Implementation of Concussion Management Policies in High Schools: The Critical Role of School Nurses.

Evidence-based practices in concussion management (CM) have been codified into legislation. However, legislation is varied, and implementation is narrowly evaluated. School nurses hold a unique position to assess the implementation of health policies. The implementation of concussion management policies across Massachusetts high schools was evaluated by the school nurse. A cross-sectional survey was sent to school nurses (N = 304), and responses (n = 201; 68.1% response rate) were tallied whereby higher scores indicated more practices being implemented. One open-text question was included to encourage nurses to provide context regarding implementation in their school. Descriptive statistics and thematic analysis were used to assess current implementation and nursing perspectives. Findings indicate that the degree of implementation varies, and some nurses reported difficulty with mobilizing clinical uptake of concussion management practices in their schools. Further implementation research is needed, and school nurses are an important stakeholder to include when assessing the clinical uptake of concussion management policies in schools.

It is time to rewrite state youth sports concussion laws.

Between 2009 and 2014, all 50 states and the District of Columbia passed legislation to improve the recognition and management of youth concussed in sports. These laws can include requirements for concussion training for school athletic personnel, concussion education for children and their parents, return-to-play (RTP) procedures, and medical clearance to for RTP. Concussion can impact academic learning and performance in children and adolescents. Postconcussion academic accommodations during recovery can be an important component of secondary prevention for mitigating the sequalae of head injury. Few state youth concussion laws, however, include provision of postconcussion return-to-learn (RTL) accommodations and most of those that do address RTL apply to student athletes only. Concussions may occur in youth who are not participating in organised sports (eg, falls, traffic crashes) and thus may not be subjected to RTL accommodations, even if the state mandates such procedures for athletes. Low income and students of colour may be more likely to have non-sports concussions than their more affluent and white peers, thus potentially creating demographic disparities in the benefits of RTL procedures. State youth sports concussion laws should be revised so that they include RTL provisions that apply to all students, athletes and non-athletes alike.

Application of Components of the Massachusetts' Sports Concussion Regulations to All Students With Concussion: A Survey of School Nurses.

Appropriate management by schools of all students with a concussion, regardless of the cause, has not received the same attention as sports-related concussions. Focus groups conducted with Massachusetts School Nurses in 2015 found that some had applied protocols required in the state's sports concussion regulations to all students with concussion, not just student athletes. We surveyed high school nurses in Massachusetts to examine (1) the extent of this practice and (2) the extent to which protocols for all students with concussion are included in school policies. Of 168 (74%) responding, 94% applied the return-to-learn and play, and medical clearance requirements to all students with concussion, regardless of how or where the concussion occurred and 77% reported their school's policy required these protocols for all students with concussion. A significant association (odds ratio: 13.3, 95% confidence interval [2.4, 72.8], p <.01) existed between the two measures. These findings have important clinical and academic implications.

Older adult fall prevention practices among primary care providers at accountable care organizations: A pilot study.

BACKGROUND: Falls are a serious and common problem among older adults. Low-tech, inexpensive, community-based fall prevention programs have been shown to be both effective and cost effective, however, these programs are not well-integrated into clinical practice. RESEARCH DESIGN: We surveyed primary care providers at a convenience sample of two accountable care organizations in Massachusetts to assess their beliefs, attitudes, knowledge, and practices relative to fall risk assessment and intervention for their older patients. RESULTS: Response rate was 71%. Providers' beliefs about the efficacy of fall risk assessment and intervention were mixed. Eighty-seven percent believed that they could be effective in reducing fall risk among their older adult patients. Ninety-six percent believed that all older adults should be assessed for fall risk; and, 85% believed that this assessment would identify fall risk factors that could be modified. Nonetheless, only 52% believed that they had the expertise to conduct fall risk assessment and only 68% believed that assessing older adult patients for fall risk was the prevailing standard of practice among their peer providers. Although most providers believed it likely that an evidence-based program could reduce fall risk among their patients, only 14% were aware of the Centers for Disease Control and Prevention's fall risk assessment algorithm (STEADI Toolkit), and only 15% were familiar with Matter of Balance, the most widely disseminated community fall risk prevention program in Massachusetts. DISCUSSION: New strategies that more directly target providers are needed to accelerate integration of fall risk assessment and intervention into primary care practice.

Evaluation of Implementation of Massachusetts Sports Concussion Regulations: Results of Focus Groups With School Nurses and Athletic Trainers.

In 2015, the Massachusetts Department of Public Health conducted focus groups with school nurses (SNs) and athletic trainers (ATs) from Massachusetts middle and high schools to assess implementation of legislated regulations relative to the management of students' head injuries incurred during extracurricular sports. Four tape-recorded focus groups were conducted by experienced facilitators. Lists of themes were synthesized by investigators for each focus group. Participating SNs and ATs supported the sports concussion legislation, felt that implementation had gone well, indicated that the law empowered them in managing return-to-school/play for students with concussion, and experienced support from their school administrators. Some SNs reported that they had applied relevant procedures to all students with head injuries, regardless of how or where the injury occurred. Challenges identified included protocols for away games, inconsistent concussion care by physicians, and a need for teacher education. Further research is required to quantify these findings.

Utilitarian walking, neighborhood environment, and risk of outdoor falls among older adults.

