The Effect of Preoperative Chlorhexidine Gluconate Cleanse on Lower Extremity Surgical Site Infections: A Retrospective Cohort Study.

BACKGROUND: Lower extremity surgical sites are at an increased risk of wound infection following Mohs micrographic surgery. OBJECTIVE: To evaluate the rate of lower extremity surgical site infections following a 14-day regimen of preoperative 4% chlorhexidine gluconate (CHG) rinses and postoperative wound occlusion for 14 days. MATERIALS AND METHODS: Retrospective data were collected from procedures performed by the senior author from January 2022 through June 2023. To meet inclusion, patients must have completed waist-down CHG soak and rinse for 14 days before surgery, including the day before surgery. In addition, the patient must have kept the dressing clean, dry, and intact until the postoperative appointment at 14 days. RESULTS: A total of 100 Mohs cases met inclusion criteria. Zero patients developed a surgical site infection. CONCLUSION: Chlorhexidine gluconate preoperative rinsing and postoperative occlusion for 14 days may minimize the risk of wound infection. Although further research is indicated, an opportunity exists for the adoption of CHG into routine clinical practice in the outpatient dermatology setting.

Multi-State Implementation of Go NAPSACC to Support Healthy Practices in the Early Care and Education Setting.

Childhood obesity in the United States is a serious problem that puts children at risk for poor health. Effective state-wide interventions are needed to address childhood obesity risk factors. Embedding evidence-based initiatives into state-level Early Care and Education (ECE) systems has the potential to improve health environments and promote healthy habits for the 12.5 million children attending ECE programs. Go NAPSACC, an online program that was adapted from an earlier paper version of Nutrition and Physical Activity Self-Assessment for Child Care (NAPSACC or NAP SACC), provides an evidence-based approach that aligns with national guidance from Caring for Our Children and the Centers for Disease Control and Prevention. This study describes approaches undertaken across 22 states from May 2017 to May 2022 to implement and integrate Go NAPSACC into state-level systems. This study describes challenges encountered, strategies employed, and lessoned learned while implementing Go NAPSACC state-wide. To date, 22 states have successfully trained 1,324 Go NAPSACC consultants, enrolled 7,152 ECE programs, and aimed to impact 344,750 children in care. By implementing evidence-based programs, such as Go NAPSACC, ECE programs state-wide can make changes and monitor progress on meeting healthy best practice standards, increasing opportunities for all children to have a healthy start.

Contributing to a Quality Patient Experience: Applying Evidence Based Practice to Support Changes in Nursing Dress Code Policies

The public image of nurse professionalism is important. Attributes of a professional nurse, such as caring, attentive, empathetic, efficient, knowledgeable, competent, and approachable, or lack thereof, can contribute positively or negatively to the patient experience. Nurses at a hospital in central northeast Pennsylvania offer their story as they considered the impact of a wide variety of individual uniform and dress choices. This article describes an evidence based practice project and survey created to increase understanding of patient perceptions regarding the professional image of nurses in this facility. Exploring patient perception of nurse image provided insight into what patients view as important. A team approach included the voice of nurses at different levels in the process. Ultimately, this work informed a revision of the health system nursing dress code. The study team also reflects on challenges, next steps in the process, and offers recommendations based on their experiences.

Evaluation of a nurse leadership development programme.

The challenge for nursing leaders responsible for workforce planning is to predict the knowledge, skills and abilities required to lead future healthcare delivery systems effectively. Succession planning requires a constant, competitive pool of qualified nursing leader candidates, and retention of those interested in career growth. Formal nursing leadership education in the United States is available through graduate education and professional nursing organisation programmes, such as the Emerging Nurse Leader Institute of the American Organization of Nurse Executives. However, there is also a need for local development programmes tailored to the needs of individual organisations. Leaders at Geisinger Health System, one of the largest rural health systems in the US, identified the need for an internal professional development scheme for nurses. In 2013 the Nurses Emerging as Leaders programme was developed to prepare nurse leaders for effective leadership and successful role transition. This article describes the programme and an evaluation of its effectiveness.

A Single Long-Term Acute Care Hospital Experience with a Pressure Ulcer Prevention Program.

