The influence of experience and credential status on perceptions of agency competency in delivery of the 10 essential environmental public health services.

Contributions made by the environmental health (EH) workforce in reducing human disease are some of the most significant to public health. A shrinking workforce and increased work complexity have called for workforce training in the 10 essential public health services. The preliminary study discussed here assesses perceived competency of the Kansas EH workforce in the 10 essential public health services and evaluates credentialing influence on perceptions. State and local food service inspectors were anonymously surveyed using the Northwest Center for Public Health Practice Environmental Health Workforce Questionnaire. Credentialed respondents reported more years of experience and supervisory responsibilities, Noncredentialed respondents were more likely than credentialed respondents to answer that their work unit was capable of providing the 10 essential public health services. Kansas should establish an accredited EH program and national credentialing requirements established for EH practitioners would encourage and institutionalize ongoing workforce training programs.

Conspicuous vs customary location of hand hygiene agent dispensers on alcohol-based hand hygiene product usage in an intensive care unit.

CONTEXT: Hand washing is considered the single most important nosocomial infection-control strategy, yet compliance rarely meets levels recommended by infection control authorities. OBJECTIVES: To determine whether placement of hand hygiene foam dispensers in more conspicuous positions and closer proximity to patients would increase use of infection control agents as measured by volume of product used. Further, to ascertain the influence of dispenser placement vs the number of dispensers available on usage by volume. METHODS: This prospective, observational study conducted in an intensive care unit was composed of three observation periods. A control period with standard agent dispenser location (8 dispensers) was followed by two experimental periods: (1) "conspicuous and immediate proximity to patient" placement (16 dispensers) and (2) standard locations with a dramatic increase in the number of dispensers (36 dispensers). RESULTS: Volume of use for alcohol-based hand hygiene agent during the three observation periods revealed a statistically significant increase in daily consumption after conspicuous and proximate positioning of dispensers (P<.001). However, increasing the number of dispensers did not increase agent use (P=.196). CONCLUSION: More conspicuous placement of dispensers containing alcohol-based hand hygiene agent (ie, immediate proximity to patients) resulted in statistically and clinically significant increases in product usage. An increase in the number of dispensers did not increase usage. The impact of dispenser positioning on usage by volume for these highly effective products should be considered when planning and implementing intensive care unit infection-control policies.

Effects of therapeutic massage on the quality of life among patients with breast cancer during treatment.

OBJECTIVE: Therapeutic massage has demonstrated positive physical and emotional benefits to offset the effects of treatments associated with breast cancer. The goal of this study was to assess the impact of therapeutic massage on the quality of life of patients undergoing treatment for breast cancer. DESIGN: Using a pre/post intervention assessment design, this prospective, convenience sample pilot study measured anxiety, pain, nausea, sleep quality, and quality of life. Treatment consisted of one 30-minute treatment per week for 3 consecutive weeks. OUTCOME MEASURES: Instruments selected for this study were used in previous massage therapy studies to measure quality of life/health status and have documented validity and reliability. RESULTS: Participants experienced a reduction in several quality of life symptom concerns after only 3 weeks of massage therapy. Respondents' cumulative pre- and post-massage mean for state anxiety, sleep quality, and quality of life/functioning showed significant improvement. Among study participants, there was variability in reported episodes of nausea, vomiting, and retching; although participants reported decreased pain and distress, changes were non-significant. CONCLUSIONS: Therapeutic massage shows potential benefits for ameliorating the effects of breast cancer treatment by reducing side affects of chemotherapy and radiation and improving perceived quality of life and overall functioning.

An assessment of a pilot asthma education program for childcare workers in a high-prevalence county.

