Hantavirus Pulmonary Syndrome: 1993-2018.

OBJECTIVES: From 1993 to 2018, hantavirus infections were reported in 39 states, with hantavirus pulmonary syndrome (HPS) as the most common and fatal manifestation. To identify differences in the presentation of HPS between children and adults, we hypothesized that children with HPS would be diagnosed later in their illness course given the nonspecific clinical features of HPS. METHODS: This was an evaluation of the clinical and demographic characteristics of national HPS cases from 1993 to 2018. Data were from the Centers for Disease Control and Prevention database and 1 state department of health, comprising 97% of US cases. We compared children (0 to 12 years), adolescents (13 to 18 years), and adults using nonparametric and parametric analyses, with additional exploratory analyses to identify clinical variables associated with mortality. RESULTS: Among 719 HPS patients, 22 (3.0%) were aged ≤12 years, 47 (6.5%) were 13 to 18 years old, and the remaining 650 (90.4%) were adults. Overall mortality was 35.4% and did not differ between age groups (P = .8). The time between symptom onset and death differed by age group, with children living a median of 2 days (interquartile range [IQR] 2 to 3), adolescents 4 days (IQR 3 to 5), and adults 5 days (IQR 4 to 8; P = .001). The mean highest hematocrit and median highest creatinine level were significantly associated with mortality in those 0 to 18 years old but not adults. CONCLUSIONS: In our dataset representing the largest study of HPS in the United States, we found that children with HPS died more quickly than adults and that highest hematocrit and creatinine levels were associated with death only among those <19 years old.

The Association of Antimicrobial Prophylaxis With Return Visits After Dog Bites in Children.

OBJECTIVES: Dog bites occur frequently in the United States, yet there are no clear guidelines for prescribing antibiotic prophylaxis in healthy children after a dog bite. The aim of our study was to assess antibiotic prophylaxis and subsequent rates of infection after dog bites in children. We hypothesized a negative association between prophylactic prescription of any antimicrobial and return visit within 14 days for infection. METHODS: In this retrospective cohort study, we assessed the frequency of antibiotic prophylaxis prescribed after dog bite injuries in patients 0 to 18 years old and subsequent return visits for infection using 2016 to 2017 medical and pharmacy claims derived from the IBM MarketScan Research Databases. We used the International Classification of Diseases-10 code W54 for dog bites then used keyword searches to find diagnoses (including infection), wound descriptions, and medications. RESULTS: Over the 2-year period, 22,911 patients were seen for dog bites that were not coded as infected. The majority, 13,043 (56.9%), were prescribed an antibiotic at the initial visit and 9868 (43.1%) were not. Of those prescribed antibiotics, 98 (0.75%; 95% confidence interval [CI], 0.60-0.90) returned with an infection, compared with 59 (0.60%; 95% CI, 0.44-0.75) of those not prescribed antibiotics. Receiving an antibiotic prescription at the initial visit was associated with a reduced rate of return for wound infection only among children whose wounds were repaired or closed. Children not receiving a prescription whose wounds were repaired were more than twice as likely to return with an infection in the subsequent 14 days as children whose wounds were not repaired (odds ratio, 2.2; 95% CI, 1.2-4.0). CONCLUSIONS: Most children are prescribed antibiotics at an initial emergency department visit after a dog bite. However, very few return for infection independent of antimicrobial prophylaxis, which suggests antibiotics are overprescribed in this setting.

Positive Relationships with Adults and Resilience to Suicide Attempt among New Mexico Hispanic Adolescents.

