minutes; P < .001) (Table 2).Discussion | Through this quality improvement process, we found that the rapid retriage protocol identified critically injured patients at higher risk for poor outcomes who could benefit from the use of rapid retriage. For critically injured ED trauma transfer patients who died, especially those with blunt trauma rather than penetrating trauma, increased time at a nontrauma hospital prior to transfer could have contributed to the higher mortality rate. In California's exclusive trauma system, data for patients cared for in nontrauma hospitals are not systematically available, even for patients transferred to a trauma center. In this study, we identified important clinical data elements that are not routinely obtained from referring nontrauma hospitals. A regional trauma center committee is using this information to create a consensus-based trauma transfer performance improvement page within each site's current trauma registry. This would enable the recording of data necessary to understand the emergency transfer process to improve the care for this vulnerable critically injured population.

Background: European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction (MI) or to exclude major adverse cardiac events (MACE) among Emergency Department (ED) patients with possible acute coronary syndrome (ACS). However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with HEART scores for excluding MACE in a multisite US cohort. Methods: A prospective cohort study was conducted at 8 US sites, enrolling adult ED patients with symptoms suggestive of ACS and without ST-elevation on electrocardiogram. Baseline and 1-hour blood samples were collected and hs-cTnT (Roche, Basel Switzerland) measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, MI, and coronary revascularization) at 30-days was adjudicated. The proportion of patients with initial hs-cTnT measures <LOQ and risk based on a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score. Results: Among 1,462 participants with initial hs-cTnT measures, 46.4% (678/1,462) were women and 37.1% (542/1,462) were African American with a mean age of 57.6 (SD±12.9) years. MACE at 30-days occurred in 14.4% (210/1,462). Initial hs-cTnT measures <LOQ occurred in 32.8% (479/1,462), yielding a NPV of 98.3% (95%CI: 96.7-99.3%) for 30-day MACE. A low risk HEART score with an initial hs-cTnT < LOQ occurred in 20.1% (294/1,462) yielding a NPV of 99.0% (95%CI: 97.0-99.8%) for 30-day MACE. A 0/1-h algorithm was complete in 1,430 patients, ruling-out 57.8% (826/1,430) with a NPV of 97.2% (95%CI: 95.9-98.2%) for 30-day MACE. Adding a low HEART score to the 0/1-h algorithm ruled-out 30.8% (441/1430) with a NPV of 98.4% (95%CI: 96.8-99.4%) for 30-day MACE. Conclusions: In a prospective multisite US cohort, an initial hs-cTnT <LOQ combined with a low risk HEART score has 99% NPV for 30-day MACE. The 0/1-h hs-cTnT algorithm did not achieve a NPV > 99% for 30-day MACE when used alone or with a HEART score. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02984436

Prehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted. Stopyra JP , Harper WS , Higgins TJ , Prokesova JV , Winslow JE , Nelson RD , Alson RL , Davis CA , Russell GB , Miller CD , Mahler SA . Prehospital modified HEART score predictive of 30-day adverse cardiac events. Prehosp Disaster Med. 2018;33(1):58-62.

The HEART Pathway had a 100% NPV for 1-year safety outcomes (MACE) without increasing downstream hospitalizations or ED visits. Reduction in 1-year objective testing was not significant.

Background In the absence of vaccines and established treatments, nonpharmaceutical interventions (NPIs) are fundamental tools to control coronavirus disease (COVID-19) transmission. NPIs require public interest to be successful. In the United States, there is a lack of published research on the factors that influence public interest in COVID-19. Using Google Trends, we examined the US level of public interest in COVID-19 and how it correlated to testing and with other countries. Objective The aim of this study was to determine how public interest in COVID-19 in the United States changed over time and the key factors that drove this change, such as testing. US public interest in COVID-19 was compared to that in countries that have been more successful in their containment and mitigation strategies. Methods In this retrospective study, Google Trends was used to analyze the volume of internet searches within the United States relating to COVID-19, focusing on dates between December 31, 2019, and March 24, 2020. The volume of internet searches related to COVID-19 was compared to that in other countries. Results Throughout January and February 2020, there was limited search interest in COVID-19 within the United States. Interest declined for the first 21 days of February. A similar decline was seen in geographical regions that were later found to be experiencing undetected community transmission in February. Between March 9 and March 12, 2020, there was a rapid rise in search interest. This rise in search interest was positively correlated with the rise of positive tests for SARS-CoV-2 (6.3, 95% CI −2.9 to 9.7; P<.001). Within the United States, it took 52 days for search interest to rise substantially after the first positive case; in countries with more successful outbreak control, search interest rose in less than 15 days. Conclusions Containment and mitigation strategies require public interest to be successful. The initial level of COVID-19 public interest in the United States was limited and even decreased during a time when containment and mitigation strategies were being established. A lack of public interest in COVID-19 existed in the United States when containment and mitigation policies were in place. Based on our analysis, it is clear that US policy makers need to develop novel methods of communicating COVID-19 public health initiatives.

