Preparing for compounding crises: Staff shortages and cyber-attack vulnerability in the era of COVID-19

In 2020, while the USA was experiencing successive waves of COVID-19, Universal Health Services experienced a major cyber attack that crippled electronic systems in over 200 hospitals, including a major academic medical centre that was playing a key regional role in COVID-19 care and clinical trials. This paper discusses the impact of the attack on clinical operations, informatics, research and teaching, contextualising the case study within more wide-scale trends driving the rise in cyber attacks on healthcare systems. The compounding relationships between COVID-19, healthcare workforce depletion and cyber-security vulnerabilities form the framework of the discussion and action plan. Commitments to institutional best practices, large-scale investments in infrastructure, and above all increasing support for the critical human actors carrying out the work, are urgently needed to secure the healthcare system against these destabilising threats. Within this context, this paper argues that information security in the healthcare sector must be reimagined and integrated with greater support for the needs of frontline healthcare workers

Juneau, Alaska’s Successful Response to COVID-19: A Case Study of Adaptive Leadership in a Complex System

Juneau, Alaska, kept COVID-19 deaths lower than in other similar jurisdictions. We argue that adaptive leadership—the early decisions and actions of Juneau’s leaders, effective communications, and emergent new collaborative structures—in the context of municipal ownership of key assets enabled Juneau’s success. The result of 61 interviews and follow-up research, this case study contributes a better understanding of which institutional design, communication, and collaborative factors mattered in responding to the pandemic. Adaptive leadership provides a better explanation for Juneau’s success than alternatives that focus on its isolation, home-rule status, and socio-economic structure.The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article was funded by the National Science Foundation ( 2028928).Ye

Integration of a vaccine checklist to promote discussion between patients and providers and to increase rate of vaccination

A vaccine checklist created by Center for Disease Control (CDC) was utilized as a tool to increase rate of vaccination in the George Washington Medical Faculty Associates medicine clinic from July 2018 to July 2019. This quality improvement project applied Plan-Do-Study-Act (PDSA) framework to iteratively integrate the checklist into clinical practice. A questionnaire, which used to assess resident\u27s vaccination practice and knowledge, showed that patients rarely initiate discussion regarding vaccination and only few medical residents remember the complex vaccine schedule. Different ways of distributing the vaccine checklist were explored; ultimately, the checklists, along with the patient intake forms, were given to the patients by the medical assistants. The integration of the vaccine checklist went smoothly with minimal interruption to workflow and 75% of the checklists were filled out by the patients. The vaccine checklist was mostly well received by the patients; it was considered educational and not overwhelming. In the last PDSA cycle, 1 patient out of 8 initiated discussion regarding vaccination with their providers during a focus visit. Incorporating the vaccine checklist with the patient intake form during every visit may act as a catalyst in increasing number of times discussion occurs. Given the complex vaccine schedule, the checklist can also be used an additional resource to help remind providers the appropriate vaccines recommendations. Future projects can incorporate the vaccine checklist into patient intake form and measure number of vaccination administered after utilization of the checklist to assess change in rate of vaccination

Reducing Unnecessary Inpatient Laboratory Testing

Excessive laboratory testing is one of many areas of waste that plague the healthcare system. Morning laboratory tests for hospitalized patients are often ordered out of routine more than due to clinical indications that may affect medical management. The aim of our project was to reduce unnecessary morning laboratory testing on a medicine inpatient service by 15% from baseline. We identified six laboratory tests that are routinely drawn on hospitalized patients (CBC, differential, BMP, LFTs, magnesium level and phosphorus level). Tests were tracked via chart review on an internal medicine resident team at a large university urban hospital over a 4-week period. We gathered baseline data prior to any interventions. The first PDSA cycle involved discussing patient-centered harms of frequent blood draws and the financial cost of individual tests. We then posted an information sheet covering these points in the team workroom. The second PDSA cycle involved distributing a test checklist for the team to go through together for each patient during daily rounds. The first PDSA cycle was well received by the residents and the information sheet remained posted in the workroom throughout the duration of the project. Average tests per patient per day decreased from 2.5 to 2.2 (decrease of 12%) following this intervention. The second PDSA cycle coincided with the rotation of new interns onto the team. Copies of the test checklist template were distributed at different times to the team attending and the senior resident, however it was not put into practice due to miscommunication of its purpose and time constraints. Average tests per patient per day remained unchanged at 2.2 following this intervention. Although the project did not meet the aim of a 15% reduction in routine morning laboratory testing, the teaching session and information sheet used in PDSA cycle #1 did prove effective in sustaining a reduction over several weeks. This is a promising intervention as it can be implemented across multiple teams at minimal cost of time and resources. The test checklist in PDSA cycle #2 was not successfully implemented on the team. It may still be an effective intervention in reducing unnecessary testing, but requires commitment from medical teams that are already limited on time. Better explaining the purpose of the checklist and promoting attending and resident interest at an earlier point may improve the value of this intervention. Reducing unnecessary laboratory testing remains an important area of quality improvement focus