Suicide is a leading cause of adolescent death and has increased in recent years. The purpose of this study was to examine the effect that relationships with adults at home and in the community had on the probability of suicide attempts of Hispanic teenagers in New Mexico. Data from the 2019 New Mexico Youth Risk and Resiliency Survey were analyzed to identify the ways in which relationships with adults influenced suicide attempts among Hispanic adolescent students. The examined factors included: relationships with adults in the home and in the community and with same-age friends, and participation in hobbies or organizations outside of school. The resiliency factors were similar for male and female Hispanic students. As positive relationships with adults at home or in the community increased, the probability of suicide attempts decreased by 37-54%. Positive relationships with same-age friends were also associated with reduced suicide attempts. Community organization involvement and hobbies affected males and females differently. Adults at home and in the community can decrease the risk of suicide for Hispanic teenagers through supportive relationships. Hybrid programs focusing on adolescent health, positive communication, and academic support, which integrate adults from home and community environments, show promise in reducing suicidal thoughts and other risk behaviors.

Identification of household dangers by parents from adult versus child visual perspective.

BACKGROUND: This study utilized videos from a child's and an adult's perspective to determine whether perspective influences the number of hazards identified by parents. METHODS: The study measured number of household dangers parents' identified. Parents (n=106) were randomized to view either the child or adult perspective videos. Groups did not differ with respect to median age (p=0.51), education (p=0.55), or number of children living at home (p=0.64). RESULTS: Median number of hazards identified in the bedroom was 3 for participants watching videos taken at either adult or child perspective (p=0.32). Parents viewing child perspective videos of the kitchen identified significantly more hazards (median=4) than parents viewing adult perspective videos (median=3) (p=0.0001). CONCLUSIONS: Although video height (perspective) did not influence the number of hazards identified in the bedroom, parents who observed the kitchen video taken at a child's height identified more hazards than those viewing a video at adult height.

Integrating Culture and History to Promote Health and Help Prevent Type 2 Diabetes in American Indian/Alaska Native Communities: Traditional Foods Have Become a Way to Talk About Health.

PURPOSE AND OBJECTIVES: The purpose of the Traditional Foods Project (TFP) was to implement and evaluate a community-defined set of strategies to address type 2 diabetes by focusing on traditional foods, physical activity, and social support. The TFP sought to answer 2 questions: first, how do we increase and sustain community access to traditional foods and related activities to promote health and help prevent type 2 diabetes? Second, how do we evaluate interventions across culturally and geographically diverse communities to demonstrate success? INTERVENTION APPROACH: Public health interventions are most effective when communities integrate their own cultures and history into local programs. The food sovereignty movement among American Indians/Alaska Natives and indigenous populations globally offers ways to address public health issues such as chronic diseases like type 2 diabetes. Historical, economic, social, and environmental determinants of health are critical to understanding the disease. EVALUATION METHODS: During 2008-2014, seventeen tribal TFP partners implemented locally designed interventions and collected quantitative and qualitative data in 3 domains: traditional foods, physical activity, and social support. Partners entered data into a jointly developed evaluation tool and presented additional program data at TFP meetings. Partner observations about the effect of the TFP were gathered in planned discussions. RESULTS: Quantitative results indicate collaborative community engagement and sustained interventions such as gardening, availability of healthy foods across venues, new health practices, health education, and storytelling. Qualitative results demonstrate the importance of tribally driven programs, underscoring the significance of traditional foods in relation to land, identity, food sovereignty, and food security. IMPLICATIONS FOR PUBLIC HEALTH: Traditional foods and food sovereignty are important areas for American Indian/Alaska Native communities to address the public health issues of chronic disease, specifically type 2 diabetes, locally and nationwide.

Joint analysis of frontal theta synchrony and white matter following mild traumatic brain injury.

Some of the most disabling aspects of mild traumatic brain injury (mTBI) include lingering deficits in executive functioning. It is known that mTBI can damage white matter tracts, but it remains unknown how this structural brain damage translates into cognitive deficits. This experiment utilized theta band phase synchrony to identify the dysfunctional neural operations that contribute to cognitive problems following mTBI. Sub-acute stage (< 2 weeks) mTBI patients (N = 52) and healthy matched controls (N = 32) completed a control-demanding task with concurrent EEG. Structural MRI was also collected. While there were no performance-specific behavioral differences between groups in the dot probe expectancy task, the degree of theta band phase synchrony immediately following injury predicted the degree of symptom recovery two months later. Although there were no differences in fractional anisotropy (FA) between groups, joint independent components analysis revealed that a smaller network of lower FA-valued voxels contributed to a diminished frontal theta phase synchrony network in the mTBI group. This finding suggests that frontal theta band markers of cognitive control are sensitive to sub-threshold structural aberrations following mTBI.

