Impact of Hurricane Harvey on Healthcare Utilization and Emergency Department Operations

Introduction: Hurricanes have increased in severity over the past 35 years, and climate change has led to an increased frequency of catastrophic flooding. The impact of floods on emergency department (ED) operations and patient health has not been well studied. We sought to detail challenges and lessons learned from the severe weather event caused by Hurricane Harvey in Houston, Texas, in August 2017.Methods: This report combines narrative data from interviews with retrospective data on patient volumes, mode of arrival, and ED lengths of stay (LOS). We compared the five-week peri-storm period for the 2017 hurricane to similar periods in 2015 and 2016.Results: For five days, flooding limited access to the hospital, with a consequent negative impact on provider staffing availability, disposition and transfer processes, and resource consumption. Interruption of patient transfer capabilities threatened patient safety, but flexibility of operations prevented poor outcomes. The total ED patient census for the study period decreased in 2017 (7062 patients) compared to 2015 (7665 patients) and 2016 (7770) patients). Over the five-week study period, the arrival-by-ambulance rate was 12.45% in 2017 compared to 10.1% in 2016 (p < 0.0001) and 13.7% in 2015 (p < 0.0001). The median ED length of stay (LOS) in minutes for admitted patients was 976 minutes in 2015 (p < 0.0001) compared to 723 minutes in 2016 and 591 in 2017 (p < 0.0001). For discharged patients, median ED LOS was 336 minutes in 2016 compared to 356 in 2015 (p < 0.0001) and 261 in 2017 (p < 0.0001). Median boarding time for admitted ED patients was 284 minutes in 2016 compared to 470 in 2015 (p < 0.0001) and 234.5 in 2017 (p < 0.001). Water damage resulted in a loss of 133 of 179 inpatient beds (74%). Rapid and dynamic ED process changes were made to share ED beds with admitted patients and to maximize transfers post-flooding to decrease ED boarding times.Conclusion: A number of pre-storm preparations could have allowed for smoother and safer ride-out functioning for both hospital personnel and patients. These measures include surplus provisioning of staff and supplies to account for limited facility access. During a disaster, innovative flexibility of both ED and hospital operations may be critical when disposition and transfer capibilities or bedding capacity are compromised

Retargeting of pre-set regions on chromosome for high gene expression in mammalian cells

We have developed a system to hunt and reuse special gene integration sites that allow for high and stable gene expression. A vector, named pRGFP8, was constructed. The plasmid pRGFP8 contains a reporter gene, gfp2 and two extraneous DNA fragments. The gene gfp2 makes it possible to screen the high expression regions on the chromosome. The extraneous DNA fragments can help to create the unique loci on the chromosome and increase the gene targeting frequency by increasing the homology. After transfection into Chinese hamster ovary cells (CHO) cells, the linearized pRGFP8 can integrate into the chromosome of the host cells and form the unique sites. With FACS, 90 millions transfected cells were sorted and the cells with strongest GFP expression were isolated, and then 8 stable high expression GFP CHO cell lines were selected as candidates for the new host cell. Taking the unique site created by pRGFP8 on the chromosome in the new host cells as a targeting locus, the gfp2 gene was replaced with the gene of interest, human ifngamma, by transfecting the targeting plasmid pRIH-IFN. Then using FACS, the cells with the dimmest GFP fluorescence were selected. These cells showed they had strong abilities to produce the protein of interest, IFN-gamma. During the gene targeting experiment, we found there is positive correlation between the fluorescence density of the GFP CHO host cells and the specific production rate of IFN-gamma. This result shows that the strategy in our expression system is correct: the production of the interesting protein increases with the increase fluorescence of the GFP host cells. This system, the new host cell lines and the targeting vector, can be utilized for highly expressing the gene of interest. More importantly, by using FACS, we can fully screen all the transfected cells, which can reduce the chances of losing the best cells.Singapore-MIT Alliance (SMA

A Case of Status-Epilepticus-Associated Transient Hyperammonemia in the Emergency Department

This report describes a case of transient hyperammonemia following tonic-clonic status epilepticus with an initial ammonia level of 537 Umol/L. This appears to be the highest transient ammonia level reported in the literature in this clinical scenario. This is an affirmation that an initial elevated ammonia level in the absence of hepatic dysfunction should be interpreted with caution when associated with status epilepticus. Repeat levels should be drawn to identify transient hyperammonemia and determine the need for treatment if levels do not decrease

Fast does not imply flawed: Analyzing emergency physician productivity and medical errors

