Advance Care Planning for Emergency Department Patients With COVID-19 Infection: An Assessment of a Physician Training Program.

OBJECTIVE: Coronavirus Disease 2019 (COVID-19) has heightened the importance of advance care planning (ACP), particularly in the emergency department (ED). The objective of this study was to determine the effect of an educational program for emergency physicians on ACP conversations in the ED during the COVID-19 pandemic. DESIGN: This was an observational pre-/post-interventional study. SETTING: This study was conducted at a Southeastern U.S. academic ED. PARTICIPANTS: 143 patients with confirmed COVID-19 infection in the 2 weeks up to and including the ED encounter of interest (between March 26 and May 25, 2020) were included. INTERVENTIONS: The primary intervention was an ACP training toolkit with three components: (1) an evidence-based guide to COVID-19 risk stratification, (2) education on language to initiate ACP conversations, and (3) modification of the electronic health record (EHR) to facilitate ACP documentation. Palliative care physicians also delivered a 60-minute ACP educational session for emergency medicine physicians. OUTCOME MEASURES: The primary outcome was a composite of ACP activities including: (1) identification of a healthcare decision-maker (HCDM), (2) an order for a code status, or (3) a documented goals of care conversation. RESULTS: There was a 25.4% (95% CI: 7.0-43.9) increase in the composite outcome of ED-based ACP. After adjustment for patient demographics and triage score, there was a non-statistically significant increase in ACP activity (OR = 2.71, 95% CI: 0.93-8.64; P = .08). CONCLUSION: A rapid and simple physician-facing educational intervention demonstrated a trend, though lacking in statistical significance, towards increased ED-based ACP activities for patients with COVID-19.

Micropepsis pineolensis gen. nov., sp. nov., a mildly acidophilic alphaproteobacterium isolated from a poor fen, and proposal of Micropepsaceae fam. nov. within Micropepsales ord. nov.

An obligately anaerobic, mildly acidophilic, fermentative alphaproteobacterium, designated strain CS4T, was isolated from an acidic, oligotrophic (nutrient poor) poor fen located near Pineola, NC, USA. Cultures contained Gram-negative, slightly curved, non-motile, non-spore-forming, non-prosthecate rods (0.1-0.4 µm in diameter and 0.4-4 µm long, depending, in part, on the growth substrate). Growth optima were 35 °C (range 15-35 °C), pH 5.6 (range of 5.0-6.8), and with 0-50 mM added NaCl (range, 0-100 mM added NaCl). The culture fermented cellobiose, d-glucose, d-mannose, fructose, galactose, glycerol, lactose, maltose, peptone, sucrose, trehalose and xylose. Respiratory growth was not detected. Major fatty acids were C18 : 1ω7c, C19 : 0 cyclo ω8c, C14 : 0 and C16 : 0. The G+C content of the DNA was 61.9±0.3 mol%. The two most closely related species phylogenetically, Rhizomicrobium palustre A48T (AB081581) and Rhizomicrobium electricum Mfc52T (AB365487) shared 94 and 93 % SSU rRNA gene sequence identity, respectively, to that of strain CS4T. Lower SSU rRNA gene sequence identities resulted from pairwise comparisons with members of the order 'Rhizobiales'(85-88 %) or Sphingomonadales(85-86 %). These findings all support the classification of strain CS4T as representative of a novel genus, family and order of Alphaproteobacteria. The type strain of the species pineolensis within the genus Micropepsis, family Micropepsaceae and order Micropepsales is CS4T (=JCM 30711T=ATCC BAA-2724T).