Patient Service: Standards and Practices for Excellence in the COVID-19 Era

From HealthLeaders Media:

During the pandemic, patients are also likely to rate their ambulatory service experience based on how carefully you protect them from exposure to COVID-19, and how well you prepare them for the changes those protections create during their visits.

Hundreds of scientists write letter to WHO arguing coronavirus is airborne: NYT

From The Hill:

A group of 239 scientists representing 32 countries is reportedly preparing to ask the World Health Organization (WHO) to revise its recommendations for the novel coronavirus due to evidence that they say supports the claim the disease is airborne.

The scientists are expected to publish an open letter making the request in a scientific journal next week, according to The New York Times. The letter is set to offer evidence that supports the position that smaller particles of the coronavirus can travel through the air and infect people.

The WHO has held that the COVID-19, the disease caused by the novel coronavirus, is transmitted mostly by large respiratory droplets that fall to floor after being discharged via a sneeze or cough. The agency has said that the virus is primarily spread through person-to-person contact and indirect contact with surfaces in the immediate environment of an infected individual.

A primer on proning in the emergency department

From JACEP Open:

Historically, the prone position was used almost exclusively in the ICU for patients suffering from refractory hypoxemia due to acute respiratory distress syndrome (ARDS). Amidst the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic, however, this technique has been increasingly utilized in settings outside of the ICU, particularly in the emergency department. With emerging evidence that patients diagnosed with COVID‐19 who are not intubated and mechanically ventilated may benefit from the prone position, this strategy should not be isolated to only those with critical illness. This is a review of the pertinent physiology and evidence supporting prone positioning along with a step‐by‐step guide meant to familiarize those who are not already comfortable with the maneuver. Placing a patient in the prone position helps to improve ventilation‐perfusion matching, dorsal lung recruitment, and ultimately gas exchange. Evidence also suggests there is improved oxygenation in both mechanically ventilated patients and those who are awake and spontaneously breathing, further reinforcing the utility of the prone position in non‐ICU settings. Given present concerns about resource limitations because of the pandemic, prone positioning has especially demonstrable value as a technique to delay or even prevent intubation. Patients who are able to self‐prone should be directed into the ”swimmer’s position” and then placed in reverse Trendelenburg position if further oxygenation is needed. If a mechanically ventilated patient is to be placed in the prone position, specific precautions should be taken to ensure the patient’s safety and to prevent any unwanted sequelae of prone positioning.

Emergency Physicians Urge Americans to Continue Covering their Face in Public

ACEP Press Release:

As regions of the country are seeing rebounding rates of COVID-19, the American College of Emergency Physicians (ACEP) reminds everyone that practicing social distancing and continuing to cover your face when in public is the best recourse to slow the spread of the virus.

“As emergency physicians continue to battle the greatest public health crisis of our generation, you can do your part to stop the virus by covering your face when you need to be around others,” said William Jaquis, MD, FACEP, president of ACEP. “Although COVID-19 continues to disrupt our way of life, we as a nation can band together in this simple step to protect ourselves and our neighbors.”

While medical professionals continue to urge anyone with COVID-19 symptoms to self-isolate, even those that don’t suspect they have the virus should cover their face because they could be asymptomatic and still be contagious. The infectious viral particles emitted when someone talks, breathes, coughs, or sneezes can remain in the air for up to three hours.

Reports have shown that covering your face with a mask or cloth during those infrequent times you need to be in public have effectively flattened the curve. According to a recent study from The Lancet spanning 16 countries, there is a 17 percent reduction in risk of infection for those wearing a mask or face covering versus those not covering their face.

The CDC and ACEP recommend that people who are not medical professionals wear cloth or homemade masks in public rather than tighter fitting medical-grade masks, like the N95. Currently, CDC recommends that anyone above the age of two wear a face covering, with exceptions for those who have trouble breathing or cannot remove a face covering without assistance.

Without a cure, personal choices and safe behaviors are the best defense against spreading COVID-19 and overwhelming our health care system. Although it may be inconvenient or uncomfortable, covering your face does not meaningfully deprive the body of oxygen. Workers in many professions wear masks that meet National Institute of Occupational Safety and Health standards all day without experiencing breathing issues. Many of the masks worn by people in fields like construction or manufacturing are heavier than the cloth coverings recommended for the public.

“Communities may be reopening but we are definitely not out of the woods yet. We cannot let down our guard. We can all do our part to safeguard our communities and prevent the spread of the virus,” said Dr. Jaquis. “Cover your face, wash your hands frequently and practice social distancing. These three simple steps offer the best protection that we have until a vaccine is developed.”

Visit www.emergencyphysicians.org for more information about protecting yourself from COVID-19.

