Impact of type of health care provider on long term asthma control.

OBJECTIVE: Asthma prevalence is high and adherence to asthma guidelines is still less than adequate. The main objective of this study was to determine if there were significant differences in outcome measures if asthma care was provided per guidelines either by physicians (pediatric pulmonologists) or specialty trained advance practice nurses (APNs). METHODS: This was a three-year, prospective cohort study of children referred by their primary care providers to a tertiary care center for better asthma control. Patients were provided asthma care per NAEPP guidelines including asthma education. Results were compared over time and between patients followed by physicians or APNs. Alpha level of significance was ≤0.05. RESULTS: The sample included 471 children, ages 2-17 years (mean = 6.4 ± 2.4 years). Physicians and APN's provided asthma care. Of the 471 children enrolled in the study, 176 (37%) were followed for the full three-year study period. At the initial visit, physician group reported more short courses of oral steroids and more unscheduled visits to PCP for acute asthma care in the past 6 months compared to those followed by APNs (<0.05 for all). Among the total cohort and both subgroups, there were significant improvements in mean Asthma Control Test (ACT), acute care need and mean days/month with asthma symptoms over a three-year period (p < 0.05). There was significantly more improvement in use of oral steroids and urgent care visits in physician group (p < 0.05). CONCLUSION: When asthma guidelines are followed, improvements in asthma control are achieved in children in both the MD and APN groups.

U.S. active-duty service women's urogenital health and operational readiness through the lens of the IBM-WASH model: A systematic integrative review.

AIM: Identify literature regarding urogenital health and hygiene practices/behaviors of U.S. active-duty service women (ADSW) with attention to environmental conditions; access to water, sanitation, and hygiene (WASH) resources in austere environments. Synthesize relationships among the 3-dimensions and 5-levels of the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH). BACKGROUND: ADSW face sex-specific urogenital health challenges due to decreased access to WASH resources in austere environments, leading to increased risk for urogenital infection-related outcomes (urinary tract infections, vulvovaginal candidiasis, and bacterial vaginosis). During military conflicts in Afghanistan and Iraq, urogenital infections in ADSW were reported as one of the top five medical encounters, and one of the top seven reasons for medical evacuation. METHODS: A systematic review was performed in MEDLINE, CINAHL, Embase, and ClinicalTrials.gov databases, between January 2007-November 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses as a reporting guideline. Eligible literature was evaluated utilizing the Johns Hopkins Research Evidence Appraisal Tool. WASH interactions were mapped using the IBM-WASH interactive matrix. RESULTS: Evidence gaps include shifting focus from "deployment" to environmental austerity; lack of training/education; shifting male-centric culture; and innovative technologies for safety/security. CONCLUSIONS: The IBM-WASH framework allowed for quantification and interpretation of complex interactions occurring in real world austere environments. Some could be overcome individually, but in aggregate they lead to progressive urogenital conditions and potential mission failure. Prevention, diagnosis, and treatment can mitigate disease sequelae. Preventive knowledge and access to innovative technologies designed for ease and private use are critical to preserve operational readiness.

Impact of asthma severity on long-term asthma control.

Background: Asthma is a common childhood disease with significant morbidity. Severe asthma accounts for just 4-6% of patients, but this group is more difficult to treat and is responsible for up to 40% of asthma expenses.Objective: The relationship between asthma severity and control is not well characterized. The main objective of this study was to determine impact of asthma severity on asthma control over time.Methods: This was a three year, prospective observational cohort study at a tertiary care children's hospital. Results were compared over time and between patients with severe and non-severe persistent asthma. Intervention included therapy based on severity and control, accompanied by a NAEPP (EPR-3) guidelines based structured asthma education program.Results: The sample included 471 children referred from primary care offices with the diagnosis of persistent asthma, mean age 6.4 ± 2.4 years. Forty-one children (8.7%) had severe persistent asthma and 430 (91.3%) children had non-severe persistent asthma (mild-moderate persistent). Our sample size decreased over the three-year period and the number of patients completing the third year were 176 (38%) and among them 20 (11.4%) had severe asthma. At the initial visit, children with severe persistent asthma had significantly more acute care needs, more daily symptoms, and lower mean Asthma Control Test™ scores compared to children with non-severe persistent asthma. Differences between groups decreased within six months with significant improvements in most indicators persisting throughout three-year follow up in both groups (p < 0.05).Conclusion: Asthma control improves independent of severity if asthma guidelines are followed.