BackgroundFor younger generations, unconstrained online social activity is the norm. Little data are available about perceptions among young medical practitioners who enter the professional clinical arena, while the impact of existing social media policy on these perceptions is unclear.ObjectiveThe objective of this study was to investigate the existing perceptions about social media and professionalism among new physicians entering in professional clinical practice; and to determine the effects of formal social media instruction and policy on young professionals’ ability to navigate case-based scenarios about online behavior in the context of professional medicine.MethodsThis was a prospective observational study involving the new resident physicians at a large academic medical center. Medical residents from 9 specialties were invited to participate and answer an anonymous questionnaire about social media in clinical medicine. Data were analyzed using SAS 9.4 (Cary, NC), chi-square or Fisher’s exact test was used as appropriate, and the correct responses were compared between different groups using the Kruskal–Wallis analysis of variance.ResultsFamiliarity with current institutional policy was associated with an average of 2.2 more correct responses (P=.01). Instruction on social media use during medical school was related to correct responses for 2 additional questions (P=.03). On dividing the groups into no policy exposure, single policy exposure, or both exposures, the mean differences were found to be statistically significant (3.5, 7.5, and 9.4, respectively) (P=.03).ConclusionsIn this study, a number of young physicians demonstrated a casual approach to social media activity in the context of professional medical practice. Several areas of potential educational opportunity and focus were identified: (1) online privacy, (2) maintaining digital professionalism, (3) safeguarding the protected health information of patients, and (4) the impact of existing social media policies. Prior social media instruction and/or familiarity with a social media policy are associated with an improved performance on case-based questions regarding online professionalism. This suggests a correlation between an instruction about online professionalism and more cautious online behavior.Improving the content and delivery of social media policy may assist in preserving institutional priorities, protecting patient information, and safeguarding young professionals from online misadventure.

BackgroundThe HEART Pathway combines a History ECG Age Risk factor (HEAR) score and serial troponins to risk stratify patients with acute chest pain. However, it is unclear whether patients with HEAR scores of <1 require troponin testing. The objective of this study is to measure the major adverse cardiac event (MACE) rate among patients with <1 HEAR scores and determine whether serial troponin testing is needed to achieve a miss rate <1%.MethodsA secondary analysis of the HEART Pathway Implementation Study was conducted. HEART Pathway risk assessments (HEAR scores and serial troponin testing at 0 and 3 hours) were completed by the providers on adult patients with chest pain from three US sites between November 2014 and January 2016. MACE (composite of death, myocardial infarction (MI) and coronary revascularisation) at 30 days was determined. The proportion of patients with HEAR scores of <1 diagnosed with MACE within 30 days was calculated. The impact of troponin testing on patients with HEAR scores of <1 was determined using Net Reclassification Improvement Index (NRI).ResultsProviders completed HEAR assessments on 4979 patients and HEAR scores<1 occurred in 9.0% (447/4979) of patients. Among these patients, MACE at 30 days occurred in 0.9% (4/447; 95% CI 0.2% to 2.3%) with two deaths, two MIs and 0 revascularisations. The sensitivity and negative predictive value for MACE in the HEAR <1 was 97.8% (95%CI 94.5% to 99.4%) and 99.1% (95% CI 97.7% to 99.8%), respectively, and were not improved by troponin testing. Troponin testing in patients with HEAR <1 correctly reclassified two patients diagnosed with MACE, and was elevated among seven patients without MACE yielding an NRI of 0.9% (95%CI −0.7 to 2.4%).ConclusionThese data suggest that patients with HEAR scores of 0 and 1 represent a very low-risk group that may not require troponin testing to achieve a missed MACE rate <1%.Trial registration numberNCT02056964

Background The Emergency Department Assessment of Chest pain Score – Accelerated Diagnostic Protocol (EDACS-ADP) is a decision aid designed to safely identify Emergency Department (ED) patients with chest pain for early discharge. Derivation and validation studies in Australasia have demonstrated high sensitivity (99-100%) for major adverse cardiac events (MACE). Objectives To validate the EDACS-ADP in a cohort of US ED patients with symptoms suspicious for acute coronary syndrome (ACS). Methods A secondary analysis of participants enrolled in the HEART Pathway Randomized Controlled Trial was conducted. This single-site trial enrolled 282 ED patients ≥ 21 years old with symptoms concerning for ACS, inclusive of all cardiac risk levels. Each patient was classified as low-risk or at-risk by the EDACS-ADP based on EDACS, ECG, and serial troponins. Potential early discharge rate and sensitivity for MACE at 30 days, defined as cardiac death, myocardial infarction (MI), or coronary revascularization were calculated. Results MACE occurred in 17/282 (6.0%) participants, including no deaths, 16/282 (5.6%) with MI, and 1/282 (0.4%) with coronary revascularization without MI. The EDACS-ADP identified 188/282 patients (66.7%, 95% CI 60.8-72.1%) as low-risk. Of these, 2/188 (1.1%, 95% CI 0.1-3.9%) had MACE at 30 days. EDACS-ADP was 88.2% (95% CI 63.6-98.5%) sensitive for MACE, identifying 15/17 patients. Of the 2 patients identified as low-risk with MACE, 1 had MI and 1 had coronary revascularization without MI. Conclusions Within a US cohort of ED patients with symptoms concerning for ACS, sensitivity for MACE was 88.2%. We are unable to validate the EDACS-ADP as sufficiently sensitive for clinical use.