Addressing mental and emotional health concerns experienced by nurses during the COVID-19 pandemic.

BACKGROUND: Nurses are the majority of the world's health work force and the frontline responders during pandemics. The mental/emotional toll can be profound if it is not identified and treated. PURPOSE: In March 2020, with New York City as the epicenter of the COVID-19 pandemic in the United States, Columbia University School of Nursing organized support circles for faculty and students providing clinical care as a healing method to address trauma. METHODS: Columbia University School of Nursing adapted guidelines and conducted Circles of Care to share, listen, and acknowledge the new challenges for nurses via Zoom. Analysis of these sessions produced major themes of concern for nurses. FINDINGS: Between March 31 and May 31, 2020, we facilitated 77 sessions with 636 attendees. Eight major themes emerged: coping mechanisms, patients suffering and dying, feelings of helplessness, frustration with COVID-19 response, silver lining, disconnection from the world, the thread that holds nurses together, and exhaustion. DISCUSSION: This report offers insight into the mental/emotional outcomes of being on the frontlines. Addressing these issues is essential for the well-being of nurses and all health care providers for an effective pandemic response.

Transforming nursing curricula for a global community.

With nurses and midwives providing the majority of health care globally, nursing education in all countries must prepare students for broader responsibilities to move the agenda forward for equitable care and universal health coverage. Columbia University School of Nursing developed and implemented a vibrant approach to curriculum transformation that included a new didactic course followed by a program of global clinical experiences to expand students' learning environments in global health. Program planning included defining learning objectives, mobilizing support within the school, establishing new sites, recruiting and preparing students, overseeing of students with host institutions, and evaluating the program. A total of twenty-four students were placed over five sites for a six-week credit-bearing global clinical experience. Students had varied clinical experiences with new understandings of the reality of health disparities. Host sites expressed a commitment to have students return in the next year, and all students stated that they would chose a global experience again. This innovation provides a transformative addition to nursing education with a deepened understanding of health disparities and nursing roles in different health systems. It strengthens the school's network of nursing and midwifery educators and opens doors for new exchanges.

Infant Colonization With Methicillin-Resistant Staphylococcus aureus or Vancomycin-Resistant Enterococci Preceding Neonatal Intensive Care Unit Discharge.

Rates of colonization with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococci (VRE) were determined for 1320 infants within 7 days of neonatal intensive care unit discharge. Overall, 4% and 1% of the infants were colonized with MRSA or VRE, respectively. Predictors identified in fixed-effects models were surgery during hospitalization (for MRSA colonization) and prolonged antimicrobial treatment (for VRE colonization).

Colonization With Antimicrobial-Resistant Gram-Negative Bacilli at Neonatal Intensive Care Unit Discharge.

BACKGROUND: The epidemiology of the colonization of infants with antimicrobial-resistant Gram-negative bacilli (GNB) at discharge from the neonatal intensive care unit (NICU) is not well understood. METHODS: A multicenter study in which rectal surveillance samples for culture were obtained at NICU discharge from infants hospitalized ≥14 days was performed. Factors associated with colonization with GNB resistant to gentamicin, third/fourth-generation cephalosporin agents, or carbapenem agents were assessed by using a fixed-effects model. RESULTS: Of these infants, 9% (119 of 1320) were colonized with ≥1 antimicrobial-resistant GNB. Prolonged treatment (≥10 days) with meropenem or third/fourth-generation cephalosporin agents or treatment for ≥5 days with a ß-lactam/ß-lactamase combination agent were associated with an increased risk of colonization with GNB resistant to gentamicin. Surgery and ≥5 days of treatment with third/fourth-generation cephalosporin agents, a ß-lactam/ß-lactamase combination agent, or metronidazole were associated with an increased risk of colonization with GNB resistant to third/fourth-generation cephalosporin agents. Female sex and prolonged treatment (≥10 days) with meropenem were associated with colonization with GNB resistant to carbapenem agents. CONCLUSIONS: Prolonged treatment with broad-spectrum antibiotics was associated with the colonization of infants with antimicrobial-resistant GNB within 7 days of NICU discharge. These findings suggest the potential for dissemination of resistant GNB from colonized infants to other NICUs, the community, or pediatric long-term care facilities. Antimicrobial stewardship efforts aimed at improving appropriate antibiotic use could have a beneficial effect on the emergence of antimicrobial-resistant GNB in the NICU population.

