Factors associated with tracheostomy-associated infection treatment: A multicenter observational study.

OBJECTIVE: To characterize factors that influence the decision to treat suspected pediatric bacterial tracheostomy-associated respiratory infections (bTRAINs; e.g., pneumonia, tracheitis). METHODS: We conducted a multicenter, prospective cohort study of children with pre-existing tracheostomy hospitalized at six children's hospitals for a suspected bTRAIN (receipt of respiratory culture plus ≥1 doses of an antibiotic within 48 h). The primary predictor was respiratory culture growth categorized as Pseudomonas aeruginosa, P. aeruginosa + ≥1 other bacterium, other bacteria alone, or normal flora/no growth. Our primary outcome was bTRAIN treatment with a complete course of antibiotics as documented by the discharge team. We used logistic regression with generalized estimating equations to identify the association between our primary predictor and outcome and to identify demographic, clinical, and diagnostic testing factors associated with treatment. RESULTS: Of the 440 admissions among 289 patients meeting inclusion criteria, 307 (69.8%) had positive respiratory culture growth. Overall, 237 (53.9%) of admissions resulted in bTRAIN treatment. Relative to a negative culture, a culture positive for P. aeruginosa plus ≥1 other organism (adjusted odds ratio [aOR] 2.3; 95% confidence interval [CI] 1.02-5.0)] or ≥1 other organism alone (aOR: 2.8; 95% CI: 1.4-5.6)] was associated with treatment. Several clinical and diagnostic testing (respiratory Gram-stain and chest radiograph) findings were also associated with treatment. Positive respiratory viral testing was associated with reduced odds of treatment (aOR: 0.5; 95% CI: 0.2-0.9). CONCLUSIONS: Positive respiratory cultures as well as clinical indicators of acute illness and nonculture test results were associated with bTRAIN treatment. Clinicians may be more comfortable withholding antibiotics when a virus is identified during testing.

Maternal stress and social support during Hurricane Florence.

In theoretical research on disaster vulnerability, access to resources is critical for optimal outcomes. Studying the impact of a hurricane on maternal stress can expand theories of disaster vulnerability. This is a cross-sectional mixed-methods prospective study of maternal stress during Hurricane Florence in the United States. Results from chi-squares compared the proportion of respondents who reported having support for a financial emergency were significant, specifically that higher income respondents indicated the ability to rely on someone in case of an emergency. A regression analysis indicated that social support was significant and negatively related to stress as a dependent variable, while evacuation status and pregnancy status were not significant predictors of stress. Five themes emerged from the overall qualitative data: concerns about infant feeding, evacuation logistics, general stress, family roles, and 'other' issues.

The role of homelessness community based organizations during COVID-19.

People experiencing homelessness are vulnerable to disasters and hazards and are at risk for contracting COVID-19. In this study, we gathered data from 10 community-based organizations (CBO's) in the United States that work to provide services for people experiencing homelessness. The combined CBO's span across rural, urban, and a mixture of both settings. We identified three needs that the CBO's indicated to be urgent: (1) the increased need for basic services among guests/clients, (2) new organizational challenges for the CBO's, and (3) issues related to emergency management and disasters. Among these urgent needs, respondents also indicated the need for emotional support for staff and volunteers experiencing burnout during the COVID-19 response. They also expressed some unique aspects of new care delivery systems, such as clients' willingness to engage in rehabilitation programs because of noncongregate sheltering options corresponding with those support services.

Validation of the Seattle Suprastomal Safety Score (5S): A Novel Measure in Pediatric Tracheostomy-Dependent Patients.

