A pilot study to improve provider adherence to NAEPP guidelines.

The prevalence and morbidity of Asthma in the United States has increased since the 1991 National Asthma Education and Prevention Program (NAEPP) and updated Expert Panel Report -3 (EPR-3) guidelines in 2007 were published. To improve provider adherence to the NAEPP EPR-3 guidelines Children's Hospital of Orange County (CHOC) in California integrated the HealtheIntentSM Pediatric Asthma Registry (PAR) into the electronic medical record (EMR) in 2015. METHODS: A serial cross-sectional design was used to compare provider management of CHOC MediCal asthma patients before 2014 (N = 6606) and after 2018 (N = 6945) integration of the Registry with NAEPP guidelines into the EMR. Four provider adherence measures (Asthma Control Test [ACT], Asthma Action Plan [AAP], inhaled corticosteroids [ICS] and spacers) were evaluated using General Linear Mixed Models and Chi square. FINDINGS: In 2018, patients were more likely to receive an ACT, (OR = 14.95, 95% CI 12.67, 17.65, p < .001), AAP (OR = 12.70, 95% CI 11.10, 14.54, p < .001), ICS (OR = 1.85, 95% CI 8.52, 14.54, p < .001) and spacer (OR = 1.45, 95% CI 1.31, 1.6, p < .001) compared to those in 2014. DISCUSSION: The pilot study showed integration of the Pediatric Asthma Registry into the EMR, as a computer decision support tool that was an effective intervention to increase provider adherence to NAEPP guidelines. Ongoing monitoring and education are needed to promote and sustain provider behavioral change. Additional research to include multi-sites and decreased time between evaluation years is recommended. APPLICATION TO PRACTICE: Can be used for excellent health policy decision making as a direct impact on patient care and outcomes, by improving provider adherence to the NAEPP guidelines.

App-Based Mindfulness Intervention to Improve Psychological Outcomes in Pretransplant Patients With Heart Failure.

BACKGROUND: Patients hospitalized with life-threatening conditions experience psychological stressors that can lead to anxiety and poor patient outcomes. Mindfulness stress reduction interventions have been shown to decrease stress and anxiety with sustained effect. LOCAL PROBLEM: In a single center's cardiac care units, only pharmacological stress reduction options were embedded in the daily care plan. METHODS: This project evaluated the feasibility and effect of a brief mindfulness intervention on stress, anxiety, and resilience in 20 hospitalized patients with advanced heart failure awaiting transplant. A 1-group, pretest-posttest design over a 4-week period was used. The intervention included a one-on-one mindfulness education session and a 12-minute audio-guided tablet computer app for daily self-practice. Outcome variables measured at baseline and 2 and 4 weeks after implementation included stress (10-item Perceived Stress Scale), anxiety (7-item Generalized Anxiety Disorder instrument), and resilience (10-item Connor-Davidson Resilience Scale). Statistical analysis included descriptive statistics and repeated-measures analysis of variance with Friedman tests, Bonferroni post hoc tests, and Wilcoxon matched-pairs tests. RESULTS: Significant reductions in stress and anxiety and increase in resilience occurred from baseline to 2 weeks and 4 weeks after intervention (all P = .001). Feasibility and acceptability were evident from patient experience survey data and focused interview responses. CONCLUSIONS: A brief mindfulness intervention holds promise for improving stress, anxiety, and resilience for patients with advanced heart failure awaiting transplant. Nurse-led stress reduction interventions are imperative for best patient outcomes. An evidence-based intervention of mindfulness practice embedded into daily usual patient care may be a feasible option.

Biopsychosocial predictors of psychological functioning among African American breast cancer survivors.

This study examined the relationships of biological and psychosocial predictors as contributing factors to the psychological functioning among breast cancer survivors. A sample of (N = 155) African American breast cancer survivors were recruited from California. A general linear model was utilized to examine the relationships. Biological and psychosocial risk factors were significant predictors for anxiety and depression. These predictors can be viewed as contributing factors to the psychological well-being of this cohort. Anxiety and depression are often under-recognized and subsequently undertreated in survivors. Understanding the predictors of depression and anxiety is necessary for incorporating a multidisciplinary approach to address this problem.

Peer-mentored preparedness (PM-Prep): a new disaster preparedness program for adults living independently in the community.

