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Population prevalence of persons infected with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), varies by subpopulation and locality. U.S. studies of SARS-CoV-2 infection have examined infections in nonrandom samples (1) or seroprevalence in specific populations* (2), which are limited in their generalizability and cannot be used to accurately calculate infection-fatality rates. During April 25-29, 2020, Indiana conducted statewide random sample testing of persons aged ≥12 years to assess prevalence of active infection and presence of antibodies to SARS-CoV-2; additional nonrandom sampling was conducted in racial and ethnic minority communities to better understand the impact of the virus in certain racial and ethnic minority populations. Estimates were adjusted for nonresponse to reflect state demographics using an iterative proportional fitting method. Among 3,658 noninstitutionalized participants in the random sample survey, the estimated statewide point prevalence of active SARS-CoV-2 infection confirmed by reverse transcription-polymerase chain reaction (RT-PCR) testing was 1.74% (95% confidence interval [CI] = 1.10-2.54); 44.2% of these persons reported no symptoms during the 2 weeks before testing. The prevalence of immunoglobulin G (IgG) seropositivity, indicating past infection, was 1.09% (95% CI = 0.76-1.45). The overall prevalence of current and previous infections of SARS-CoV-2 in Indiana was 2.79% (95% CI = 2.02-3.70). In the random sample, higher overall prevalences were observed among Hispanics and those who reported having a household contact who had previously been told by a health care provider that they had COVID-19. By late April, an estimated 187,802 Indiana residents were currently or previously infected with SARS-CoV-2 (9.6 times higher than the number of confirmed cases [17,792]) (3), and 1,099 residents died (infection-fatality ratio = 0.58%). The number of reported cases represents only a fraction of the estimated total number of infections. Given the large number of persons who remain susceptible in Indiana, adherence to evidence-based public health mitigation and containment measures (e.g., social distancing, consistent and correct use of face coverings, and hand hygiene) is needed to reduce surge in hospitalizations and prevent morbidity and mortality from COVID-19.

OBJECTIVES: To plan for coronavirus infectious disease 2019 (COVID-19) vaccine distribution, the Indiana Department of Health surveyed nursing home and assisted living facility staff. DESIGN: Cross-sectional analysis of an anonymous survey sent via text message link to personal cell phones and emails. SETTING AND PARTICIPANTS: Nursing home and assisted living facility staff in Indiana. MEASURES: Staff characteristics including age, gender, race, ethnicity, role in the facility, experience in long-term care, and geographic location of facility were self-reported along with prior infection and willingness to receive an approved vaccine as soon as it is available. Responses were weighted to represent staff statewide. Weighted frequencies and logit regression estimated characteristics associated with vaccine willingness. RESULTS: There were 8,243 responses to the survey. For nursing home staff (survey delivered via 23,232 working phone numbers), there was a 33% response rate). There were 2,372 (29%) in nurse aide or similar roles and 1,602 nurses providing direct clinical care (19%). Overall, 45% of respondents indicated they would receive an approved COVID-19 vaccine as soon as available. Of those unwilling to take the vaccine when first available, 44% would consider in the future. Concerns about side effects was the primary reason for vaccine hesitancy (70%). Characteristics associated with increased willingness were age over 60, male, and white race (P < .0001). No statistically significant differences were observed among staff self-reporting prior SARS-CoV-2 infection. CONCLUSIONS AND IMPLICATIONS: The willingness to receive the COVID-19 vaccine immediately or in the future may be as high as 69%, but varies among subgroups of nursing home staff which has implications for distribution. Educating staff on the vaccine may be critical for increasing uptake. Widespread vaccination holds the promise of protection against serious illness and death and a return of visitors and activities that support improved quality of life. This promise will not be realized without strong uptake of the vaccines.

Objectives To assess whether using coronavirus disease 2019 (COVID-19) community activity level can accurately inform strategies for routine testing of facility staff for active severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Design Cross-sectional study. Setting and Participants In total, 59,930 nursing home staff tested for active SARS-CoV-2 infection in Indiana. Measures Receiver operator characteristic curves and the area under the curve to compare the sensitivity and specificity of identifying positive cases of staff within facilities based on community COVID-19 activity level including county positivity rate and county cases per 10,000. Results The detection of any infected staff within a facility using county cases per 10,000 population or county positivity rate resulted in an area under the curve of 0.648 (95% confidence interval 0.601‒0.696) and 0.649 (95% confidence interval 0.601‒0.696), respectively. Of staff tested, 28.0% were certified nursing assistants, yet accounted for 36.9% of all staff testing positive. Similarly, licensed practical nurses were 1.4% of staff, but 4.7% of positive cases. Conclusions and Implications We failed to observe a meaningful threshold of community COVID-19 activity for the purpose of predicting nursing homes with any positive staff. Guidance issued by the Centers for Medicare and Medicaid Services in August 2020 sets the minimum frequency of routine testing for nursing home staff based on county positivity rates. Using the recommended 5% county positivity rate to require weekly testing may miss asymptomatic infections among nursing home staff. Further data on results of all-staff testing efforts, particularly with the implementation of new widespread strategies such as point-of-care testing, is needed to guide policy to protect high-risk nursing home residents and staff. If the goal is to identify all asymptomatic SARS-Cov-2 infected nursing home staff, comprehensive repeat testing may be needed regardless of community level activity.