Suicide Attempt Resiliency in American Indian, Hispanic, and Anglo Youth in New Mexico: The Influence of Positive Adult Relationships.

The purpose of this study was to identify whether positive relationships with adults at home, school, and in the community are protective for suicide among American Indian/Alaska Native, Hispanic, and Anglo adolescents. Using data from the New Mexico version of the 2015 Centers for Disease Control and Prevention Youth Risk Behavior Survey, we found that positive relationships with adults affected past-year suicide attempts differently in youth from the 3 groups. The final multivariable model for American Indian/Alaska Native youth included only positive relationships with adults in the home. Among Hispanic and Anglo youth, adults in the home and also in the community were protective.

Reduction in Head Computed Tomography Ordering in Pediatric Emergency Patients: Effect of National Publication and Local Availability of Urgent Neurology Appointments.

OBJECTIVE: The objective of this study was to evaluate the effect of the Pediatric Emergency Care Applied Research Network (PECARN) blunt head trauma guidelines and implementation of urgent neurology follow-up (UNF) appointments on an observed decline in head computed tomography (CT) use for pediatric emergency department (PED) patients presenting with headache, seizure, and trauma. METHODS: Patients ages 0 to 18 years presenting to and discharged from an urban tertiary care PED with chief complaint of trauma, headache, and seizure between 2007 and 2013 were retrospectively included. The total number of head CTs obtained in the trauma, headache, and seizure groups was compared before and after the publication of the PECARN guidelines in 2009 and the implementation of urgent UNF within a week from PED discharge in 2011, respectively. RESULTS: Between 2007 and 2013, 24,434 encounters were identified with 2762 head CTs performed. Analysis demonstrated a decline in pediatric head CTs for trauma (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.2) after the publication of the PECARN study on blunt head trauma, for headache (OR, 1.4; 95% CI, 1.1-1.8) and seizure (OR, 1.9; 95% CI, 1.4-2.6) with UNF. However, cross comparison (headache and seizure with PECARN and trauma with UNF) also demonstrated similar significant declines. CONCLUSIONS: The decline in head CTs observed at our institution demonstrated a strong linear relationship, yet cannot be solely attributed to the PECARN blunt head trauma study or the implementation of UNF.

Assessing the Prevalence and Predictors of Bullying Among Emergency Medical Service Providers.

Background: Bullying as a stressor in the workplace has been evaluated in numerous settings. It has never been evaluated in the emergency medical service (EMS) environment where bullying can occur from many different sources. The Negative Acts Questionnaire-Revised (NAQ-R) is a 22-question validated tool for evaluating bullying. Our hypothesis was that we could identify a shortened version of the NAQ-R that identifies bullying as accurately as the full screening tool. Methods: This was a cross sectional study of EMS providers in our local EMS transport agency. The local EMS agency transports approximately 50,000 patients per year and is a paramedic level response system. Results on the NAQ-R were on a 5-point Likert scale for each of 22 different categories of bullying that were summed by adding each questions 1-5 response for the 22 questions. Respondents were also categorized as victims or non-victims of bullying based on being positive for any of the 22 types of bullying at least once a week. We performed a binomial decision tree analysis and a cross-validation. Results: Data were collected from 153 providers. Mean age was 33 ± 10 years and 50% were male. Total years in EMS were 8 ± 8 years. NAQ-R summed results in our group ranged between 22 and 88, with an average of 40 ± 15. A NAQ-R score of 33 or less was 91% accurate in identifying non-victims and a score of 45 or more was 94% accurate in identifying victims. The majority at 51% (77/152) of respondents were victims of one or more types of bullying. A combination of five questions was 94% accurate in identifying a victim of bullying among EMS providers. Cross validation resulted in a misclassification risk estimate of 0.12 ± .03. Conclusion: NAQ-R bullying scores in EMS are similar or higher than numbers in other fields. Five questions on the NAQ-R were 94% accurate in identifying victims of bullying in EMS providers.