OBJECTIVE: Suprastomal collapse and granulation are common sequelae of pediatric tracheostomy. We present the first measure of suprastomal obstructive pathology, the Seattle Suprastomal Safety Score (5S), an instrument with 2 domains: collapse and granulation. STUDY DESIGN: Cross-sectional repeated testing survey. SETTING: Electronic survey. METHODS: A library of images was assembled from still pictures of the suprastomal area in 50 patients who previously underwent trachea-bronchoscopy at a quaternary children's hospital. Five pediatric otolaryngologists and 2 pediatric pulmonologists reviewed the images in random, blinded fashion and provided 5S scores. Participants repeated this process 2 to 4 weeks later. Interrater agreement was calculated with an intraclass correlation coefficient (ICC) with a 2-way random-effects model and Fleiss's κ. Intrarater agreement was measured with an ICC using a 2-way mixed-effects model as well as with test-retest correlations using Spearman rank coefficient. All measures were performed separately on collapse and granulation domains. RESULTS: ICC for interrater agreement was 0.88 (95% CI, 0.82-0.93) for collapse and 0.97 (95% CI, 0.96-0.98) for granulation, indicating almost perfect agreement. Fleiss's κ demonstrated moderate agreement for collapse and almost perfect agreement for granulation. ICC for intrarater agreement was 0.95 (95% CI, 0.93-0.97) and 0.99 (95% CI, 0.98-0.99) for collapse and granulation, respectively, indicating almost perfect agreement. Spearman rank correlation for test-retest demonstrated substantial agreement for collapse and almost perfect agreement for granulation. CONCLUSION: The 5S demonstrates excellent interrater and intrarater agreement, making it highly reliable as a novel measure of suprastomal collapse and granulation in tracheostomy-dependent pediatric patients.

Pregnancy, Birthing, and Postpartum Experiences During COVID-19 in the United States.

The research aims of this project were to understand the impact of the COVID-19 pandemic on pregnancy, birthing, and postpartum experiences in the United States. Our data include responses from 34 states within the US. Findings from our analyses indicate that higher perceived social support predicted higher scores of well-being, while higher scores of perceived loneliness predicted lower scores of well-being, and higher trauma predicted lower well-being measured as satisfaction with life. Qualitative data support these findings, as well as the finding that there were various sources of stress for respondents during pregnancy, birth, and the postpartum timeframe-particularly in terms of managing work/occupation obligations and childcare. Additionally, this research fills a gap in understanding infant feeding in emergencies. Respondents perceived that early release from the hospital reduced access to lactation support, and many respondents reported receiving free samples of breastmilk substitutes through a variety of sources.

Disaster Preparedness among Service Dog Puppy- Raisers (Human Subject Sample).

Little is known about the ways in which puppy raisers engage in disaster preparedness for their puppies (or "guide dogs in training"). The aim of this research is to understand disaster preparedness among service dog puppy raisers. A web-based survey was distributed to people raising puppies in a service dog training program (n = 53 complete survey responses). Questions in the survey included items about disaster preparedness and plans for canine safety in hazards events. Out of those who said they had an evacuation plan for their puppy in training, 59% stated they would put the dog in their vehicles for evacuating to safety in the event of a hurricane or other disaster. The odds of first-time puppy raisers who considered evacuation for Hurricane Irma in 2017 was 15.3 times the odds of repeat raisers. Over half the raisers reported that they did not have a disaster kit. Additionally, 82% of respondents indicated that having a service puppy in training makes them feel safer. These results can be used as a foundation for service dog organizations in disaster preparedness among their puppy raiser volunteers and in designing recruitment messages for new volunteers.

An Integrated Scenario Ensemble-Based Framework for Hurricane Evacuation Modeling: Part 1-Decision Support System.

This article introduces a new integrated scenario-based evacuation (ISE) framework to support hurricane evacuation decision making. It explicitly captures the dynamics, uncertainty, and human-natural system interactions that are fundamental to the challenge of hurricane evacuation, but have not been fully captured in previous formal evacuation models. The hazard is represented with an ensemble of probabilistic scenarios, population behavior with a dynamic decision model, and traffic with a dynamic user equilibrium model. The components are integrated in a multistage stochastic programming model that minimizes risk and travel times to provide a tree of evacuation order recommendations and an evaluation of the risk and travel time performance for that solution. The ISE framework recommendations offer an advance in the state of the art because they: (1) are based on an integrated hazard assessment (designed to ultimately include inland flooding), (2) explicitly balance the sometimes competing objectives of minimizing risk and minimizing travel time, (3) offer a well-hedged solution that is robust under the range of ways the hurricane might evolve, and (4) leverage the substantial value of increasing information (or decreasing degree of uncertainty) over the course of a hurricane event. A case study for Hurricane Isabel (2003) in eastern North Carolina is presented to demonstrate how the framework is applied, the type of results it can provide, and how it compares to available methods of a single scenario deterministic analysis and a two-stage stochastic program.

Maternal health services for refugee populations: Exploration of best practices.