Gram-Negative Bacilli in Infants Hospitalized in The Neonatal Intensive Care Unit.

BACKGROUND: Gram-negative bacilli (GNB) account for a significant burden of infection and colonization in neonatal intensive care units (NICUs), and antibiotic resistance among these pathogens is of increasing concern. METHODS: A prospective cohort study was performed in 4 NICUs between May 2009 and April 2012. The body sites from which GNB were isolated, antimicrobial susceptibilities of the GNB isolated, and antimicrobial therapy were assessed. RESULTS: Attending neonatologists treated 3.0% (188 of 6184) of eligible infants for GNB infection; 23% of 214 GNB isolates were nonsusceptible to antimicrobial agents, including gentamicin (14.8%), piperacillin-tazobactam (9.9%), third-generation cephalosporin (7.0%), and/or carbapenem agents (4.5%). Gentamicin was the most commonly used antibiotic overall, and much of its use was empiric. However, third-generation cephalosporin agents and cefepime were used more commonly as targeted therapy for identified Gram-negative pathogens. CONCLUSIONS: One-quarter of the GNB isolates were nonsusceptible to ≥1 antibiotic. Antimicrobial stewardship strategies for reducing antimicrobial use in NICUs should be implemented.

Multicenter Study of Hand Carriage of Potential Pathogens by Neonatal ICU Healthcare Personnel.

A multicenter surveillance study was performed to determine the rates of hand carriage of potential pathogens among healthcare personnel in four neonatal intensive care units. Staphylococcus aureus, enterococci, and gram-negative bacilli were recovered from 8%, 3%, and 2% of 1000 hand culture samples, respectively.

Development of an antimicrobial stewardship intervention using a model of actionable feedback.

We describe the development of an audit and feedback intervention to improve antibiotic prescribing in the neonatal intensive care unit (NICU) using a theoretical framework. Participants included attending physicians, neonatal fellows, pediatric residents, and nurse practitioners. The intervention was based on the "model of actionable feedback" which emphasizes that feedback should be timely, individualized, nonpunitive, and customized to be effective. We found that real-time feedback could not be provided for the parameters established in this study, as we had to collect and analyze numerous data elements to assess appropriate initiation and continuation of antibiotics and required longer intervals to examine trends in antibiotic use. We learned during focus groups that NICU clinicians strongly resisted assigning individual responsibility for antibiotic prescribing as they viewed this as a shared responsibility informed by each patient's laboratory data and clinical course. We were able to create a non-punitive atmosphere thanks to written informed consent from NICU attendings and assurance from leadership that prescribing practices would not be used to assess job performance. We provided customized, meaningful feedback integrating input from the participants. Adapting the principles of the "model of actionable feedback" to provide feedback for antimicrobial prescribing practices proved challenging in the NICU setting.

Predictors of flu vaccination among urban Hispanic children and adults.

BACKGROUND: Flu vaccination is effective for preventing infection, but coverage levels in the USA remain low-especially among racial/ethnic minorities. This study examines factors associated with flu vaccination in a predominantly Hispanic community in Manhattan, New York. METHODS: Households were recruited during the 2006-2007 and 2007-2008 flu seasons. Primary household respondents were interviewed to determine knowledge of flu transmission/treatment and vaccination status and demographic information for all household members. RESULTS: Vaccination coverage was 47.3% among children <5, 39.3% among 5-17-year-olds, 15.3% among 18-49-year-olds, 31.0% among 50-64-year-olds and 37.1% among adults ≥65 in year 1; and 53.1% among children <5, 43.6% among 5-17-year-olds, 19.5% among 18-49-year-olds, 34.1% among 50-64-year-olds and 34.3% among adults ≥65 in year 2. For children, younger age, having a chronic respiratory condition (eg, asthma), and greater primary respondent knowledge of flu were positively associated with vaccination. Among adults, female gender, older age, higher education, greater primary respondent knowledge of flu, having been born in the USA and having a chronic respiratory condition were positively associated with vaccination. The most common reasons cited for not being vaccinated were the beliefs that flu vaccination was unnecessary or ineffective. CONCLUSIONS: Possible methods for increasing vaccination levels in urban Hispanic communities include improving health literacy, making low-cost vaccination available and encouraging providers to use other office visits as opportunities to mention vaccination to patients. REGISTRATION NUMBER: This study is registered at http://ClinicalTrials.gov (NCT00448981).