Observational Study of Grand Canyon Rim-to-Rim Day Hikers: Determining Behavior Patterns to Aid in Preventive Search and Rescue Efforts.

INTRODUCTION: Grand Canyon National Park has seen an increase in visitors traversing the canyon from rim to rim (R2R) in a single day. R2R hikers travel over 33.8 km (21 mi) over 3300 m (11,000 ft) of elevation change and endure large temperature changes. Grand Canyon emergency medical service providers provide emergency medical services to over 1100 visitors annually. Direct guidance by Preventive Search and Rescue rangers has improved safety. The objective of this study was to examine visitors attempting an R2R traverse and to enhance PSAR rangers' anticipatory guidance. METHODS: We conducted an observational study of R2R hikers in the spring and fall of 2015. Hikers consented to study inclusion and were interviewed at the starting trailhead, canyon bottom, and exit trailhead. We performed a survey and collected biometric data. RESULTS: We enrolled 617 visitors with a median age of 43 y (interquartile range [IQR] 33-53); 65% were male and 46% had hiked the R2R a median number of 3 times previously (IQR 2-7). Hydration strategies included water bottle only (20%), hydration bladder only (31%), and both water bottle and hydration bladder (48%). R2R crossers had an average start time of 0530 (SD 1.3 h) and median crossing time of 11.9 h (IQR 10.7-13.3). Crossing time and self-reported fatigue were negatively correlated with prior R2R experience (P=0.02). CONCLUSIONS: Crossing R2R in a day is hazardous and associated with risk of injury and illness. The results of this study can be used by Preventive Search and Rescue to reduce these risks by educating hikers.

Suicide Risk and Resiliency Factors Among Hispanic Teens in New Mexico: Schools Can Make a Difference.

BACKGROUND: Youth suicide is a serious public health problem in the United States. School environments, and the attention of school adults, are promising but minimally studied avenues for promoting mental health among students. METHODS: The 2013 New Mexico Youth Risk and Resiliency Survey data were analyzed to identify ways in which the school environment influences suicide attempts in a sample of Hispanic students. Factors examined were: relationships with school adults, speaking a language other than English at home, being born outside the United States and not having enough to eat. Odds ratios were used to measure relationships. RESULTS: Factors influencing suicide attempt were similar for boys and girls. The odds of suicide attempt declined by approximately one third as measures of positive relationships with school adults increased. Post-high school education plans also were protective. Being born outside the United States and not having enough to eat increased the odds of past-year suicide attempt. Speaking a language other than English at home was a weak risk factor for suicide attempt only among Hispanic girls. CONCLUSIONS: Teachers and other school adults can decrease suicide risk for Hispanic teens by forming supportive relationships with students. Special consideration should be given to providing free breakfast in schools.

The Association Between Positive Relationships with Adults and Suicide-Attempt Resilience in American Indian Youth in New Mexico.

This study examined the 2013 New Mexico Youth Risk and Resiliency Survey (NM-YRRS) to determine whether cultural connectedness and positive relationships with adults protected against suicide attempts among American Indian and Alaska Native (AI/AN) youth and whether these relationships differed by gender. The sample included 2,794 AI/AN students in grades 9 to 12 who answered the question about past-year suicide attempts. Protective factor variables tested included relationships with adults at home, school, and the community. The language spoken at home was used as a proxy measure for cultural connectedness. Positive relationships with adults were negatively associated with the prevalence of past-year suicide attempts in bivariate analysis. However, language spoken at home was not associated with the prevalence of suicide attempts. Multivariate analysis showed that among girls, relationships with adults at home, at school, and in the community were independently associated with lower suicide-attempt prevalence. Among boys, only relationships with adults at home showed such an association. These results have important implications for the direction of future research about protective factors associated with AI/AN youth suicide risk as well as in the design of suicide intervention and prevention programs.

