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The ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has resulted in rapid surges of critically ill patients infected with coronavirus disease 2019 (COVID‐19) pneumonia presenting to the emergency department (ED) and requiring ICU admission nationwide. Despite adaptations in critical care personnel staffing, bed availability and supply provision, many inpatient ICUs have become acutely crowded, leading to boarding of critically ill patients with COVID‐19 and other diseases in the ED. To address this scenario at our urban, safety net, tertiary care institution in the spring of 2020, we designed and implemented a temporary “emergency department‐intensive care unit” (ED‐ICU) patient care service. Critical care‐trained emergency physicians took call and came into the hospital overnight/on weekends to provide bedside treatment to admitted ICU patients boarding for prolonged periods in our ED. In this manuscript, we describe the creation and execution of the ED‐ICU service and the characteristics and management of the patients who received care under this model.

The threat of a catastrophic public health emergency causing life-threatening illness or injury on a massive scale has prompted extensive federal, state, and local preparedness efforts. Modeling studies suggest that an influenza pandemic similar to that of 1918 would require ICU and mechanical ventilation capacity that is significantly greater than what is available. Several groups have published recommendations for allocating life-support measures during a public health emergency. Because there are multiple ethically permissible approaches to allocating scarce life-sustaining resources and because the public will bear the consequences of these decisions, knowledge of public perspectives and moral points of reference on these issues is critical. Here we describe a critical care disaster resource allocation framework developed following a statewide community engagement process in Maryland. It is intended to assist hospitals and public health agencies in their independent and coordinated response to an officially declared catastrophic health emergency in which demand for mechanical ventilators exceeds the capabilities of all surge response efforts and in which there has been an executive order to implement scarce resource allocation procedures. The framework, built on a basic scoring system with modifications for specific considerations, also creates an opportunity for the legal community to review existing laws and liability protections in light of a specific disaster response process.

There is an epidemic of opioid abuse. This article discusses the history of opioid use. Abusers of opioids are at great risk of harm. There have been increasing legislative efforts to curb this abuse and we present a review of the current state of these laws. Naloxone has made a profound impact in the care of these patients if they present for medical care early enough. This paper discusses naloxone pharmacodynamics, its use in the medical setting, and how its use is now being expanded to include nontraditional providers with take home naloxone programs.

Background. Google Flu Trends (GFT) is a novel Internet-based influenza surveillance system that uses search engine query data to estimate influenza activity and is available in near real time. This study assesses the temporal correlation of city GFT data to cases of influenza and standard crowding indices from an inner-city emergency department (ED). Methods. This study was performed during a 21-month period (from January 2009 through October 2010) at an urban academic hospital with physically and administratively separate adult and pediatric EDs. We collected weekly data from GFT for Baltimore, Maryland; ED Centers for Disease Control and Prevention‐reported standardized influenzalike illness (ILI) data; laboratory-confirmed influenza data; and ED crowding indices (patient volume, number of patients who left without being seen, waiting room time, and length of stay for admitted and discharged patients). Pediatric and adult data were analyzed separately using cross-correlation with GFT. Results. GFT correlated with both number of positive influenza test results (adult ED, r 5 0.876; pediatric ED, r 5 0.718) and number of ED patients presenting with ILI (adult ED, r 5 0.885; pediatric ED, r 5 0.652). Pediatric but not adult crowding measures, such as total ED volume (r 5 0.649) and leaving without being seen (r 5 0.641), also had good correlation with GFT. Adult crowding measures for low-acuity patients, such as waiting room time (r 5 0.421) and length of stay for discharged patients (r 5 0.548), had moderate correlation with GFT. Conclusions. City-level GFT shows strong correlation with influenza cases and ED ILI visits, validating its use as an ED surveillance tool. GFT correlated with several pediatric ED crowding measures and those for low-acuity adult patients.

In the event of a catastrophic disaster, healthcare resources may be completely overwhelmed. To address this, the federal Agency for Healthcare Research and Quality has recommended using “crisis standards of care” during such an event.These standards would recommend allocating scarce medical resources to do the greatest good for the greatest number of patients.In a dire catastrophic event, such standards may include the allocation of intensive care unit (ICU) resources to maximize patient survival.Triage protocols that seek to efficiently allocate ICU resources during a disaster have been reviewed by the Institute of Medicine. Such protocols suggest the exclusion of patients with high mortality or high resource requirements from ICU care to do the most good for the greatest number of patients. In extreme circumstances, these protocols recommend withdrawing ICU resources from sicker patients in favor of more salvageable patients.However, if providers were to follow the earlier protocols in a disaster and withdraw and reallocate ICU care, criminal or civil liability could result. Two legal solutions to avoid this potential for liability have been suggested in this article.