Improved quality-of-life of caregivers of children with asthma through guideline-based management.

OBJECTIVE: The quality of life (QOL) of caregivers of children with asthma may be related to children's responses to asthma management. AIM: To evaluate change in QOL over time of caregivers of children with asthma through guideline-based management. DESIGN: This was a 3-year prospective cohort study of children with asthma referred to our pediatric asthma center. Families completed Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), the Asthma Control Test™ (ACT), and reported the number of days/month of albuterol use and wheezing at each clinic visit. RESULTS: We enrolled 143 children, ages 7-17 years (mean = 10.6 ± 2.9), 56.6% male, 70.6% Caucasian. Patients were managed by the same MD (n = 65,45.5%) or APN (n = 78,54.5%) over time. The mean total PACQLQ significantly increased over the 3-year period (F = 67.418, p < .001). Total scores at the first visit were 4.8 ± 1.6, which improved to 6.1 ± 1 at the 3-month follow-up visit. This improvement was sustained at the 1, 2, and 3-year clinic visits. PACQLQ emotional function (F = 60.798, p < .001) and activity limitation (F = 41.517, p < .001) domains significantly improved as well. PACQLQ scores were significantly associated with improved ACT scores (r = .37 to .47, p < .05), fewer days/month of albuterol use (r = -.25 to -.36., p < .05), and wheezing (r = -.28 to -.33, p < .05). There were no significant differences in PACQLQ, or asthma clinical outcome measures between MD and APN providers. CONCLUSION: Use of National Asthma Education and Prevention Program (NAEPP) guidelines significantly improved QOL of caregivers of children with asthma and in asthma-related symptoms. Improvements over time were independent of type of providers.

Operational Failures Detected by Frontline Acute Care Nurses.

Frontline nurses encounter operational failures (OFs), or breakdowns in system processes, that hinder care, erode quality, and threaten patient safety. Previous research has relied on external observers to identify OFs; nurses have been passive participants in the identification of system failures that impede their ability to deliver safe and effective care. To better understand frontline nurses' direct experiences with OFs in hospitals, we conducted a multi-site study within a national research network to describe the rate and categories of OFs detected by nurses as they provided direct patient care. Data were collected by 774 nurses working in 67 adult and pediatric medical-surgical units in 23 hospitals. Nurses systematically recorded data about OFs encountered during 10 work shifts over a 20-day period. In total, nurses reported 27,298 OFs over 4,497 shifts, a rate of 6.07 OFs per shift. The highest rate of failures occurred in the category of Equipment/Supplies, and the lowest rate occurred in the category of Physical Unit/Layout. No differences in OF rate were detected based on hospital size, teaching status, or unit type. Given the scale of this study, we conclude that OFs are frequent and varied across system processes, and that organizations may readily obtain crucial information about OFs from frontline nurses. Nurses' detection of OFs could provide organizations with rich, real-time information about system operations to improve organizational reliability. © 2017 Wiley Periodicals, Inc.

Environmental exposures and family history of asthma.

BACKGROUND: Asthma pathogenesis is a complex interaction of genetic, ethnic, environmental and social/life style risk factors. AIM: The goal of this study was to identify associations, if any, in children with asthma, between environmental risk factors (exposure to second-hand tobacco smoke (STS), pet ownership, race and a family history of asthma. METHODS: After IRB approval, from June 2011 to December 2014, 823 children with asthma were enrolled in this prospective cross sectional study. At the initial visit, families completed a questionnaire with information on family history of asthma, having a pet at home and exposure to STS by parents at home. Chi square analyses were calculated, with alpha level of significance ≤0.05. RESULTS: History of asthma in parents, siblings or grandparents was reported by 575 (69.8%) patients including father (n = 154, 17.8%) and mother (n = 235, 26.5%). Children with family history of asthma (n = 575) were significantly more likely to have a pet at home and exposure to STS (n = 347, 60.3% and n = 198, 34.4%, respectively) compared to families without a history of asthma (n = 124, 50%, p = 0.006 and n = 44, 17.7%, p < 0.001, respectively). Similarly, asthmatic children with exposure to STS (n = 241) were significantly more likely to have a pet at home and a family history of asthma (n = 153, 63.5% and n = 197, 81.7%, respectively) compared to children with no STS exposure (n = 315, 55.5%, p = 0.034 and n = 371, 65.3%, p < 0.001 respectively). CONCLUSIONS: Significantly more asthmatic children with immediate relatives with a history of asthma have a pet at home and experience STS exposure compared to children without relatives with a history of asthma, suggesting association between life style choices/environmental exposures and family history of asthma.

