The battle over state lines: Leveraging an interstate compact to ensure continuity of care

Background: As a result of COVID-19-related precautions, states temporarily relaxed certain restrictions on telehealth services during the pandemic, including waiving licensing requirements so physicians could serve patients across state lines, but many states ended this flexibility in 2021. According to two online surveys fielded by the Cystic Fibrosis Foundation (CFF) to accredited centers in 2020 and 2021, 65% of programs reported providing care to patients living in another state. Of these, 18.5% reported that some of their out-of-state (OOS) patients were not able to access telehealth services because of licensure-related issues [1]. CFF Compass fielded 20 calls from people with cystic fibrosis (CF) in 15 states requesting assistance in accessing their OOS care center, accounting for more than 25% of all network adequacy inquiries received during that time. CFF recognized the need for policy change to improve access to OOS care for people with CF. Method(s): In 2021, we interviewed five CF care centers about their experiences with telehealth and OOS licensing. The administrative burden of applying for multiple state medical licenses was a key barrier to providing remote OOS care, and CFF identified the Interstate Medical Licensure Compact (IMLC) as one solution. The IMLC streamlines the licensing application process for physicians who want to practice in multiple states. From January 2021 to March 2022, CFF supported legislation in 10 states to join the IMLC by sending letters with 31 care center director co-signers. CFF also hosted a webinar in June 2021 to educate CF care centers about the IMLC as away to pursue multiple medical licenses with one application. We shared follow-up information about the IMLC through CFF COVID-19 digest emails. CFF sent a survey in March 2022 to all CF care centers to understand current use of and barriers to telehealth for CF care teams. Data from this survey are forthcoming. Result(s): Before CFF's engagement in January 2021, 30 states and the District of Columbia were members of the IMLC. As of April 8, 2022, five additional states have passed legislation to join the IMLC, reflecting a 17% increase in state participation from January 2021 to March 2022. Within the 35 participating states at present,126 CF care center programs will have the potential to use the IMLC. CFF has supported legislation in all six states with pending legislation to join the IMLC in 2022. Increased physician awareness of IMLCwas evidenced by physician participation from 20 states in thewebinar, aswell as broad distribution of the recording via the COVID- 19 digest to 288 CF programs in 49 states afater the session. Conclusion(s): Although more states taking action to join the IMLC is an important step, challenges persist. Even in IMLC member states, CF providers express concerns about the cost and administrative burden of maintaining licenses in multiple states. Permanent regulations regarding use of and reimbursement for telehealth remain uncertain. To better understand current challenges and opportunities for telehealth and remote OOS care, CFF is supporting additional research and advocacy.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

An Interdisciplinary Design Project for Undergraduate Engineering Training - Portable Real-Time Polymerase Chain Reaction System

Our world has been permanently changed by the pandemic outbreak of COVID-19 starts around the end of 2019. In the first few months of 2020, the whole world was in urgent need of an effective, easy, and quick method for the identification of the infection of the new virus. Polymerase Chain Reaction (PCR) machine, which can test DNA samples by rapidly making millions of copies of a specific DNA sample through the PCR process, including the COVID-19 virus, can perfectly fit this demand. In this study, a design project on PCR is introduced for undergraduate education in electrical and mechanical engineering. The objective of this project is to develop a low-cost, ease-of-use, wallet-size, portable real-time PCR (RT-PCR) machine for accurate testing of various bacteria or viruses. The key function of the PT-PCR system is to precisely control and maintain the temperature of the bio-sample solution within a range between 55℃ and 95℃. The RT-PCR system is centrally controlled by a microcontroller Raspberry Pi 3. It receives temperature measurements from thermistors and operates the heating lid, the thermoelectric module, and the cooling fan to regulate the temperatures required in repetitive thermal cycles. This project provides students opportunities in studying and practicing a wide range of engineering technics and skills, including mechanical design, electronics design, microcomputer programming, system control, power electronics, sensors and actuators, data acquisition and processing, cellphone app development. Students can gain comprehensive understanding of the design of multiphysics system after they overcome various challenges emerging in the project. From the view of engineering education, the process of this project development has demonstrated the importance and benefits of adopting complex interdisciplinary engineering problems for student teams to solve, especially those involve contemporary issues. Copyright 2022. © by the International Institute of Informatics and Systemics. All rights reserved.

