Emergency Physicians' Adherence to Center for Disease Control and Prevention Guidance During the 2009 Influenza A H1N1 Pandemic

Development of a Telemedicine Screening Program During the COVID-19 Pandemic

Background: Telemedicine use increased during the COVID-19 pandemic due to concerns for patient and provider safety. Given the lack of testing resources initially and the large geographical range served by Augusta University (AU), a telemedicine platform with up-to-date screening guidelines was implemented for COVID-19 testing in March 2020. Our objective was to understand the level of adherence to telemedicine screening guidelines for COVID-19. Methods: The study population included health care providers and population who participated in an encounter in the AU Health Express Care virtual care program from March 22 to May 21, 2020. All encounters were intended to be for COVID-19 screening, free, and available 24 h per day, 7 days per week. Screening guidelines were developed by AU based on information from the Centers for Disease Control and Prevention and the Georgia Department of Public Health. Results: Among 17,801 total encounters, 13,600 were included in the final analysis. Overall adherence to screening guidelines was 71% in the adult population and 57% in the pediatric population. When providers did not follow guidelines, 72% determined that the patient should have a positive screen. Guidelines themselves determined that only 52% of encounters should have a positive screen. Providers' specialty significantly correlated with guideline adherence (p = 0.002). Departments with the highest adherence were psychiatry, neurology, and ophthalmology. No significant correlation was found between guideline adherence and provider degree/position. Conclusions: This study provides proof of concept of a free telehealth screening platform during an ongoing pandemic. Our screening experience was effective and different specialties participated. Our patient population lived in lower than average income zip codes, suggesting that our free telemedicine screening program successfully reached populations with higher financial barriers to health care. Early training and a posteriori knowledge of telemedicine was likely key to screening guideline adherence.

The role of tacit knowledge in communication and decision-making during emerging public health incidents

Strong communication systems for knowledge exchange are required to prevent, respond to and mitigate the effects of emerging public health incidents (EPHIs). The objective of this paper is to examine how "tacit knowledge" - implicit knowledge used to guide everyday practice - is employed in professional relationships and communication processes between public health and acute care settings. A qualitative study design was used to explore the experiences of key informants from public health and acute care settings in Ontario, Canada, to examine how specific dimensions of tacit knowledge are employed in communications about EPHIs. Twenty-six in-depth interviews were conducted from 2014 to 2015. The results describe the way in which participants employ discretion and knowledge of local context, and rely on relationships built on trust and credibility, to facilitate decision-making and communication during EPHIs. Given the uncertainty characterizing most EPHIs, communicators rely a great deal on their informal knowledge and networks which allow them to remain flexible and respond quickly to changing situations. The results reveal that communication about public health guidance during emergencies is a complex and active process that draws from past experiences of the individuals involved, and is shaped by the requirements of local circumstances. The broader implications of these findings for building resilient and responsive health systems are considered. In particular, for rethinking the authority of standardized forms of evidence in public health decision-making, and the importance of knowledge which is grounded in the uniqueness of specific local contexts.

Effective communication of public health guidance to emergency department clinicians in the setting of emerging incidents: a qualitative study and framework

BACKGROUND

Evidence to inform communication between emergency department clinicians and public health agencies is limited. In the context of diverse, emerging public health incidents, communication is urgent, as emergency department clinicians must implement recommendations to protect themselves and the public. The objectives of this study were to: explore current practices, barriers and facilitators at the local level for communicating public health guidance to emergency department clinicians in emerging public health incidents; and develop a framework that promotes effective communication of public health guidance to clinicians during emerging incidents.

METHODS

A qualitative study was conducted using semi-structured interviews with 26 key informants from emergency departments and public health agencies in Ontario, Canada. Data were analyzed inductively and the analytic approach was guided by concepts of complexity theory.

RESULTS

Emergent themes corresponded to challenges and strategies for effective communication of public health guidance. Important challenges related to the coordination of communication across institutions and jurisdictions, and differences in work environments across sectors. Strategies for effective communication were identified as the development of partnerships and collaboration, attention to specific methods of communication used, and the importance of roles and relationship-building prior to an emerging public health incident. Following descriptive analysis, a framework was developed that consists of the following elements: 1) Anticipate; 2) Invest in building relationships and networks; 3) Establish liaison roles and redundancy; 4) Active communication; 5) Consider and respond to the target audience; 6) Leverage networks for coordination; and 7) Acknowledge and address uncertainty. The qualities inherent in local relationships cut across framework elements.

