Air or Ground Transport to the Critical Care Resuscitation Unit: Does It Really Matter?

OBJECTIVE: Critically ill patients requiring urgent interventions or subspecialty care often require transport over significant distances to tertiary care centers. The optimal method of transportation (air vs. ground) is unknown. We investigated whether air transport was associated with lower mortality for patients being transferred to a specialized critical care resuscitation unit (CCRU). METHODS: This was a retrospective study of all adult patients transferred to the CCRU at the University of Maryland Medical Center in 2018. Our primary outcome was hospital mortality. The secondary outcomes included the length of stay and the time to the operating room (OR) for patients undergoing urgent procedures. We performed optimal 1:2 propensity score matching for each patient's need for air transport. RESULTS: We matched 198 patients transported by air to 382 patients transported by ground. There was no significant difference between demographics, the initial Sequential Organ Failure Assessment score, or hospital outcomes between groups. One hundred sixty-four (83%) of the patients transported via air survived to hospital discharge compared with 307 (80%) of those transported by ground (P = .46). Patients transported via air arrived at the CCRU more quickly (127 [100-178] vs. 223 [144-332] minutes, P < .001) and were more likely (60 patients, 30%) to undergo urgent surgical operation within 12 hours of CCRU arrival (30% vs. 17%, P < .001). For patients taken to the OR within 12 hours of arriving at the CCRU, patients transported by air were more likely to go to the OR after 200 minutes since the transfer request (P = .001). CONCLUSION: The transportation mode used to facilitate interfacility transfer was not significantly associated with hospital mortality or the length of stay for critically ill patients.

Prevalence of peri-intubation major adverse events among critically ill patients: A systematic review and meta analysis.

BACKGROUND: Peri-intubation major adverse events (MAEs) are potentially preventable and associated with poor patient outcomes. Critically ill patients intubated in Emergency Departments, Intensive Care Units or medical wards are at particularly high risk for MAEs. Understanding the prevalence and risk factors for MAEs can help physicians anticipate and prepare for the physiologically difficult airway. METHODS: We searched PubMed, Scopus, and Embase for prospective and retrospective observational studies and randomized control trials (RCTs) reporting peri-intubation MAEs in intubations occurring outside the operating room (OR) or post-anesthesia care unit (PACU). Our primary outcome was any peri-intubation MAE, defined as any hypoxia, hypotension/cardiovascular collapse, or cardiac arrest. Esophageal intubation and failure to achieve first-pass success were not considered MAEs. Secondary outcomes were prevalence of hypoxia, cardiac arrest, and cardiovascular collapse. We performed random-effects meta-analysis to identify the prevalence of each outcome and moderator analyses and meta-regressions to identify risk factors. We assessed studies' quality using the Cochrane Risk of Bias 2 tool and the Newcastle-Ottawa Scale. RESULTS: We included 44 articles and 34,357 intubations. Peri-intubation MAEs were identified in 30.5% of intubations (95% CI 25-37%). MAEs were more common in the intensive care unit (ICU; 41%, 95% CI 33-49%) than the Emergency Department (ED; 17%, 95% CI 12-24%). Intubation for hemodynamic instability was associated with higher rates of MAEs, while intubation for airway protection was associated with lower rates of MAEs. Fifteen percent (15%, 95% CI 11.5-19%) of intubations were complicated by hypoxia, 2% (95% CI 1-3.5%) by cardiac arrest, and 18% (95% CI 13-23%) by cardiovascular collapse. CONCLUSIONS: Almost one in three patients intubated outside the OR and PACU experience a peri-intubation MAE. Patients intubated in the ICU and those with pre-existing hemodynamic compromise are at highest risk. Resuscitation should be considered an integral part of all intubations, particularly in high-risk patients.

Solidarity and strife after the Atlanta spa shootings: A mixed methods study characterizing Twitter discussions by qualitative analysis and machine learning.

