Lawrence General Hospital

IntroductionIn the emergency care setting, implementation of infection prevention and control (IPC) practices can be challenging due to numerous factors including emergency department (ED) crowding and boarding of patients, high staff-turnover rates, and acuity of patient needs. Understanding how the unique nature of the ED environment impacts IPC implementation is essential to reducing healthcare-associated infections and to improving patient safety. In this study we aimed to assess ED leaders’ perceptions of IPC practices to identify areas for potential intervention and inform targeted process improvement initiatives.MethodsBetween January–July 2023, ED leaders across the United States were queried about their IPC practices using the National Emergency Department Inventories (NEDI)-USA survey, which is administered annually to all EDs in the US. An expanded survey was administered in a subset of EDs to assess healthcare personnel training for IPC, reported adherence to recommended practices and policies related to disinfection of reusable medical equipment and environment, use of personal protective equipment, hand hygiene practices, patient care space cleaning and disinfection, use of transmission-based precautions signage, risk perceptions of how healthcare personnel practice contributes to healthcare-associated infections and barriers to appropriate room cleaning.ResultsOf the 289 facilities surveyed, 159 (55%) responded, and among responding EDs, 67 (42%) reported seeing ≥ 40,000 patients in the prior year. Regarding healthcare personnel training, 84% (131/156) of ED leaders reported that ≥80% of their ED healthcare personnel were correctly trained in IPC procedures according to their hospital’s policies. Perception of healthcare personnel compliance with IPC practices, however, was lower. Although 75% (118/157) of EDs reported > 80% compliance with correct N95 respirator use, compliance with transmission-based precaution signage was identified as a significant gap, with 30% (47/159) of EDs reporting that they never, rarely, or only sometimes posted signs for patients who required them. Further, 69% (61/89) of EDs reported that they never, rarely, or only sometimes posted transmission-based precaution signs for patients in hallways or overflow treatment spaces.ConclusionThis national survey found that ED leaders perceive that their healthcare personnel have a high level of knowledge of IPC policies and compliance with some, but not all, IPC policies in the ED. The overall high perceptions of compliance stand in contrast to prior published observations of poor IPC practice in ED settings, suggesting complex relationships between perception and practice that may impact patient safety outcomes. These findings can guide future targeted interventions to improve IPC compliance, reduce healthcare-associated infections, and improve patient safety in emergency settings.

Most research in residency training has focused on quality improvement within a single program. We explored resident involvement in curricular and clinical practice change, the learning environment, and resident satisfaction in 3-year family medicine residencies compared to matched 4-year residencies. We used two surveys to capture data. One was for program directors, which assessed the level of resident involvement in curricular and practice transformation. The second was a resident survey, which asked residents to rate their involvement in curricular change and practice transformation, the learning environment, and satisfaction with training. Both were administered annually between 2013 and 2019. Response rates ranged from 84.6% to 100%. Findings revealed no overall difference in resident involvement in curricular change, but the program director survey findings indicated that a higher proportion of residents in 4-year programs were using a broader diversity of approaches to working on quality improvement (QI) projects compared to those in 3-year programs. We also found statistical differences in the number of QI projects completed per year, with 34.1% completing three or more in 4-year programs compared to 13.3% in 3-year programs (P<.001). We found a positive correlation between resident involvement, learning environment, and satisfaction with training for both 3-year (range 0.489-0.666; P=.001) and 4-year residents (range 0.441-0.529; P=.001). Four-year residents were involved in a greater number of quality improvement projects and had a more diverse profile of involvement than those in 3-year residency programs. Involvement in practice and curricular change and the learning environment were associated with greater levels of resident satisfaction with training in both 3-year and 4-year programs.

Children and Young People are being labelled with psychiatric diagnoses at higher rates than ever before (e.g. NHS Digital, 2022). This is despite significant concerns with the diagnostic model in mental health, including that it locates problems within individuals, can lead to stigmatisation and can seem insufficiently curious about their voices and experience. There are good examples of non-diagnostic approaches that are non-blaming, trauma-informed and put the voices of children, young people and families at their heart. This article describes three: Adverse Childhood Experiences, Power Threat Meaning Framework and Emotion-Based Cognitive Behaviour Therapy, showing how they can apply to clinical practice.

