Longitudinal Assessment of Coronavirus Disease 2019 Vaccine Acceptance and Uptake Among Frontline Medical Workers in Los Angeles, California.

BACKGROUND: Sentiments of vaccine hesitancy and distrust in public health institutions have complicated the government-led coronavirus disease 2019 (COVID-19) vaccine control strategy in the United States. As the first to receive the vaccine, COVID-19 vaccine attitudes among frontline workers are consequential for COVID-19 control and public opinion of the vaccine. METHODS: In this study, we used a repeated cross-sectional survey administered at 3 time points between 24 September 2020 and 6 February 2021 to a cohort of employees of the University of California, Los Angeles Health and the Los Angeles County Fire Department. The primary outcome of interest was COVID-19 vaccination intent and vaccine uptake. RESULTS: Confidence in COVID-19 vaccines and vaccine uptake rose significantly over time. At survey 1, confidence in vaccine protection was 46.4% among healthcare workers (HCWs) and 34.6% among first responders (FRs); by survey 3, this had risen to 90.0% and 75.7%, respectively. At survey 1, about one-third of participants intended to receive a vaccine as soon as possible. By survey 3, 96.0% of HCWs and 87.5% of FRs had received a COVID-19 vaccine. CONCLUSIONS: Attitudes toward vaccine uptake increased over the study period, likely a result of increased public confidence in COVID-19 vaccines, targeted communications, a COVID-19 winter surge in Los Angeles County, and ease of access from employer-sponsored vaccine distribution.

Humoral responses to SARS-CoV-2 mRNA vaccines: Role of past infection.

Two mRNA vaccines (BNT162b2 and mRNA-1273) against severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) are globally authorized as a two-dose regimen. Understanding the magnitude and duration of protective immune responses is vital to curbing the pandemic. We enrolled 461 high-risk health services workers at the University of California, Los Angeles (UCLA) and first responders in the Los Angeles County Fire Department (LACoFD) to assess the humoral responses in previously infected (PI) and infection naïve (NPI) individuals to mRNA-based vaccines (BNT162b2/Pfizer- BioNTech or mRNA-1273/Moderna). A chemiluminescent microparticle immunoassay was used to detect antibodies against SARS-CoV-2 Spike in vaccinees prior to (n = 21) and following each vaccine dose (n = 246 following dose 1 and n = 315 following dose 2), and at days 31-60 (n = 110) and 61-90 (n = 190) following completion of the 2-dose series. Both vaccines induced robust antibody responses in all immunocompetent individuals. Previously infected individuals achieved higher median peak titers (p = 0.002) and had a slower rate of decay (p = 0.047) than infection-naïve individuals. mRNA-1273 vaccinated infection-naïve individuals demonstrated modestly higher titers following each dose (p = 0.005 and p = 0.029, respectively) and slower rates of antibody decay (p = 0.003) than those who received BNT162b2. A subset of previously infected individuals (25%) required both doses in order to reach peak antibody titers. The biologic significance of the differences between previously infected individuals and between the mRNA-1273 and BNT162b2 vaccines remains uncertain, but may have important implications for booster strategies.

Implementation of the Los Angeles Tiered Dispatch System is associated with an increase in telecommunicator-assisted CPR.

BACKGROUND: In 2015, the Los Angeles Fire Department (LAFD) replaced the Medical Priority Dispatch System® (MPDS) with a new, homegrown Los Angeles Tiered Dispatch System (LA-TDS). The objective of this study was to assess the impact of this new dispatch system on telecommunicator-assisted CPR (T-CPR). METHODS: This was an interrupted time series study of out-of-hospital cardiac arrest (OHCA) cases where resuscitation was attempted with LAFD 9-1-1 telecommunicators using either MPDS® (January 1, 2014 to March 31, 2014) or LA-TDS (January 1, 2015 to March 31, 2015). Trained non-LAFD abstractors listened to all 9-1-1 calls and recorded if T-CPR was initiated, and the elapsed time from the start of the call until key events. The primary outcome was prevalence of T-CPR. RESULTS: Of 1027 calls during the study period, 597 9-1-1 calls met study inclusion/exclusion criteria (including 289 in MPDS cohort, 308 in LA-TDS cohort). The prevalence of T-CPR was significantly greater using LA-TDS (57%) vs. MPDS (43%) (OR 1.86, 95% CI 1.3-2.6). The LA-TDS cohort demonstrated a significant decrease (p < 0.001) in time to recognition of cardiac arrest, time to dispatch, and time to first T-CPR chest compression while there was no significant difference in the elapsed time to first description of agonal breathing. For cases where the telecommunicator had the opportunity to assess consciousness and breathing, there was a significant improvement in cardiac arrest recognition in < 1 min, prevalence of T-CPR (p < 0.001), and T-CPR started in <2 min (p < 0.001). CONCLUSION: Implementation of the new Los Angeles Tiered Dispatch System was associated with decreased time to recognition of cardiac arrest and an increased rate of T-CPR compared to the previously used Medical Priority Dispatch System®.