OBJECTIVE: To assess changes in knowledge, attitudes, and intentions among childcare workers before and after an asthma-management-education session. METHODS: Between May and August 2004 five asthma-education sessions were provided for childcare workers from Sonoma County, California. A total of 71 childcare workers came to the sessions. Before and after each session we assessed the participants' knowledge, attitudes, and intentions about asthma. RESULTS: Participant knowledge of asthma causes (eg, air quality, common cold) and interventions (eg, bronchodilators), asthma trigger control plans, ability to identify a child who needs medical attention for asthma, and comfort level with caring for a child with asthma increased significantly. Their knowledge about asthma triggers, early warning signs, and asthma control plans was high before and after the asthma education intervention. Their stated intentions to utilize their asthma knowledge were high before and after the training, which may indicate willingness to implement knowledge and attitude change. CONCLUSIONS: Asthma education can improve childcare workers' knowledge about asthma-control strategies and attitudes toward asthma interventions.

Outcomes of tube thoracostomies performed by advanced practice providers vs trauma surgeons.

BACKGROUND: The role of advanced registered nurse practitioners and physician assistants in emergency departments, trauma centers, and critical care is becoming more widely accepted. These personnel, collectively known as advanced practice providers, expand physicians' capabilities and are being increasingly recruited to provide care and perform invasive procedures that were previously performed exclusively by physicians. OBJECTIVES: To determine whether the quality of tube thoracostomies performed by advanced practice providers is comparable to that performed by trauma surgeons and to ascertain whether the complication rates attributable to tube thoracostomies differ on the basis of who performed the procedure. METHODS: Retrospective blinded reviews of patients' charts and radiographs were conducted to determine differences in quality indicators, complications, and outcomes of tube thoracostomies by practitioner type: trauma surgeons vs advanced practice providers. RESULTS: Differences between practitioner type in insertion complications, complications requiring additional interventions, hospital length of stay, and morbidity were not significant. The only significant difference was a complication related to placement of the tube: when the tube extended caudad, toward the feet, from the insertion site. Interrater reliability ranged from good to very good. CONCLUSIONS: Use of advanced practice providers provides consistent and quality tube thoracostomies. Employment of these practitioners may be a safe and reasonable solution for staffing trauma centers.

Evaluating program effectiveness: creating a reliable and valid tool.

This study was done to assess the reliability of a pretest/ posttest design for a mass-casualty burn disaster continuing education (CE) program. Based on program objectives, an instrument to assess knowledge, skills, confidence, and competence in burn assessment and management was designed. The instrument's internal consistency, split-half reliability, and individual items were analyzed. Measures of reliability were moderately high, and item analysis identified no poorly constructed items. The instrument appears to be a reliable measurement of effectiveness for the CE program and will be consistent in measuring changes based on the training. The results may be useful to others who are planning CE training programs.

Preparing for burn disasters: predictors of improved perceptions of competency after mass burn care training.

INTRODUCTION: Prehospital and community hospital healthcare providers in the United States must be prepared to respond to burn disasters. Continuing education is the most frequently utilized method of updating knowledge, skills, and competence among healthcare professionals. Since preparedness training must meet multiple educational demands, it is vital to understand how participants' work and educational experience and the program's content and delivery methods impact knowledge acquisition, and how learning influences confidence and competence to perform new skills. PURPOSE: The purpose of this exploratory, convenience sample study was to identify healthcare provider characteristics and continuing education training content areas that were predictive of self-reported improvement in competence after attending a mass-casualty burn disaster continuing education program. METHODS: Logistic regression analysis of data from a post-training evaluation from nine, one-day continuing education conferences on mass burn care was used to identify factors associated with improved self-reported competency to respond to mass burn casualties. RESULTS: The following factors were associated most closely with increased self-reported competency: (1) prehospital work setting (odds ratio (OR) = 3.06, confidence interval (CI) = 0.83-11.30, p = 0.09); (2) 11 or more years of practice (OR = 0.31, CI = 0.09-1.08, p = 0.07); and (3) practice in an urban setting (OR = 0.01, CI = 0.18-0.82, p < 0.01). Confidence items included: (1) ability to implement appropriate airway management modalities (OR = 2.31, CI = 1.03-5.17, p < 0.04); (2) manage patients with electrical injuries (OR = 4.86, CI = 1.84-12.85, p < 0.001); (3) identify non-survivable injuries (OR = 2.24, CI = 0.93-5.43, p = 0.07); and (4) recognize special problems associated with burns in young children or older adults (OR = 2.14, CI = 0.87-5.23, p = 0.10). The final model explained 89.9% of the variability in self-reported competence. CONCLUSIONS: Interventions used to train healthcare providers for burn disasters must cover a broad range of topics. However, learning needs may vary by practice setting, work experience, and previous exposure to disaster events. This evaluation research provides three-fold information for continuing education research: (1) to identify content areas that should be emphasized in future burn care training; (2) to be used as a model for CE evaluation in other domains; and (3) to provide support that many factors must be considered when designing a CE program. Results may be useful to others who are planning CE training programs.

