Louisiana nurseries: a growing industry dealing with labor shortages

This article presents an overview of the growth of the Louisiana nursery industry and the labour challenges the industry is facing. Labour issues in the nursery industry are not easily solved, considering the nature and seasonality of employment and competition from other industries. Despite the benefits associated with the H-2A guest worker program, particularly securing seasonal workers in times of need, which allows nurseries to cope with labour shortages, few Louisiana nurseries rely on the H-2A program. Moreover, prolonged impact of the COVID-19 pandemic also raises concerns on ways the industry needs may change and how it will affect securing labour.

The impact of COVID-19 on the specificity of d-dimer for pulmonary embolism

Study Objective: D-dimer utility in diagnosing pulmonary embolism (PE) in the setting of COVID-19 has not been clearly established. Patients presenting with COVID-19 are screened for disease severity with d-dimer. The primary outcome of this study was to evaluate the test characteristics of d-dimer assay for the exclusion of PE in patients with COVID-19 in both the academic and community setting.

LANGUAGE-SPECIFIC BARRIERS AND FACILITATORS TO TELEMEDICINE USE FACED BY SAFETY-NET HEALTH CARE SETTINGS DURING THE COVID-19 PANDEMIC

BACKGROUND: The COVID-19 pandemic forced many primary care visits from in-person to remote via telemedicine, including phone and video visits. Health systems face challenges ensuring telemedicine access for patients with limited English proficiency (LEP) who are disproportionately seen in safetynet health settings. METHODS: We examined safety-net health settings delivering primary care via telemedicine during the pandemic and participating in a quality improvement collaborative across California (n=43 sites, n=11 interview sites). All sites reported the number and modality of primary care visits (in-person, phone, video), patient demographics, payer mix, and language needs. For qualitative data, we purposively sampled to capture sites representing geographic diversity, a range of telemedicine maturity, and with large populations of patients best served in non-English languages. We then conducted semistructured interviews focused on barriers and facilitators to use and uptake of telemedicine among patients, providers, and staff. Interviews were audio recorded, transcribed, and analyzed with a focus on language-specific considerations, using a mixed inductive/deductive approach informed by the Consolidated Framework for Implementation Research. RESULTS: The sites cared for racially and ethnically diverse patients with nearly 75% on Medicaid. Over half of patients (52%) across sites were better served in a language other than English (median: 50%, range 39-83%). All sites experienced an immense increase in the number of telemedicine visits conducted in the six months after March 2020 compared with the six months prior (range: 258-8,273,200%). As of February 2021, most sites provided a minority of telemedicine visits over video compared with phone (median: 5% video, range 0-69%). Interview data showed that most sites mapped telephone visits workflows onto pre-existing infrastructure and resources. Telemedicine vendors provided limited language options and sites faced challenges integrating interpretation services into video visits. Interview respondents were concerned that patients with LEP faced intersecting challenges related to technology access and limited digital literacy, exacerbating language-related barriers to telemedicine. Sites relied on language concordant staff and additional technical support to overcome barriers and facilitate access for LEP patients. CONCLUSIONS: While telemedicine has potential to increase access to primary care, care settings must prioritize language concordance among patients, providers, and staff, and telemedicine platform developers must adapt existing tools to improve their accessibility for patients with LEP.

Understanding the Relationship Between the Emergency Department Built Environment and Physician Burnout Through High Fidelity Virtual Reality Modeling