Improving pediatric asthma care: A partnership between pediatric primary care clinics and a free-standing Children's Hospital.

BACKGROUND: Asthma is a common chronic disease of childhood. Providers' adherence to asthma guidelines is still less than optimal. OBJECTIVES: To determine if an Asthma Education Program aimed at primary care practices can improve asthma care within practices and if the results vary by duration of the program. METHODS: Ten practices were randomly assigned to an Early Asthma Education Intervention (EI) group or a Delayed Asthma Education Intervention (DI) group. The EI group received the intervention for 12 months and was monitored for 6 additional months. The DI group was observed without intervention for 12 months, then received the intervention for 6 months, and was monitored for 6 additional months. The program included training of asthma educators in each practice and then monitoring for improvement in medical record documentation of National Asthma Education and Prevention Program (NAEPP) asthma quality indicators by blinded random review of patient charts. RESULTS: In the EI group, 6-, 12-, and 18-month data revealed significant improvement in documentation of asthma severity, education, action plan, night time symptoms, and symptoms with exercise compared to baseline and compared to DI group at baseline and at the 12-month interval. In the DI group, significant improvement in documentation in all of the above endpoints and also in documentation of NAEPP treatment guidelines was noted at 18 and 24 months. In both groups, documentation levels remained relatively stable at 6 months after the intervention, with no significant differences between groups. While improved, guideline adherence was <80% for half of the indicators. CONCLUSION: In-office training of non-physician asthma providers improves the quality of asthma care.

Screening high-risk children for asthma through a community intervention.

OBJECTIVE: Many children, particularly those from inner city neighborhoods, have undiagnosed asthma. This study was done to evaluate the effectiveness of an asthma screening, referral and follow-up intervention in an inner city community setting in early identification of children at risk for undiagnosed asthma. METHODS: A descriptive longitudinal cohort design was used to assess children at baseline and at a 2-year follow-up. Parents of children in a private day school and a church Sunday school (N = 103) completed a validated Asthma Screening Tool at both time periods. Children with asthma and at risk for asthma were referred to a primary care provider (PCP). RESULTS: At baseline, screening of 103 children, ages 3-17 years (mean=7.7 ± 2.9), were categorized as known asthma diagnosis (n = 22), at-risk for undiagnosed asthma (n = 52) and not at-risk for asthma (n = 29). Sixty-two (60.2%) parents responded to the 2-year follow-up. Referral to PCP was kept by 61.5% from the known asthma group and by 24% of children at-risk for asthma. At 2-year follow-up, among not at-risk group, no one converted to at risk status, but majority of children among known asthma group continued to have uncontrolled asthma symptoms, and very few received daily preventive asthma medications. CONCLUSIONS: The asthma screening, referral and follow-up intervention for inner city children in a community setting was successful in early identification of patients at-risk for asthma. More education for PCPs on guidelines for diagnosis and management of asthma is needed to decrease childhood asthma morbidity.

Changes in Pulmonary Function and Controlled Ventilation-High Resolution CT of Chest After Antibiotic Therapy in Infants and Young Children with Cystic Fibrosis.