Abstract Objective To determine whether emergency physician productivity is associated with the risk of medical errors. Methods We retrospectively analyzed quality assurance (QA) and billing data over 3 years at 2 urban emergency departments. Faculty physicians working 400 hours or more at either site were included. We measured physician years of experience, age, gender, patients seen per hour (PPH), and relative value units billed per hour (RVU/h). From an established QA process, we obtained adjudicated medical errors to calculate rates of medical errors per 1000 patients seen as the outcome. We discretized numeric variables and used Kruskal–Wallis testing to examine relationships between independent variables and rates of medical errors. Results We included data for 39 physicians at site A and 42 at site B. The median rate of errors per 1000 patients was 1.6 (interquartile range [IQR], 1.1–1.9) at site A and 3.3 (IQR, 2.4–3.9) at site B. At site A, RVU/h was associated with error rates (P = 0.03), with medians of 2.0, 1.2, 1.7, and 1.3 errors per 1000 patients, from slowest to fastest quartiles. At site B, PPH was associated with error rates (P < 0.01), with medians of 3.9, 3.7, 2.4, and 2.7 errors per 1000 patients, from slowest to fastest quartiles. There was no significant relationship between error rates and PPH at site A or RVU/h at site B. Conclusions Rates of medical errors were associated with 1 metric of physician productivity at each site, with higher error rates seen among physicians with slower productivity

Survey-based Evaluation of Resident and Attending Financial Literacy

Introduction: Physician finances are linked to wellness and burnout. However, few physicians receive financial management education. We sought to determine the financial literacy and educational need of attending and resident physician at an academic emergency medicine (EM) residency.&nbsp; Methods: We performed a cross-sectional, survey study at an academic EM residency. We devised a 49-question survey with four major domains: demographics (16 questions); Likert-scale questions evaluating value placed on personal finances (3 questions); Likert-scale questions evaluating perceived financial literacy (11 questions); and a financial literacy test based on previously developed and widely used financial literacy questions (19 questions). We administered the survey to EM attendings and residents. We analyzed the data using descriptive statistics and compared attending and resident test question responses.&nbsp; Results: A total of 44 residents and 24 attendings responded to the survey. Few (9.0% of residents, 12.5% of attendings) reported prior formal financial education. However, most respondents (70.5% of residents and 79.2% of attendings) participated in financial self-learning. On a five-point Likert scale (not at all important: very important), respondents felt that financial independence (4.7 ± 0.8) and their finances (4.7±0.8) were important for their well-being. Additionally, they valued being prepared for retirement (4.7±0.9). Regarding perceived financial literacy (very uncomfortable: very comfortable), respondents had the lowest comfort level with investing in the stock market (2.7±1.5), applying for a mortgage (2.8±1.6), and managing their retirement (3.0±1.4). Residents scored significantly lower than attendings on the financial literacy test (70.8% vs 79.6%, P&lt;0.01), and residents scored lower on questions pertaining to investment (78.8% v 88.9%, P&lt;0.01) and insurance and taxes (47.0% v 70.8%, P&lt;0.01). Overall, respondents scored lower on questions about retirement (58.8%, P&lt;0.01) and insurance and taxes (54.7%, P&lt;0.01). Conclusion: Emergency physicians’ value of financial literacy exceeded confidence in financial literacy, and residents reported poorer confidence than attendings. We identified deficiencies in emergency physicians’ financial literacy for retirement, insurance, and taxes

Surgical management of non-dysraphic cervical intramedullary lipoma: A report of two cases

Background: Intradural spinal lipomas without an associated dysraphism, represent a fraction of an already-rare entity. These lesions often present with progressive neurologic deficits. The underlying pathophysiology of these lesions is poorly understood as are the underlying factors that predispose these masses to grow. Case description: We present two cases: an 11-year-old female and a 56-year-old female, each with a cervical spinal intramedullary lipoma presenting with slowly worsening neurological deficits. Each of these lesions were microsurgically debulked and underwent a duraplasty with an Alloderm® patch (Allergan) with rapidly improving symptoms postoperatively. Conclusions: Subpial lipomas, without associated spinal dysraphism, are a rare entity, and both its pathogenesis and the techniques used in management remain uncertain. In our patients, resection of the lipoma with exposure of the lipoma spinal cord interface was performed to a variable degree, while respecting the transiting nerve roots and spinal cord anatomy, with immediate postoperative improvement in function. This reaffirms the benefit of mass reduction and supports a limited decompression. Even the use of a duraplasty to decompress the spinal cord and restore the spinal CSF circulation can greatly impact the postoperative course. Our patients support the relationship between hormonal flux, weight gain, and the onset of symptoms