PURPOSE: The occurrence of pressure ulcers (PrUs) challenges care facilities. Few studies report PrU reduction efforts in long-term acute care (LTAC). This study described the PrU reduction efforts of a single, LTAC facility using the Medline Pressure Ulcer Prevention Program (mPUPP). DESIGN: This study was a quasi-experimental, quality improvement project, with pre- and postmeasurement design. METHODS: Outcomes were tracked for 24 months. The mPUPP was implemented in month 11. Education for caregivers was provided through an interactive web-based suite. In addition, all Patient Care Technicians attended a 4-week 1-hour inservice. New skin care products were implemented. The facility also implemented an algorithm for treatment of wounds. FINDINGS: There was a significant reduction in the mean monthly hospital-acquired PrU (nPrU) rate when preprogram is compared to postprogram. CONCLUSIONS: Sustainable nPrU reduction can be achieved with mPUPP. CLINICAL RELEVANCE: LTAC hospitals could expect to reduce nPrU with education and incentive of caregivers.

Time Playing Outdoors Among Children Aged 3-5 Years: National Survey of Children's Health, 2021.

INTRODUCTION: Federal guidelines recommend physical activity throughout the day for preschool-aged children. Time playing outdoors can support physical activity participation, health, and development. Estimates of time playing outdoors among U.S. children aged 3-5 years have not been published. METHODS: Parent/caregiver-reported data on children aged 3-5 years from the 2021 National Survey of Children's Health were analyzed in 2022-23. Chi-square tests were used to identify differences in time playing outdoors by sociodemographic and neighborhood characteristics. Multiple logistic regression analyses were conducted with significant characteristics for weekdays and weekend days. RESULTS: Among 11,743 children aged 3-5 years, 37% played outdoors for ≤1 hour on weekdays, and 24% played outdoors for ≤1 hour on weekend days. In 9 states, ≥40% of children played outdoors for ≤1 hour on weekdays. Adjusted models for weekdays and weekend days showed a greater likelihood of ≤1 hour playing outdoors among those in all racial/ethnic groups compared to non-Hispanic White, those who lived in metropolitan statistical areas, those who did not participate in child care, and those whose adult proxy disagreed with "we watch out for each other's children in this neighborhood." The weekday model showed additional differences by sex, with girls more likely to have ≤1 hour of time playing outdoors. CONCLUSIONS: Nearly 40% of preschool-aged children play outdoors for ≤1 hour per day on weekdays, with differences by sociodemographic and neighborhood characteristics. Further study and interventions focused on building supportive, equitable communities might increase the amount of time preschool-aged children spend playing outdoors.

Development and implementation of a workshop for young adults with diabetes entering college and the workforce.

The process of transitioning from pediatric to adult diabetes care for adolescents and young adults is challenging. This transition period may include many life changes, and can be fraught with worsening glycemic control leading to increased risk for diabetes-related hospitalizations and complications. Research has demonstrated that increased support during this period can help maintain engagement in diabetes care. Transition guidelines highlight the importance of preparation and readiness for transition. In this article, we discuss the development, implementation and content of a workshop for patients and parents/caregivers preparing for the transition to college, the workforce and adult diabetes care.

Short-term use of CGM in youth onset type 2 diabetes is associated with behavioral modifications.

Background: Continuous glucose monitoring (CGM) is beneficial to glycemic control in youth with type 1 diabetes (T1D) and adults with type 2 diabetes (T2D); however, studies in youth with T2D are limited. Objective: Determine if 10-day trial CGM use in youth with T2D improves glycemic control and behavioral modifications. Methods: Youth with T2D > 3 months, on insulin, with no prior CGM use were enrolled. Staff placed CGM and provided education. Participants received 5-day and 10-day follow-up phone calls to review CGM data, behavioral modifications, and adjust insulin doses as needed. We compared 5-day to 10-day TIR, and baseline to 3-6 month HbA1c via paired t-test. Results: Participants (n=41) had median age of 16.2 y, were 61% female, 81% NH Black, median diabetes duration of 0.8 y, and baseline HbA1c of 10.3%. A majority had household income<$50,000 (81%) and parental education level of HS or less (73%). Average 5-day TIR 49% was similar to 10-day TIR 51% (p=0.62). There was no change in HbA1c after 3-6 months (10.2% v 10.3%, p=0.89). Nineteen participants completed full 10-day CGM use; of those, 84% wanted a CGM long-term. Adolescents reported behavioral changes including increased blood sugar checks, increased insulin administration and overall improved diabetes management. Conclusion: Although 10-day CGM use did not impact short-term or long-term glycemic control in youth with T2D, most participants reported behavioral changes and wanted to continue using CGM. Future studies with longer use of CGM may clarify the potential impact of CGM in youth with T2D.

Worsening glycemic control in youth with type 2 diabetes during COVID-19.

