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BACKGROUND: The National Football League (NFL) and National Football League Players Association (NFLPA) implemented a set of strict protocols for the 2020 season with the intent to mitigate COVID-19 risk among players and staff. In that timeframe, the league's 32 teams completed 256 regular season games and several thousand meetings and practices. In parallel, community cases of COVID-19 were highly prevalent. We assess the risk of holding a 2020 NFL season by comparing community and player COVID-19 infections. METHODS: We used county-level COVID-19 test data from each team to establish baseline distributions of infection rates expected to occur in a population similar in age and sex to NFL players. We used a binomial distribution to simulate expected infections in each community cohort and compared these findings with observed COVID-19 infections in players. RESULTS: Over a 5-month period (1 August 2020 to 2 January 2021), positive NFL player infections (n = 256) were 55.7% lower than expected when compared to simulations from NFL community cohorts. For 30 of 32 teams (94%), observed counts fell at or below expectation, including 28 teams (88%) for which rates were lower. Two teams fell above baseline expectation. CONCLUSIONS: The NFL/NFLPA protocols that governed team facilities, travel, gameday, and activities outside of the workplace were associated with lower infection rates among NFL players compared to the surrounding community. The NFL's 2020-2021 season are consistent with the hypothesis that robust testing and behavioral protocols support a safe return to sport and work.

Customer service initiatives in healthcare have become a popular way of attempting to improve patient satisfaction. This study investigates the effect of clinically focused customer service training on patient satisfaction in the setting of a 62,000-visit emergency department and level I trauma center. Analysis of patient complaints, patient compliments, and a statistically verified patient-satisfaction survey indicate that (1) all 14 key quality characteristics identified in the survey increased dramatically in the study period; (2) patient complaints decreased by over 70 percent from 2.6 per 1,000 emergency department (ED) visits to 0.6 per 1,000 ED visits following customer service training; and (3) patient compliments increased more than 100 percent from 1.1 per 1,000 ED visits to 2.3 per 1,000 ED visits. The most dramatic improvement in the patient satisfaction survey came in ratings of skill of the emergency physician, likelihood of returning, skill of the emergency department nurse, and overall satisfaction. These results show that clinically focused customer service training improves patient satisfaction and ratings of physician and nurse skill. They also suggest that such training may offer a substantial competitive market advantage, as well as improve the patients' perception of quality and outcome.

Two American football players on the same team were diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections on the same day. Our investigation, including whole genome sequencing, confirmed that players did not transmit MRSA to one another nor did they acquire the MRSA from a single source within the training facility.

Douglas J. Casa, PhD, ATC, FNATA, FACSM (Chair)*†; Jon Almquist, VATL, ATC*; Scott A. Anderson, ATC*; Lindsay Baker, PhD‡; Michael F. Bergeron, PhD, FACSM§; Brian Biagioli, EdD||; Barry Boden, MD¶; Joel S. Brenner, MD, MPH, FAAP#; Michael Carroll, MEd, LAT, ATC*; Bob Colgate**; Larry Cooper, MS, LAT, ATC*; Ron Courson, PT, ATC, NREMT-I, CSCS*; David Csillan, MS, LAT, ATC*; Julie K. DeMartini, MA, ATC†; Jonathan A. Drezner, MD††; Tim Erickson, CAA‡‡; Michael S. Ferrara, PhD, ATC, FNATA*; Steven J. Fleck, PhD, CSCS, FNSCA, FACSM§§; Rob Franks, DO, FAOASM||||; Kevin M. Guskiewicz, PhD, ATC, FNATA, FACSM*; William R. Holcomb, PhD, LAT, ATC, CSCS*D, FNATA, FNSCA§§; Robert A. Huggins, MEd, ATC†; Rebecca M. Lopez, PhD, ATC, CSCS†; Thom Mayer, MD, FACEP¶¶; Patrick McHenry, MA, CSCS*D, RSCC§§; Jason P. Mihalik, PhD, CAT(C), ATC##; Francis G. O’Connor, MD, MPH, FACSM††; Kelly D. Pagnotta, MA, ATC, PES†; Riana R. Pryor, MS, ATC†; John Reynolds, MS, VATL, ATC*; Rebecca L. Stearns, PhD, ATC†; Verle Valentine, MD††

This article analyzes past legal trends in emergency medicine with an effort to project those trends and current developments into future legal issues that will confront emergency physicians and emergency departments. Special emphasis is placed on insurance trends and professional liability insurance developments along with medical malpractice claims past, present, and future. Also discussed in this article is the health care industry environment and ways that it might affect future legal challenges for emergency medicine.