Background: On March 16, 2021, a white man shot and killed eight victims, six of whom were Asian women at Atlanta-area spa and massage parlors. The aims of the study were to: (1) qualitatively summarize themes of tweets related to race, ethnicity, and racism immediately following the Atlanta spa shootings, and (2) examine temporal trends in expressions hate speech and solidarity before and after the Atlanta spa shootings using a new methodology for hate speech analysis. Methods: A random 1% sample of publicly available tweets was collected from January to April 2021. The analytic sample included 708,933 tweets using race-related keywords. This sample was analyzed for hate speech using a newly developed method for combining faceted item response theory with deep learning to measure a continuum of hate speech, from solidarity race-related speech to use of violent, racist language. A qualitative content analysis was conducted on random samples of 1,000 tweets referencing Asians before the Atlanta spa shootings from January to March 15, 2021 and 2,000 tweets referencing Asians after the shooting from March 17 to 28 to capture the immediate reactions and discussions following the shootings. Results: Qualitative themes that emerged included solidarity (4% before the shootings vs. 17% after), condemnation of the shootings (9% after), racism (10% before vs. 18% after), role of racist language during the pandemic (2 vs. 6%), intersectional vulnerabilities (4 vs. 6%), relationship between Asian and Black struggles against racism (5 vs. 7%), and discussions not related (74 vs. 37%). The quantitative hate speech model showed a decrease in the proportion of tweets referencing Asians that expressed racism (from 1.4% 7 days prior to the event from to 1.0% in the 3 days after). The percent of tweets referencing Asians that expressed solidarity speech increased by 20% (from 22.7 to 27.2% during the same time period) (p < 0.001) and returned to its earlier rate within about 2 weeks. Discussion: Our analysis highlights some complexities of discrimination and the importance of nuanced evaluation of online speech. Findings suggest the importance of tracking hate and solidarity speech. By understanding the conversations emerging from social media, we may learn about possible ways to produce solidarity promoting messages and dampen hate messages.

Leveraging 13 million responses to the U.S. COVID-19 Trends and Impact Survey to examine vaccine hesitancy, vaccination, and mask wearing, January 2021-February 2022.

BACKGROUND: The urgency of the COVID-19 pandemic called upon the joint efforts from the scientific and private sectors to work together to track vaccine acceptance and prevention behaviors. METHODS: Our study utilized individual responses to the Delphi Group at Carnegie Mellon University U.S. COVID-19 Trends and Impact Survey, in partnership with Facebook. We retrieved survey data from January 2021 to February 2022 (n = 13,426,245) to examine contextual and individual-level predictors of COVID-19 vaccine hesitancy, vaccination, and mask wearing in the United States. Adjusted logistic regression models were developed to examine individual and ZIP code predictors of COVID-19 vaccine hesitancy and vaccination status. Given the COVID-19 vaccine was rolled out in phases in the U.S. we conducted analyses stratified by time, January 2021-May 2021 (Time 1) and June 2021-February 2022 (Time 2). RESULTS: In January 2021 only 9% of U.S. Facebook respondents reported receiving the COVID-19 vaccine, and 45% were vaccine hesitant. By February 2022, 80% of U.S. Facebook respondents were vaccinated and only 18% were vaccine hesitant. Individuals who were older, held higher educational degrees, worked in white collar jobs, wore a mask most or all the time, and identified as white and Asian had higher COVID-19 vaccination rates and lower vaccine hesitancy across Time 1 and Time 2. Essential workers and blue-collar occupations had lower COVID vaccinations and higher vaccine hesitancy. By Time 2, all adults were eligible for the COVID-19 vaccine, but blacks and multiracial individuals had lower vaccination and higher vaccine hesitancy compared to whites. Those 55 years and older and females had higher odds of wearing masks most or all the time. Protective service, construction, and installation and repair occupations had lower odds of wearing masks. ZIP Code level percentage of the population with a bachelors' which was associated with mask wearing, higher vaccination, and lower vaccine hesitancy. CONCLUSION: Associations found in earlier phases of the pandemic were generally found to also be present later in the pandemic, indicating stability in inequities. Additionally, inequities in these important outcomes suggests more work is needed to bridge gaps to ensure that the burden of COVID-19 risk does not disproportionately fall upon subgroups of the population.

Post-traumatic stress in healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis.

The SARS-CoV-2 (COVID-19) pandemic has increased healthcare worker (HCW) susceptibility to mental illness. We conducted a meta-analysis to investigate the prevalence and possible factors associated with post-traumatic stress disorder (PTSD) symptoms among HCW during the COVID-19 pandemic. We searched PubMed, SCOPUS and EMBASE databases up to May 4th, 2022. We performed random effects meta-analysis and moderator analyses for the prevalence of PTSD-relevant symptoms and severe PTSD symptoms. We identified 1276 studies, reviewed 209 full-text articles, and included 119 studies (117,143 participants) with a total of 121 data points in our final analysis. 34 studies (24,541 participants) reported prevalence of severe PTSD symptoms. Approximately 25.2% of participants were physicians, 42.8% nurses, 12.4% allied health professionals, 8.9% auxiliary health professionals, and 10.8% "other". The pooled prevalence of PTSD symptoms among HCWs was 34% (95% CI, 0.30-0.39, I2 >90%), and 14% for severe PTSD (95% CI, 0.11 - 0.17, I2 >90%). The introduction of COVID vaccines was associated with a sharp decline in the prevalence of PTSD, and new virus variants were associated with small increases in PTSD rates. It is important that policies work towards allocating adequate resources towards protecting the well-being of healthcare workers to minimize adverse consequences of PTSD.