The authors studied a health promotion program called PM-Prep (Peer-Mentored Prep), which was designed to improve disaster preparedness among adults living independently in the community. PM-Prep consists of four 2-hour classes co-taught by a health educator and peer-mentors. Adults were randomly assigned to an experimental arm or a wait-list control arm. Earthquake safety knowledge and preparedness supplies were assessed prior to the intervention and at 1 month after the intervention (N  =  82). Adults in the experimental arm significantly increased preparedness by 19 percentage points, from 56% to 75% completed (p < .0001), and improved their knowledge by 8 percentage points, from 79% to 87% correct (p  =  .001). This is the first peer-mentored, targeted, and tailored disaster preparedness program tested with this population.

The association of health literacy, social support, self-efficacy and interpersonal interactions with health care providers in low-income Latina mothers.

OBJECTIVE: We explored relationships between maternal health literacy (HL), communicative self-efficacy (SE), social support (SS) and maternal perception of interactions with health care providers (HCPs). METHODS: Using a cross-sectional, correlational design, we assessed sociodemographic characteristics, maternal HL, social support, communicative self-efficacy, and interpersonal interactions with HCPs among 124 low-income Latina mothers of young children. RESULTS: Informal SS significantly predicted maternal SE in interactions. SE predicted maternal perception of a HCP's ability to "elicit and respond to her concerns." DISCUSSION: Interventions to improve maternal self-efficacy in interacting with HCPs among low health literate Latina mothers may positively impact pediatric health outcomes.

Health literacy and interpersonal interactions as predictors of maternal perception of ambulatory care for low-income, Latino children.

OBJECTIVE: This study explores whether maternal HL (MHL) and maternal perception of health care provider (HCP) interpersonal interactions predict maternal perception of quality of pediatric ambulatory care received. METHODS: This cross-sectional study included 124 low-income Latina mothers of children 3 months to 4 years. Maternal HL, perception of maternal-HCP interpersonal interactions, and perception of pediatric ambulatory care were measured using well-validated surveys. RESULTS: In adjusted hierarchical regression models, HCP fail to speak clearly (ß=-.225, 95% CI -13.998, -1.960, p=.01) and explain results (ß=.344, 95% CI 3.480, 13.010, p=.001) predicted perception of quality of developmental guidance received. Explaining results (ß=.422, 95% CI 5.700, 14.089, p=<.001), working out treatment together (ß=.441, 95% CI 6.657, 13.624, p<.001) and MHL (ß=-.301, 95% CI -7.161, -2.263, p<.001) predicted perception of family centeredness of care. CONCLUSIONS: Speaking with clarity, explaining results fully and working with the mother to determine a child's plan of care is most predictive of whether she feels her child is receiving high quality pediatric ambulatory care services. PRACTICE IMPLICATIONS: Interventions that target mother and provider interaction may improve perception of care.

Remote monitoring of pain and symptoms using wireless technology in children and adolescents with sickle cell disease.

PURPOSE: The purpose of this study was to examine (a) symptoms, (b) pain characteristics (intensity, location, quality), (c) pain medications and nonpharmacological strategies used for pain, (d) thoughts and feelings, and (e) healthcare visits. We also examined the relationship between pain and sleep. DATA SOURCES: Pain and symptoms were entered on an electronic e-Diary using a smartphone and were remotely monitored by an advanced practice registered nurse (APRN). Sixty-seven children and adolescents (10-17 years) reported mild to severe pain at home that did not require healthcare visits. Symptoms reported were (a) general symptoms such as tiredness/fatigue (34.7%), headache (20.8%), yellowing of the eyes (28.4%); (b) respiratory symptoms such as sniffling (32.9%), coughing (19.1%), changes in breathing (10.0%); and (c) musculoskeletal symptoms such as stiffness in joints (15.8%). A significant negative correlation was found between pain and sleep (r = -.387, p = .024). Factors that predict pain included previous history of sickle cell disease (SCD) related events, symptoms, and negative thoughts. CONCLUSION: Pain and multiple symptoms entered on a web-based e-Diary were remotely monitored by an APRN and prompted communications, further evaluation, and recommendations. IMPLICATIONS FOR PRACTICE: Remote monitoring using wireless technology may facilitate timely management of pain and symptoms and minimize negative consequences in SCD.