Clinical vignettes provide an understanding of antibiotic prescribing practices in neonatal intensive care units.

OBJECTIVE: To use clinical vignettes to understand antimicrobial prescribing practices in neonatal intensive care units (NICUs). DESIGN: Vignette-based survey. SETTING: Four tertiary care NICUs. PARTICIPANTS: Antibiotic prescribers in NICUs. METHODS: Clinicians from 4 tertiary care NICUs completed an anonymous survey containing 12 vignettes that described empiric, targeted, or prophylactic antibiotic use. Responses were compared with Centers for Disease Control and Prevention guidelines for appropriate use. RESULTS: Overall, 161 (59% of 271 eligible respondents) completed the survey, 37% of whom had worked in NICUs for 7 or more years. Respondents were more likely to appropriately identify use of targeted therapy for methicillin-susceptible Staphylococcus aureus, that is, use of oxacillin rather than vancomycin, than for Escherichia coli, that is, use of first-generation rather than third-generation cephalosporin, (P < .01). Increased experience significantly predicted appropriate prescribing (P = .02). The proportion of respondents choosing appropriate duration of postsurgical prophylaxis (P < .01) and treatment for necrotizing enterocolitis differed by study site (P = .03). CONCLUSIONS: The survey provides insight into antibiotic prescribing practices and informs the development of future antibiotic stewardship interventions for NICUs.

Barriers to mask wearing for influenza-like illnesses among urban Hispanic households.

OBJECTIVES: To identify barriers to mask wearing and to examine the factors associated with the willingness to wear masks among households. DESIGN AND SAMPLE: We used data sources from a study assessing the impact of 3 nonpharmaceutical interventions on the rates of influenza: exit interviews; home visits with a subset of the mask group; and a focus group. MEASURES: Risk perception score, univariate analysis, and logistic regression were conducted to identify the characteristics and predictors of mask use. Thematic barriers to mask wearing were identified from qualitative data obtained at home visits and focus group. RESULTS: Respondents from the mask group, when compared with the nonmask group, demonstrated higher risk perception scores concerning influenza (maximum score: 60, means: 37.6 and 30.2, p<.001) and increased perception of effectiveness of mask wearing (maximum score: 10, means: 7.8 and 7.3, p=.043). There was no significant association between demographic, attitudinal, or knowledge variables and adherence to wearing masks. Thematic barriers were identified such as social acceptability of mask use, comfort and fit, and perception of the risk/need for masks. CONCLUSIONS: Face masks may not be an effective intervention for seasonal or pandemic influenza unless the risk perception of influenza is high. Dissemination of culturally appropriate mask use information by health authorities and providers must be emphasized when educating the public.

Antibiotic identification, use, and self-medication for respiratory illnesses among urban Latinos.

PURPOSE: The purpose of this study was to describe the extent to which antibiotic and nonantibiotic medications commonly used for upper respiratory infections (URIs) were correctly identified by a sample of urban dwelling Latinas and the association of medication identification with antibiotic use and self-medication. DATA SOURCES: One hundred women completed an interview and were asked to identify whether a list of 39 medications (17 antibiotics, 22 nonantibiotics) were antibiotics or not, whether anyone in the household had used the medication, their ages, and the source of the medication. RESULTS: Overall, participants correctly identified 62% of nonantibiotics and 34% of antibiotics. Seventy three (73%) women in the study reported antibiotic use by at least one member of the household in the past year. Among users, self-medication was reported in 67.2% of antibiotics for adults, but in only 2.4% of children. There was no difference in antibiotic recognition between those who self-medicated and those who did not, but antibiotic self-medication was associated with a significantly lower recognition of nonantibiotics (p= .01). IMPLICATIONS FOR PRACTICE: Measures to improve antibiotic utilization should address self-medication and consider the cultural and social context in which antibiotic use occurs.