Leveraging 13 million responses to the Facebook COVID-19 Trends and Impact Survey to examine vaccine hesitancy, vaccination, and mask wearing, January 2021-February 2022.

Background: The urgency of the COVID-19 global pandemic called upon the joint efforts from the scientific and private sectors to work together to track vaccine acceptance, prevention behaviors, and symptoms. Methods: Our study utilized individual responses to the Facebook’s COVID-19 Trends and Impact Survey from January 2021 to February 2022 (n=13,426,245) to examine contextual and individual-level predictors of COVID-19 vaccine hesitancy, vaccination, and mask wearing. Adjusted logistic regression models were developed to examine individual and zip code predictors of COVID-19 vaccine hesitancy and vaccination status. Given the COVID vaccine was rolled out in phases in the U.S. we conducted analyses stratified by time, January 2021-May 2021 (Time 1) and June 2021-February 2022 (Time 2). Results: On January 2021 only 9% of Facebook respondents reported receiving the COVID-19 vaccine, and 45% were vaccine hesitant. By February 2022, 80% of respondents were vaccinated and only 18% were vaccine hesitant. Individuals who were older, held higher educational degrees, worked in white collar jobs, wore a mask most of the time or some of the time, and identified as white and Asian had higher COVID-19 vaccination rates and lower vaccine hesitancy across Time 1 and Time 2. COVID vaccinations were lower among essential workers and blue-collar occupations (OR=0.31-0.40) including those in food preparation and serving, construction, installation and repair, transportation, and production in Time 1. In Time 2, these disparities attenuated but were still present (OR-0.36-0.64). For these same occupation groups, vaccine hesitancy was higher (OR=1.88-2.30 in Time 1) and (OR=2.05-2.80 in Time 2). By Time 2, all adults were eligible for the COVID-19 vaccine, but blacks (OR=0.71; 95% CI: 0.70-0.72) and multiracial (OR=0.47; 95% CI: 0.47-0.48) individuals had lower vaccination and higher vaccine hesitancy compared to whites. Conclusions: Associations found in earlier phases of the pandemic were generally found to also be present later in the pandemic, indicating stability in inequities. Additionally, inequities in these important outcomes suggests more work is needed to bridge gaps to ensure that the burden of COVID-19 risk does not disproportionately fall upon subgroups of the population.

Emergent Endoscopy for Esophageal Foreign Body Removal: The Impact of Location.

Background Timely intervention is essential for the successful removal of ingested foreign bodies. Emergent endoscopy (EGD) is usually performed in the emergency department (ED), operating room (OR), intensive care unit (ICU), or endoscopy suite. However, because the endoscopy suite is not always available, this study investigated the impact of location outside of the endoscopy suite on the successful removal of ingested foreign bodies and other patient outcomes. Methodology We reviewed charts of patients who underwent EGD for foreign body removal at an academic quaternary center between January 01, 2012, and December 31, 2020. We defined successful EGD as retrieval of the foreign body at the first attempt and not requiring subsequent endoscopy or surgical intervention. We performed descriptive and inferential statistical analyses and conducted classification and regression trees to compare endoscopy procedure length (EPL) and hospital length of stay (HLOS) between different locations. Results We analyzed 77 patients, of whom 13 (17%) underwent endoscopy in the ICU, 46 (60%) in the OR, and 18 (23%) in the ED. Endoscopic removal failed in four (5%) patients. Endoscopy length was significantly shorter in the OR (67 (48-122) minutes) versus the ICU (158 (95-166) minutes, P = 0.004) and the ED (111 (92-155) minutes, P = 0.009). Time to procedure was similar if the procedure was performed in the ED (278 minutes), the ICU (331 minutes), or the OR (378 minutes). The median (interquartile range) of HLOS for the OR group (0.87 (0.54-2.03) days) was significantly shorter than the ICU group (2.26 (1.47-6.91) days, P = 0.007). Conclusions While performing endoscopy for esophageal foreign body removal in the OR may be associated with a shorter EPL and HLOS, no location was inferior for overall outcomes. Further prospective and randomized studies are needed to confirm our findings.

Nurses and Efficacy of Ultrasound-Guided Versus Traditional Venous Access: A Systemic Review and Meta-Analysis.