Two Types of Prehospital Systems Interventions that Triage Low-Acuity Patients to Alternative Sites of Care.

OBJECTIVES: This study retrospectively compared alternatives for navigating low-acuity patients in two emergency medical services systems. System A involved a response to every 9-1-1 request with an "evaluate, treat, and refer" process, in which paramedics decided whether patients could be treated on-scene and referred to a primary care provider or urgent care center. System B used a "telephone triage and referral" process, in which callers of low severity were diverted from 9-1-1 to call centers where nurses provided advice and/or a referral to a primary care provider/urgent care center. We hypothesized that systems A and B would differ in terms of the percentage of patients following referral instructions and the percentage of patients who were satisfied with their care. METHODS: Independent variables were age, sex, and ZIP code. The two outcome measures were whether the patient followed the instructions given and patient satisfaction. χ(2) tests and multivariate logistic regression were used. RESULTS: Controlling for age, sex, income, and race, patients in system A had a lower likelihood of following instructions (odds ratio 0.31; 95% confidence interval 0.14-0.69). Satisfaction rates were high (>93%) but equivalent. CONCLUSIONS: The odds were lower that callers in system A would follow instructions. Satisfaction rates suggest that people are willing to accept alternatives to transport to the emergency department and high percentages of patients follow the instructions given.

Outcome of trauma patients immobilized by emergency department staff, but not by emergency medical services providers: a quality assurance initiative.

BACKGROUND: Prehospital selective cervical spine immobilization (CSI) is a relatively new concept. In our emergency medical services (EMS) system, protocols for selective CSI are widely used; yet, some patients who are brought to the hospital without CSI undergo secondary immobilization and cervical spine imaging in the emergency department (ED). Immobilization in the ED, after a decision not to immobilize by EMS, suggests that either the prehospital assessment is not trusted or the patient has developed new symptoms over time. We undertook a quality assurance initiative to evaluate whether trauma patients brought to the ED without CSI, who then underwent secondary CSI and imaging in the ED, had injuries that were initially missed by EMS selective CSI protocol. METHODS: This was a 36-month retrospective data analysis of blunt trauma patients transported directly from the field to the University of New Mexico Hospital level I trauma center by Albuquerque Ambulance Service (AAS) between March 2009 and February 2012. Inclusion criteria were age 18 years and older, transported by AAS without CSI, and cervical spinal imaging done in the ED. Patients were excluded if they were being transported between facilities, were prisoners, and/or refused CSI. A positive finding was defined as any acute abnormality identified by the attending radiologist on the final imaging report. RESULTS: The study included 101 patients who met inclusion criteria. There were no significant missed injuries. Ninety-four of the 101 patients received cervical spinal CT imaging at an estimated cost of $1,570 per scan, not including physician charges. The remaining patients had plain film radiographic imaging. No patients had magnetic resonance imaging. CONCLUSIONS: In this retrospective quality assurance initiative, none of 101 patients who underwent secondary CSI and imaging in the ED had a missed acute cervical injury. No patients had any adverse effects or required treatment, yet these patients incurred substantial costs and increased radiation exposure. While our results suggest hospital personnel should have confidence in prehospital decisions regarding CSI, continued surveillance and a large-scale, prospective study are needed to confirm our findings.

Rural-urban disparities in school nursing: implications for continuing education and rural school health.