Impact of a collaborative community case management program on a low-income uninsured population in Sedgwick County, KS.

This cross-sectional study assessed the impact of a collaborative nursing/social worker case management (CM) intervention on emergency department (ED) use, health status, and health locus of control (HLOC) in a low-income uninsured population. Using a pre-post intervention design, key outcomes were assessed using paired t test. A statistically significant (48%) reduction in total ED visits resulted in an estimated charge avoidance of US$1,446,280. Physical health status improved significantly; however, mental health status and HLOC scores showed minimal change. This CM model may assist vulnerable groups in gaining access to care and improved health.

Regionalization: collateral benefits of emergency preparedness activities.

INTRODUCTION: To assess the impact of regionalization of Kansas counties associated with emergency preparedness since 2002 via local health departments (LHDs). METHODS: Three focus groups were conducted in May 2005 with 31 Kansas health department employees. Most participants were public health administrators, women, and 40 years or older. RESULTS: Regionalization was perceived as "absolutely necessary" by participants and resulted in improved collaboration and communication among LHDs. The process supported the development of relationships, trust, and mutual respect among LHDs and other governmental agencies. Participants agreed that LHD functioning has improved the delivery and availability of public health services, increased the efficiency and timeliness of operations, and enhanced public health's visibility in emergency preparedness efforts. Moreover, regionalization added resources to LHDs including personnel, knowledge, technology, technical expertise, and fiscal resources. Dissatisfaction with regionalization was associated with insufficient funding, frustration with changing preparedness guidelines, and differences between state and local expectations. Participants identified four issues necessary to sustain regions: funding, documented benefits, commitment from LHDs and their communities, and engagement from local elected officials. DISCUSSION: The regionalization process has been beneficial for LHDs and produced tangible and intangible benefits. Barriers to regionalization expansion should be addressed for additional collaborative ventures.

Preparing for burn disasters: evaluation of a continuing education training course for pre-hospital and hospital professionals in Kansas.

"Preparing for Burn Disasters: A Training Course for Pre-Hospital and Hospital Professionals in Kansas," a continuing education program designed to provide licensed health care practitioners a training opportunity for multiple burn victim incidents, emphasized the challenges that the community-wide multidisciplinary team faces when responding to burn disasters. A pre-post survey design was used to assess changes in participants' knowledge and self-rated ability, confidence, and competence to perform in a burn disaster before and after training. Participants (N = 383) were predominantly female (71.1%), 40 years or older (57.7%), nurses (52.2%), were employed in a pre-hospital care setting (38%), and had worked in healthcare for 10 years or fewer (53.6%). The percentage of correct responses pre- vs post-test increased between 30% and 65% on two-thirds of the knowledge items. On the basis of paired-samples t-test analysis, statistically significant increases in participants' overall self-ratings of ability and confidence in burn management were observed in every content area. Most participants (64%) felt competent or highly competent to manage multiple burn casualties after the training program, and most participants (58%) indicated that they intended to incorporate the newly acquired knowledge into their daily practice within 2 weeks. Evaluation results demonstrate that a successful program was designed and implemented. The curriculum and teaching methods achieved desired goals for improved knowledge, which appear to have been translated to enhanced abilities, confidence and competence in burn assessment and treatment modalities.

