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.

Background: Palliative care is insufficiently integrated in the continuum of care for older people. It is unclear to what extent healthcare policy for older people includes elements of palliative care and thus supports its integration. Aim: (1) To develop a reference framework for identifying palliative care contents in policy documents; (2) to determine inclusion of palliative care in public policy documents on healthcare for older people in 13 rapidly ageing countries. Design: Directed documentary analysis of public policy documents (legislation, policies/strategies, guidelines, white papers) on healthcare for older people. Using existing literature, we developed a reference framework and data extraction form assessing 10 criteria of palliative care inclusion. Country experts identified documents and extracted data. Setting: Austria, Belgium, Canada, Czech Republic, England, Japan, Mexico, Netherlands, New Zealand, Singapore, Slovenia, South Korea, Spain. Results: Of 139 identified documents, 50 met inclusion criteria. The most frequently addressed palliative care elements were coordination and continuity of care (12 countries), communication and care planning, care for family, and ethical and legal aspects (11 countries). Documents in 10 countries explicitly mentioned palliative care, nine addressed symptom management, eight mentioned end-of-life care, and five referred to existing palliative care strategies (out of nine that had them). Conclusions: Health care policies for older people need revising to include reference to end-of-life care and dying and ensure linkage to existing national or regional palliative care strategies. The strong policy focus on care coordination and continuity in policies for older people is an opportunity window for palliative care advocacy.

Introduction: Computed tomography angiography (CTA) is used to screen patients for cerebrovascular injury after blunt trauma, but risk factors are not clearly defined in children. This modality has inherent radiation exposure. We set out to better delineate the risk factors associated with blunt cervical vascular injury (BCVI) in children with attention to the predictive value of seatbelt sign of the neck. Methods: We collected demographic, clinical and radiographic data from the electronic medical record and a trauma registry for patients less than age 18 years who underwent CTA of the neck in their evaluation at a Level I trauma center from November 2002 to December 2014 (12 years). The primary outcome was BCVI. Results: We identified 11,446 pediatric blunt trauma patients of whom 375 (2.7%) underwent CTA imaging. Fifty-three patients (0.4%) were diagnosed with cerebrovascular injuries. The average age of patients was 12.6 years and included 66% males. Nearly half of the population was white (52%). Of those patients who received CTA, 53 (14%) were diagnosed with arterial injury of various grades (I-V). We created models to evaluate factors independently associated with BCVI. The independent predictors associated with BCVI were Injury Severity Score >/= 16 (odds ratio [OR] [2.35]; 95% confidence interval [CI] [1.11-4.99%]), infarct on head imaging (OR [3.85]; 95% CI [1.49-9.93%]), hanging mechanism (OR [8.71]; 95% CI [1.52-49.89%]), cervical spine fracture (OR [3.84]; 95% CI [1.94-7.61%]) and basilar skull fracture (OR [2.21]; 95% CI [1.13-4.36%]). The same independent predictors remained associated with BCVI when excluding hanging mechanism from the multivariate regression analysis. Seatbelt sign of the neck was not associated with BCVI (p=0.68). Conclusion: We have found independent predictors of BCVI in pediatric patients. These may help in identifying children that may benefit from screening with CTA of the neck.

The COVID-19 pandemic disrupted hospital operations. Anecdotal evidence suggests financial performance likewise suffered, yet little empirical research supports this claim. This study aimed to explore the impact of the pandemic on the financial performance of the most prominent academic hospitals in the United States. Data from the 115 largest major teaching hospitals in the United States were extracted from the American Hospital Directory for three years (2019–2021). We hypothesized that the year and region would moderate the relationship between a hospital’s return on assets (financial performance) and specific operational variables. We found evidence through descriptive statistics and multivariate moderated regressions that financial positions rebounded in 2021, mainly through reductions in adjusted full-time employees and liabilities and an increase in non-operating income. Our results also found that the Midwest region significantly outperformed the other three regions, particularly in terms of lower salaries and operational expenses. These findings suggest potential for future initiatives encouraging efficiency and finding alternate sources of income beyond patient income. Hospitals should focus on improving financial reserves, building out non-operational revenue streams, and implementing operational efficiencies to foster better financial resiliency. These suggestions may enable healthcare administrators and facilities to adapt to future pandemics and environmental turbulence.

Background: Psychiatric co-occurring disorders among individuals with opioid use disorder has primarily focused on epidemiological surveys of patients in continuous or long-term treatment, yet little is known about the socio-economically vulnerable who are non-treatment seeking prior to an emergency response. Methods: We retrospectively analyzed data from patients who had enrolled in a study involving home outreach to patients referred from police, emergency medical services (EMS), or hospital emergency departments following an emergency response. The sample is largely socio-economically vulnerable with high rates of unemployment and uninsured. Eligible consenting patients received an intervention consisting of medication (buprenorphine), behavioral counseling, and peer support. Participants completed semi-structured, psychological instruments to assess current and prior history for both substance use and mental health disorders. We used descriptive statistics to evaluate rates of co-occurring mental health comorbidity. Results: Among 102 patients (average age = 36.5 years old), approximately 61 (59.8%) reported a prior mental health diagnosis, with 31 (30.3%) currently on medications for their diagnoses. Mood and anxiety disorders were most frequently recorded. Just over half (51%) had received any prior treatment for their substance use. Of those with dual disorders, 67.2% had experienced prior suicidal thoughts, and 63.7% reported polysubstance use of 5 or more substances. Conclusion: Co-occurring psychiatric disorders, and specifically mood and anxiety disorders, appear to be prevalent in vulnerable populations at an increased rate. Mental health assessments should routinely be performed in the emergency setting and in early stages of treatment.

Interventions to reduce the stigma of substance use disorders by health professionals often include didactic instruction combined with an interactive component that includes a guest speaker in recovery. Few interactive studies have focused on pharmacy students. Community pharmacists are moving to the front lines to battle the opioid epidemic; therefore, pharmacy students should be included in interventions aimed at reducing stigma by health professionals. This study examined the effects of a contact-based interactive intervention delivered by a peer recovery support specialist on perceived stigma of opioid use disorder among third-year pharmacy students (N = 115) enrolled in an integrative psychiatry course. Stigma was measured using the Brief Opioid Stigma Scale. Our study found significant differences in students' perceived stigma, both with their personal beliefs and their beliefs regarding the public, supporting the use of interactive presentations by peer recovery support specialists to decrease perceived stigma of opioid use disorder by health professionals. This type of intervention for pharmacy students shows promise in reducing substance use disorder stigma and should be further explored.