Modeling community COVID-19 transmission risk associated with U.S. universities.

The ongoing COVID-19 pandemic is among the worst in recent history, resulting in excess of 520,000,000 cases and 6,200,000 deaths worldwide. The United States (U.S.) has recently surpassed 1,000,000 deaths. Individuals who are elderly and/or immunocompromised are the most susceptible to serious sequelae. Rising sentiment often implicates younger, less-vulnerable populations as primary introducers of COVID-19 to communities, particularly around colleges and universities. Adjusting for more than 32 key socio-demographic, economic, and epidemiologic variables, we (1) implemented regressions to determine the overall community-level, age-adjusted COVID-19 case and mortality rate within each American county, and (2) performed a subgroup analysis among a sample of U.S. colleges and universities to identify any significant preliminary mitigation measures implemented during the fall 2020 semester. From January 1, 2020 through March 31, 2021, a total of 22,385,335 cases and 374,130 deaths were reported to the CDC. Overall, counties with increasing numbers of university enrollment showed significantly lower case rates and marginal decreases in mortality rates. County-level population demographics, and not university level mitigation measures, were the most significant predictor of adjusted COVID-19 case rates. Contrary to common sentiment, our findings demonstrate that counties with high university enrollments may be more adherent to public safety measures and vaccinations, likely contributing to safer communities.

Design and testing of the safety of the SARUS-CPR hood for novice resuscitators.

BACKGROUND AND AIMS: Bystanders should be protected against aerosols, droplets, saliva, blood and vomitus during resuscitation after cardiac arrest The SARUS (safer - airway - resuscitation) CPR airway hood™ is a clear plastic cover and integrated mask that envelopes the head and torso. Our objectives were to test leakage using saline aerosol generation tests, then assess the performance of the hood during mock cardio-pulmonary resuscitation on a manikin. METHODS: A checklist was validated by comparing the performance of 10 novices against 10 experts during mock resuscitation. Thereafter, 15 novices were tested with and without the hood, in a randomised cross-over study, one week apart. RESULTS: Laboratory analysis showed a > 99% reduction of saline particles detected 5 cm, 75 cm and 165 cm above volunteers wearing the hood. On manikins, experts scored better compared to novices, 8.5 (0.7) vs 7.6 (1.2), difference (95%CI) 0.9 (0.4-1.3), P = 0.0004. Novice performance was equivalent using the hood and standard equipment, 7.3 (1.4) vs 7.3 (1.1) respectively, difference (90%CI) 0.0 (-0.3 - 0.3), P = 0.90. CONCLUSION: Aerosol transmission reduced in the breathing zone. Simulated resuscitation by novices was equivalent with and without the hood.

Leader-follower parasocial interaction scale

In the ubiquitous mediated world in which we live, we daily encounter organizational leaders through mediated communication. New communication technology and the age of the COVID-19 pandemic have made these mediated encounters even more pronounced, leading to more opportunities for parasocial interaction with organizational leaders by various publics. This chapter provides a theoretical model and quantitative measurement for assessing parasocial interaction in the social scientific tradition of middle range analysis. The leader-follower parasocial interaction scale provided here is a useful tool for assessing the persuasive influence of leaders on those who follow them. © 2021, IGI Global. All rights reserved.

Pulmonary vascular disease in COVID-19: insights from artificial intelligence analysis in a large multicentre imaging database