Influence of semi-recumbent position on intra-abdominal pressure as measured by bladder pressure.

BACKGROUND: Intra-abdominal pressure (IAP) obtained by bladder pressure measurement is used to detect impending abdominal compartment syndrome (ACS), but, while it is recommended to use a supine position, the literature describes IAP measurement in varying positions. This study evaluated the impact of body position at differing head-of-bed (HOB) elevations on bladder pressure when planned to be used as a surrogate IAP measurement. MATERIALS AND METHODS: Forty-five trauma patients admitted to a surgical intensive care unit underwent bladder pressure measurements at 0, 15, 30, 45 degrees HOB position and 30 degrees HOB position plus 15 degrees of reverse Trendelenburg tilt; these measurements were performed in counterbalanced fashion and assessed by built-in angle indicators on the bed rails of each bed. Study participants were connected to an IAP monitoring kit via their indwelling Foley catheter. RESULTS: A total of 675 bladder pressure measurements were obtained with 135 measurements at each of five HOB elevations (0 degrees , 15 degrees , 30 degrees , 45 degrees , 30 degrees +15 degrees tilt). Statistically significant differences occurred between all HOB elevations. Statistically significance differences also occurred at different BMI statuses. CONCLUSIONS: Elevating HOB significantly increases bladder pressure measurement. Bladder pressure measurements in nonsupine positions may not provide valid interpretation for IAP, and more so in cases of increased body mass index.

Evaluation of interdisciplinary terrorism preparedness programs: a pilot focus group study.

Many terrorism preparedness trainings occur throughout the United States, yet few qualitatively examine trainees' needs and interests, reactions to training, or suggestions for training improvement. Eleven posttraining focus groups were conducted with 31 training participants at six sites. Participants were stratified by health profession discipline, and discipline-specific moderators conducted each session to better understand and probe for feedback. One additional moderator attended all sessions to increase consistency in methods across sessions. Focus group participants assessed changes in their perceptions, knowledge, and beliefs about terrorism preparedness. Participants reported perceiving terrorism as a potential threat but less likely than natural disasters. All-hazards crossover training for responding to terrorism and natural disasters was requested. The training was viewed positively, including the enrollment process, training content, and reference materials. Participants reported increased confidence in abilities to recognize a terrorist event. Participants stated they would like the training repeated annually with more first responders in attendance. Participants from rural areas had unique training needs based on limited resources and multiple roles of staff. While most participants wanted a longer, multispecialty conference with in-depth, discipline-specific breakout sessions, physicians requested shorter, separate training. Multispecialty training methods were successful and appreciated. This pilot study may serve as a template for qualitative evaluation of terrorism preparedness conferences for health professionals.

Knowing who your partners are: terrorism-preparedness training for nurses.

Continuing education events addressing terrorism preparedness must be evaluated to measure their impact on knowledge acquisition and to assess changes in perceptions, attitudes, and beliefs. The purpose of this focus group study was to evaluate the effectiveness of a terrorism-preparedness training program. The majority of participants thought the training content was extensive, detailed, informative, and practical. Participants reported feeling increased confidence in their abilities to anticipate, recognize, and respond to a terrorist event, and said they made changes related to terrorism preparedness in their homes, workplaces, and communities. This evaluation was useful in identifying strengths and weaknesses of a statewide continuing education program and describing future training needs. Results may be useful to others who are planning terrorism-preparedness training.

Help on the line: telephone-triage use, outcomes, and satisfaction within an uninsured population.

