Secondary School State Athletic Association Health and Safety Policy Development Processes.

BACKGROUND: The National Federation of State High School Associations provides recommendations regarding health and safety policies; however, policy development is governed at the state level. Given interstate differences in governance, the primary purpose was to describe processes that State High School Athletic Associations (SHSAAs) utilize to develop a new policy. The secondary objective was to determine what methods associations use to implement new policies. METHODS: A cross-sectional survey requested SHSAA (n = 51) representatives to report how athlete health and safety policies are introduced, revised, approved, and implemented within their state. The 22-question survey was developed to gather variables for the aims of the study. Descriptive statistics were calculated for each survey item. RESULTS: Of states who responded (n = 33), most reported a 2-committee (n = 24, 72.7%) process for developing and vetting policies, with initiation from the Sports Medicine Advisory Committee (n = 27, 81.8%), followed by an executive-level committee (n = 18, 66.7%). States reported total time from policy initiation to final approval ranged from 2 weeks to over 12 months. When a new policy was approved, most states indicated implementation began with an e-mail (n = 24, 72.7%) sent to Athletic Directors (n = 26, 78.8%). School principal or district superintendent were reported as the position in charge of compliance (36.4%, n = 12). CONCLUSIONS: Most SHSAAs use a 2-step process to write and review an athlete health and safety policy before approval. SHSAAs that require a longer policy development time could delay the implementation of important health measures. SHSAAs could consider additional communication methods to ensure information reaches all stakeholders.

Adoption of Lightning Safety Best-Practices Policies in the Secondary School Setting.

CONTEXT: Lightning-related injuries are among the top 10 causes of sport-related death at all levels of sport, including the nearly 8 million athletes participating in US secondary school sports. OBJECTIVE: To investigate the adoption of lightning safety policies and the factors that influence the development of comprehensive lightning safety policies in United States secondary schools. DESIGN: Cross-sectional study. SETTING: Secondary school. PATIENTS OR OTHER PARTICIPANTS: Athletic trainers (ATs). MAIN OUTCOME MEASURE(S): An online questionnaire was developed based on the "National Athletic Trainers' Association Position Statement: Lightning Safety for Athletics and Recreation" using a health behavior model, the precaution adoption process model, along with facilitators of and barriers to the current adoption of lightning-related policies and factors that influence the adoption of lightning policies. Precaution adoption process model stage (unaware for need, unaware if have, unengaged, undecided, decided not to act, decided to act, acting, maintaining) responses are presented as frequencies. Chi-square tests of associations and prevalence ratios with 95% CIs were calculated to compare respondents in higher and lower vulnerability states, based on data regarding lightning-related deaths. RESULTS: The response rate for this questionnaire was 13.43% (n = 365), with additional questionnaires completed via social media (n = 56). A majority of ATs reported maintaining (69%, n = 287) and acting (6.5%, n = 27) a comprehensive lightning safety policy. Approximately 1 in 4 ATs (25.1%, n = 106) described using flash to bang as an evacuation criterion. Athletic trainers practicing in more vulnerable states were more likely to adopt a lightning policy than those in less vulnerable states (57.4% versus 42.6%, prevalence ratio [95% CI] = 1.16 [1.03, 1.30]; P = .009). The most commonly cited facilitator and barrier were a requirement from a state high school athletics association and financial limitations, respectively. CONCLUSIONS: A majority of ATs related adopting (eg, maintaining and acting) the best practices for lightning safety. However, many ATs also indicated continued use of outdated methods (eg, flash to bang).

Emergency Action Plans in Secondary Schools: Barriers, Facilitators, and Social Determinants Affecting Implementation.

CONTEXT: Secondary schools (SSs) inconsistently adopt emergency action plans (EAPs) for athletics. OBJECTIVE: To describe the barriers, facilitators, and social determinants influencing EAP adoption in SSs in the United States. DESIGN: Cross-sectional study. SETTING: Secondary schools. PATIENTS OR OTHER PARTICIPANTS: A national sample of athletic trainers (ATs; n = 9642) and athletic directors (ADs; n = 9687) were invited to participate in a Web-based questionnaire. A total of 1273 (13.2%) ATs and 702 (9.2%) ADs responded to the survey. MAIN OUTCOME MEASURE(S): The questionnaire addressed self-reported barriers to, facilitators of, and social determinants (eg, locale, funding classification [eg, public or private SS]) of EAP adoption. The responses of ATs and ADs were analyzed separately. Barriers, facilitators, and social determinants were evaluated using descriptive statistics. Contingency (2 × 2) tables were used to calculate the odds ratios (ORs) of adopting an EAP and the presence of each social determinant. RESULTS: Perceived barriers to implementation were a lack of knowledge about how to implement an EAP and financial limitations. Facilitators were having access to health care personnel, state mandates, and support from a person in an authoritative position. Compared with ATs at rural schools, ATs at suburban schools displayed greater odds of having an EAP (χ2 = 5.63, P = .01, OR = 1.63 [95% confidence interval = 1.08, 2.44]). According to the ADs' responses, a larger SS enrollment (≥500) led to greater odds of adopting an EAP (OR = 2.02 [95% confidence interval = 1.41, 2.89]). CONCLUSIONS: Perceived barriers to EAP adoption suggest that ATs and ADs need to be educated so they can provide additional information on the low cost of EAP adoption. Further, ADs described state mandates as facilitators to improve EAP adoption; therefore, efforts to educate state leaders about the need for mandated policies may be warranted. Certain social determinants (eg, school enrollment) may affect EAP adoption, but not every proposed determinant significantly affected adoption.