Aims and ObjectivesAn increased incidence of pulmonary thrombosis (PT) and right ventricular (RV) dysfunction is reported in COVID-19. The clinical significance is not fully understood and there are few large, multicentre studies. The National Covid-19 Chest Imaging Database (NCCID) was analysed for prevalence of PT in COVID-19 patients;we hypothesised associations between macroscopic PT, severity of parenchymal disease, evidence of RV dysfunction on CT and mortality.MethodsNCCID is a multicentre UK-wide centralised database comprised of radiological images from hospitalised COVID-19 patients. 391 thoracic contrast CT scans from 14 centres across England and Wales performed between 2nd March 2020 – 10th September 2020 underwent automated post-processing software (IMBIO LLC.) to determine RV:LV diameter ratio. Scans were manually reported for PT and quantitatively scored for arterial obstruction and severity of parenchymal involvement using CT- Severity Scoring (CT-SS)[1]. Imaging metrics were analysed for association with PT and 30 day mortality.ResultsAutomated RV:LV analysis was successful in 90% (351/391) of scans. Mean age: 64, 53% (186/351) male. Mortality data was available for 325 patients: 22 died within 30 days of scan (6.7% (22/325)).Macroscopic PT was present in 16% (56/351). Median Qanadli score was 6% (IQR 3%-17.5%), indicating low burden arterial obstruction. PT was not associated with mortality (p=0.18).RV:LV >1 on CT was observed in 59% (206/351) (mean RV:LV 1.08). RV:LV was significantly higher in the presence of PT (mean RVLV 1.17 vs 1.06 p=0.011, χ2(2) = 6.499). RV:LV was not predictive of mortality (AUC 0.467, CI 0.358–0.576).CT-SS significantly predicted mortality (AUC 0.787, p=<0.0005, CI 0.693–0.881). However there was no correlation between severity of parenchymal involvement and RV:LV (r 0.82, p=0.123), nor presence of PT (χ2(2) 2.305, p=0.129).ConclusionsRV dilatation and PT were prevalent in this multicentre cohort of COVID-19 patients, but were not associated with mortality or parenchymal disease severity. PT is frequently low burden and, in contrast to PT outside the context of COVID-19, RV:LV >1 is not discriminatory for prognosis.ReferenceYang R., et al. Chest CT severity score: an imaging tool for assessing severe COVID-19. Radiology: Cardiothoracic Imaging 2020;2(2):e200047. doi: 10.1148/ryct.2020200047

Aerosol generation during endonasal instrumentation in the clinic setting

Background: The potential risk for transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) duringendoscopic endonasal instrumentation has been described in recent anecdotal reports. Additionally, recent simulations incadaveric models have demonstrated aerosol generation during power endonasal instrumentation. Endonasal proceduresare commonly performed in the outpatient clinic setting, and with a potential for aerosol generation, these procedures maypose a potential exposure risk to clinic staff. Objective: To provide a greater understanding of aerosol generation and exposure risk during endoscopic endonasalinstrumentation in the outpatient clinic setting. Methods: Using an optical particle sizer, airborne particles concentrations in particles per cubic foot (p/ft ) were measuredduring 30 nasal endoscopies in the outpatient clinic setting. Aerosol measurements were collected within an 18-inch radiusfrom the patient's head during 11 different diagnostic nasal endoscopies and 19 different nasal endoscopies with suctionand mechanical debridement. To identify any particle effect from endonasal instrumentation, airborne particles measuring0.3, 0.5, 1.0, 2.5, 5.0, and 10.0 microns (μm) in diameter were recorded at distinct time points throughout diagnostic anddebridement endoscopies. To account for the effects of native patient breathing on aerosol concentrations, all endoscopymeasurements were compared to aerosol concentrations measured prior to procedure initiation. Results: Compared to preprocedure aerosol levels, no significant increase in mean aerosol concentrations was measuredduring diagnostic nasal endoscopies. However, compared to preprocedure aerosol levels, a statistically significant increasein mean particle concentrations was measured during cold instrumentation at 2,462 p/ft (95% CI: 837-4,088;p = 0.005).The use of suction instrumentation was also associated with a statistically significant increase in mean particleconcentrations at 2,973 p/ft (95% CI: 1,419-4,529;p = 0.001). In total, greater than 99% of all measured particles wereless than 2.5 μm in diameter, with comparable particle size distributions observed during all forms of endonasalinstrumentation. Conclusion: When measured with an optical particle sizer, diagnostic nasal endoscopy with a rigid endoscope is notassociated with increased particle aerosolization in patients for which sinonasal debridement is not indicated. In patientsneeding sinonasal debridement, the use of cold and suction instrumentation was associated with increased particle aerosolization. The observed generation of airborne particles, especially sub-micrometer aerosols, during endonasaldebridement may increase exposure risk for clinic staff to SARS-CoV-2 compared to patient native breathing. Appropriatepersonal protective equipment use and patient screening should be utilized for all office-based endonasal procedures.