Study Objectives: To understand how the emergency department built environment contributes to physician burnout. Methods: We conducted semi-structured interviews of attending physicians who work regularly at the study institution, an urban ED, Level 1 Trauma Center with an annual census of 85, 000 and an EM residency program. Physicians were first asked about overall burnout followed by questions relating the physical environment to burnout. Subjects participated in a virtual reality (VR) simulation of the study ED. In the VR simulation, subjects placed virtual “sticky notes” to describe elements of the environment that contributed to or relieved burnout. Physicians also completed occupant comfort surveys to measure their overall satisfaction with the built environment for three different ED spaces. The surveys contained prompts for 6 categories: acoustics, air quality, cleanliness and maintenance, lighting, layout and furnishings, temperature (photo). A modified grounded theory approach was used to analyze interview transcripts, VR collected virtual memos and surveys. Results: 19 emergency physicians were enrolled (68% male, 42% early-, 42% mid-, 16% late-career) Average Maslach Burnout Inventory scores were 2.8 for emotional exhaustion, 2.4 for depersonalization and 4.8 for personal accomplishment. Sources of overall ED burnout were most commonly attributed to to ED volume, crowding, lack of resources, lack of institutional support, provider metrics, difficult patients, medico-legal concerns, worsening job market and effects of COVID-19. For the main study question, 71 themes were coded over 6 built environment domains and 25 themes related to impact and burnout. Of the 6 environmental domains, layout, cleanliness and acoustics were more commonly associated with burnout compared to air quality, lighting and temperature. An internal waiting room was the strongest contributor to physician burnout due to the close proximity to unassigned (waiting) patients associated with interruptions, distractions and concern for provider safety which contributed to emotional exhaustion and depersonalization. Increased distance to patient rooms was connected with a sense of depersonalization. Clutter, non-useful displays, poor organization and equipment issues were frequently noted and connected to a sense of disorganization and decreased personal accomplishment. Additionally, poor visualization of patients and monitors from physician workstations contributed to decreased situational awareness, anxiety, lack of provider safety and decreased personal accomplishment. Other frequently cited components included lack of visual/acoustical privacy in hallways, patient proximity to physician workstations associated with patient discomfort, medico-legal concerns, emotional exhaustion and depersonalization. 100% of the physicians agreed or strongly agreed that the VR simulation was helpful to elicit memories and reflection about the built environment. Conclusion: The study reflects associations between the ED built environment and components of physician burnout. Interventions aimed at balancing distance to patients (unassigned and assigned), reducing clutter and disorganization, balancing the acoustical environment and improving patient comfort and privacy may improve provider wellness. [Formula presented]

A systematic approach to improving oral chemotherapy consent compliance in a rural cancer center

Background: Ensuring quality and comprehensive cancer care for our patients,families and our communities have been goals for the Cancer Center since its inception. To achieve these goals we must encourage collaborative decision-making, patient autonomy and promote a culture of patient safety with regards to all aspects of care, including treatment planning. Oral chemotherapy consent compliance has been a measured monthly Quality metric by the Cancer Center since 2018. A steady decline in compliance began in June 2019. 38% of all patients prescribed new oral chemotherapy did not sign an Informed Consent prior to beginning therapy. Lack of compliance may compromise patient safety and autonomy. In order to ensure our patients are fully informed regarding recommended treatment options, we evaluated our compliance to ASCO's Quality Oncology Practice Initiative (QOPI) Core Module, Measure 14 which requires a signed patient consent for chemotherapy. This project was initiated during the 2020 Quality Training Program (QTP) in Alexandria, Virginia and progressed through the COVID-19 pandemic. Methods: Using the systematic approach and quality improvement tools taught during the QTP, we engaged a multidisciplinary Quality Improvement (QI) team to assist in gathering, organizing and interpreting data. The QI team sought input from all providers, their associated teams and Navigators regarding current processes and barriers. Process maps were created for each team;with both variables and percent of consent compliance being compared. The QI team identified common barriers to obtaining consent. A Cause and Effect Diagram, Pareto Chart and Prioritization Matrix were used narrowing the focus for the changes developed for improvement. Two quarterly Plan-Do-Study-Act (PDSA) cycles were conducted from March through September 2020. Results: PDSA cycle one was implemented in March of 2020 immediately prior to the COVID-19 pandemic affecting our area. Despite the competing priority of COVID Pandemic, results improved to 76% compliance over a 4 month period. PDSA cycle 2 was implemented at the end of July 2020. Following PDSA cycle 2, compliance rates improved to 91%. With no additional process changes, compliance continues to maintain through April of 2021 at 92%. Conclusions: The use of the QTP systematic approach improved oral chemotherapy consent compliance to just short of our 92% improvement goal. In spite of the obstacles brought about by COVID-19, compliance rates for August-October 2020 increased to 91%. As a result of the study process, we are now more cognizant of the variability in practices among our providers. This awareness will aid us in development and success of future processes. We continue to monitor compliance and adjust processes related to oral chemotherapy informed consent to accommodate on-going COVID-19 implications, staffing variances and everchanging approved chemotherapy regimens.

Stenting of intracranial stenosis through an angioplasty balloon catheter-a case series