Reversing the "Risk-Treatment Paradox" of Bleeding in Patients Undergoing Percutaneous Coronary Intervention: Risk-Concordant Use of Bleeding Avoidance Strategies Is Associated With Reduced Bleeding and Lower Costs.

Background Bleeding is a common, morbid, and costly complication of percutaneous coronary intervention. While bleeding avoidance strategies ( BAS ) are effective, they are used paradoxically less in patients at high risk of bleeding. Whether a patient-centered approach to specifically increase the risk-concordant use of BAS and, thus, reverse the risk-treatment paradox is associated with reduced bleeding and costs is unknown. Methods and Results We implemented an intervention to reverse the bleeding risk-treatment paradox at Barnes-Jewish Hospital, St. Louis, MO, and examined: (1) the temporal trends in BAS use and (2) the association of risk-concordant BAS use with bleeding and hospital costs of percutaneous coronary intervention. Among 3519 percutaneous coronary interventions, there was a significantly increasing trend ( P=0.002) in risk-concordant use of BAS . The bleeding incidence was 2% in the risk-concordant group versus 9% in the risk-discordant group (absolute risk difference, 7%; number needed to treat, 14). Risk-concordant BAS use was associated with a 67% (95% confidence interval, 52-78%; P<0.001) reduction in the risk of bleeding and a $4738 (95% confidence interval, 3353-6122; P<0.001) reduction in per-patient percutaneous coronary intervention hospitalization costs (21.6% cost-savings). Conclusions In this study, patient-centered care directly aimed to make treatment-related decisions based on predicted risk of bleeding, led to more risk-concordant use of BAS and reversal of the risk-treatment paradox. This, in turn, was associated with a reduction in bleeding and hospitalization costs. Larger multicentered studies are needed to corroborate these results. As clinical medicine moves toward personalization, both patients and hospitals can benefit from a simple practice change that encourages objectivity and mitigates variability in care.

Novel Patient-Centered Approach to Facilitate Same-Day Discharge in Patients Undergoing Elective Percutaneous Coronary Intervention.

BACKGROUND: Same-day discharge (SDD) after elective percutaneous coronary intervention is safe, less costly, and preferred by patients, but it is usually performed in low-risk patients, if at all. To increase the appropriate use of SDD in more complex patients, we implemented a "patient-centered" protocol based on risk of complications at Barnes-Jewish Hospital. METHODS AND RESULTS: Our objectives were as follows: (1) to evaluate time trends in SDD; (2) to compare (a) mortality, bleeding, and acute kidney injury, (b) patient satisfaction, and (c) hospital costs by SDD versus no SDD (NSDD); and (3) to compare SDD eligibility by our patient-centered approach versus Society for Cardiovascular Angiography and Interventions guidelines. Our patient-centered approach was based on prospectively identifying personalized bleeding, mortality, and acute kidney injury risks, with a personalized safe contrast limit and mitigating those risks. We analyzed Barnes-Jewish Hospital's National Cardiovascular Data Registry CathPCI Registry data from July 1, 2009 to September 30, 2015 (N=1752). SDD increased rapidly from 0% to 77% (P<0.001), independent of radial access. Although SDD patients were comparable to NSDD patients, SDD was not associated with adverse outcomes (0% mortality, 0% bleeds, and 0.4% acute kidney injury). Patient satisfaction was high with SDD. Propensity score-adjusted costs were $7331 lower/SDD patient (P<0.001), saving an estimated $1.8 million annually. Only 16 patients (6.95%) met the eligibility for SDD by Society for Cardiovascular Angiography and Interventions guidelines, implying our patient-centered approach markedly increased SDD eligibility. CONCLUSIONS: With a patient-centered approach, SDD rapidly increased and was safe in 75% of patients undergoing elective percutaneous coronary intervention, despite patient complexity. Patient satisfaction was high, and hospital costs were lower. Patient-centered decision making to facilitate SDD is an important opportunity to improve the value of percutaneous coronary intervention.

Tryptophan in the pore of the mechanosensitive channel MscS: assessment of pore conformations by fluorescence spectroscopy.

Structural changes in channel proteins give critical insights required for understanding the gating transitions that underpin function. Tryptophan (Trp) is uniquely sensitive to its environment and can be used as a reporter of conformational changes. Here, we have used site-directed Trp insertion within the pore helices of the small mechanosensitive channel protein, MscS, to monitor conformational transitions. We show that Trp can be inserted in place of Leu at the two pore seal positions, Leu(105) and Leu(109), resulting in functional channels. Using Trp(105) as a probe, we demonstrate that the A106V mutation causes a modified conformation in the purified channel protein consistent with a more open state in solution. Moreover, we show that solubilized MscS changes to a more open conformation in the presence of phospholipids or their lysoforms.