Anxiety and Depression Among Pediatric Emergency Nurses and Physicians During the Coronavirus Disease 2019 Pandemic.

INTRODUCTION: To determine anxiety and depression levels among pediatric acute care nurses and physicians before and after vaccine implementation during the coronavirus disease 2019 pandemic. METHODS: Prospective cross-sectional study of emergency medicine and urgent care providers at a metropolitan quaternary pediatric emergency department, including 2 satellite emergency departments and 7 urgent care sites. Anxiety and depression symptoms were assessed using the Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-2. Nurses and physicians were surveyed twice using the Generalized Anxiety Disorder-7 in May 2020 and March 2021 and once with the Patient Health Questionnaire-2 in March 2021. RESULTS: In total, 189 surveys were completed in May 2020 (response rate 48%), and 243 surveys were completed in March 2021 (response rate 52%). Nurses reported higher Generalized Anxiety Disorder-7 scores compared to physicians for both years, though Patient Health Questionnaire-2 scores were similar. Mean Generalized Anxiety Disorder-7 scores decreased for both nurses and physicians between the 2 response periods. Amongst those who had a history of anxiety, chronic medical conditions, or were living with a high-risk individual, higher rates of anxiety were observed. Respondents endorsed the need for increased psychological support during a pandemic, with adequate and timely psychological support provided by the hospital, and stated their households were financially affected by the pandemic. Respondents reported fewer feelings of anxiety after self and public vaccination. DISCUSSION: Study findings support increased psychological support for frontline nurses and physicians during a pandemic, particularly for those with a history of anxiety or chronic medical conditions, or those living with a high-risk individual.

The COVID-19 Elective for Pediatric Residents: Learning About Systems-Based Practice During a Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has prompted pediatric residency programs to adjust the delivery of educational curricula and to update content relevant to the pandemic. OBJECTIVE: In this descriptive paper, we present how we rapidly developed and implemented a COVID-19 pandemic elective for pediatric residents. METHODS: This curriculum was established at a single tertiary care children's hospital in June 2020. We used the ADDIE (analysis, design, development, implementation, evaluation) framework to develop a two-week elective (30 hours) consisting of six flexibly scheduled modules. We administered post-elective surveys and exit interviews to solicit feedback to improve the elective and obtain effectiveness of our educational interventions. RESULTS: We developed an asynchronous online COVID-19 Elective for Pediatric Residents. The curriculum modules focus on pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the disaster management ecosystem, simulation of clinical care, mental health ramifications, and public health consequences. We also include six in-situ experiences (visits to a drive-through COVID-19 testing site, testing laboratory and local public health department, a simulation of a critically ill child, and meetings with emergency managers and social workers) to solidify learning and allow for further reflection. To date, eight participants have taken the elective. All participants strongly agreed on a five-point Likert item survey that the elective enhanced their knowledge in current evidence-based literature for COVID-19, disaster preparedness, hospital response, management of the critically ill child, and mental and public health ramifications. All participants agreed this curriculum was relevant to and will change their practice. CONCLUSIONS: We demonstrate how a COVID-19 elective for pediatric residents could be quickly developed and implemented. The pilot results show that pediatric trainees value asynchronous learning, supplemented by relevant in-situ experiences. Moreover, these results suggest that this curriculum provides needed disaster response and resiliency education for pediatric residents.

US Hospital Preparedness to Manage Unidentified Individuals and Reunite Unaccompanied Minors with Family Members During Disasters: Results from a Nationwide Survey.