Prime the Line! A Case Report of Air Embolism from a Peripheral IV Line in the Field.

Venous air embolisms are rare but a cause of potentially life-threatening events with associated cardiovascular, pulmonary and neurologic effects. We report the first prehospital case of a venous air embolism in a 31-year-old male who became hemodynamically unstable after a peripheral intravenous catheter with unprimed tubing was placed by paramedics in the prehospital setting and diagnosed in the emergency department. We highlight the clinical presentation, diagnosis and emergency management of venous air embolisms.

Advanced Practice Providers in the Field: Implementation of the Los Angeles Fire Department Advanced Provider Response Unit.

Background: To address the growing number of low-acuity patients in the 911-EMS system, the Los Angeles Fire Department (LAFD) launched a pilot program placing an Advanced Provider Response Unit (APRU) in the field so that a prehospital nurse practitioner (NP) could offer patients treatment/release on scene, alternative destination transport, and linkage with social services. Objective: To describe the initial 18-month experience implementing this new APRU. Methods: This is a retrospective, descriptive review of all APRU-attended patients from January 2016 to June 2017. The APRU was an ambulance staffed by an NP and a firefighter/paramedic, equipped with basic point-of-care testing capability, and linked to incidents by either being summoned by on-scene first responders or by monitoring EMS radio traffic. Descriptive statistics were used and outcome measures included counts of clients attended, treat/release rates, impact on total time in service for other LAFD resources, patient need for subsequent re-use of 911 and self-reported experience of care. Results: During its first 18 months in service, the APRU attended 812 patients, including 792 911-patient incidents. 400 of these 911-patients (50.5%) were treated and released on scene or medically cleared and transported to an alternative site for specialty care. This included 76 patients with primary psychiatric complaints who were medically-cleared and transported directly to a mental health urgent care center. An additional 18 high utilizers of 911 were attended by the APRU and connected with a social work organization, and 12 of 18 (66.7%) decreased their use of EMS in the 90-days following APRU evaluation and referral. Of the 400 911-patients that did not go to the emergency department (ED), 26 (6.5%) re-contacted 911 within 3 days: all were transported to the ED with normal vital signs and without prehospital intervention, and all were ultimately discharged home from the ED. As a result of APRU intervention, 458 other LAFD field resources were quickly placed back in service and made available for the next time-critical call. Conclusions: Advanced practice providers such as nurse practitioners can be incorporated into the prehospital setting to address a growing subset of 911-patients whose needs can be met outside of the ED.

Safety of Tiered-Dispatch for 911 Calls for Abdominal Pain.

INTRODUCTION: Many dispatch systems send Advanced Life Support (ALS) resources to patients complaining of abdominal pain even though the majority of these incidents require only Basic Life Support (BLS). With increasing 911-call volume, resource utilization has become more important to ensure that ALS resources are available for time-critical emergencies. In 2015, a large, urban fire department implemented an internally developed, tiered-dispatch system. Under this system, patients reporting a chief complaint of abdominal pain received the closest BLS ambulance dispatched alone emergency if located within three miles of the incident. The objective of this study was to determine the safety of BLS-only dispatch to abdominal pain by determining the frequency of time-sensitive events. METHODS: This was a retrospective review of electronic health records of one emergency medical service provider agency from May 2015-2018. Inclusion criteria were a chief complaint of abdominal pain from a first- or second-party caller, age over 15, and the patient was reported to be alert and breathing normally. The primary outcome was the prevalence of time-sensitive events, including cardiopulmonary resuscitation (CPR), defibrillation, or airway management. Secondary outcomes were hypotension (systolic blood pressure < 90 mmHg); or a prehospital 12 lead-electrocardiogram (ECG) demonstrating ST-elevation myocardial infarction (STEMI) criteria or a wide complex arrhythmia. Descriptive statistics were used. RESULTS: During the study period, there were 1,220,820 EMS incidents, of which 33,267 (2.72%) met inclusion criteria. The mean age was 49.9 years (range 16-111, standard deviation [SD] 19.6); 14,556 patients (56.2%) were female. Time-sensitive events occurred in seven cases (0.021%), mean age was 75.3 years (range 30-86, SD18.7); 85.7% were female. Airway management was required in seven cases (0.021%), CPR in six cases (0.018%), and defibrillation in one case (0.003%). Two of the seven (28.6%) cases involved dispatch protocol deviations. Hypotension was present in 240 (0.72%) cases; six (0.018%) cases had 12-lead ECGs meeting STEMI criteria; and no cases demonstrated wide complex arrhythmia. CONCLUSION: Among adult 911 patients with a dispatch chief complaint of abdominal pain, time-sensitive events were exceedingly rare. Dispatching a BLS ambulance alone appears to be safe.

