Improving Intranasal Naloxone Distribution for Harm Reduction in Emergency Departments

Introduction: The COVID19 pandemic has exacerbated the opioid epidemic in Ohio, with increased numbers of opioid overdoses recentl recorded. Emergency departments (EDs) commonly serve as a first point of medical contact for those with opioid overdose and those at risk for overdose. Access to addiction treatment and harm reduction resources within EDs is critical in preventing opioid overdoses and related deaths. Nationwide efforts to increase medication for opioid use disorder (MOUD) access have been underway largely through the use of buprenorphine-based medications;other strategies such as distribution of intranasal naloxone kits (i.e. Narcan) in the ED have not received as much attention. Since 2015, The Ohio State University Wexner Medical Center (OSU) at both its community and main campus hospitals has sought to increase the distribution of intranasal naloxone kits to those at risk of opioid overdose. Due to low distribution rates at these sites, in 2019 these kits were provided free-of-charge through the Ohio Department of Health Project DAWN (Deaths Avoided with Naloxone) initiative. Despite education efforts and staff training, these resources remain severely underutilized, with the community hospital outperforming the main hospital. Method(s): In a medical student driven project, the frequency of intranasal naloxone distribution to qualifying patients was tracked over a six-month period from January to June 2021. Inclusion criteria for eligible patients included those presenting with a chief complaint of opioid overdose, withdrawal, or those with history of OUD. In an effort to determine why distribution remains underutilized, a qualitative internet-based survey was deployed to nursing staff and prescribers (advanced practice practitioners, resident and attending physicians). To determine the perception of intranasal naloxone use for harm reduction and barriers to distribution, the survey queried the importance, perceived need, indications, and ability to distribute intranasal naloxone in a combination of yes/no and free-text responses. Result(s): Over the six-month study period, < 10% of more than 500 eligible patients received intranasal naloxone kits at both campuses. In total, 72 providers were interviewed, 27 of whom were prescribers and 45 were nurses. All participants completed the survey in its entirety. Survey results indicated that despite an adequate knowledge base, significant logistical barriers to distribution remained. This included not knowing the process required to order and dispense kits, a lack of clearly defined roles in the distribution process, and logistical issues in the physical location of kits throughout the ED. Conclusion(s): Despite willing and knowledgeable providers, logistical issues slowed intranasal naloxone distribution in a patient population more likely to leave against medical advice and less likely to interact with medical providers. This implies that even for those for whom a kit is ordered they may not have it in hand when leaving the ED, missing a rare opportunity to provide harm reduction devices to those most in need. Efforts are underway to improve distribution of the intranasal naloxone kits, including additional orientation for off-service interns, the development of a best practice advisory, and the utilization of standing orders.

Elementary Students Learn How To Engineer Online (RTP)

The educational disruptions caused by COVID-19 in the spring of 2020 were vast. Schools utilized a variety of instructional methods from paper packets to varying amounts of online synchronous and asynchronous instruction. One Nashville independent elementary school provided lesson plans each day for students to complete, with the assistance of their parents, largely asynchronously. To combat the difficulties encountered by families with two working parents and children frustrated by this type of learning, a zoom-conference based class consisting of three second grade children was created. Each day Monday through Thursday the children were presented a hands-on engineering design challenge that utilized materials found in their homes. The children had not been previously exposed to the engineering design process (EDP). The theoretical framework for this study lies in the areas of engineering identity as well as teamwork and feedback through engineering discourse. The research questions for this study were the following: 1) What are the impacts of teaching the engineering design process online via zoom conference on development of children's ability to use engineering discourse? Are students able to master the steps of the engineering design process? How do students learn to receive and implement feedback from their peers and the teacher over zoom? How is teamwork affected as compared to in-person experiences? 2) If any how do children develop their engineering identity through a series of zoom conference-based engineering design challenges? To answer these questions, data were derived from recordings of the online sessions and observations of student behavior and statements, the PowerPoint slides that were used to facilitate the course, photos and videos created by parents of the students' designs, and interviews with the children. Qualitative data analysis followed an inductive approach. The utilization of multiple data sources allowed for a complete picture of what is taking place during the sessions and how it impacted the children's understanding and practice of the engineering design process. The children became very facile with the EDP and its steps. They looked forward to the design challenge each day, often using it as motivation to get through their required schoolwork before starting the challenge. At times they struggled to give and especially to receive feedback from their peers, particularly when it involved criticism. All three children reported believing that they are an engineer, an indicator of a forming engineering identity. © American Society for Engineering Education, 2021

The COVID-19 pandemic and palliative care units: A cross-sectional survey of the informational needs of caregivers

Background: Visiting restrictions placed on palliative care units due to the COVID-19 pandemic have resulted in emotional and psychological distress to patients, their caregivers and families. However, the informational needs of caregivers during pandemic visiting restrictions have never been studied. Aim: To identify the informational needs of caregivers of patients admitted to an end-of-life palliative care unit under COVID-19 visiting restrictions. Methods: Nineteen caregivers of patients admitted to a single palliative care unit while under pandemic visiting restrictions were recruited. A cross-sectional telephone survey was performed, which examined the importance of different informational needs of caregivers and how well these needs were being met. Results: Receiving information about hospital regulations/procedures, health updates about the patient, social support for the patient and how to communicate with the patient in light of visitor restrictions were 'very important' to caregivers. In contrast, caregivers were 'neutral' towards receiving information about accessing psychosocial/emotional support for the caregiver and religious/spiritual support for the patient. Qualitative data summaries provided a richer understanding of these quantitative rankings. Conclusion: These findings will assist healthcare professionals in providing optimal informational support to caregivers during visitor restrictions in order to improve the growing psychological impact on this population.