Unaccompanied minors and other unidentified individuals may present to hospitals during disasters and require reunification with family. Hospital preparedness for family reunification during disasters has never been assessed. We sent members of the Association of Healthcare Emergency Preparedness Professionals an anonymous online survey in July and August 2019 to assess their hospital's reunification readiness during a disaster. Scores on preparedness to manage unidentified patients were calculated based on 21 indicators, each with a score of 0 or 1. A multivariate linear regression was conducted to delineate factors associated with higher preparedness scores. In total, 88 individuals participated (response rate = 33.4%). All agreed that reunification preparedness is important, but far fewer (χ2 = 33.8, P < .001) believed their hospital was prepared to reunify unidentified individuals during a disaster (n = 58, 65.9%). Most (n = 56, 63.6%) had at least some written reunification plan. Preparedness scores ranged from 0 to 21 (mean = 8.0, standard deviation = 7.3). Predictors of preparedness included having a pediatrician on the hospital disaster planning committee, conducting a disaster exercise that simulated an unaccompanied minor scenario, and implementing the 2018 American Academy of Pediatrics Reunification Planning Tool. Findings from this study indicate that many US hospitals are not prepared to reunify unaccompanied minors or other separated family members during a disaster. The planning tool is a free resource that hospitals can use to improve their hospital reunification plans. Hospitals should prioritize development of reunification plans to ensure rapid response during a future event. Use of the planning tool can aid in development and improvement of these plans.

Novel Use of Home Pulse Oximetry Monitoring in COVID-19 Patients Discharged From the Emergency Department Identifies Need for Hospitalization.

OBJECTIVES: Our objective was to evaluate patient-reported oxygen saturation (SpO2 ) using pulse oximetry as a home monitoring tool for patients with initially nonsevere COVID-19 to identify need for hospitalization. METHODS: Patients were enrolled at the emergency department (ED) and outpatient testing centers. Each patient was given a home pulse oximeter and instructed to record their SpO2 every 8 hours. Patients were instructed to return to the ED for sustained home SpO2  < 92% or if they felt they needed emergent medical attention. Relative risk was used to assess the relation between hospitalization and home SpO2  < 92% in COVID-19-positive patients. RESULTS: We enrolled 209 patients with suspected COVID-19, of whom 77 patients tested positive for COVID-19 and were included. Subsequent hospitalization occurred in 22 of 77 (29%) patients. Resting home SpO2  < 92% was associated with an increased likelihood of hospitalization compared to SpO2  ≥ 92% (relative risk = 7.0, 95% confidence interval = 3.4 to 14.5, p < 0.0001). Home SpO2  < 92% was also associated with increased risk of intensive care unit admission, acute respiratory distress syndrome, and septic shock. In our cohort, 50% of patients who ended up hospitalized only returned to the ED for incidental finding of low home SpO2 without worsening of symptoms. One-third (33%) of nonhospitalized patients stated that they would have returned to the ED if they did not have a pulse oximeter to reassure them at home. CONCLUSIONS: This study found that home pulse oximetry monitoring identifies need for hospitalization in initially nonsevere COVID-19 patients when a cutoff of SpO2 92% is used. Half of patients who ended up hospitalized had SpO2  < 92% without worsening symptoms. Home SpO2 monitoring also reduces unnecessary ED revisits.

Chronic Obstructive Pulmonary Disease in the Intensive Care Unit: Antibiotic Treatment of Severe Chronic Obstructive Pulmonary Disease Exacerbations.

Patients who suffer from chronic obstructive pulmonary disease (COPD) often experience deterioration of baseline respiratory symptoms, acute exacerbations of COPD (AECOPD), that become more frequent with disease progression. Based on symptom severity, approximately 20% of these patients will require hospitalization. The most common indicators for intensive care unit (ICU) admission have been found to be worsening or impending respiratory failure and hemodynamic instability. Bacterial and viral bronchial infections are the causative triggers in the majority of COPD exacerbations in the ICU, with a comprehensive assessment revealing them in 72% of cases. The distribution of bacterial pathogens involved in AECOPD requiring ICU admission show an increased incidence of gram-negative respiratory isolates, including Pseudomonas and Enterobacteriaceae spp., when compared with outpatient exacerbations. Evaluation of these patients requires careful attention to comorbid conditions. An effort to rapidly obtain lower respiratory samples for microbiological samples prior to initiation of antibiotics should be made as adequate samples can guide subsequent modifications of antibiotic treatment if the clinical response to empiric treatment is poor. Empiric antibiotic treatment should be promptly initiated in all patients with a major consideration for the choice being the presence of risk factors for Pseudomonas infection. Evaluation of clinical response at 48 to 72 hours is crucial, and total duration of antibiotics of 5 to 7 days should be adequate.