Introduction: The COVID-19 pandemic has disproportionately affected minority and lower socioeconomic populations, who also have higher rates of type 2 diabetes (T2D). The impact of virtual school, decreased activity level, and worsening food insecurity on pediatric T2D is unknown. The goal of this study was to evaluate weight trends and glycemic control in youth with existing T2D during the COVID-19 pandemic. Methods: A retrospective study of youth <21 years of age diagnosed with T2D prior to March 11, 2020 was conducted at an academic pediatric diabetes center to compare glycemic control, weight, and BMI in the year prior to the COVID-19 pandemic (March 2019-2020) to during COVID-19 (March 2020-2021). Paired t-tests and linear mixed effects models were used to analyze changes during this period. Results: A total of 63 youth with T2D were included (median age 15.0 (IQR 14-16) years, 59% female, 74.6% black, 14.3% Hispanic, 77.8% with Medicaid insurance). Median duration of diabetes was 0.8 (IQR 0.2-2.0) years. There was no difference in weight or BMI from the pre-COVID-19 period compared to during COVID-19 (Weight: 101.5 v 102.9 kg, p=0.18; BMI: 36.0 v 36.1 kg/m2, p=0.72). Hemoglobin A1c significantly increased during COVID-19 (7.6% vs 8.6%, p=0.0002). Conclusion: While hemoglobin A1c increased significantly in youth with T2D during the COVID-19 pandemic, there was no significant change in weight or BMI possibly due to glucosuria associated with hyperglycemia. Youth with T2D are at high risk for diabetes complications, and the worsening glycemic control in this population highlights the need to prioritize close follow-up and disease management to prevent further metabolic decompensation.

Implementing an MSN nursing program at a distance through an urban-rural partnership.

Recruiting, retaining, and educating advanced practice nurses is essential to meet the growing need for advanced practice nurses in rural and urban communities. Through the support of Health Resources and Services Administration funding, the urban school of nursing expanded its MSN program and implemented the graduate curriculum on its rural campus by utilizing emerging online and distance education technologies. The purpose of this manuscript is to provide an overview of expanding an existing MSN program offered in an urban, traditional classroom setting to rural graduate nursing students via an online synchronous format. In addition, the article will describe the rural growth of the existing neonatal nurse practitioner program as an exemplar and the different methodologies that are being used in each program to engage the rural nurse practitioner students in clinical courses. In addition, strategies to address barriers related to rural nurse practitioner student recruitment and retention will be discussed.

Communication frequency between visits is associated with improved glycemic control in pediatric diabetes.

OBJECTIVES: Children with diabetes are advised to see their diabetes team every 3 months, with interim communication to address insulin dose adjustments. Despite increasing digital accessibility, there is limited data on whether provider-patient communication frequency is associated with glycemic control in pediatric diabetes. We assessed patterns of communication between diabetes clinic visits and whether communication frequency via electronic messaging (EM) and telephone was associated with glycemic control in pediatric diabetes. METHODS: Retrospective chart review of 267 children with type 1 (T1DM) and type 2 diabetes (T2DM) over a 1-year period (July 2018-June 2019) at an urban academic pediatric diabetes center. Association between frequency of communication (via EM and telephone) and HbA1c was analyzed using regression analysis. RESULTS: Of 267 participants, 224 (84%) had T1DM, 43 (16%) had T2DM, mean age 11.6 years (SD 4), mean duration of diabetes 3.5 years (SD 3.4), and mean HbA1c 73.8 ± 23 mmol/mol (8.9 ± 2.2%). Most participants (82%) communicated with their diabetes team at least once per year, with a mean number of overall communications of 10.3 ± 13.6 times. Communications were via EM (48%), phone (40%), or both (53%). Participants with more frequent communication had lower HbA1c values (p=0.007), even when controlling for age, sex, provider, and number of clinic visits per year. We determined that a threshold of three communications per year was associated with a lower HbA1c (p=0.006). CONCLUSIONS: More frequent communication with the diabetes team between visits is associated with improved glycemic control. Initiatives to contact diabetes patients between clinic visits may impact their overall glycemic control.

Enhancing the clinical adjunct role to benefit students.

This article describes solutions to one of the challenges that nursing programs throughout the nation face--the employment of clinically expert nurse practitioners and clinical nurse specialists as clinical adjunct faculty who lack the educational foundation to teach students. Some of the difficulties experienced by clinical adjunct faculty, university administrators, and full-time faculty are presented. Solutions described include a clinical adjunct workshop, collaboration between hospitals and universities, mentoring, and incorporation of technology. Collaboration, commitment, and thoroughness are essential to the development of the clinical adjunct in the role of clinical educator.