BACKGROUND: Infants with cystic fibrosis (CF) develop early progressive lung disease which may be asymptomatic. Infant pulmonary function tests (IPFT) and controlled ventilation-high resolution computed tomography (CV-HRCT) of chest can detect early asymptomatic lung disease. It is not well established that these objective measures can detect changes in lung disease after clinical interventions. OBJECTIVE: The purpose of this study was to evaluate usefulness of IPFT and CV-HRCT to detect changes in lung disease after intravenous (IV) antibiotic therapy in infants with early CF-related lung disease. STUDY DESIGN: IPFTs and CV-HRCT done before and after 2 weeks of IV antibiotics in infants at our institution over the last 12 years were compared. CV-HRCTs were compared using the modified Brody scoring system. RESULTS: The sample included 21 infants, mean age 85.2 ± 47.6 weeks. Mean change in weight was 0.4 ± 0.38 kg (p = 0.001). Significant changes in IPFT included mean % predicted FEV(0.5) (+13.5 %, p = 0.043), mean %FEF(25-75) (+30.2 %, p = 0.008), mean %RV/TLC (-11.2 %, p = 0.008), and mean %FRC/TLC (-4.5 %, p = 0.001). Total Brody scores improved from a median of 10 to 5 (p < 0.001) as did mean scores for airway wall thickening (p = 0.050), air trapping (p < 0.001), and parenchymal opacities (p = 0.003). CONCLUSION: IPFT and CV-HRCT can be used as objective measures of improvement in lung disease for infants with CF treated with antibiotics.

Demographics, clinical course, and outcomes of children with status asthmaticus treated in a pediatric intensive care unit: 8-year review.

OBJECTIVE: This study was done to understand the demographics, clinical course, and outcomes of children with status asthmaticus treated in a tertiary care pediatric intensive care unit (PICU). METHODS: The medical charts of all patients above 5 years of age admitted to the PICU at Nationwide Children's Hospital, Columbus, OH, USA, with status asthmaticus from 2000 to 2007 were reviewed retrospectively. Data from 222 encounters by 183 children were analyzed. RESULTS: The mean age at admission in years was 11 ± 3.8. The median PICU stay was 1 day (range, 1-12 days) and median hospital stay was 3 days. The ventilated group (n = 17) stayed a median of 2 days longer in the PICU and hospital. Nearly half of the children (n = 91; 50%) did not receive daily controller asthma medications. Adherence to asthma medications was reported in 125 patient charts of whom 43 (34%) were compliant. Exposure to smoking was reported in 167 of whom 70 (42%) were exposed. Among patients receiving metered dose inhaler (MDI), only 39 (18%) were using it with a spacer. Among 105 patient charts asthma severity data were available, of them 21 (20%) were labeled as mild intermittent, 29 (28%) were mild persistent, 26 (25%) were moderate persistent, and 29 (28%) were severe persistent. Compared to children with only one PICU admission during the study period (n = 161), children who had multiple PICU admissions (n = 22) experienced more prior emergency department visits and hospitalizations for asthma symptoms. There were no fatalities. CONCLUSION: Asthmatics with any disease severity are at risk for life-threatening asthma exacerbations requiring PICU stay, especially those who are not adherent with their daily medications.

Impact of elexacaftor-tezacaftor-ivacaftor on bacterial colonization and inflammatory responses in cystic fibrosis.

BACKGROUND: Cystic fibrosis (CF) is a multisystem disease with progressive deterioration. Recently, CF transmembrane conductance regulator (CFTR) modulator therapies were introduced that repair underlying protein defects. Objective of this study was to determine the impact of elexacaftor-tezacaftor-ivacaftor (ETI) on clinical parameters and inflammatory responses in people with CF (pwCF). METHODS: Lung function (FEV1 ), body mass index (BMI) and microbiologic data were collected at initiation and 3-month intervals for 1 year. Blood was analyzed at baseline and 6 months for cytokines and immune cell populations via flow cytometry and compared to non-CF controls. RESULTS: Sample size was 48 pwCF, 28 (58.3%) males with a mean age of 28.8 ± 10.7 years. Significant increases in %predicted FEV1 and BMI were observed through 6 months of ETI therapy with no change thereafter. Changes in FEV1 and BMI at 3 months were significantly correlated (r = 57.2, p < 0.01). There were significant reductions in Pseudomonas and Staphylococcus positivity (percent of total samples) in pwCF through 12 months of ETI treatment. Healthy controls (n = 20) had significantly lower levels of circulating neutrophils, interleukin (IL)-6, IL-8, and IL-17A and higher levels of IL-13 compared to pwCF at baseline (n = 48). After 6 months of ETI, pwCF had significant decreases in IL-8, IL-6, and IL-17A levels and normalization of peripheral blood immune cell composition. CONCLUSIONS: In pwCF, ETI significantly improved clinical outcomes, reduced systemic pro-inflammatory cytokines, and restored circulating immune cell composition after 6 months of therapy.