More than meets the eye: Point-of-care ultrasound diagnosis of acute optic neuritis in the emergency department.

Optic neuritis (ON) is an inflammatory condition that causes demyelination and thickening of the optic nerve leading to acute/subacute vision loss. It is frequently associated with other conditions like multiple sclerosis, but is often misdiagnosed, which can lead to a suboptimal prognosis. Ultrasound is rarely utilized to help make this diagnosis, even though it can easily detect a thickened retrobulbar optic nerve sheath diameter. We describe four cases in which ultrasonographic measurement of the optic nerve sheath diameter aided in the diagnosis of ON.

The Critical Role of Dispatch.

There are 240 million 9-1-1 calls in the United States every year. The burden of managing these emergencies until first responders can arrive is on the dispatchers working in the 5806 public safety answering points, more commonly known as dispatch centers. They are the first link in the chain of survival between the public and the remainder of the health care system. Dispatchers play a critical role in the early identification of emergencies, assignment of appropriate emergency resources, and provision of life-sustaining interventions like dispatcher-assisted cardiopulmonary resuscitation and disaster management.

Sports injuries to high school athletes with disabilities.

INTRODUCTION: Physical activity in sports comes with an inherent risk for injury. For children with disabilities, their injury risk may be complicated by preexisting disability. However, very little research exists on sports injuries to young athletes with disabilities. To best manage potential injuries to children with disabilities, data on sports injury patterns are needed. The purpose of this study was to measure the frequency of and risk factors for injury to high school athletes with disabilities. METHODS: A total of 210 athletes from 8 special education high schools that are part of an interscholastic sports league participated in the study. Seven of the 8 schools were followed for 1 season each of basketball, softball, soccer, and field hockey, and 1 school enrolled only during field hockey. Data were collected from coaches on daily exposure sessions (game, practice, and conditioning, as well as length of session), athlete characteristics (disability, gender, age, seizure history, and behavioral problems), and nature of injuries resulting in any type of medical treatment. RESULTS: Thirty-eight injuries were reported among 512 special athletes for a rate of 2.0 per 1000 athlete exposures. Soccer (3.7 per 1000) had the highest rate of injury. More than half of the injuries were abrasions and contusions. Those at highest risk for injury were athletes with autism, athletes with histories of seizures, and starters. Athletes with autism had approximately 5 times the injury rate of athletes with mental disabilities. Athletes with seizures had >2.5 times the rate of injury reported among those with no seizure history. CONCLUSIONS: This adapted sports program is a reasonably safe activity for children with disabilities. Nonetheless, findings have important implications for prevention. The preparticipation medical examination may be an excellent opportunity to create special guidelines, particularly for athletes with autism and seizure history.

Injuries to high school football athletes in California.

BACKGROUND: Among all high school sports, football has the highest rate of injury. Prior research has been limited primarily because of challenges in surveillance, defining injuries, and measuring exposures. HYPOTHESIS: Football injury patterns differ across player and session characteristics. STUDY DESIGN: Descriptive epidemiology study. METHODS: More than 5000 football players from 87 high schools in California were observed for 2 seasons (2001 and 2002). School representatives were trained to collect data on injuries, player characteristics, and daily exposures. Data were analyzed using descriptive statistics and clustered Poisson regression. RESULTS: Players sustained 25.5 injuries per 100 players, 9.3 injuries per 10,000 player-hours, and 8.4 injuries per 100 session-hours. Session rates were highest during games, on artificial turf (13.8 of 100), during foggy weather (25.1 of 100), and on clear evenings (21 of 100). Offensive and defensive backfielders had about a 20% increased rate of injury compared with linemen. The adjusted injury rate for starters was 60% higher than the rate for nonstarters (relative rate, 1.6; 95% confidence interval, 1.4-1.9). CONCLUSION: Risk profiles differed by experience, playing position, and surface types. We recommend future sports injury research that measures time-dependent exposures at the individual level and for various types of environmental playing conditions.