Telephone triage programs have been shown to be cost-effective and favorably utilized by insured populations. However, there are 45 million Americans who are uninsured and who do not have access to telephone nursing. A telephone triage service was piloted for local uninsured residents. Within the 17-month trial period, 320 calls were received, representing 207 clients. This study reports on the results of the telephone survey with a cross-sectional sample of uninsured triage patrons (N = 80). One half reported they would have sought other medical care if the telephone triage service had not been available. Most callers (98%) believed that their health care concern was understood. Moreover, 98% agreed with the advice given, and 90% reported following up on the advice given. Overall satisfaction by the uninsured population with the telephone-based nurse triage service was positive and appears to be an effective and acceptable tool by those uninsured individuals who utilized its services.

Quantitative evaluation of "Can It Happen in Kansas: Response to Terrorism and Emerging Infections".

PURPOSE: This study describes the evaluation of a 2-year plan to train 10 percent of Kansas' multidisciplinary health professionals for response to terrorism and emerging infections. This project was part of a national effort covering 19 states funded by the Health Resources and Services Administration in 2003. METHODS: The initial training occurred in six 2-day workshops. A terrorism preparedness questionnaire was developed to assess Health Resources and Services Administration terrorism response competencies/learning objectives. These were measured before, after, and 3 months after training in a hybrid cross-sectional and cohort follow-up design. RESULTS: Health professionals' mean scores significantly improved on all four Health Resources and Services Administration terrorism self-reported competencies from pretest to posttest. Three months posttraining, health professionals' mean scores decreased slightly but remained significantly higher than their pretest scores. CONCLUSIONS: This project prepared healthcare professionals to respond to the medical consequences of terrorism. The integration of core competencies into the evaluation plan allowed for trainees to evaluate their confidence and abilities. The evaluation plan and curriculum may serve as useful tools for preparation of healthcare workers nationwide, with the potential to rebuild the public health infrastructure to assume preparedness responsibilities.

Stigma and safe havens: a medical sociological perspective on African-American female epilepsy patients.

PURPOSE: Very little is known about the attitudes and behaviors of minorities with epilepsy. This pilot study explored access to health care, help-seeking behaviors, and adherence to treatment among African-American females with epilepsy. METHODS: Ethnographic interviews were conducted with 10 African-American female adults. RESULTS: Findings indicate four major obstacles to care: limited financial resources, lack of knowledge about epilepsy among African-Americans, poor patient-provider communication, and lack of social support. Social support impacted individuals seeking surgery, and also affected purchasing medication, adherence to medical treatment, and needed transportation. Lack of knowledge and misinformation about epilepsy in the African-American community and poor communication with physicians contribute to the social stigma felt by these patients. CONCLUSIONS: The behavioral epidemiology of epilepsy among African-Americans is lacking. This disease exacerbates health disparities for this population. These findings point to a need for a safe haven for these individuals.

Assessment of patient and provider satisfaction scales for project access.

OBJECTIVE: This study examined the underlying variables that contribute to patient and provider satisfaction with Project Access, a physician-driven program that connects low-income, uninsured adults (aged 18-64) to denoted specialty care and hospital services. SUBJECTS AND METHODS: Of the 550 physicians and 1400 patients participating per year, 125 physicians and 164 patients completed and returned the 14- and 15-item satisfaction questionnaires, respectively. The data from both surveys were factor analyzed. RESULTS: Patient satisfaction data factored into 4 dimensions: respect from program implementation staff, respect from pre-Project Access enrollment staff, practical health-related issues, and the level of understanding of Project Access guidelines and expectations. Provider satisfaction data factored into 3 dimensions: external services available to patients, receiving recognition and respect, and the administration of Project Access. CONCLUSIONS: Patients' feelings of respect seemed to be closely associated with their satisfaction with Project Access, in addition to the helpfulness of the program. Providers also considered respect and recognition an important factor contributing to their satisfaction, in addition to ease of administrative duties and services available to patients.