Impact of non-pharmaceutical interventions on URIs and influenza in crowded, urban households.

OBJECTIVES: We compared the impact of three household interventions-education, education with alcohol-based hand sanitizer, and education with hand sanitizer and face masks-on incidence and secondary transmission of upper respiratory infections (URIs) and influenza, knowledge of transmission of URIs, and vaccination rates. METHODS: A total of 509 primarily Hispanic households participated. Participants reported symptoms twice weekly, and nasal swabs were collected from those with an influenza-like illness (ILI). Households were followed for up to 19 months and home visits were made at least every two months. RESULTS: We recorded 5034 URIs, of which 669 cases reported ILIs and 78 were laboratory-confirmed cases of influenza. Demographic factors significantly associated with infection rates included age, gender, birth location, education, and employment. The Hand Sanitizer group was significantly more likely to report that no household member had symptoms (p < 0.01), but there were no significant differences in rates of infection by intervention group in multivariate analyses. Knowledge improved significantly more in the Hand Sanitizer group (p < 0.0001). The proportion of households that reported > or = 50% of members receiving influenza vaccine increased during the study (p < 0.001). Despite the fact that compliance with mask wearing was poor, mask wearing as well as increased crowding, lower education levels of caretakers, and index cases 0-5 years of age (compared with adults) were associated with significantly lower secondary transmission rates (all p < 0.02). CONCLUSIONS: In this population, there was no detectable additional benefit of hand sanitizer or face masks over targeted education on overall rates of URIs, but mask wearing was associated with reduced secondary transmission and should be encouraged during outbreak situations. During the study period, community concern about methicillin-resistant Staphylococcus aureus was occurring, perhaps contributing to the use of hand sanitizer in the Education control group, and diluting the intervention's measurable impact.

Research findings from nonpharmaceutical intervention studies for pandemic influenza and current gaps in the research.

In June 2006, the Centers for Disease Control and Prevention released a request for applications to identify, improve, and evaluate the effectiveness of nonpharmaceutical interventions (NPIs)-strategies other than vaccines and antiviral medications-to mitigate the spread of pandemic influenza within communities and across international borders (RFA-CI06-010). These studies have provided major contributions to seasonal and pandemic influenza knowledge. Nonetheless, key concerns were identified related to the acceptability and protective efficacy of NPIs. Large-scale intervention studies conducted over multiple influenza epidemics, as well as smaller studies in controlled laboratory settings, are needed to address the gaps in the research on transmission and mitigation of influenza in the community setting. The current novel influenza A (H1N1) pandemic underscores the importance of influenza research.

Effect of intensive education on knowledge, attitudes, and practices regarding upper respiratory infections among urban Latinos.

BACKGROUND: Although upper respiratory infections (URIs) take a major social and economic toll, little research has been conducted to assess the impact of educational interventions on knowledge, attitudes, and practices of community members regarding prevention and treatment of URIs, particularly among recently immigrated urban Latinos who may not be reached by the mainstream healthcare system. OBJECTIVES: The objective of this study was to assess the impact of a culturally appropriate, home-based educational intervention on the knowledge, attitudes, and practices regarding prevention and treatment of URIs among urban Latinos. METHODS: Using a pretest-posttest design, Spanish-language educational materials available from sources such as the Centers for Disease Control and Prevention were adapted based on feedback from community focus groups and provided to households during an in-person home visit every 2 months (generally three to four visits). Outcome data regarding knowledge, attitudes, and practices were collected in home-based interviews using an 85-item instrument adapted and pilot tested from three other validated instruments. Nonparametric and multiple linear regression analyses were used to summarize data and identify predictors of knowledge scores. RESULTS: Four hundred twenty-two households had complete data at baseline and 6 months. Knowledge and attitude scores were improved significantly, and use of alcohol hand sanitizer and rates of influenza vaccine were increased significantly (all p <.01). DISCUSSION: Although this home-based educational intervention was successful in improving knowledge, attitudes, and self-reported practices among urban Latinos regarding prevention and treatment of URIs, further research is needed to determine the cost-effectiveness of such a person-intensive intervention, the long-term outcomes, and whether less intensive interventions might be equally effective.