PFAB-driven clinical and patient education

Objective: We sought to study how an adult cystic fibrosis (CF) Patient Family Advisory Board (PFAB) can influence and co-produce patient and staff education in collaboration with their CF care team. Novel approaches in this study are: 1) learner needs analyses were driven by the PFAB, 2) study and abstract were created by patient PFAB member. Background: In addition to improving quality of care, patient safety, satisfaction, and engagement, the Institute for Patient and Family Centered Care (IPFCC) recommends the establishment of a PFAB to design patient-centric initiatives such as quality improvement, patient education, as well as healthcare provider and clinical staff education (Johnson, Abraham. 2012). Despite this recommendation, there are few studies on how patientdriven education is designed or implemented. The INOVA Adult CF Clinic PFAB articulated their perspective of clinical staff learner needs for Respiratory Therapy (RT), Emergency Department (ED), and Inpatient Nursing Teams (APU). They also helped to advise the need for and content of educational COVID-19 webinars to the patient population. Patients who were PFAB members provided educational content and the patient perspective in these workshops. Methods: Thematic analysis of educational sessions and PFAB meetings were used to study how PFABs can influence and co-produce clinical staff and patient education. Qualitative data were collected and analyzed from observation of 7 PFAB meetings and digital collaborative planning documents used by the PFAB to discuss patient-driven educational needs and session plans. Observational data were collected from 3 staff education sessions that were co-presented with a CF care team member and CF patient PFAB member who gave a short personal account of their experience with their disease. These included: one RT session, two inpatient nursing staff sessions. Plans were made for an ED session in August. Observational qualitative data was also collected from two COVID-19 webinars that were conducted with input and participation of the PFAB in sharing experiences and presenting content. Results: Thematic analysis showed that PFABs can increase engagement of clinical staff and augment educational opportunities for both patients and staff by addressing patient-centered learning needs. Patients who provided first-person accounts of their lived experience as part of a learning session promoted empathy and engagement amongst both staff and patients. Co-produced COVID webinars resulted in a 250% increase in attendance over a three-month period. Chat-box and verbal question participation of co-produced COVID webinars also increased. In addition, the PFAB-driven educational initiatives promoted psychological ownership (Avey, et al. 2009) within the PFAB itself. This has led to attitudes such as higher commitment, responsibility, and engagement of patient PFAB members and CF clinical staff. Opportunities for further research in this area include exploring the extent to which these themes are also promoted by administering formal pre- and post-intervention assessments to staff learners as well as PFAB members.

Patient-centered care of hospitalized adults with cystic fibrosis-a collaboration between the CF care team and the patient family advisory board

Background: The Inova Adult CF Program developed a Patient Family Advisory Board (PFAB) to facilitate patient and family centered care. The PFAB has been actively involved in providing input on multiple issues and expressed interest in initiating and actively participating in a quality improvement project related to CF care. Together with the CF care team, it was decided to focus on inpatient care. Methods: We identified inpatient respiratory care as an area of focus. For baseline data, we developed a survey regarding inpatient experience of respiratory care. Three primary observations emerged as common themes: 1. Desire for a more personalized airway clearance schedule 2. Desire to be more independent with airway clearance regimen 3. Concern that nebulizer sets were not consistently cleaned in accordance with CF guidelines Based on this, the PFAB and CF team evaluated ways to provide personalized scheduling and administration of respiratory medications and chest physiotherapy. A respiratory therapy preference card was created to address this. It includes 1) preferences of timing of airway clearance, 2) preferred nebulized medicines and airway clearance modalities, 3) preferred level of supervision with airway clearance. Next, a combined CF provider-patient in-service for respiratory therapists (RT) was conducted to facilitate an open dialogue with regards to integration of the preference card. Implementation of the preference card involves the following: the preference card is included in a customized CF admissions folder, which is given to the CF patient on admission. The CF patient fills out the card and gives it to the respiratory therapist, who incorporates these preferences into their workflow. For monitoring, we will check in with the patients during the hospitalization to determine if the protocol was followed and if the respiratory medications were administered as per the preferred schedule. A check-in with RT would also be completed to determine any barriers. Data: Baseline data were collected through a pre-intervention survey sent to all CF adults hospitalized in the prior two years. A post-intervention survey is planned after the intervention to asses for changes in respiratory care satisfaction scores. Unfortunately, implementation of our project has been delayed by the COVID-19 pandemic. Conclusions: Partnership between the PFAB and care team helps direct quality improvement initiatives. The PFAB provides unique insight and can be engaged to help develop, implement, and study quality improvement initiatives to help provide improved care.