BACKGROUND: Ultrasound-guided venous cannulation is an increasingly popular tool for peripheral intravenous catheter placement among nursing providers as opposed to standard of care landmark-based placement methods. This systematic review and meta-analysis assessed the use of ultrasound-guided versus landmark-based catheter cannulation among nursing providers across existing literature. METHODS: PubMed, Scopus, and Embase were searched for eligible studies from their beginning to June 11, 2021. Outcomes were the rate of first successful placement, procedure length, and number of total attempts. Bias and study quality were assessed using the Cochrane's Risk of Bias and the Newcastle-Ottawa Scale tools, respectively. Random-effects meta-analysis and assessed heterogeneity via Q-statistics and I2 values were used. RESULTS: The meta-analysis included 7 randomized clinical studies and 527 patients; 276 (52%) underwent ultrasound-guided cannulation and were associated with 2 times higher likelihood (odds ratio, 2.08; 95% confidence interval, 1.43-3.0; P < .001; I2 < 0.001; 95% confidence interval, 0-18) of first successful placement by nurse clinicians. Ultrasound-guided venous cannulation by nurses was associated with similar number of attempts, procedure length, and patients' satisfaction, compared with standard-of-care cannulation. CONCLUSIONS: This study demonstrated the advantage of nurses' ultrasound-guided venous cannulation over landmark-based cannulation methods for first successful placement, although other outcomes were not significantly different between methods. Additional multisite studies with adequately powered sample sizes are necessary to confirm these findings.

Progress and push-back: How the killings of Ahmaud Arbery, Breonna Taylor, and George Floyd impacted public discourse on race and racism on Twitter.

This study examined whether killings of George Floyd, Ahmaud Arbery, and Breonna Taylor by current or former law enforcement officers in 2020 were followed by shifts in public sentiment toward Black people. Methods: Google searches for the names "Ahmaud Arbery," "Breonna Taylor," and "George Floyd" were obtained from the Google Health Application Programming Interface (API). Using the Twitter API, we collected a 1% random sample of publicly available U.S. race-related tweets from November 2019-September 2020 (N = 3,380,616). Sentiment analysis was performed using Support Vector Machines, a supervised machine learning model. A qualitative content analysis was conducted on a random sample of 3,000 tweets to understand themes in discussions of race and racism and inform interpretation of the quantitative trends. Results: The highest rate of Google searches for any of the three names was for George Floyd during the week of May 31 to June 6, the week after his murder. The percent of tweets referencing Black people that were negative decreased by 32% (from 49.33% in November 4-9 to 33.66% in June 1-7) (p < 0.001), but this decline was temporary, lasting just a few weeks. Themes that emerged during the content analysis included discussion of race or racism in positive (14%) or negative (38%) tones, call for action related to racism (18%), and counter movement/arguments against racism-related changes (6%). Conclusion: Although there was a sharp decline in negative Black sentiment and increased public awareness of structural racism and desire for long-lasting social change, these shifts were transitory and returned to baseline after several weeks. Findings suggest that negative attitudes towards Black people remain deeply entrenched.

Efficacy of Ultrasound-Guided Peripheral Intravenous Cannulation versus Standard of Care: A Systematic Review and Meta-analysis.

Peripheral intravenous cannulation (PIV) is a common and necessary procedure in the emergency department (ED). Patients with PIV access encounter significant treatment delay. Ultrasound guidance for PIV (USGPIV) cannulation is a modality to reduce delay of care in such patients, but its efficacy, when compared with cannulation by the standard of care (SOC), the landmark and palpation method, has not been well established. We performed a random effects meta-analysis of available literature that compared USGPIV with SOC cannulation. We searched PubMed, Scopus and EMBASE until October 2020 for eligible studies in adult patients. We excluded non-English language, non-full-text studies. Our primary outcome was rate of first successful cannulation. Other outcomes were number of attempts and patient satisfaction. After identifying 284 studies and screening 74 studies, we included 10 studies. There were 1860 patients, 966 (52%) in the USGPIV group and 894 (48%) who received the SOC. Sixty-six percent of patients were female. USGPIV cannulation was associated with a two-times higher likelihood of first successful cannulation (odds ratio: 2.1, 95% confidence interval [CI]: 1.65-2.7, p < 0.001, I2 = 2.9%). While procedure length was similar in both groups, USGPIV was associated with a significantly smaller number of attempts (standardized mean difference [SMD]: -0.272, 95% CI: -0.539 to -0.004, p = 0.047) and significantly higher patient satisfaction (SMD: 1.467, 95% CI: 0.92-2.012, p < 0.001). There was low heterogeneity among our included studies, which were mostly randomized control trials. Our study confirmed that USGPIV cannulation offers a more effective modality, compared with SOC, to improve quality of care for patients with difficult PIV access.