Environmental factors of obesity in communities with native Hawaiians.

OBJECTIVE: To compare the fast food outlets and exercise resources across 3 communities with varying percentages of Native Hawaiians (NH) and to correlate these findings with obesity prevalence. METHODS: Data on all food and exercise resources were collected from January through July 2006 within a 1-mile radius in 3 distinct communities (site A = higher % NH to site C = lower % NH). Comparisons between communities were analyzed in 2007 using Fisher's Exact and ANOVA. RESULTS: Trends in obesity prevalence paralleled the percentage of NHs. After adjusting for population size, site B had a greater number of fast food outlets (p < 0.001) than site A or C, and more exercise facilities compared to site A (p = 0.05). Availability of fast food outlets was significantly greater at site A compared to site C (p = 0.03). Usage of exercise facilities was not significantly different between sites although exercise resources were in 'poorer' condition at site A compared to site B or C (p < or = 0.05). DISCUSSION: Results confirm the increased frequency of obesogenic environmental factors and their correlation with obesity trends across 3 distinct NH communities. These results suggest that environmental factors may offer another means for reducing obesity disparities in minority communities.

Partnerships to address obesity disparities in Hawai'i: the PILI 'Ohana Project.

Community-based participatory research (CBPR) is an approach to scientific research that is gaining broader application to address persistent problems in health care disparities and other hypothesis-driven research. However, information on how to form CBPR community-academic partnerships and how to best involve community partners in scientific research is not well-defined. The purpose of this paper is to share the experience of the Partnership for Improving Lifestyle Interventions (PILl) 'Ohana Project in forming a co-equal CBPR community-academic partnership that involved 5 different community partners in a scientific research study to address obesity disparities in Native Hawaiians and other Pacific Peoples (i.e., Samoans, Chuukese, and Filipinos). Specifically, the paper discusses (1) the formation of our community-academic partnership including identification of the research topic; (2) the development of the CBPR infrastructure to foster a sustainable co-equal research environment; and (3) the collaboration in designing a community-based and community-led intervention. The paper concludes with a brief summary of the authors' thoughts about CBPR partnerships from both the academic and community perspectives.

Teaching complex trauma care in a curriculum challenges critical thinking and clinical judgment--how nurses can help.

Incorporating complex content into a nursing curriculum presents students with the knowledge and thinking skills necessary to enter a career in nursing. A level 1 trauma center is a prefect environment to advance these thinking skills. Nurses act as professional role models and teachers as they clarify and explain their thinking to a student. When experienced nurses show invitational behaviors to students and share their knowledge with them, they ignite a strong desire within the student to progress. Caring, communication, and inclusion are key components that synergize the teaching/learning experience. The development of critical thinking is a continuous process that is best achieved through collaboration between the student, faculty, and professional, experienced nurses.

Key Program Findings and Insights From the Baby-Friendly Hawaii Project.

BACKGROUND: Breastfeeding is the optimal method for infant feeding. In the United States, 81.1% of mothers initiate breastfeeding; however, only 44.4% and 22.3% of mothers are exclusively breastfeeding at 3 and 6 months, respectively. Research aim: The Centers for Disease Control and Prevention provides guidance and funding to state health departments to support strategies to improve breastfeeding policies and practices in the hospital, community, and worksite settings. In 2010, the Hawaii State Department of Health received support from the Centers for Disease Control and Prevention to launch the Baby-Friendly Hawaii Project (BFHP) to increase the number of Hawaii hospitals that provide maternity care consistent with the Ten Steps to Successful Breastfeeding and increase the rate of women who remain exclusively breastfeeding throughout their hospital stay. METHODS: For this article, we examined the BFHP's final evaluation report and Hawaii breastfeeding and maternity care data to identify the role of the BFHP in facilitating improvements in maternity care practices and breastfeeding rates. RESULTS: Since 2010, 52 hospital site visits, 58 trainings, and ongoing technical assistance were administered, and more than 750 staff and health professionals from BFHP hospitals were trained. Hawaii's overall quality composite Maternity Practices in Infant Nutrition and Care score increased from 65 (out of 100) in 2009 to 76 in 2011 and 80 in 2013, and Newborn Screening Data showed an increase in statewide exclusive breastfeeding from 59.7% in 2009 to 77.0% in 2014. CONCLUSION: Implementation and findings from the BFHP can inform future planning at the state and federal levels on maternity care practices that can improve breastfeeding.

The development of connective tissue diseases in patients with autoimmune hepatitis: a case series.