Pediatric medical line safety: the prevalence and severity of medical line entanglements.

The purpose of this cross-sectional study was to describe the prevalence and severity of medical line entanglements among pediatric patients (N = 486). Most patients, with ages from birth to 6 years, had at least 1 medical line (n = 444, 91%), and 294 children (60%) had 2 to 11 medical lines. Observed entanglements included lines around body parts (n = 31), lines under the body (n = 71), and lines tangled with other lines (n = 50). One third of the children were at risk for adverse events due to entanglements, and 1 patient actually experienced real harm.

Hospitalized children's perspectives on the quality and equity of their nursing care.

Hospitalized children and adolescents (n = 496), aged 6 to 21 years, were asked to evaluate the quality of their nursing care by describing nurse behaviors that they liked and disliked. They named 1673 positive nurse behaviors (12 categories) that made them feel good, happy, safe, and cared about, including "gives me what I need when I need it" (42.3%) and "checks on me often" (34.7%). Six categories of negative nurse behaviors (n = 485), such as "does things to me that hurt or are uncomfortable" (64.1%) and "wakes me up" (24%), made them feel sad, bad, mad, scared, or annoyed.

Challenges and conundrums in the validation of Pediatric Fall Risk Assessment tools.

The 10-item Pediatric Fall Risk Assessment (PFRA) was developed to evaluate patients at low- or high-risk for falling. To avoid the unnecessary use of resources for children not likely to fall, children evaluated as high-risk are targeted for more intensive fall prevention interventions. In a retrospective, case-control design, the precision, accuracy, and error rate of the PFRA with patients ages 1 month to 24 years were evaluated. Cases included children who fell (n = 326), and controls (n = 326) were children from the same cohort who did not fall. Inter-rater agreement (precision) on PFRA cut-off scores was 95.1%, but accuracy was unacceptably low due to 60% false-positive and 58.5% false-negative risk ratings. Neither the PFRA nor three other widely used pediatric fall risk scales have sufficient precision or accuracy to justify implementing or withholding a high-risk fall prevention protocol. Several logistic and methodological challenges must be addressed before further development of these tools.

Impact of guideline adherence and race on asthma control in children.

BACKGROUND: Asthma control in African Americans (AA) is considered more difficult to achieve than in Caucasian Americans (CA). The aim of this study was to compare asthma control over time among AA and CA children whose asthma is managed per NAEPP (EPR-3) guidelines. METHODS: This was a one-year prospective study of children referred by their primary care physicians for better asthma care in a specialty asthma clinic. All children received asthma care per NAEPP guidelines. Results were compared between CA and AA children at baseline and then at three-month intervals for one year. RESULTS: Of the 345 children, ages 2-17 years (mean = 6.2 ± 4), 220 (63.8%) were CA and 125 (36.2%) were AA. There were no significant differences in demographics other than greater pet ownership in CA families. At baseline, AA children had significantly more visits to the Emergency Department for acute asthma symptoms (mean = 2.3 [Formula: see text] compared to CA (1.4 ± 2.3, P = 0.003). There were no other significant differences in acute care utilization, asthma symptoms (mean days/month), or mean asthma control test (ACT) scores at baseline. Within 3-6 months, in both groups, mean ACT scores, asthma symptoms and acute care utilization significantly improved (P < 0.05 for all) and change over time in both groups was comparable except for a significantly greater decrease in ED visits in AA children compared to CA children (P = 002). CONCLUSION: Overall, improvement in asthma control during longitudinal assessment was similar between AA and CA children because of  consistent use of NAEPP asthma care guidelines.

Accuracy of vaginal symptom self-diagnosis algorithms for deployed military women.