PURPOSE: Little is known about the professional and educational challenges experienced by rural school nurses. We conducted this study to describe disparities between the urban and rural professional school nurse workforce in New Mexico and to identify how best to meet the continuing education needs of New Mexico's rural school nurse workforce. METHODS: We analyzed state data from a 2009 New Mexico Department of Health school nurse workforce survey (71.7% response rate). We included all survey respondents who indicated working as a school nurse in a public school setting in any grade K-12 and who identified their county of employment (N = 311). FINDINGS: Rural school nurses were twice as likely as metropolitan nurses to provide clinical services to multiple school campuses (67.3% compared to 30.1%, P < .0001). They were less likely to hold a nursing degree at the baccalaureate level or higher (62.7% compared to 82.3%, P = .0002). Rural school nurses were less likely than metropolitan nurses to have received recent continuing education on anaphylaxis (P < .0001), asthma (P = .027), body mass index (BMI)/healthy weight (P = .0002), diabetes (P < .0001), lesbian, gay, bisexual and transgender (LGBT) health (P = .0004), and suicide risk identification and prevention (P = .015). Online courses and telehealth were identified by rural school nurses as among the preferred means for receiving continuing education. CONCLUSIONS: Our findings support the provision of online courses and telehealth content to address urban-rural disparities in school nursing education and support rural school health.

Does ambulance response time influence patient condition among patients with specific medical and trauma emergencies?

OBJECTIVES: The relation between patient outcome and ambulance response times is unknown. We sought to measure the influence of shorter response times on patient outcomes. The objective of the study was to determine whether ambulance response time makes a difference in the outcomes of emergency medical services (EMS) patients with specific traumatic and medical emergencies. METHODS: This study was conducted in a metropolitan EMS system serving a population of 800,000, including urban and rural areas. Cases were included if the private EMS service was the first medical provider on scene, the case was priority 1, and the patients were 13 years old and older. A 14-month time period was used for the data evaluation. Four diagnoses were examined: motor vehicle crash injuries, penetrating trauma, difficulty breathing, and chest pain complaints. Data collected included ambulance response times, initial vital signs, and the number of vital signs out of range. Cases seen at the single major trauma center were selected for evaluation of hospital outcome. Correlation coefficients were used to evaluate interactions between independent and outcome variables. RESULTS: Of the 2164 cases we reviewed, the EMS service responded significantly faster to trauma complaints at 4.5 minutes (n = 254) than medical complaints at 5.9 minutes (n = 1910). In the trauma center sample of 559 cases, response time was not related to hospital days (P = 0.5), admissions (P = 0.7), intensive care unit admissions (P = 0.4), or deaths (P = 0.3). CONCLUSIONS: This study showed that in cases seen at a major trauma center, longer response times were not associated with worse outcomes for the diagnostic groups tested.

Assessing EMS scope of practice for utility and risk: the New Mexico EMS Interventions Assessment Project, Phase One results.

INTRODUCTION: Few emergency medical services (EMS) interventions in New Mexico have been assessed for efficacy, potential harm, or potential benefit. There is concern that many interventions added over the years may be outdated, harmful, or ineffective in the EMS setting. A formal process for reviewing the state EMS scope of practice using literature review and expert consensus is discussed. In Phase One of the project, interventions in the New Mexico EMS scope of practice were prioritized for further review by surveying a national cadre of EMS experts to evaluate EMS interventions using a utilitarian harm/benefit metric. METHODS: An electronic survey based on the 2010 New Mexico EMS Scope of Practice statute was administered from March through June, 2011. A national cadre of 104 respondents was identified. Respondents were either State EMS medical directors or EMS fellowship directors. Respondents were asked to rate the potential harm and the potential benefit of specific EMS interventions on a 5-point ordinal scale. Median harm and benefit scores were calculated. RESULTS: A total of 88 completed surveys were received following 208 emailed invitations to 104 respondents (43% response rate). Twenty-two (22) highest-priority interventions (those with a harm/benefit median score ratio of >1) were identified. Seven additional second-priority interventions were also identified. These interventions will be advanced for formal literature review and expert consensus. CONCLUSIONS: The New Mexico EMS Interventions Project offers a novel model for assessing a prehospital scope of practice.