Severe Bandemia Is Not Associated With Increased Risk for Adverse Events in General Pediatric Emergency Department Patients.

INTRODUCTION:  The presence of band cells > 10% of the total white blood cell (WBC) count ("bandemia") is often used as an indicator of serious bacterial illness (SBI). Results from studies of bandemia as a predictor of SBI were conflicting and little is known about the relationship between severe bandemia (SB) and clinical outcomes from SBI in children. We hypothesized that SB (band level > 20%) is not associated with adverse outcomes in an emergency department (ED) pediatric population. METHODS: Medical records from children between the ages of two months and 18 years with SB who presented to a tertiary referral regional hospital were studied. Outcomes were categorized as severe adverse events (SAEs) or moderate adverse events (MAEs). Multivariate logistic regressions were used to assess the association between SB and outcomes. RESULTS:  We analyzed 102 patients. Mean age (standard deviation, SD) was 5.25 (0.5) years, 18 (18%) had MAE, 21 (21%) had SAE, and no patients died. Mean band levels were similar between groups: no adverse events 28 (10) vs. SAE 31 (9) vs. MAE 27 (8), p=0.64. Multivariate logistic regressions showed SB was not associated with any adverse events (odds ratio (OR) 1.04, 95% confidence interval (CI) 0.9-1.1, p=0.27). Non-normal X-ray (XR) (OR 17, 95% CI 3.3-90, p<0.001) was associated with MAE, while non-normal computerized tomography (CT) scan (OR 15.4, 95% CI 2.2-100+, p=0.002) was associated with SAE. CONCLUSION:  SB was not associated with higher odds of adverse events among the general ED pediatric population. Clinicians should base their clinical judgment on the overall context of history, physical examinations, and other laboratory and imaging data.

Intubation rate of patients with hypoxia due to COVID-19 treated with awake proning: A meta-analysis.

BACKGROUND: Awake prone positioning (PP), or proning, is used to avoid intubations in hypoxic patients with COVID-19, but because of the disease's novelty and constant evolution of treatment strategies, the efficacy of awake PP is unclear. We conducted a meta-analysis of the literature to assess the intubation rate among patients with COVID-19 requiring oxygen or noninvasive ventilatory support who underwent awake PP. METHODS: We searched PubMed, Embase, and Scopus databases through August 15, 2020 to identify relevant randomized control trials, observational studies, and case series. We performed random-effects meta-analyses for the primary outcome of intubation rate. We used moderator analysis and meta-regressions to assess sources of heterogeneity. We used the standard and modified Newcastle-Ottawa Scales (NOS) to assess studies' quality. RESULTS: Our search identified 1043 articles. We included 16 studies from the original search and 2 in-press as of October 2020 in our analysis. All were observational studies. Our analysis included 364 patients; mean age was 56.8 (SD 7.12) years, and 68% were men. The intubation rate was 28% (95% CI 20%-38%, I2 = 63%). The mortality rate among patients who underwent awake PP was 14% (95% CI 7.4%-24.4%). Potential sources of heterogeneity were study design and setting (practice and geographic). CONCLUSIONS: Our study demonstrated an intubation rate of 28% among hypoxic patients with COVID-19 who underwent awake PP. Awake PP in COVID-19 is feasible and practical, and more rigorous research is needed to confirm this promising intervention.

Exploring U.S. Shifts in Anti-Asian Sentiment with the Emergence of COVID-19.

Background: Anecdotal reports suggest a rise in anti-Asian racial attitudes and discrimination in response to COVID-19. Racism can have significant social, economic, and health impacts, but there has been little systematic investigation of increases in anti-Asian prejudice. Methods: We utilized Twitter's Streaming Application Programming Interface (API) to collect 3,377,295 U.S. race-related tweets from November 2019-June 2020. Sentiment analysis was performed using support vector machine (SVM), a supervised machine learning model. Accuracy for identifying negative sentiments, comparing the machine learning model to manually labeled tweets was 91%. We investigated changes in racial sentiment before and following the emergence of COVID-19. Results: The proportion of negative tweets referencing Asians increased by 68.4% (from 9.79% in November to 16.49% in March). In contrast, the proportion of negative tweets referencing other racial/ethnic minorities (Blacks and Latinx) remained relatively stable during this time period, declining less than 1% for tweets referencing Blacks and increasing by 2% for tweets referencing Latinx. Common themes that emerged during the content analysis of a random subsample of 3300 tweets included: racism and blame (20%), anti-racism (20%), and daily life impact (27%). Conclusion: Social media data can be used to provide timely information to investigate shifts in area-level racial sentiment.