BACKGROUND: Deployed military women have an increased risk for development of vaginitis due to extreme temperatures, primitive sanitation, hygiene and laundry facilities, and unavailable or unacceptable healthcare resources. The Women in the Military Self-Diagnosis (WMSD) and treatment kit was developed as a field-expedient solution to this problem. OBJECTIVES: The primary study aims were to evaluate the accuracy of women's self-diagnosis of vaginal symptoms and eight diagnostic algorithms and to predict potential self-medication omission and commission error rates. METHOD: Participants included 546 active duty, deployable Army (43.3%) and Navy (53.6%) women with vaginal symptoms who sought healthcare at troop medical clinics on base.In the clinic lavatory, women conducted a self-diagnosis using a sterile cotton swab to obtain vaginal fluid, a FemExam card to measure positive or negative pH and amines, and the investigator-developed WMSD Decision-Making Guide. Potential self-diagnoses were "bacterial infection" (bacterial vaginosis [BV] and/or trichomonas vaginitis [TV]), "yeast infection" (candida vaginitis [CV]), "no infection/normal," or "unclear." The Affirm VPIII laboratory reference standard was used to detect clinically significant amounts of vaginal fluid DNA for organisms associated with BV, TV, and CV. RESULTS: Women's self-diagnostic accuracy was 56% for BV/TV and 69.2% for CV. False-positives would have led to a self-medication commission error rate of 20.3% for BV/TV and 8% for CV. Potential self-medication omission error rates due to false-negatives were 23.7% for BV/TV and 24.8% for CV. The positive predictive value of diagnostic algorithms ranged from 0% to 78.1% for BV/TV and 41.7% for CV. DISCUSSION: The algorithms were based on clinical diagnostic standards. The nonspecific nature of vaginal symptoms, mixed infections, and a faulty device intended to measure vaginal pH and amines explain why none of the algorithms reached the goal of 95% accuracy. The next prototype of the WMSD kit will not include nonspecific vaginal signs and symptoms in favor of recently available point-of-care devices that identify antigens or enzymes of the causative BV, TV, and CV organisms.

Accuracy of the clinical diagnosis of vaginitis compared with a DNA probe laboratory standard.

OBJECTIVE: To estimate the accuracy of the clinical diagnosis of the three most common causes of acute vulvovaginal symptoms (bacterial vaginosis, candidiasis vaginitis, and trichomoniasis vaginalis) using a traditional, standardized clinical diagnostic protocol compared with a DNA probe laboratory standard. METHODS: This prospective clinical comparative study had a sample of 535 active-duty United States military women presenting with vulvovaginal symptoms. Clinical diagnoses were made by research staff using a standardized protocol of history, physical examination including pelvic examination, determination of vaginal pH, vaginal fluid amines test, and wet-prep microscopy. Vaginal fluid samples were obtained for DNA analysis. The research clinicians were blinded to the DNA results. RESULTS: The participants described a presenting symptom of abnormal discharge (50%), itching/irritation (33%), malodor (10%), burning (4%), or others such as vulvar pain and vaginal discomfort. According to laboratory standard, there were 225 cases (42%) of bacterial vaginosis, 76 cases (14%) of candidiasis vaginitis, 8 cases (1.5%) of trichomoniasis vaginalis, 87 cases of mixed infections (16%), and 139 negative cases (26%). For each single infection, the clinical diagnosis had a sensitivity and specificity of 80.8% and 70.0% for bacterial vaginosis, 83.8% and 84.8% for candidiasis vaginitis, and 84.6% and 99.6% for trichomoniasis vaginalis when compared with the DNA probe standard. CONCLUSION: Compared with a DNA probe standard, clinical diagnosis is 81-85% sensitive and 70-99% specific for bacterial vaginosis, Candida vaginitis, and trichomoniasis. Even under research conditions that provided clinicians with sufficient time and materials to conduct a thorough and standardized clinical evaluation, the diagnosis and, therefore, subsequent treatment of these common vaginal problems remains difficult. LEVEL OF EVIDENCE: II.

Critical care air transport team (CCATT) nurses' deployed experience.

The objective of this study was to use descriptive and phenomenological methods with Critical Care Air Transport Team (CCATT) nurses to identify knowledge and skills required to provide care for critically ill patients in a combat environment. Unstructured interviews, focus groups, written narratives, group interviews, participant observation, and review of in-flight documentation of care were used to obtain data from 23 registered nurses who had deployed with CCATT missions. Dimensions that emerged from the data included: clinical and operational competence, personal, physical, and psychosocial readiness, soldier and survival skills, leadership, administrative concerns, group identification and integration, aircraft air and evacuation familiarity, and nurse characteristics. This information should be shared with CCATT trainers and unit personnel to better prepare them for the realities of future deployments. Future research could incorporate these data into a self-assessment scale to evaluate CCATT nurses' readiness for future deployments.