Introduction Microcatheter exchange increases the risks of intracranial angioplasty and stenting using the Wingspan/Gateway system and may have contributed to the high procedural risks in the SAMMPRIS trial. We present a case series of direct stent deployment through the balloon catheter, simplifying the technique of intracranial angioplasty and stenting using self-expanding stents. Materials and Methods We retrospectively reviewed all patients who underwent stenting for intracranial stenosis with deployment of the Neuroform Atlas stent through the Gateway balloon in our hospital system since this technique was first utilized in October 2020. Procedural success, complication rate, short term clinical and imaging follow-up were assessed. Results Ten Neuroform Atlas stents were deployed through either the Gateway or Emerge balloon catheter in eight patients. The median age was 59 (range 30-75) and 50% were female. All patients had symptomatic severe intracranial stenosis with mean stenosis of 83% (range 70% to 90%). Six patients had recurrent strokes and had failed medical therapy, while two patients presented with acute stroke symptoms and were treated emergently. Mean post-stenting stenosis was 32% (range 0% to 50%). Two procedures were performed under conscious sedation and the rest under general anesthesia. Four stents were placed in the supraclinoid internal carotid artery (ICA), one in the middle cerebral artery M1, two in M2, two in the basilar artery and one in the intracranial vertebral artery. All five patients who underwent short-term follow-up angiograms (mean interval 1.2 months) had further improvement of residual stenosis. There were no ischemic or hemorrhagic periprocedural complications. None of the patients had recurrent TIAs or strokes. One patient died of a COVID-19 infection. One patient had transient neurological deterioration at four months due to profound hypoglycemia. Conclusion Deploying self-expanding stents through an angioplasty balloon catheter is feasible, safe, and can greatly simplify the procedure. The Neuroform Atlas stent is strong enough to prevent immediate recoil of intracranial stenosis after angioplasty.

The impact of COVID-19 on the sensitivity of D-dimer for pulmonary embolism.

OBJECTIVE: This study seeks to evaluate the test characteristics of D-dimer for pulmonary embolism (PE) in patients with a concurrent diagnosis of COVID-19. We hypothesized that the sensitivity of D-dimer for PE at current institutional cut points would be similar to those without COVID-19. METHODS: This is a multicenter retrospective observational cohort study across five urban and suburban EDs in the same health care system. The electronic health record was queried for all computed tomography pulmonary angiography (CTPA) studies from December 1, 2019, to October 22, 2020. All ED patients who underwent CTPA had D-dimer and COVID-19 testing completed in a single encounter were included in the study. Baseline demographics were obtained. Test characteristics of D-dimer for PE were calculated for patients with and without COVID-19. Additionally, receiver operator characteristics (ROC) curves were constructed for two different D-dimer assays. RESULTS: There were 1158 patient encounters that met criteria for analysis. Performance of D-dimer testing for PE was similar between COVID-19-positive and -negative patients. In COVID-19-positive patients, the sensitivity was 100% (95% confidence interval [CI] = 87.6%-100%), specificity was 11.9% (95% CI = 7.9%-17.1%), and negative predictive value (NPV) was 100%. In COVID-19-negative patients the sensitivity was 97.6% (95% CI = 91.5%-99.7%), specificity was 14.4% (95% CI = 12.1%-17%), and NPV was 98.3% (95% CI = 93.8%-99.6%). For assay 1 the area under the curve (AUC) for COVID-19-positive patients was 0.76 (95% CI = 0.68-0.83), and for COVID-19-negative patients, 0.73 (95% CI = 0.69-0.77). For assay 2, AUC for COVID-19-positive patients was 0.85 (95% CI = 0.77-0.92), and for COVID-19-negative patients, 0.80 (95% CI = 0.77-0.84). Inspection of the ROC curve for assay 1 revealed that 100% sensitivity was maintained up to a threshold of 0.67 FEU (fibrinogen equivalent units; from 0.50 FEU) with an increase in specificity to 29% (from 18.7%), and for assay 2, 100% sensitivity was maintained up to a threshold of 662 D-dimer units (DDU; from 230 DDU) with an increased specificity to 59% (from 6.1%). CONCLUSION: Results from this multicenter retrospective study did not find a significant difference in sensitivity of D-dimer for PE due to concomitant COVID-19 infection. Further study is required to determine if PE can safely be excluded based on D-dimer results alone in patients with suspected or proven COVID-19 or if adjusted D-dimer levels could have a role in management.

Point-of-Care Ultrasound in the Evaluation of COVID-19.

BACKGROUND: The novel coronavirus SARS-CoV-2 has caused a pandemic, overwhelming health care systems around the world. Hospitals around the world, including the United States, have been struggling to adapt to the influx of patients with COVID-19, the illness caused by SARS-CoV2, given limited resources and high demand for medical care. OBJECTIVES: This article seeks to provide emergency physicians with a guide to sonographic findings in COVID-19 and an algorithm by which point-of-care lung ultrasound may assist emergency physicians caring for these patients during the SARS-CoV-2 pandemic. DISCUSSION: The studies currently being published have established a typical set of ultrasound findings in COVID-19. Point-of-care lung ultrasound is rapid and accessible in most emergency departments in the United States, and even in many resource-poor settings. CONCLUSION: Point-of-care ultrasound provides numerous benefits to emergency providers caring for patients with COVID-19, including decreasing resource utilization, assisting in diagnosis, guiding management of the critically ill patient, and aiding in rapid triage of patients under investigations for COVID-19.