Dynamic Masking: A Proposal of Burden-Based Metrics for Masking in K-12 Schools During the COVID-19 Pandemic.

BACKGROUND: Ongoing masking of K-12 children has not been universally accepted despite recommendation from public health authorities. In states without universal mask mandates for schools, district administrators are forced to make masking decisions under significant local political pressures. There is a call for endpoints to masking to allow communities to tailor mitigation while keeping schools safe, focusing on harm reduction. METHODS: We reviewed existing measures for the safe opening of schools and designed a stepwise, accessible approach to the removal of masks in the K-12 setting. RESULTS: Focusing first on the assessment of school impact due to COVID-19 disease and then considering the context of existing community transmission levels allows for a metrics-based approach to masking that is flexible and practical, enabling school officials to adapt quickly to the pandemic landscape in their communities, independent of political pressures. CONCLUSIONS: While this proposal is preliminary, a dynamic metric system for masking may encourage those communities who wish to minimize masking to adopt masks during highest risk periods, protecting against SARS-CoV-2 transmission in schools and allowing for more holistic harm reduction. This approach may serve to guide districts during times of uncertainty when central guidance short of universal masking is lacking.

COVID-19 Transmission during Transportation of 1st to 12th Grade Students: Experience of an Independent School in Virginia.

BACKGROUND: In-school transmission of COVID-19 among K-12 students is low when mitigation layers are used, but the risk of acquiring COVID-19 during school bus transportation is not well defined. Given the operational limitations of many school districts, more data is needed to determine what mitigation is required to keep COVID-19 transmission low during bus transport. METHODS: An independent school in Virginia monitored 1154 students in grades 1 to 12 with asymptomatic PCR testing every 2 weeks from August 24, 2020 to March 19, 2021, during the highest community transmission. Fifteen buses served 462 students while operating at near capacity of 2 students in every seat, using a physical distancing minimum of 2.5 ft, universal masking, and simple ventilation techniques. RESULTS: A total of 39 individuals were present on buses during their COVID-19 infectious period, which resulted in the quarantine of 52 students. Universal testing and contact tracing revealed no transmission linked to bus transportation. CONCLUSIONS: This study demonstrates a model for the safe operation of school buses while near capacity. COVID-19 transmission can be low during student transport when employing mitigation including simple ventilation, and universal masking, at minimal physical distances and during the highest community transmission.

In Situ Simulation for Ventilator Management in Emergency Medicine.

BACKGROUND: Emergency physicians have a residency graduation milestone to effectively manage the airway and initiate mechanical ventilation. However, many emergency medicine (EM) residents report rarely or never feeling comfortable managing mechanically ventilated patients. Our goal was to determine the effectiveness of an in situ simulation program for EM residents to successfully manage a ventilator on a high-fidelity patient simulator. METHODS: This was a prospective observational educational study of EM residents executed in four steps. Baseline performance was assessed by observed standard clinical examination (OSCE) in a checklist manner after our routine classroom-based annual ventilator teaching. The in situ simulation was executed in a small-group format located in the trauma bay of the ED using only equipment available in the clinical setting. Performance at 1 week and 8 months after the educational intervention was assessed by repeat OSCE. The results were assessed using paired Student's t-tests. RESULTS: There was a statistically significant improvement in all checklist markers of successful ventilator management on repeat OSCE after the in situ simulation intervention. A final unannounced retention OSCE was administered 8 months after the intervention with no additional interval training. The improved performance persisted 8 months later. CONCLUSIONS: This in situ simulation study demonstrated improved checklist scoring on ventilator management in simulated critically ill patients by EM residents. This improvement persisted 8 months after the educational intervention.

Pediatric myth: fever and petechiae.

A child presenting with petechiae and fever is assumed to have meningococcemia or another form of bacterial sepsis and therefore to require antibiotics, blood cultures, cerebrospinal fluid analysis and hospital admission. A review of the literature challenges this statement and suggests that a child presenting with purpura (or petechiae), an ill appearance and delayed capillary refill time or hypotension should be admitted and treated for meningococcal disease without delay. Conversely, a child with a petechial rash, which is confined to the distribution of the superior vena cava, is unlikely to have meningococcal disease. Outpatient therapy in this context is appropriate. In other children, a reasonable approach would be to draw blood for culture and C-reactive protein (CRP) while administering antibiotics. If the CRP is normal, these children could be discharged to follow-up in 1 day, whereas children with CRP values greater than 6 mg/L would be admitted.

Motivation for stopping tobacco use among emergency department patients.

OBJECTIVES: To determine the feasibility of new models for reinforcing tobacco-use-cessation interventions initiated in the emergency department (ED). The authors assessed the level of motivation to quit tobacco use among a general population of ED patients; the proportion who receive tobacco-use assessments, information, and interventions from ED providers; and the desired timing of tobacco-use interventions. METHODS: Face-to-face interviews with a convenience sample of 376 adult patients receiving care in the ED at the Mayo Clinic in Rochester, Minnesota. RESULTS: Of the 376 participants, 27% (100/376; 95% CI = 22% to 31%) currently used one or more forms of tobacco. Thirty percent (30/100; 95% CI = 21% to 40%) of tobacco users were in the preparation stage of change for tobacco cessation. The median score on the Contemplation Ladder was 6 (range: 0-10). Twenty-seven percent (27/100; 95% CI = 19% to 37%) of all tobacco users would have been interested in a tobacco-use treatment after the ED visit, such as telephone-based counseling. Of the current tobacco users either receiving or desiring a tobacco-use intervention, 74% (25/34; 95% CI = 56% to 87%) would be interested in receiving an intervention component after the ED visit. CONCLUSIONS: ED patients who use tobacco demonstrate motivation to quit and express interest in receiving interventions to assist them after the ED visit. Previous investigations have observed that ED patients do not attend interventions prescribed after the initial ED encounter. These findings suggest that the development of new models for reinforcing tobacco-use interventions initiated in the ED deserve exploration, such as linking them to a tobacco quitline.

A survey of characteristics of smokeless tobacco users in a treatment program.

OBJECTIVE: To determine the characteristics and outcomes of smokeless tobacco (ST) users receiving interventions in an outpatient tobacco-dependence treatment program. METHODS: Survey was mailed with telephone follow-up to ST users treated during a 2-year period. RESULTS: Nicotine replacement therapy and family and social support were the most helpful intervention components in maintaining tobacco abstinence. Continuing ST users face significant barriers to abstinence such as high levels of nicotine dependence, lack of motivation, nicotine withdrawal symptoms, and stress. CONCLUSIONS: Enhancing confidence in their ability to quit, managing stress, prescribing bupropion SR, offering nicotine replacement therapy to relieve withdrawal symptoms, and providing ongoing support may be important for ST users in tobacco- dependence treatment programs.