiatric symptoms are a relatively uncommon cause of mania and may persist or recede with treatment. A case of mania in a cancer patient with brain metastasis and steroid use, with no prior history of mania, is discussed herein.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have gained momentum as a viable treatment option for primary or recurrent malignancies with peritoneal metastasis (PM). Despite significant progress over the last 30 years, this field has lacked in high-quality randomized, controlled trials, with most data supporting the use of CRS and HIPEC coming from smaller retrospective and prospective trials. Ultimately, validation of treatment efficacy and outcomes will require large, collaborative, well-organized, outcomes-based studies. Thus far, the use of CRS and HIPEC in metastatic gastric, ovarian, pancreatic, and other gastrointestinal malignancies has spurred further development of a growing number of prospective clinical trials to study outcomes and survival benefit. This chapter summarizes some of the notable, completed clinical trials and current trials being conducted.

Objective:Glucocorticoids (GCs) are used as standard treatment for acute attacks of multiple sclerosis (MS). However, GCs eventually lose efficacy and do not prevent disease progression. Macrophage migration inhibitory factor (MIF) is the only known proinflammatory cytokine induced by GCs that inhibits their anti-inflammatory effects. Therefore, we investigated whether MIF plays a role in resistance to GC treatment in experimental autoimmune encephalomyelitis (EAE), an animal model of MS.Methods:EAE was induced in wild-type (Wt) and MIF knockout (MIF−/−) mice followed by treatment with dexamethasone (Dex) before or upon disease onset. Splenocytes and brain mononuclear cells were harvested for cytokine ELISPOT assay and flow cytometry analysis.Results:Treatment of EAE with Dex was substantially more efficacious in MIF−/− mice than Wt mice. Dex treatment decreased MOG35-55–induced cytokine production by Wt or MIF−/− CD4+ T cells only at the onset of EAE but inhibited upregulation of T-bet during acute and chronic phases of disease, particularly in MIF−/− mice. Furthermore, passive EAE induced by adoptive transfer of T cells showed that Dex was highly effective in ameliorating disease induced by MIF−/− CD4+ T cells but not by Wt CD4+ T cells. The expression of T-bet and VLA-4 was decreased in CD4+ T cells in MIF−/− mice compared with Wt mice.Conclusions:Our data establish MIF as a key molecule in resistance of pathogenic CD4+ T cells to GC treatment in EAE and as a potential target to enhance the effectiveness of steroid treatment in neuroinflammatory disorders.

Purpose:To examine the impact of a Continuum of Care Resident Pharmacist on (1) heart failure 30-day hospital readmissions and (2) compliance with Joint Commission Heart Failure core measure 1 at a community hospital.Methods:The Continuum of Care Network led by a Continuum of Care Resident Pharmacist was established in August 2011. The Continuum of Care Resident Pharmacist followed Continuum of Care Network patients and retrospectively collected data from August 2011 to December 2012. Thirty-day readmission rates for Continuum of Care Network heart failure patients versus non-Continuum of Care Network heart failure patients were compared and analyzed. Joint Commission Heart Failure core measure 1 compliance rates were retrospectively collected from January 2011 and compared to data after establishment of the Continuum of Care Network.Results:In all, 162 Continuum of Care Network patients and 470 non-Continuum of Care Network patients were discharged with a diagnosis of heart failure from August 2011 to December 2012. Continuum of Care Network heart failure patients had a lower 30-day all-cause readmission rate compared to non-Continuum of Care Network heart failure patients (12% versus 24%, respectively; p = 0.005). In addition, Heart Failure core measure 1 compliance rates improved from the 80th percentile to the 90th percentile after implementation of the Continuum of Care Network (p = 0.004). The top three interventions performed by the Continuum of Care Resident Pharmacist were discharge counseling (74.1%), providing a MedActionPlan™ (68.5%), and resolving medication reconciliation discrepancies (64.8%).Conclusion:The study findings suggest that a Continuum of Care Resident Pharmacist contributed to lowered heart failure readmission rates and improved Heart Failure core measure 1 compliance rates. Future randomized, controlled trials are needed to confirm these findings.

Children evaluated in emergency departments for blunt head trauma (BHT) frequently undergo computed tomography (CT), with some requiring pharmacological sedation. Cranial CT sedation complications are understudied. The objective of this study was to document the frequency, type, and complications of pharmacological sedation for cranial CT in children. We prospectively enrolled children (younger than 18 years) with minor BHT presenting to 25 emergency departments from 2004 to 2006. Data collected included sedation agent and complications. We excluded patients with Glasgow Coma Scale scores of less than 14. Of 57,030 eligible patients, 43,904 (77%) were enrolled in the parent study; 15,176 (35%) had CT scans performed or planned, and 527 (3%) received pharmacological sedation for CT. Sedated patients' characteristics were as follows: median age, 1.7 years (interquartile range, 1.1-2.5 years); male 61%; Glasgow Coma Scale score of 15, 86%; traumatic brain injury on CT, 8%. There were 488 patients (93%) who received 1 sedative. Sedation use (0%-21%) and regimen varied by site. Pentobarbital (n = 164) and chloral hydrate (n = 149) were the most frequently used agents. Sedation complications occurred in 49 patients (9%; 95% confidence interval [CI], 7%-12%): laryngospasm 1 (0.2%; 95% CI, 0%-1.1%), failed sedation 31 (6%; 95% CI, 4%-8%), vomiting 6 (1%; 95% CI, 0.4%-2%), hypotension 13 (4%; 95% CI, 2%-7%), and hypoxia 1 (0.2%; 95% CI, 0%-2%). No cases of apnea, aspiration, or reversal agent use occurred. One patient required intubation. Vomiting and failed sedation were most common with chloral hydrate. Pharmacological sedation is infrequently used for children with minor BHT undergoing CT, and complications are uncommon. The variability in sedation medications and frequency suggests a need for evidence-based guidelines.