Abstract As the SARS-CoV-2 pandemic continues to affect millions across the globe, the risk of coinfection with tuberculosis (TB) threatens patients' health and challenges our diagnostic capabilities. Here, we present a case of TB with pulmonary and laryngeal involvement complicated by coinfection with COVID-19. This case illustrates the importance of laboratory and imaging findings to differentiate between COVID-19 and TB and explores the potential for steroid use in laryngeal TB.

To assess whether outpatient cervical ripening with a synthetic osmotic dilator shortens the length of hospital stay in term pregnancies undergoing labor induction. Pregnant participants scheduled for labor induction at term with unfavorable cervix (less than 3-cm dilated and less than 60% effaced) and not requiring inpatient maternal or fetal monitoring were consented, and synthetic osmotic dilator rods were inserted on the day of scheduled induction. After reassuring fetal heart tracing, patients randomized to the outpatient group were asked to return 12 hours after insertion or sooner if needed. Those randomized to the inpatient group remained in the hospital. After the first round of ripening, additional ripening, oxytocin, and labor management were left up to the clinical health care professionals. The primary outcome was the proportion of participants with hospital stays longer than 48 hours. We estimated that a sample size of 338 would provide 85% power to detect a 30% difference between groups. From November 2018 to November 2021, 339 participants were randomized (171 inpatient, 167 outpatient, one withdrawal). Four patients in the outpatient group were admitted before12 hours for suspected labor and rupture of membranes, and 19 in the inpatient group had the device removed before 12 hours. The proportion of participants with hospital stays longer than 48 hours was lower in the outpatient group compared with the inpatient group (89 [53%] vs 152 [89%], relative risk [RR] 0.60, 95% CI 0.52-0.70). Patients in the outpatient group had a shorter total length of stay and time from admission to active labor. They were more likely to have a vaginal delivery within 24 hours of admission and were less likely to receive analgesics during ripening. Route of delivery and other maternal and neonatal outcomes were not significantly different between groups. Outpatient cervical ripening with a cervical osmotic dilator decreased hospital stay compared with inpatient ripening, without significant adverse outcomes. Medicem Technology s.r.o., Czech Republic. ClinicalTrials.gov, NCT03665688.

Abstract Background We sought to determine the immunologic abnormalities in patients following SARS-CoV-2 vaccines who experience post-acute sequelae of COVID-19 (PASC)-like symptoms > 4 weeks post vaccination. In addition, we investigated whether the potential etiology was similar to PASC. Design: We enrolled 50 post-vaccination individuals who experience PASC-like symptoms, 10 healthy individuals, and 35 individuals post-vaccination without symptoms. We performed multiplex cytokine/chemokine profiling with machine learning as well as SARS-CoV-2 S1 protein detection on monocyte subsets using flow cytometry and mass spectrometry. Results We determined that post-vaccination individuals with PASC-like symptoms had similar symptoms to PASC patients. When analyzing their immune profile, post-vaccination individuals had statistically significant elevations of sCD40L, CCL5, IL-6, and IL-8. SARS-CoV-2 S1 and S2 protein were detected in CD16 + monocytes using flow cytometry and mass spectrometry on sorted cells. Conclusions Post-vaccination individuals with PASC-like symptoms exhibit markers of platelet activation and pro-inflammatory cytokine production which may be driven by the persistence of SARS-CoV-2 S1 protein persistence in intermediate and non-classical monocytes.

Critical Care Medicine: January 2022 - Volume 50 - Issue 1 - p 337 doi: 10.1097/01.ccm.0000809068.86574.53

Innovation is essential to the growth of family medicine as a specialty and to maintaining excellence in training and patient care in a health care environment under constant change.[1][1],[2][2] However, many leaders in family medicine residency education feel hindered by the standardization