The Patient Safety and Quality Improvement Act 1 (PSQIA or Act) was signed into law on July 29, 2005. This Act represents the first federal legislative attempt to directly and systematically addres...

Objectives The Patient Safety and Quality Improvement Act (PSQIA) of 2005, inspired by the Institute of Medicine's (IOM) 1999 report To Err Is Human, affords federal protections in exchange for error disclosures. However, the PSQIA is unlikely to be effective unless frontline providers are aware of its existence. In this study, we assessed the quantity of publications regarding this protection within the medical literature. Methods Four reviewers independently evaluated 2060 safety-related articles, identified through a PubMed database search, to determine whether they discussed actual (or proposed) national legal protections for voluntary reporting of medical errors. Using a reviewer method based on a standard Delphi consensus model, agreement was achieved if at least 3 of 4 reviewers agreed with the decision. Results Articles were separated into pre-IOM report (1990-1999) and post-IOM report (2000-2008) literature. No articles were determined to be "on topic" in the pre-IOM period (n = 624). Twenty-seven articles were considered "on topic" in the post-IOM period (n = 1436), constituting 1.8% of the period total (95% confidence interval, 1.2%-2.6%). Of the 27 on topic articles, 7 appeared in practice-related journals, whereas the remaining 20 were in journals with a health policy or health care administration focus. Conclusions Few published studies were found in clinical journals describing the PSQIA. This raises serious concerns and indicates that physicians may not be aware of the new legal protections afforded for error disclosure. If the health care system is to realize the benefits of error reporting systems, greater education of physicians regarding their legal protections may be needed.

The Belmont Report established beneficence, justice, and autonomy as the basic principles of informed consent. 1 These ideals of principlism have been applied to varied scenarios within medicine. O...

Malm and colleagues (2008) consider whether healthcare providers are duty-bound to expose themselves to a significant risk of illness and potential death in the service of patients during a pandemi...

On 11 June 2009 the World Health Organization raised the pandemic alert level to Phase 6 and declared that a global pandemic was underway. The causative pathogen, an H1N1 influenza A virus, was a triplereassortant combination of swine, avian and human influenza that initially appeared in Mexico earlier that year (Cao et al, 2009). In April 2009, the first US cases of H1N1 were confirmed by the Centers for Disease Control and Prevention (CDC) (Jain et al, 2009). Since then, many more clinical cases have been reported to the CDC and to public health authorities.

Study objective We measure the rate of emergency department (ED) specimen processing error reduction after implementation of an electronic physician order entry system paired with a bar-coded specimen labeling process. Methods A cohort pre- and postintervention study was conducted in the ED during a 61-month period ending September 2008 in a large urban teaching hospital. Historically, laboratory order and requisition processing was done by hand. Interventions included implementing an ED-specific electronic documentation and information system, which included physician order entry with patient verification through bar-coded wristbands and bar-coded specimen labels. The main outcome measure was processing error rate, defined as unlabeled/mislabeled/wrong patient specimen or requisition. Pre- and postimplementation data were tabulated monthly and compared in aggregate by χ 2 test. The contribution of ED error to total institution specimen error was also calculated. Results Of the 724,465 specimens collected preintervention, 3,007 (0.42%) were recorded as errors versus 379 errors (0.11%) of 334,039 specimens collected postintervention, which represents a 74% relative and 0.31% absolute decrease (95% confidence interval 0.28% to 0.32%). The proportion of institutional errors contributed by the ED was reduced from 20.4% to 11.4%, a 44% relative and 9.0% absolute reduction (95% confidence interval 7.7% to 10.3%). Subanalysis revealed that the majority of continued errors occur when the physician order entry/bar-code system could not be used (eg, blood bank or surgical pathology specimens). Conclusion Combining an electronic physician order entry with bar-coded patient verification and electronic documentation and information system–generated specimen labels can significantly reduce ED specimen-related errors, with sizable influence on institutional specimen-related errors. Continued use of hand labeling and processing for special specimens appears inadvisable, though the cost-effectiveness of this intervention has not been established.

