Tailoring Household Disaster Preparedness Interventions to Reduce Health Disparities: Nursing Implications from Machine Learning Importance Features from the 2018-2020 FEMA National Household Survey.

Tailored disaster preparedness interventions may be more effective and equitable, yet little is known about specific factors associated with disaster household preparedness for older adults and/or those with African American/Black identities. This study aims to ascertain differences in the importance features of machine learning models of household disaster preparedness for four groups to inform culturally tailored intervention recommendations for nursing practice. A machine learning model was developed and tested by combining data from the 2018, 2019, and 2020 Federal Emergency Management Agency National Household Survey. The primary outcome variable was a composite readiness score. A total of 252 variables from 15,048 participants were included. Over 10% of the sample self-identified as African American/Black and 30.3% reported being 65 years of age or older. Importance features varied regarding financial and insurance preparedness, information seeking and transportation between groups. These results reiterate the need for targeted interventions to support financial resilience and equitable resource access. Notably, older adults with Black racial identities were the only group where TV, TV news, and the Weather Channel was a priority feature for household disaster preparedness. Additionally, reliance on public transportation was most important among older adults with Black racial identities, highlighting priority needs for equity in disaster preparedness and policy.

Evaluating barriers and facilitators to healthcare providers' use of an emergency department electronic referral portal for high-risk children with asthma using the Theoretical Domains Framework.

OBJECTIVE: Urban children with asthma are at risk for frequent emergency department (ED) visits and suboptimal asthma management. ED visits provide an opportunity for referrals to community-based asthma management services. Electronic medical record-based referral portals have been shown to improve quality of care but use of these portals by healthcare providers (HCPs) is variable. The purpose of the study was to investigate facilitators, barriers, and recommendations to improve the use of an electronic referral portal to connect children presenting with asthma exacerbations in an urban pediatric ED to community-based education and case management services. METHODS: The study was grounded in the Theoretical Domains Framework, an implementation provided the theoretical basis of the study. All ED HCPs were invited to complete qualitative interviews; twenty-three HCPs participated. Interviews were coded using directed content analysis. RESULTS: Facilitators to portal use included its relative ease of use and HCP beliefs regarding the importance of such referrals for preventive asthma care. Barriers included insufficient time to make referrals, lack of information regarding the community agency and challenges communicating the value of the referral to patients and/or their caregivers. CONCLUSIONS: Successfully engaging HCPs working in ED settings to use electronic portals to refer children with asthma to community agencies for health services may involve helping providers increase their comfort and knowledge of the external provider agency, ensuring organizational leaders support the need for preventive asthma care and provision of feedback to HCPs on the success of such referrals in meeting the needs of those families served.

Sensitivity Analysis: A Method to Promote Certainty and Transparency in Nursing and Health Research.

Nursing and health researchers may be presented with uncertainty regarding the utilization or legitimacy of methodological or analytic decisions. Sensitivity analyses are purposed to gain insight and certainty about the validity of research findings reported. Reporting guidelines and health research methodologists have emphasized the importance of utilizing and reporting sensitivity analyses in clinical research. However, sensitivity analyses are underreported in nursing and health research. The aim of this methodological overview is to provide an introduction to the purpose, conduct, interpretation, and reporting of sensitivity analyses, using a series of simulated and contemporary case examples.

Bicycle handlebar injuries - a systematic review of pediatric chest and abdominal injuries.

OBJECTIVE: The severity of handlebar injuries can be overlooked due to subtle signs and wide range of associated internal injuries. Our objective was to describe thoracoabdominal injuries due to bicycle handlebars and their outcomes in children. METHODS: Articles that reported thoracoabdominal injuries were identified from database conception to March 3, 2019 using PubMed, EMBASE, Cochrane Library, CINHAHL Complete, Web of Science and Scopus. A systematic review of studies of thoracoabdominal handlebar injuries in children ≤21 years on human-powered bicycles in English was performed. Information on demographics, clinical features, injuries, interventions and outcomes was noted. RESULTS: A total of 138 articles were identified from 1952 to 2019. There were 1072 children (males, 85.1%) and 1255 thoracoabdominal injuries. Mean age was 9.7 ± 3.3 years old. Common clinical features included abdominal pain and guarding, vomiting, fever and a handlebar imprint. The liver was the most frequently injured organ. Surgery was performed in 338 children with a mean age of 10.0 ± 3.3 years. Twenty-seven children (2.5%) were discharged and returned due to worsening symptoms, of whom 23 (85.2%) required surgery. Thirty-one children (2.9%) transferred to a higher level of care due to injury severity. Two deaths were reported. CONCLUSION: Bicycle handlebars can cause significant thoracoabdominal injuries. Presence of abdominal pain, vomiting, fever or a circular imprint on the chest or abdomen should prompt further workup. Future studies on diagnostic modalities and best practices are needed to lower the chance of missed injuries.