The American College of Emergency Physicians (ACEP) is the national medical society representing emergency medicine. Through continuing education, research, public education and advocacy, ACEP advances emergency care on behalf of its 39,000 emergency physician members, and the more than 150 million Americans they treat on an annual basis. For more information, visit www.acep.org and www.emergencyphysicians.org.

Asymptomatic COVID-19 patients may be just as infectious, study finds

From Becker’s:

Asymptomatic COVID-19 carriers may be just as infectious as those displaying symptoms, a study accepted for publication in Nature found.

Researchers tested more than 70 percent of residents in a small Italian town that locked down in February due to COVID-19.

About 42.5 percent of residents with confirmed COVID-19 infections were asymptomatic. There was no statistically significant difference in asymptomatic and symptomatic patients’ viral load, which offers a measure of infectivity.

Journal Watch: Pediatric CPR at Emergency Department Handoff

From EMSWorld:

High-quality CPR increases the likelihood of survival from cardiac arrest. However, the best methods and initiatives to improve CPR quality can be system-dependent.

This month we review a manuscript that describes the results of a quality improvement initiative by a multidisciplinary team that included prehospital and pediatric emergency department providers. The authors began with the conclusion of an interprofessional committee that transfer of pediatric OHCA (out-of-hospital cardiac arrest) patients from prehospital to pediatric emergency department care “frequently involved inadequate compressions, prolonged pauses, and challenges with defibrillator pad application.” Their objective was to minimize those pauses in chest compressions during pediatric OHCA patient handoffs.

Among Those Disrupted By COVID-19: The Nation’s Newest Doctors

From Kaiser Health News:

July 1 is a big day in medical education. It’s traditionally the day newly minted doctors start their first year of residency. But this year is different. Getting from here to there — from medical school to residency training sites — has been complicated by the coronavirus.

In some instances, the medical students graduating this year — some of whom graduated early to help in the hospitals attached to their medical schools — have it easier than students directly behind them.

Almost from the start of the outbreak, third- and fourth-year students who would typically spend much or all of their time in the hospital were shut out to avoid being exposed to the coronavirus. Even the newly graduated doctors were generally kept away from COVID-19 patients.

Ten Defendants Charged in $1.4 Billion Rural Hospital Pass-Through Billing Scheme

From the Department of Justice:

Ten individuals, including hospital managers, laboratory owners, billers and recruiters, were charged in an indictment unsealed today for their participation in an elaborate pass-through billing scheme using rural hospitals in several states as billing shells to submit fraudulent claims for laboratory testing.  The indictment alleges that from approximately November 2015 through February 2018, the conspirators billed private insurance companies approximately $1.4 billion for laboratory testing claims as part of this fraudulent scheme, and were paid approximately $400 million.

How severe is the pandemic where you live?

From the Harvard Global Health Initiative:

Cambridge, July 1, 2020 — Uncertainty is the currency of pandemics. As evidence on the new coronavirus, how it spreads and who falls ill from it emerges slowly, policy makers and the public have to base their decisions on the best information available. Experts help interpret the evidence, but they may differ on details that can be confusing for non-experts — and filtering out what matters from a rising sea of misinformation has become a daunting task.

To help cut through the noise and sometimes conflicting advice, a network of research, policy and public health experts convened by Harvard’s Global Health Institute and Edmond J. Safra Center for Ethics today launches a Key Metrics For COVID Suppression framework that provides clear, accessible guidance to policy makers and the public on how to target and suppress COVID-19 more effectively across the nation.

“The public needs clear and consistent information about COVID risk levels in different jurisdictions for personal decision-making, and policy-makers need clear and consistent visibility that permits differentiating policy across jurisdictions”, explains Danielle Allen, director of the Edmond J. Safra Center for Ethics at Harvard University.  “We also collectively need to keep focused on what should be our main target: a path to near zero case incidence.”

The new framework brings clarity to metrics that help communities determine the severity of the outbreak they are responding to. A new COVID Risk Level map shows if a county or state is on the green, yellow, orange or red risk level, based on the number of new daily cases. The framework then delivers broad guidance on the intensity of control efforts needed based on these COVID risk levels. It offers key performance indicators for testing and contact tracing across all risk levels, as a backbone for suppression efforts.

Vaccine Confidence

From Becker’s:

The CDC has spent three months developing a plan to rebuild Americans’ “vaccine confidence,” CDC Director Robert Redflield, MD, told the Senate’s health and education committee June 30, according to The New York Times. Dr. Redfield and other top health officials said they are concerned many Americans will refuse to get vaccinated against COVID-19 once a vaccine is available, which could hinder efforts to control the pandemic. The vaccine plan includes a large public relations campaign to encourage vaccinations.