Low sensitivity of rapid diagnostic test for influenza.

The QuickVue Influenza A+B Test (Quidel) was used to test nasal swab specimens obtained from persons with influenza-like illness in 3 different populations. Compared with reverse-transcriptase polymerase chain reaction, the test sensitivity was low for all populations (median, 27%; range, 19%-32%), whereas the specificity was high (median, 97%; range, 96%-99.6%).

Retention and protocol adherence of Hispanic volunteers in a longitudinal trial.

OBJECTIVES: To compare Hispanic research volunteers with high and low levels of study retention and adherence. METHODS: Correlational analysis of demographics, recruitment strategies, knowledge, and attitudes of 470 households in a clinical trial. RESULTS: Within 12 months, 53 (11.3%) households dropped out; those less certain about some factual information were more likely to drop out (P < 0.05). Participants born outside the United States were more likely to adhere to protocols (P = 0.03). Flyers were effective for recruiting only 3% of participants. CONCLUSIONS: In newly immigrated populations, written recruitment materials may be ineffective; knowledge and attitudes may be important for study retention and adherence.

Preferences among immigrant Hispanic women for written educational materials regarding upper respiratory infections.

The need for culturally appropriate health education materials for Hispanic populations has been widely recognized, and Spanish-language materials are available through a number of private and governmental organizations. We convened two focus groups to elucidate preferences regarding how health-related messages are obtained and to identify which educational materials available in Spanish were preferred by 26 recently immigrated Hispanic homemakers who had received 15 different bimonthly written documents as part of a community-based clinical trial to prevent household transmission of colds and influenza. Participants gave three primary reasons for volunteering to participate in the study: to provide better care for their children (96.2%, 25/26), to get information (96.2%, 25/26), and to get free products (47.1%, 8/17). Their primary sources of health-related information were relatives and friends (42.9%, 6/14), clinicians (35.7%, 5/14), mass media (14.3%, 2/14) or the emergency room (7.1%, 1/14); none mentioned the internet. Materials using either a question and answer or true/false format were clearly preferred, even when other options were more colorful or had lower reading levels. Printed educational materials may be ineffective unless they include a more systematic assessment of the user's perceived needs for the information as well as consideration of format. In this population, a question and answer or true/false format and materials that could be shared with their children were greatly preferred.

Knowledge and misconceptions regarding upper respiratory infections and influenza among urban Hispanic households: need for targeted messaging.

BACKGROUND: To characterize knowledge and misconceptions regarding viral upper respiratory infections (URI) among urban Hispanics and identify correlates of greater knowledge. METHODS: In-home interviews conducted by trained research coordinators in 453 primarily Hispanic households (2,386 members) in northern Manhattan. RESULTS: The majority of respondents attributed URI to weather-related conditions. While most agreed that colds and flu were caused by viruses, 88.1% also agreed that they were caused by bacteria, and a small proportion reported that URI may be caused by evil eye ('mal de ojo', 7.1%) or sudden fright ('susto', 3.3%). Only 29.8% agreed that colds and flu would improve without medication; 89.9% stated that antibiotics are needed to treat viral throat infections. Most were well versed about influenza vaccination and reported that a recommendation from a healthcare provider would definitely influence them to get vaccinated. DISCUSSION: Misconceptions about the role of antibiotics in the treatment of viral infections pose considerable risk in this population. Explicit, targeted recommendations from healthcare providers regarding vaccination and judicious antibiotic use as well as media campaigns targeted to Hispanics should be effective strategies for reducing misconceptions and improving health behaviors.