Facilitating pediatric patient-provider communications using wireless technology in children and adolescents with sickle cell disease.

INTRODUCTION: Use of wireless devices has the potential to transform delivery of primary care services for persons with sickle cell disease (SCD). The study examined text message communications between patients and an advanced practice registered nurse (APRN) and the different primary care activities that emerged with use of wireless technology. METHODS: Patients (N = 37; mean age 13.9 ± 1.8 years; 45.9% male and 54.1% female) engaged in intermittent text conversations with the APRN as part of the Wireless Pain Intervention Program. Content analyses were used to analyze the content of text message exchanges between patients and the APRN. RESULTS: The primary care needs that emerged were related to pain and symptom management and sickle cell crisis prevention. Two primary care categories (collaborating and coaching), four primary care subcategories (screening, referring, informing, and supporting), and 16 primary care activities were evident in text conversations. DISCUSSION: The use of wireless technology may facilitate screening, prompt management of pain and symptoms, prevention or reduction of SCD-related complications, more efficient referral for treatments, timely patient education, and psychosocial support in children and adolescents with SCD.

A crossover randomized prospective pilot study evaluating a central venous catheter team in reducing catheter-related bloodstream infections in pediatric oncology patients.

BACKGROUND: Treatment for most children with cancer includes the use of a central venous catheter (CVC). CVCs provide reliable venous access for delivery of chemotherapy and supportive care. This advantage is mitigated by an increased risk of bloodstream infections (BSIs). Despite the ubiquitous use of CVCs, few prospective studies have been conducted to address infection prevention strategies in pediatric oncology patients. DESIGN: Prospective, crossover pilot study of a CVC team intervention versus standard care. SETTING: Two inpatient oncology units in a metropolitan children's hospital. PATIENTS: A total of 41 patients/135 admissions for the experimental unit (EU) and 41/129 admissions for the control unit (CU). METHODS: Patients received a CVC blood draw bundle procedure by a CVC registered nurse (RN) team member (experimental intervention: EU) for 6 months and by the assigned bedside RN (standard care: CU) for 6 months. Feasibility of implementing a CVC RN team; a significant difference in CVC-related BSIs between the team intervention versus standard care and risk factors associated in the development of CVC-related BSIs were determined. RESULTS: There were 7 CVC-related BSIs/1238 catheter days in the EU group (5.7/1000 catheter days) versus 3 CVC-related BSIs/1419 catheter days in the CU group (2.1/1000 catheter days; P = .97). Selected risk factors were not significantly associated with the development of a CVC-related BSI. CONCLUSIONS: A CVC team in the care of pediatric oncology patients is feasible; however, a larger cohort will be required to adequately determine the effectiveness of the team reducing CVC-related BSIs.

"Targeting to zero" in pediatric oncology: a review of central venous catheter-related bloodstream infections.

Reducing or eliminating hospital acquired infections is a national quality of care priority. The majority of the 12,400 children diagnosed with cancer each year require long-term intravenous access to receive intensive and complex therapies. These children are at high risk for infection by nature of their disease and treatment, which often involves use of a central venous catheter (CVC). Throughout the nation, nurses assume frontline responsibility for safe, quality CVC care to minimize the risk of potentially life-threatening infections. Substantial financial and human costs are associated with CVC-related bloodstream infections, including prolonged hospital lengths of stay and increased care required to treat these infections. The purpose of this review of the literature is to summarize existing adult and pediatric data on CVC-related bloodstream infections and explore nursing models of CVC care that may improve pediatric oncology patient outcomes.

Feasibility of the use of a reliable and valid central venous catheter blood draw bundle checklist.

The primary objective of this study was to test the feasibility of creating a central venous catheter blood draw bundle checklist to ensure adherence to the evidence-based blood draw procedure. This study included establishing checklist reliability and validity and periodic observations in 2 inpatient pediatric oncology units. The findings provided support for the reliability and validity of this checklist based on content validity, test-retest reliability, interrater agreement, and internal consistency and reinforced the need for periodic observations to ensure consistency in proper central venous catheter blood draw procedures.

Cost-effectiveness analysis of behavioral interventions to improve vaccination compliance in homeless adults.