Pediatric minor head injury related return visits to the emergency department and their outcome.

BACKGROUND: Minor head injury (MHI) in children is a common emergency department (ED) presentation. It is well established that majority of these patients don't require imaging and can be safely discharged. What is less known is how often these children come back to the ED and the outcome of their revisits? The objective of this study was to describe the frequency and outcome of unscheduled return visits (RVs) for MHI in a pediatric ED. METHODS: A retrospective chart review of emergency department RV's database was conducted from August 2016 to July 2019. MHI patients <18 years of age who came back to the ED within 72 h of their index visit - for head injury related complaints - were eligible for inclusion. RESULTS: Return visit rate for MHI was around 1% (61/6225). Of these, 55.7% (34/61) were female and 85.5% (53/61) were in the age group 2-17 years. Three-fourths of the revisits were for concussion-related symptoms. Nearly two-thirds of the patients required one or more interventions upon revisit. Missed clinically important traumatic brain injury was rare. Only one patient required operative intervention upon revisit. Though largely unpreventable, 5% (3/61) of the revisits were deemed potentially avoidable. CONCLUSION(S): RVs secondary to MHI in children remain low and are associated with good outcomes.

Minor head injury transfers: Trends and outcomes.

BACKGROUND: Children with traumatic head injury are often transferred from community Emergency Departments (ED) to a Pediatric Emergency Department (PED). The primary objective of this study was to describe the outcomes of minor head injury (MHI) transfers to a PED. The secondary objective was to report Computed Tomography (CT) utilization rates for MHI. METHODS: We conducted a retrospective study of children aged ≤18 years transferred to our PED for MHI from 2013 to 2018. Patients with Glasgow Coma Scale (GCS) < 14, coagulopathies, history of brain mass/shunt and suspected non-accidental trauma were excluded. Data collected included demographics, interventions performed, and disposition. MHI risk stratification and clinically important traumatic brain injury (ciTBI) were defined per the Pediatric Emergency Care Applied Research Network (PECARN) head injury guidelines. Descriptive statistics were reported using general measures of frequency and central tendency. RESULTS: A total of 1078 children with MHI were analyzed based on eligibility criteria. The majority of patients were male (62%) and ≥ 2 years of age (69.3%). Subspecialist consultation (57.2%) and neuroimaging (27.4%) were the most commonly performed interventions in the PED. Only 14 children (1.3%) required neurosurgical intervention. One-third of the transferred patients required no additional work-up. Two-thirds of the patients (66.6%) were directly discharged from the PED. Though the total number of MHI transfers per year declined steadily during the study period (from 271/year to 119/year), CT head utilization remained relatively similar across the study years (60.3% to 70.8%). A higher proportion of children received CT in the ED when compared to the PED for low-risk (28.9% vs 15.8%) and intermediate-risk groups (42.8% vs 29.4%). CONCLUSIONS: The majority of pediatric MHI transfers are discharged home following a subspecialty consultation and/or neuroimaging. Despite guidelines and a low incidence of ciTBI, CT utilization remains high in the intermediate and low risk MHI groups, especially in the community settings. Targeted interventions are needed to reduce the potentially avoidable transfers and low-value performance of CT in children with MHI.

Factors associated with avoidable interhospital transfers for children with a minor head injury.