CONCLUSIONS

This research indicates that relationships are central to effective communication between public health agencies and emergency department clinicians at the local level. Our framework which is grounded in qualitative evidence focuses on strategies to promote effective communication in the emerging public health incident setting and may be useful in informing practice.

Clinical diagnosis of influenza in the ED

BACKGROUND

Timely and accurate diagnosis of influenza remains a challenge but is critical for patients who may benefit from antiviral therapy. This study determined the test characteristics of provider diagnosis of influenza, final ED electronic medical record (EMR) diagnosis of influenza, and influenza-like illness (ILI) in patients recommended to receive antiviral treatment according to Centers for Disease Control and Prevention (CDC) guidelines. In addition, we evaluated the compliance with CDC antiviral guidelines.

METHODS

A prospective cohort of adults presenting to a tertiary care ED with an acute respiratory illness who met CDC criteria for recommended antiviral treatment were enrolled and tested for influenza. A clinical diagnosis of influenza was assessed by asking the clinician: "Do you think this patient has influenza?" Influenza-like illness was defined according to current CDC criteria.

RESULTS

In this cohort of 270 subjects, 42 (16%; 95% confidence interval [CI], 11%-20%) had influenza. Clinician diagnosis had a sensitivity of 36% (95% CI, 22%-52%) and specificity of 78% (95% CI, 72%-83%); EMR final ED diagnosis had a sensitivity of 26% (95% CI, 14%-42%) and specificity of 97% (95% CI, 94%-99%); ILI had a sensitivity of 31% (95% CI, 18%-47%) and specificity of 88% (95% CI, 83%-92%). Only 15 influenza-positive patients (36%) received antiviral treatment.

CONCLUSION

Clinician diagnosis, final ED EMR diagnosis, and ILI have low sensitivity for diagnosing influenza, and there is overall poor compliance with CDC antiviral treatment recommendations. Improved methods of influenza diagnosis are needed to help guide management in the clinical setting.

Influenza-like illness, the time to seek healthcare, and influenza antiviral receipt during the 2010-2011 influenza season-United States

BACKGROUND

Few data exist describing healthcare-seeking behaviors among persons with influenza-like illness (ILI) or adherence to influenza antiviral treatment recommendations.

METHODS

We analyzed adult responses to the Behavioral Risk Factor Surveillance System in 31 states and the District of Columbia (DC) and pediatric responses in 25 states and DC for January-April 2011 by demographics and underlying health conditions.

RESULTS

Among 75 088 adult and 15 649 child respondents, 8.9% and 33.9%, respectively, reported ILI. ILI was more frequent among adults with asthma (16%), chronic obstruction pulmonary disease (COPD; 26%), diabetes (12%), heart disease (19%), kidney disease (16%), or obesity (11%). Forty-five percent of adults and 57% of children sought healthcare for ILI. Thirty-five percent of adults sought care ≤ 2 days after ILI onset. Seeking care ≤ 2 days was more frequent among adults with COPD (48%) or heart disease (55%). Among adults with a self-reported physician diagnosis of influenza, 34% received treatment with antiviral medications. The only underlying health condition with a higher rate of treatment was diabetes (46%).

CONCLUSIONS

Adults with underlying health conditions were more likely to report ILI, but the majority did not seek care promptly, missing opportunities for early influenza antiviral treatment.

Cost-utility of rapid polymerase chain reaction-based influenza testing for high-risk emergency department patients

STUDY OBJECTIVE

We evaluate the cost-effectiveness of polymerase chain reaction (PCR)-based rapid influenza testing and treatment for influenza in adult emergency department (ED) patients who are at high risk for or have evidence of influenza-related complications.

METHODS

We developed a cost-utility decision analysis model that assessed adult patients presenting to the ED with symptoms of an acute respiratory infection, who met the Centers for Disease Control and Prevention criteria for recommended antiviral treatment. Analysis was performed from the societal perspective, with incremental comparisons of 4 influenza testing and treatment strategies: treat none, treat according to provider judgment, treat according to results of a PCR-based rapid diagnostic test, and treat all.

RESULTS

Treating no patients with antivirals was dominated by all other strategies that increased in both cost and benefit in the following order: treat according to provider judgment, treat according to results of a PCR-based rapid diagnostic test, and treat all. As influenza prevalence increases, treating all patients eventually dominated all other options.

CONCLUSION

The economic benefit of incorporating use of rapid PCR-based influenza testing for ED patients at risk of developing influenza-related complications depends on influenza prevalence; treatment guided by physician diagnosis or rapid testing, and treatment of all patients is more effective and less costly than no treatment.