Cold War Discourse and Geopolitical Flashpoints in Post-Covid-19 Northeast Asia

This paper examines the possible ramifications of the COVID-19 pandemic as they relate to changing American strategic posture and geopolitical dynamics in Northeast Asia. Since the spread of the pandemic, the overall security situation in Northeast Asia appears to be worsening, contrary to public expectations. Disputes over the origin of the COVID-19 pandemic between Beijing and Washington have aggravated the Sino-American relationship, already shifting from the existing “cold peace” between the two into a Cold War. The authors explore the new and rapidly evolving Cold War discourse in the United States and traces its geopolitical implications across Northeast Asia. The first section examines emerging patterns of new Cold War discourse and practice in the United States. The second discusses four major geopolitical flashpoints in the region: the dynamics of military modernization and strategic arms races between China and the United States, Taiwan Strait relations, the South China Sea, and the Korean Peninsula. Finally, the paper makes suggestions to mitigate rising geopolitical tensions in Northeast Asia. © 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group on behalf of the Nagasaki University.

Skill retention after traditional versus video resuscitation training in filipino nursing students

INTRODUCTION: The Philippines has a high neonatal mortality rate. Helping Babies Breathe (HBB) simulation training has been shown to reduce early neonatal mortality with a focus on initiating bag mask ventilation (BMV) within the first minute of life. The frequency and interval for refresher training to ensure competence in HBB skills is not well-described. This study was conducted to assess the retention of resuscitation skills by Filipino nursing students when refresher HBB coursework is delivered via traditional in-person instruction compared to coursework delivered via remote telecoaching (video), with time to initiate BMV as the primary outcome. METHODS: Nursing students in Mati, Philippines (n=49) were traditionally trained in HBB;validated OSCE was used to assess pre-training and post-training skills. Students were divided into 2 month, 4 month, and 6 month follow-up and further divided within these time-based groups into video (V) or traditional (T) follow-up, for a total of 6 novel groups. OSCE was administered to test skill retention at follow-up. RESULTS: No student successfully performed BMV prior to 1 minute during pre-testing;immediately post-training, 73% of students performed BMV prior to 1 minute with an average time of 57.9 seconds. Students retested at 2 months averaged of 83.7 s and students retested for the first time at 4 months averaged 90.2 s prior to BMV initiation. Students tested for a second time at 4 months, following their initial retraining at 2 months, initiated BMV at an average of 70.4 s. There was no significant difference in individual decay of time to initiation of BVM between video and traditional trainees at 4 month follow-up (p=0.77). Due to COVID-19 restrictions, 6 month follow-up was unable to be completed. CONCLUSIONS: Skill decay was evident in both groups, with time to initiate BMV increasing between assessments. However, with a single refresher training, decay declined;it is likely this trend would continue with more frequent training. The finding of no significant difference between time to BMV after video vs traditional re-training suggests that virtual training may be a reasonable alternative in the future. This may be particularly important in the current era of educational modifications necessitated by pandemic travel restrictions.

Implementation and evaluation of a simulation-based shock curriculum in the Philippines

INTRODUCTION: Children in low-middle income countries are disproportionately affected by shock, resulting in high mortality. Simulation has been successfully used as an educational tool in some low-resource settings. The objective of this study was to develop and evaluate educational efficacy of a simulation-based pediatric shock curriculum for pediatric residents in Manila, Philippines. We hypothesized that there would be decreased time to administration of first fluid bolus on a simulated mannequin after participation in the curriculum. METHODS: Prospective pre/post cohort study assessing a skills-based shock curriculum consisting of a multiple choice pre/post-test and a videotaped simulation-based pre/posttest. Implemented at Philippine Children's Medical Center in March 2020. Performance in simulation shock scenario was assessed by standardized checklist. Outcome measures were compared pre- and post intervention. Interrater and intrarater reliability on checklist assessed. RESULTS: Due to the COVID-19 pandemic, resident enrollment in the study was stopped prematurely. A total of 24 residents were enrolled. 96% of participants were female. Individuals reported a mean of 4/5 confidence in English in the medical setting (SD .66 CI 95% 3.7-4.3). Confidence in identifying shock (3.8 -> 4.3 p <0.01), identifying malnutrition (3.2 -> 4.1 p <0.01), managing hypovolemic shock (3.6 -> 4.3 p <0.01), managing septic shock (3.3 -> 4.1 p <0.01) and placing an IO (2.8 -> 4.0 p <0.01) all increased. Mean written test score showed no significant improvement (9.4/10 to 9.8/10, p = 0.15) but this may have been related to high pre-intervention performance on knowledge based test. The time to initiation of fluids did not change (83 s -> 75 s p = 0.42), although all residents initiated fluids within five minutes both pre and post-intervention. The total score on the checklist improved (9.8 -> 14.7, p <0.01). CONCLUSIONS: There was no difference in time to initiation of fluids pre/post intervention. There was improvement in confidence with shock concepts. Overall score on the checklist improved, which may be the most accurate marker of knowledge acquisition in this scenario. Through international collaboration it is possible to establish a successful simulation-based education program for trainee.