OBJECTIVES: To study the prevalence of connective tissue diseases (CTD) in patients with autoimmune hepatitis (AIH). METHODS: We identified 11 cases of AIH over the past 7 years at our institution, through a systematic chart review of patients with this diagnosis. Their charts were reviewed for the development of systemic CTD. RESULTS: Three of the 11 patients with a definitive diagnosis of AIH developed systemic CTD. All were white: 2 women and 1 man, with an age range of 33 to 62 years, and with disease duration of 1 to 7 years. One patient developed systemic lupus erythematosus (SLE) with vasculitis and peripheral neuropathy. The second developed limited scleroderma and the third developed undifferentiated connective tissue disease (UCTD) and interstitial lung disease. There appear to be shared susceptibility alleles for AIH and CTD in addition to the shared positive autoantibodies. CONCLUSIONS: Patients with AIH may be at increased risk for developing systemic CTD. Conversely, a review of the literature reveals that patients with systemic CTD may be at increased risk of developing AIH. Patients with either AIH or CTD should be monitored for further development of concurrent autoimmune diseases.

Neonatal staff and advanced practice nurses' perceptions of bereavement/end-of-life care of families of critically ill and/or dying infants.

BACKGROUND: Parents need compassionate care when an infant dies. Nurses can provide such care and possibly facilitate grieving, yet often have inadequate preparation in bereavement/end-of-life care. OBJECTIVE: To describe neonatal nurses' perceptions of bereavement/end-of-life care of families of critically ill and/or dying infants. METHODS: A cross-sectional, descriptive, correlational mailed survey design was used. The 55-item Bereavement End-of-Life Attitudes About Care: Neonatal Nurses Scale containing 4 sections (comfort, roles, involvement, and demographics) was mailed to 240 hospitals in the United States. RESULTS: The final response rate was 52% (190 completed data sets from 125 hospitals). Respondents were comfortable with many aspects of bereavement/end-of-life care. Comfort and roles scores correlated significantly with number of years as a neonatal intensive care nurse. Respondents agreed about many important aspects of their roles with patients' families, especially the importance of providing daily support to the families. Most respondents identified caring for a dying infant, the actual death of an infant, and language or cultural differences as influential factors in the level of their involvement with families. CONCLUSIONS: Education on bereavement/end-of-life care could affect nurses' comfort with caring for families of critically ill and/or dying infants. Additional education on cultural competence would be helpful. Educators must promote the inclusion of content on bereavement/end-of-life care in nursing curricula. Finally, researchers must focus more attention on factors that promote and inhibit bereavement/end-of-life care of families of critically ill and/or dying infants.

A call to collaboration: the federal commitment to suicide prevention.

The federal government, largely through the U.S. Department of Health and Human Services (HHS), sponsors an array of science-based suicide prevention initiatives. This article details the prevention-related agendas and collaborative efforts of five operating divisions within the Department of Health and Human Services: the Substance Abuse and Mental Health Services Administration, National Institutes of Health, Centers for Disease Control and Prevention, Indian Health Service, and Health Resources and Services Administration. The article highlights HHS's activities and their link to the National Strategy for Suicide Prevention, the plan which will guide the nation's suicide prevention efforts for the next decade.

Renal disease disparities in Asian and Pacific-based populations in Hawai'i.

The prevalence of end-stage renal disease (ESRD) in the United States is expected to double over the next 10 years. The identification of ethnic differences in the prevalence, treatment, morbidity, and mortality related to chronic kidney disease (CKD) is of great concern. Asian Americans comprise a rapidly expanding sector of the U.S. population and are reported to have ESRD growth rates that are approximately 50% higher than caucasians. Hawai'i has a large, well-established Asian and Pacific-based population that facilitates the examination of disparities in renal disease among the state's diverse ethnic groups. The prevalence of ESRD in Hawai'i has continued to rise due, in part, to high rates of diabetes, glomerulonephritis, and hypertension reported in Asian Americans and Pacific-based populations. ESRD patients in Hawai'i have a two-fold higher prevalence of glomerulonephritis, compared with the general ESRD population in the United States. Other potential sources of renal disparities-such as cultural factors, language barriers, and health access factors-among Hawaii's major ethnic groups are assessed. However, few studies have examined the relative contribution of these potential factors. Consequently, efforts to reduce and eventually eliminate renal disease disparities will require a better understanding of the major sources of health disparities, such as timely medical care, a diverse health workforce, and cultural/social barriers, that affect optimal health care practices in Asian and Pacific-based populations.