AIMS: To estimate the cost-effectiveness of three behavioral interventions provided to enhance hepatitis A virus (HAV) and hepatitis B virus (HBV) joint vaccination (HAV/HBV) compliance among homeless persons living in Los Angeles County. SCOPE: A cost-effectiveness analysis (CEA) based on data from a randomized trial where the costs and compliance data from the trial are incorporated into two Markov models, simulating the natural history of acute and chronic hepatitis infection, following HAV/HBV vaccination. CONCLUSIONS: Reductions in HBV-related disease is cost-effective to society and is associated with substantial improvements in quality of life.

Rodent allergen in Los Angeles inner city homes of children with asthma.

Recent studies have examined the presence of mouse allergen in inner city children with asthma. Researchers have found high levels of rodent allergen in homes sampled in the northeast and midwest United States, but there has been considerable variation between cities, and there have been few studies conducted in western states. We evaluated the frequency of rodent sightings and detectable mouse allergen and the housing conditions associated with these outcomes in inner city homes in Los Angeles. Two hundred and two families of school children, ages 6-16 living in inner city neighborhoods, participated in the study. Families were predominantly Latino (94%), and Spanish speaking (92%). At study entry, parents completed a home assessment questionnaire, and staff conducted a home evaluation and collected kitchen dust, which was analyzed for the presence of mouse allergen. Fifty-one percent of homes had detectable allergen in kitchen dust. All 33 families who reported the presence of rodents had detectable allergen in the home and were also more likely to have increased levels of allergen compared to those who did not report rodents. Unwashed dishes or food crumbs, lack of a working vacuum, and a caretaker report of a smoker in the home were all significantly associated with a greater risk of rodent sightings or detectable allergen (P<0.05). Detached homes were significantly more likely to have detectable allergen. The prevalence of allergen is common enough that it may have public health implications for asthmatic children, and detectable allergen was not routinely identified based on rodent sightings. Many of the predictors of rodent allergen are amenable to low-cost interventions that can be integrated with other measures to reduce exposure to indoor allergens.

Household smoking behavior and ETS exposure among children with asthma in low-income, minority households.

Environmental tobacco smoke (ETS) exposure was measured among 242 children with asthma who live in homes where at least one person smokes. Subjects were identified through clinics, schools, community agencies, and hospitals serving low-income, medically underserved communities in Los Angeles. Parents were surveyed about smoking behaviors in the household, children's ETS exposure, and attitudes towards smoking and smoking behavior change. Validation measures included urine cotinine for the child with asthma and passive air nicotine monitors placed in the subjects' homes. Overall reported levels of household smoking and ETS exposure were low, with a significant amount of household smoking taking place outside rather than inside the home. Over 47% of the respondents reported absolute restrictions against smoking in the home, and these restrictions were associated with lower reported levels of smoking, ETS exposure, and air nicotine and urine cotinine concentrations.

The quality of health care for adults with developmental disabilities.

OBJECTIVE: The purpose of this study was to determine the health status of adults with developmental disabilities residing in community settings and the quality of the preventive, medical, dental, and psychiatric services they receive. METHODS: Data were collected on a sample of 353 adults residing in Los Angeles, California, in 1997. Historical data were obtained from study subjects or caregivers, physical and dental examinations were performed, blood was drawn for analysis, and a psychiatrist reviewed medical records for reports of psychiatric diagnoses and consultations. RESULTS: Health markers, such as rates of obesity, and laboratory test results of routine screening panels including blood cell counts, hemoglobin, and hematocrits; blood concentrations of liver enzymes and other enzymes, cholesterol, and tryglycerides; and urinalyses were within normal limits for an adult population. However, preventive services were notably lacking, especially for individuals living at home. Fewer than half of the study subjects had received influenza vaccine; only a third of those living alone or with family or friends had received this vaccination. Chart audits revealed that about a third received psychotropic medications, but only 24% of these individuals had psychiatric consultations noted in their record. Further, 36% of this medicated group received psychotropic drugs without any identifiable diagnosis, and simultaneous receipt of two or more antipsychotics was not uncommon. CONCLUSIONS: Given that the U.S. health care system fails to ensure the provision of preventive services for all people, including the developmentally disabled, a systematic overhaul is necessary to establish an effective quality assurance program that will provide preventive medical, dental, and psychiatric services for people with developmental disabilities.