Healthcare employees were tested for antibodies against severe acute respiratory coronavirus virus 2 (SARS-CoV-2). Among 734 employees, the prevalence of SARS-CoV-2 antibodies was 1.6%. Employees with heavy coronavirus disease 2019 (COVID-19) exposure had similar antibody prevalence as those with limited or no exposure. Guidelines for PPE use seem effective for preventing COVID-19 infection in healthcare workers.

Background Death notification can be challenging for emergency medicine physicians, who have no prior established relationship with the patient or their families. The GRIEV_ING death notification curriculum was developed to facilitate the delivery of the bad news of a patient's death and has been shown to improve learners' confidence and competence in death notification. Rapid-cycle deliberate practice (RCDP), a facilitator-guided, within-event debriefing technique, has demonstrated an improvement in learners' skills in a safe learning environment. The aim of this study was to identify whether the use of this technique is an effective method of teaching the GRIEV_ING curriculum, as demonstrated by learners' improved confidence, cognitive knowledge and performance. Rapid-cycle deliberate practice (RCDP), a facilitator-guided within-event, debriefing technique, has demonstrated an improvement in learners' skills in a safe learning environment METHODS: A 4-hour pilot curriculum was developed to educate and assess residents on the delivery of death notification. The curriculum consisted of a pre-intervention evaluation, the intervention phase, and a post-intervention evaluation. The cognitive test, critical action checklist, and self-efficacy/confidence surveys were identical for both pre- and post-intervention evaluations. A Wilcoxon rank-sum test was used to evaluate differences in scores between pre- and post-intervention groups. Results Twenty-two emergency medicine residents participated in the study. We observed an increase in median self-efficacy scores (4.0 [4.0-5.0], p ≤ 0.0001), multiple-choice GRIEV_ING scores (90.0 [80.0-90.0], p ≤ 0.0001) and performance scores for death notification (48.5 [47.0-53.0], p = 0.0303). Discussion The RCDP approach was found to be an effective method to train emergency medicine residents in the delivery of the GRIEV_ING death notification curriculum. This approach is actionable with few resources except for content experts trained in RCDP methodology and the application of the GRIEV_ING mnemonic.

High patient turnover can result in fragmentation of nursing care. It can also increase nursing workload and thus impede the ability of nurses to provide safe and high-quality care. We reviewed 20 studies that examined patient turnover in relation to nursing workload, staffing, and patient outcomes as well as interventions in inpatient hospital settings. The studies consistently addressed the importance of accounting for patient turnover when estimating nurse staffing needs. They also showed that patient turnover varied by time, day, and unit type. Researchers found that higher patient turnover was associated with adverse events; however, further research on this topic is needed because evidence on the effect of patient turnover on patient outcomes is not yet strong and conclusive. We suggest that researchers and administrators need to pay more attention to patterns and levels of patient turnover and implement managerial strategies to reduce nursing workload and improve patient outcomes.

Introduction: Alcohol use disorders (AUD) place a significant burden on individuals and society. Theemergency department (ED) offers a unique opportunity to address AUD with brief screening tools andearly intervention. We undertook a systematic review of the effectiveness of ED brief interventions forpatients identified through screening who are at risk for AUD, and the effectiveness of these interventionsat reducing alcohol intake and preventing alcohol-related injuries. Methods: We conducted systematic electronic database searches to include randomized controlled trialsof AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Twoauthors graded and abstracted data from each included paper. Results: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD.Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a controlintervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significantdifferences between control and intervention groups in their main alcohol-outcome criteria of number ofdrink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumptionin both the control and intervention groups; of those, seven studies did not identify a significant interventioneffect for the main outcome criteria, but nine observed some significant differences between BI and controlconditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking anddriving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g.reduction in driving while intoxicated). Conclusion: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction inalcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury),and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the EDappears to have a short-term effect in reducing at-risk drinking.