CQI or TQM programs were developed from industrial models dating back to the 1930s. The original philosophic underpinnings guiding CQI included SPC, in which rigorous statistical methods were used to study industrial flow processes. As originally adopted by the Japanese, CQI is credited, to a significant degree, with the emergence of the Japanese economy as a major world leader. Nonetheless, the original CQI concepts were developed and implemented by American researchers, including Deming and Juran. The application of industrial models of quality improvement to service businesses in general and the health care industry in particular have met with substantial success in a number of different settings. Far from representing a management fad, CQI represents a solid management philosophy with a strong statistical background that stands in sharp contrast to traditional management in this country. CQI recognizes that the majority of defects result from a failure of the processes through which the product or service is generated, as opposed to the workers themselves. To a significant degree, CQI empowers service providers (through the strong commitment of top management) to participate in improving the processes through which products and services are delivered. As efforts unfold to contain health care costs and maintain quality in the face of declining resources, CQI programs are likely to be essential to success. Nonetheless, adopting CQI requires a significant commitment on the part of top management to the training and retraining of health care providers and the recognition that traditional management philosophies and techniques have largely failed to produce the quantum leaps in quality that will be required in the coming years.

Since the 2001 anthrax attacks, an extensive body of literature has evolved, but there has been a limited focus on the management of pediatric-specific issues. We looked at the symptom complexes of all pediatric patients presenting to the emergency department of our hospital during this period and examined whether their presentations would likely allow current guidelines to be used as potential screening criteria to identify children infected with anthrax.We retrospectively reviewed emergency department records of all adult and pediatric patients (up to the age of 21 years) at Inova Fairfax Hospital during this time, when a large, and at the time ill-defined, group in the Washington, DC, metropolitan area was at risk for pulmonary anthrax. Two cases of anthrax infection were identified at this hospital in exposed adult postal workers. Screening algorithms (described by Mayer et al. and Hupert et al.) were applied to adult and pediatric patients with the presence of fever (38 degrees C), tachycardia, or other symptoms compatible with pulmonary anthrax. Specifically, the usefulness of these guidelines as potential screening tools to identify possibly infected children was examined.Of 767 pediatric patients seen in the emergency department during the study period, 312 met criteria for review (41%; 95% CI: 37-44%). Four adult patients (0.4%; 95% CI: 0.1-0.9%) had at least five clinical symptoms, fever, and tachycardia; two of them had inhalational anthrax. No pediatric patient presented with five or more clinical symptoms. Twelve children (3.9%; 95% CI: 2-6.6%) presented with four clinical symptoms; five of the 12 had neither fever nor tachycardia. Children, particularly infants and toddlers, presented with nonspecific symptom complexes primarily limited to fever, vomiting, cough, and trouble breathing.Existing guidelines are likely to be unreliable as a screening tool for inhalational anthrax in children, largely because of the children's inability to adequately communicate a suggestive symptom complex.

This article has presented an overview of the duties, responsibilities, and management roles of the emergency department Medical Director, a position that can be among the most challenging, stimulating, and exciting in medicine. However, prior to accepting a position as an Emergency Department medical director, one should have a clear understanding of what the job entails. Careful discussions with the hospital administration, medical staff, nursing personnel, and staff emergency physicians should be undertaken to learn the perceptions of these people and expectations of the position. Once the job has been accepted, using the roles, responsibilities, and duties detailed herein may be of benefit--but should always be applied with good judgment, tactful cooperation, and common sense. Finally, it should not be surprising to a medical director to find, as Spinoza did many years ago, that the excellent thing he aspires to are as difficult as they are rare.

Over an 18-month period, 56 pediatric patients who sustained severe neurologic insults under went intracranial pressure (ICP) monitoring. Indications for monitoring ICP were (1) a Glasgow Coma Scale (GCS) score of 7 or less or (2) loss of consciousness with inability to utter recognizable words or follow commands. Diagnoses were head trauma (n = 40), Reye's syndrome (n = 10), and hypoxic encephalopathy due to near-drowning (n = 6). Eighty per cent of patients had ICP el evations requiring treatment. The complication rate was 5.3 per cent, with no serious compli cations or infections noted. Overall mortality was 14 per cent, but patients with hypoxic en cephalopathy had significantly higher mortality (33%) when compared to patients with head trauma (12.5%) or Reye's syndrome (10%). Other factors associated with a poor outcome included presence of an intracranial mass lesion, GCS score, ICP elevations, hypoxemia, hypotension, hypercarbia, and the presence of multiple injuries (p < 0.01). Early diagnosis and aggressive treatment in these patients, including the use of ICP monitoring, has resulted in acceptable recovery in over 85 per cent of these patients.

This document is from the Trauma Care Systems Repository, developed by the American College of Emergency Physicians Trauma Committee.

SUMMARY This article outlines the elements of successful ED marketing, as well as providing definitions for terms used within the marketing process. In today's competition and rapidly changing environment, marketing and public relations are tools that every ED Medical Director may want to consider. Because the marketing process requires a great deal of time and effort, as well as a high degree of intellectual honesty, it should never be entered into without a strong commitment. However, marketing the ED can be among the most productive, stimulating, and gratifying experiences for the ED Medical Director, the emergency department physicians, and all ED service personnel.