Recurrent pericarditis in a young man with asymptomatic Chlamydia urethritis

A 33 year-old previously healthy man presented with a third episode of chest pain, dyspnea on exertion, and fevers. He had been discharged 2 weeks prior on colchicine and indomethacin after being diagnosed with acute pericarditis. Lab work showed mild leukocytosis, and an increased ESR and CRP. Echocardiogram showed pericardial effusion and tamponade physiology. Chest CT showed mediastinal lymphadenopathy and pericardial effusion. A pericardiocentesis was performed, with 400mL of grossly purulent fluid, with lymphocytic predominance, drained. A pericardial drain was also placed. Thorough history taking revealed that the patient had unprotected intercourse with female partners in recent months. A broad STI panel was sent, and urine PCR was positive for Chlamydia. The patient was started on azithromycin, which was switched to doxycycline due to side effects. The pericardial drain output reduced drastically, and it was removed after 7 days. Fluid cultures were all negative, and a validated Chlamydia PCR test for pericardial fluid was not available. Broad rheumatological workup was negative, except for an isolated positive anti ds-DNA. Symptoms did not reoccur. Chlamydial infections are a relatively uncommon cause of acute pericarditis and myocarditis worldwide, although there are significant uncertainties surrounding its incidence. In the era of rising STI incidence, improved characterization of their complications is imperative. The above case highlights the importance of keeping a broad differential when encountering “idiopathic” pericarditis and related clinical entities, and of using clinical diagnosis to complement the reliance on molecular testing, especially when considering unusual sites of infection

History of defibrillation

Sudden cardiac death is believed to be involved in nearly a quarter of all human deaths, with ventricular fibrillation being its most common mechanism.1 One of the first descriptions of ventricular fibrillation and its link to sudden cardiac death belongs to the British physiologist John A. McWilliam, a former student of the famous Carl Ludwig, who was working at the University of Aberdeen. He wrote in the late 1880s2 that ventricular fibrillation wreaks chaos across the fibers of the heart, trapping the organ in a helpless quiver and depriving the body of oxygen, bringing about death within a matter of minutes. The story of how modern medicine and technology came together first to understand, and then to defeat fibrillation, is enlightening on many levels. It begins with astounding cures that seem to predate the discovery of the phenomenon itself; dives into the gothic with grisly experiments on executed criminals; rises into the light as the understanding of both electricity and cardiac pathophysiology increases; and flows vigorously into the modern blossoming of cardiopulmonary medicine and intensive care. It involves lessons transmitted across academic generations and geopolitical divisions, and discoveries made possible by cooperation of fields as dissimilar as surgery and electrical engineering. However, it also abounds with examples of great gaps of understanding, lengthy detours, and misdirected research; many key discoveries were preceded by periods of stagnation, while others were in fact set aside and had to be rediscovered altogether many decades later. However, as this chapter shows, the delays were seldom arbitrary and the detours seldom fruitless. It was the result of efforts by many devoted experts, many of them working in parallel or in competition, that led to the creation of defibrillation as we know it today. The case of the divergent investigations of alternating-versus direct-current electric shock therapy is particularly illustrative. © 2009 Springer US

Seroprevalence of HIV, hepatitis B virus, and HCV among injection drug users in Connecticut: Understanding infection and coinfection risks in a nonurban population

Objectives. We examined HIV, hepatitis B virus (HBV), and HCV sero prevalence in an interim analysis and the potential risk factors associated with these infections among injection drug users (IDUs) residing in nonurban communities of south western Connecticut. Methods. We recruited and interviewed active adult IDUs about their injection associated risk and conducted serological tests for HIV, HBV, and HCV. Regression analyses were performed to identify risk factors for infection and coinfection. Results. Among 446 participants, 51.6% carried at least 1 infection, and 16.3% were coinfected. Infection risk was associated with longer duration of injection use, overdose, substance abuse treatment, depression, and involvement with the criminal justice system. Co infection was associated with longer injection drug use, lower education, overdose, and criminal justice involvement. Multivariate models identified injection drug use duration, substance abuse treatment, and criminal justice involvement as the most significant predictors of infection; injection drug use duration and education were the most significant predictors of coinfection. Conclusions. Suburban IDUs are at significant risk for acquiring single and multiple viral infections. Effective harm reduction strategies are needed to reach users early. There might be roles for interventions in the treatment and justice systems in which IDUs interact