Aclidinium bromide and formoterol fumarate for the maintenance treatment of chronic obstructive pulmonary disease.

Introduction: Treatment options for COPD have evolved rapidly in the last decade and inhaled bronchodilators have largely supplanted the use of oral bronchodilators because of their increased efficacy and excellent safety with topical delivery to the lung. Recently added to the therapeutic armamentarium are fixed-dose combinations (FDC) of two long acting bronchodilators. LAMAs (long acting muscarinic antagonists) and LABAs (long acting beta agonists) are the main classes available and use different pathways to effectively produce bronchial smooth muscle relaxation.Areas covered: The most recent inhaled FDC LAMA/LABA to come to market is Aclidinium Bromide and Formoterol Fumarate. We searched databases of PubMed, Cochrane Library, and manufacturers' websites and retrieved all the randomized-controlled trials (RCTs) conducted with these drugs up to September 2019.Expert opinion: It is likely that FDCs will become the core of our COPD pharmacotherapy for all but the mildest COPD patients. These individual drugs have excellent efficacy and safety records for the maintenance treatment of COPD. Studies have demonstrated that twice daily treatment with aclidinium/formoterol resulted in significant improvement in lung function and an improved exercise tolerance when compared to placebo. Adverse effects are within the range of what is seen with other LAMA/LABA combinations.

Repeat Intravenous Ketamine Dosing in Children Undergoing Emergency Department Procedural Sedation.

BACKGROUND: Patients undergoing procedural sedation with intravenous ketamine often receive repeat doses to maintain dissociation; however, data between doses are lacking. OBJECTIVES: The purpose of this study was to characterize the frequency, time interval, and dosages of ketamine received by children undergoing procedural sedation and to explore the effects of age and body mass index on these parameters. METHODS: This was a retrospective study of patients 1 to 18 years of age undergoing procedural sedation with intravenous ketamine in a pediatric emergency department between October 2016 and June 2017. Total repeat ketamine dosages were standardized to a 1-h sedation. RESULTS: Four hundred nineteen patients were included in the analysis. The median sedation time was 33.0 minutes (interquartile range [IQR] 25.0-45.0). Three hundred sixty-three patients (86.6%) received at least 1 repeat ketamine dose. The median time between doses was 7.0 minutes (IQR 5.0-12.0). Children <6 years of age, compared with older children, received higher hourly doses of ketamine in mg/kg/h (2.8 [IQR 1.8-3.9] vs. 1.8 [IQR 1.2-2.6], pc < 0.01). Children <3 years of age, compared with older children, received the highest hourly dose of ketamine in mg/kg/h (3.7 [IQR 2.3-5.0] vs. 1.9 [IQR 1.4-2.8], pc < 0.01). Ketamine repeat and hourly dosing does not appear to be significantly different in children of differing body mass index classes. CONCLUSIONS: Patients undergoing ketamine sedation often receive repeat doses to maintain dissociation. Patients <3 years of age received the highest total repeat ketamine dosages.

l-DOPA improves odor discrimination learning in rats.

Using a forced-choice odor discrimination task in rats, we show here that intraperitoneal injections of l-DOPA improve rats' odor discrimination performance in comparison to control rats injected with saline. Although the exact mechanism of l-DOPA and potential action on dopamine receptors remains unclear, the present results indicate that rats injected with the 20-50 mg/kg of l-DOPA performed significantly better in an odor discrimination task than did control rats. In addition, we observed a significant correlation between the concentration of l-DOPA and odor discrimination performance.