The federal government states that local communities are primarily responsible for public health planning and implementation during a severe pandemic. Accordingly, an assessment of the current healthcare capabilities in these communities and planning for deficiencies is required. This article assesses the impact and healthcare capabilities of a specific model local community in a mid-Atlantic state. Two statistical models demonstrate the likely impact of both mild and severe pandemics on local healthcare resources. Both models reveal significant deficiencies that local communities may face. In the event of a severe 1918-type pandemic influenza or a mild influenza pandemic, many local community healthcare systems will likely have inadequate resources to respond to the crisis; such a healthcare emergency would likely overwhelm local community resources and current public health practices. Proper planning at the community level is critical for being truly prepared for such a public health emergency.

The endocytic pathway of eukaryotes is essential for the internalization and trafficking of macromolecules, fluid, membranes, and membrane proteins. One of the most enigmatic aspects of this process is endocytic recycling, the return of macromolecules (often receptors) and fluid from endosomes to the plasma membrane. We have previously shown that the EH-domain protein RME-1 is a critical regulator of endocytic recycling in worms and mammals. Here we identify the RAB-10 protein as a key regulator of endocytic recycling upstream of RME-1 in polarized epithelial cells of the Caenorhabditis elegans intestine. rab-10 null mutant intestinal cells accumulate abnormally abundant RAB-5-positive early endosomes, some of which are enlarged by more than 10-fold. Conversely most RME-1-positive recycling endosomes are lost in rab-10 mutants. The abnormal early endosomes in rab-10 mutants accumulate basolaterally recycling transmembrane cargo molecules and basolaterally recycling fluid, consistent with a block in basolateral transport. These results indicate a role for RAB-10 in basolateral recycling upstream of RME-1. We found that a functional GFP-RAB-10 reporter protein is localized to endosomes and Golgi in wild-type intestinal cells consistent with a direct role for RAB-10 in this transport pathway.

The eventuality of another influenza pandemic and the recent concern over H5N1, avian flu, require an assessment of local community healthcare capabilities. As the federal government has recently stated that such local communities will be primarily responsible for public health planning and implementation during a severe pandemic, an assessment of the current capabilities in these communities and planning for deficiencies must commence immediately. In this article, we have assessed the impact and capabilities of a model local county community in suburban Maryland. Our two statistical models demonstrate the likely impact of a mild, 1968 Hong Kong Flu pandemic in comparison to a severe, 1918 Spanish Flu type pandemic respectively. Both of these statistical models reveal significant resource deficiencies that many local communities may face. Additionally, we discuss some negative consequences that pandemic policy implementation itself may have on local communities and healthcare systems. Some recommendations for pandemic planning are suggested.

The author evaluates current concerns over medical professionalism in residency training. The recent professionalism requirements for residents promulgated by the Accreditation Council for Graduate Medical Education (ACGME) are discussed in relation to the atmosphere of current training. The author first reviews a recent study showing that unprofessional behavior may significantly correlate with burnout, as evaluated by the Maslach Burnout Inventory. Among the elements of that inventory, depersonalization is shown to significantly correspond to unprofessional actions and behavior. Several surveys and studies evaluating residency treatment and stress are reviewed and three sources of training stress are identified: (1) abusive treatment of residents, (2) financial pressures, and (3) pessimism and uncertainty in the medical field. The extent and effects of these stressors are discussed and evaluated in relation to depersonalization, depression, and unprofessional behavior. Each of these pressures is found to correlate with negative effects on residents, such as depersonalization, decreased satisfaction, depression, and burnout. In turn, such effects are found to potentially cause unprofessional behavior among residents. In light of these findings, the author suggests several modifications to the current graduate medical training environment to mitigate such stressors, promote professionalism, and increase morale. Prevention of abusive treatment of residents, alleviation of financial pressure, increased educational opportunities, and role modeling are suggested as beneficial interventions that may foster professionalism and prevent inappropriate behavior. The author indicates that such environmental changes would likely foster professionalism in young physicians more effectively than would ethics seminars or in-class training. Accordingly, the author suggests environmental changes to decrease residency stress as the most effective means of promoting the new ACGME requirements and the ideals of professionalism.