The full scope of women's health needs is not necessarily addressed in refugee camps and after resettlement, particularly pregnancy and postnatal services. The aims of this research are to examine the maternal care services provided to refugee women in camps and after resettlement to the United States, and to analyse organisational successes and challenges in service provision. With this understanding, policies can improve service delivery for refugee women. We interviewed respondents from five organisations, ranging from local non-profits to international non-governmental organisations. Most of the organisations do not provide direct medical care, but rather education and social service support to clients, and in some cases midwife training. Their success stemmed from a focus on client capacity building, individualised support, effective partnerships, and cultural competency. Respondents described the need for physical resources, effective leadership, and additional personnel, especially with linguistic capabilities. The dialogue in the interviews supports themes of education as empowerment and client self-sufficiency. Respondents emphasised the importance of funding and policies that support their work. This knowledge can lead to improved models of service delivery and inform the development of best practices and policies in maternal and reproductive health for refugee women.

The Effect of Mass Evacuation on Infant Feeding: The Case of the 2016 Fort McMurray Wildfire.

Objectives We examine the ways in which the 2016 Fort McMurray wildfire evacuation affected infant feeding. Our primary objective is to understand the decisions and perceptions of primary caregivers of children age 0-36 months who evacuated from Fort McMurray, Canada. Methods We used a mixed methods approach to assess the overall impact that the evacuation had on infant feeding. Specific outcome variables for the quantitative research are: decision-making, access to support and resources, and changes in routine. Participants were recruited using a purposive sampling technique through infant feeding in emergency support groups on social media in which members were primarily evacuees from the Fort McMurray wildfire. Loglinear results include a model of feeding methods before and after the wildfire evacuation. Results Content analyses results from qualitative data support findings from the loglinear model. Specifically, the findings suggest that the evacuation was associated with a reduction in breastfeeding and an increase in use of infant formula The open-ended data revealed that caregivers experienced stress during and after the evacuation due to moving from place to place, food insecurity associated with artificial feeding, warding off unhealthy food for older children, and managing family reunification. In addition, respondents reported that breastfeeding was a source of comfort for infants and contributed to a sense of empowerment. Conclusions for Practice This study sets forth important groundwork for understanding decision-making, stress, logistics, and social factors that influence infant feeding in a large-scale evacuation event. Emergency management, health workers, and nutrition experts can provide support to families in disasters to mitigate some of the adverse impacts the evacuation may have on infant feeding.

Maternal Perceptions of Infant Feeding and Health in the Context of the 2015 Nepal Earthquake.

BACKGROUND: Displacement caused by the 2015 earthquake in Nepal exacerbated poor health and nutrition for thousands of women and children. Research aim: This study aimed to identify the perceptions of Nepalese mothers residing in earthquake relocation camps regarding barriers, facilitators, and situational factors influencing breastfeeding and family well-being. METHODS: An exploratory, rapid ethnographic approach was used during two fieldwork phases. Phase 1 consisted of reconnaissance and observation, whereas Phase 2 consisted of observation and qualitative semistructured interviews with infant caretakers ( N = 14). RESULTS: We found evidence of human milk substitutes donated by various groups after the earthquake, despite Nepal's media statement condemning these donations. Participants in this study expressed concerns about their milk supply. They also expressed concerns about the impending winter season combined with distress about the 2015 fuel crisis and the impact that this had on their infants and children. Furthermore, participants expressed choices about infant feeding that were influenced by traditional Nepalese practices. Specifically, homemade complementary foods and spices designed to boost lactation were identified as being used during daily infant feeding practices. CONCLUSION: Infant caretakers need culturally specific support for breastfeeding after disasters. These findings can directly influence future interventions concerning Nepalese mothers' perceptions, infant care, and feeding practices in disaster scenarios.

Lack of Cultural Competency in International Aid Responses: The Ebola Outbreak in Liberia.

A cornerstone of effective disaster management is that response should always begin and end at the local level (1). The response to the Ebola virus disease (EVD) outbreak in Liberia, West Africa, was a combination of independent efforts by many nations and organizations. Many of these independent efforts ignored or were not able to work with the local levels of emergency management in Liberia. This oversight occurred because of the Liberian's mistrust of both their government and foreign aid groups, as well as the lack of cultural competency demonstrated by the aid groups. The health-care and emergency management infrastructure in Liberia appeared to be non-existent at the beginning of the EVD outbreak. However, there were resources available at the community level: the Liberians and their culture. Although these resources were rarely used, there were some instances in which communities were included in response efforts. It was in these instances that possible improvements to international disaster response protocol were found.