INTRODUCTION: Children with minor head injuries (MHI) are routinely transferred to a pediatric trauma center for definitive care. Unwarranted transfers result in minimal benefit to the patient and add substantially to healthcare costs. The purpose of this study is to explore the factors associated with avoidable interhospital transfers of children with MHI. METHODS: We conducted a retrospective cohort study of children <18 years of age transferred to our pediatric emergency department (PED) for MHI between January 2013 and December 2018. Patients transferred for non-accidental trauma, and those with a history of coagulopathies, underlying neurological conditions, intraventricular shunts and developmental delay were excluded. Transfers were categorized as avoidable if none of the following interventions were required at our PED: procedural sedation, anticonvulsant initiation, subspecialty consultation, intensive care unit admission or hospital admission for ≥2 nights, intubation or operative intervention. We collected demographics, injury mechanism, neuroimaging results, interventions performed and PED disposition. Binary logistic regression was conducted to provide adjusted associations between patient characteristics and the risk of avoidable interhospital transfers. RESULTS: We analyzed 1078 transfers for MHI, of which 450 (42%) transfers were classified as avoidable. Children in the avoidable transfer group tended to be younger, less likely to have experienced loss of consciousness, and more likely to belong to the the group at lowest risk for a clinically important traumatic brain injury (ciTBI). Our multivariable model determined that children less than 2 years of age (OR = 1.75; 95% CI = 1.3-2.37), low-risk group for ciTBI (OR = 1.66; 95% CI = 1.22-0.1), and a positive head CT at the transferring hospital (OR = 0.06; 95% CI = 0.02-0.1) were all significantly associated with avoidable transfers. CONCLUSION: There is a high rate of avoidable transfers in children with MHI. Focused interventions targeting risk factors associated with avoidable transfers may reduce unwarranted interhospital transfers.

Testing the utility of the newest vital sign (NVS) health literacy assessment tool in older African-American patients.

OBJECTIVE: To evaluate utility of the newest vital sign (NVS) which can be completed in 3min compared to the short version test of functional literacy in adults (S-TOFHLA) that takes 7min for health literacy in the older African American patients. METHODS: We enrolled 62 older (age>65 years) African American patients and administered the NVS and the S-TOFHLA. A score of less than 4 for the NVS and less than 16 for the S-TOFHLA was indicative of limited health literacy. RESULTS: Mean age of our patients was 73.2+7.9 years with an average education level of twelfth grade. Using S-TOFHLA 51% of the subjects were deemed to be sufficiently literate, with a score of 23.0+8.6 compared to 56% on the NVS with a score of 3.0+1.9. The average time for completing the NVS was 11min in our patient population. CONCLUSION: Based on our data, while health literacy level can be assessed with the NVS its practicality as a quick screening tool in the elderly population appears limited. PRACTICE IMPLICATIONS: Knowing the level of patient's health literacy may help physicians deliver health information in the format that patients can understand.

Variable length tandem repeat polyglutamine sequences in the flexible tether region of the Tsr chemotaxis receptor of Escherichia coli.

Methyl-accepting chemotaxis proteins (MCPs) are receptors that play an important role in bacterial chemotaxis. Methylation of Tsr, the MCP that mediates chemotaxis towards serine in Escherichia coli, is thought to be facilitated by binding of the methyltransferase to a flexible tether region at the C-terminal end of Tsr. This study analysed natural length variants of the tether that occur in E. coli due to genetic instability in tandem repeat DNA sequences that code for glutaminyl (Q) residues, creating polyQ sequences of variable lengths in the tether region. The tsr gene of E. coli K-12 (strain MG1655) codes for 4Q at the beginning of its 35 aa tether region. The tether varies in length from 35 to 47 residues among pathogenic and non-pathogenic strains of Escherichia, Shigella spp., Salmonella, Yersinia and Photorhabdus. Among previous sequences, Escherichia and Shigella mostly have 4Q and 7Q variants, and one strain (E. coli HS) has 10Q. In E. coli isolated from 50 humans and 75 animals (dogs, cats, horses, birds, etc.), polyQ up to 13Q (44 aa tether) were identified (6 strains); relative frequencies were 7Q ( approximately 77 % of the total) >4Q (14 %) >13Q (5 %) >10Q (4 %). Phylogenetic analysis revealed that E. coli strains with 10Q or 13Q largely fell within two clusters. Serine chemotaxis was not significantly different among 7Q, 10Q and 13Q strains, and was comparable to chemotaxis in the frequently studied K-12 strain. These results are consistent with models indicating that polyQ sequences from 7Q to 13Q are flexible, and that longer tethers, within this range, would not change the precision of adaptation mediated by methylation. Studies of this naturally variable polyQ region in E. coli may also have relevance to mechanisms that mediate polyQ instability in human genetic diseases.