Ondansetron oral dissolving tablets are superior to normal saline alone for prehospital nausea.

BACKGROUND: Antiemetics have been shown to be effective in multiple hospital settings, but few studies have been done in the prehospital environment. OBJECTIVES: Our hypotheses were 1) that the amount of normal saline administered during an emergency medical services (EMS) transport was not related to a change in nausea and vomiting and 2) that the addition of the ondansetron orally disintegrating tablet (ODT) would decrease the degree of nausea. METHODS: This was a pre-post study of two cohorts of consecutive patients with nausea in the prehospital setting. During phase 1 of the study, our local EMS agency adopted a protocol form to complete whenever a patient with nausea and/or vomiting was assessed and transported to one of the area hospitals. Patients were asked to rate their nausea on a visual analog scale (VAS) and a Likert scale, and saline administration and active vomiting were documented. During phase 2, our EMS system adopted the use of ondansetron ODT for nausea and continued to complete the same forms. The nausea forms completed by EMS during phase 1 (saline only) and phase 2 (ondansetron ODT) were evaluated and compared. For both phases, the primary outcome measures were the change in VAS nausea rating (0 = no nausea, 100 = most nausea imaginable) from beginning to end of the transport and the results on the Likert scale completed at the end of the transport. Relationships were considered significant if p < 0.01. RESULTS: Data were collected from 274 transports in phase 1 and 372 transports in phase 2. The average patient age was 50 ± 12 years. In phase 1 of the study, 178 of 274 patients (65%) received normal saline (mean volume ± standard deviation = 265 ± 192 mL). There was no significant correlation between the VAS change and the amount of fluid administration in either phase of the study. Conversely, during phase 2, patients receiving ondansetron ODT showed significant improvement in both measures of nausea. The difference in nausea improvement between phase 1 and phase 2 was significant (difference in VAS change: 24.6; 95% confidence interval 20.9, 28.3). CONCLUSION: There was no improvement in patient nausea related to quantity of saline alone during an EMS transport. The addition of ondansetron ODT resulted in a significant improvement in degree of nausea.

Hypertension in the ED: a multifaceted intervention to change provider practice.

This project measured the effect of a multifaceted intervention on health care provider identification and treatment of undiagnosed hypertensive patients. The intervention comprised provider education, audit, and feedback. The primary outcomes were pre-/postintervention differences in the proportion of patients presenting with elevated blood pressure who were (1) identified, (2) given blood pressure measurements, (3) counseled regarding behavior change, (4) prescribed medications, and (5) advised of the need for follow-up. These 5 behaviors were selected based on the recommendations in the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Rates of all 5 outcomes improved significantly after the intervention, with prevalence differences ranging from 5% to 25%. However, despite increases, rates for each behavior remained low. At no point during the study were all 5 practitioner behaviors documented for an individual patient. In conclusion, while an intervention composed of education and practitioner audit and feedback improved practitioner behaviors in treating patients with elevated blood pressure, additional interventions are needed to bring practitioner behaviors up to the level of JACHO standards.

School nurse online emergency preparedness training: an analysis of knowledge, skills, and confidence.

The objective of this study was to evaluate the effectiveness of a computer-assisted emergency preparedness course for school nurses. Participants from a convenience sample (52) of school nurses from New Mexico were randomly assigned to intervention or control groups in an experimental after-only posttest design. Intervention group participants completed 15 online emergency preparedness training modules followed by posttests, and control group participants completed the posttests without taking the training modules. Tests measured emergency preparedness with written exams, confidence surveys, and skills performance in videotaped scenarios; the videotaped scenarios were scored by Pediatric Emergency Medicine physicians blinded to whether the participants were in the intervention or control group. The intervention group participants scored significantly higher in tests of knowledge and skills than control group participants. Confidence Survey scores did not differ significantly. The online training modules are a valuable resource for improving school nurse emergency preparedness knowledge and skills but may not affect participants' confidence.