OBJECTIVES: We examined the roles of utilitarian and recreational walking in relation to occurrence of outdoor falls in older adults. METHODS: We analyzed data on walking habits, falls, and fall injuries among participants of MOBILIZE Boston, a prospective cohort study of 765 community-dwelling women and men, mainly aged 70 years or older, in Boston, Massachusetts. Neighborhood socioeconomic status (SES) indicators were assessed at census block group level. Falls were recorded during a total of 2066.5 person-years of follow-up (September 2005-December 2009), and the median length of follow-up was 2.9 years (range = 0.04-4.3). RESULTS: . Lower neighborhood SES indicators were associated with more utilitarian walking and higher rates of falls on sidewalks, streets, and curbs. Falls on sidewalks and streets were more likely to result in an injury than were falls in recreational areas. Utilitarian-only walkers tended to live in neighborhoods with the lowest neighborhood SES and had the highest rate of outdoor falls despite walking 14 and 25 fewer blocks per week than the recreational-only and dual walkers, respectively. CONCLUSIONS: . Improving the safety of walking environments in areas where older adults shop and do other errands of necessity is an important component of fall prevention.

Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study.

BACKGROUND: One approach to preventing opioid overdose, a leading cause of premature, preventable mortality, is to provide overdose education and naloxone distribution (OEND). Two outstanding issues for OEND implementation include 1) the dissemination of OEND training from trained to untrained community members; and 2) the concern that OEND provides active substance users with a false sense of security resulting in increased opioid use. METHODS: To compare overdose rescue behaviors between trained and untrained rescuers among people reporting naloxone rescue kit use; and determine whether heroin use changed after OEND, we conducted a retrospective cohort study among substance users in the Massachusetts OEND program from 2006 to 2010. We used chi square and t-test statistics to compare the differences in overdose management characteristics among overdoses managed by trained versus untrained participants. We employed Wilcoxon signed rank test to compare median difference among two repeated measures of substance use among participants with drug use information collected more than once. RESULTS: Among 4,926 substance-using participants, 295 trained and 78 untrained participants reported one or more rescues, resulting in 599 rescue reports. We found no statistically significant differences in help-seeking (p = 0.41), rescue breathing (p = 0.54), staying with the victim (p = 0.84) or in the success of naloxone administration (p = 0.69) by trained versus untrained rescuers. We identified 325 OEND participants who had drug use information collected more than once. We found no significant overall change in the number of days using heroin in past 30 days (decreased 38%, increased 35%, did not change 27%, p = 0.52). CONCLUSION: Among 4926 substance users who participated in OEND, 373(7.6%) reported administering naloxone during an overdose rescue. We found few differences in behavior between trained and untrained overdose rescuers. Prospective studies will be needed to determine the optimal level of training and whether naloxone rescue kits can meet an over-the-counter standard. With no clear evidence of increased heroin use, this concern should not impede expansion of OEND programs or policies that support them.

Using surveillance data to inform a SUID reduction strategy in Massachusetts.

BACKGROUND: Non-supine infant sleep positions put infants at risk for sudden unexpected infant death (SUID). Disparities in safe sleep practices are associated with maternal income and race/ethnicity. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a nutrition supplement program for low-income (≤185% Federal Poverty Level) pregnant and postpartum women. Currently in Massachusetts, approximately 40% of pregnant/postpartum women are WIC clients. To inform the development of a SUID intervention strategy, the Massachusetts Department of Public Health (MDPH) investigated the association between WIC status and infant safe sleep practices among postpartum Massachusetts mothers using data from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey. METHODS: PRAMS is an ongoing statewide health surveillance system of new mothers conducted by the MDPH in collaboration with the Centers for Disease Control and Prevention (CDC). PRAMS includes questions about infant sleep position and mothers' prenatal WIC status. Risk Ratio (RR) and 95 percent confidence intervals (CI) were calculated for infant supine sleep positioning by WIC enrollment, yearly and in aggregate (2007-2010). RESULTS/OUTCOMES: The aggregate (2007-2010) weighted sample included 276,252 women (weighted n ≈ 69,063 women/year; mean survey response rate 69%). Compared to non-WIC mothers, WIC mothers were less likely to usually or always place their infants in supine sleeping positions [RR = 0.81 (95% CI: 0.80, 0.81)]. Overall, significant differences were found for each year (2007, 2008, 2009, 2010), and in aggregate (2007-2010) by WIC status. CONCLUSION: Massachusetts WIC mothers more frequently placed their babies in non-supine positions than non-WIC mothers. While this relationship likely reflects the demographic factors associated with safe sleep practices (e.g., maternal income and race/ethnicity), the finding informed the deployment of an intervention strategy for SUID prevention. Given WIC's statewide infrastructure and the large proportion of pregnant/postpartum women in Massachusetts that are enrolled in WIC, a WIC-based safe sleep intervention may be an effective SUID reduction strategy with potential national application.

Trends in opioid-related fatal overdoses in Massachusetts, 1990-2003.

UNLABELLED: Since 1997, poisoning, particularly from heroin and other opioids, has been the leading cause of injury mortality in Massachusetts. Our aim was to describe recent trends in opioid-related poisoning deaths among Massachusetts residents. METHODS: Massachusetts death files for the years 1990-2003, as coded by International Classification of Disease, Ninth Revision and International Classification of Disease, Tenth Revision, were used to identify all poisoning deaths and opioid-related poisoning deaths; rates were age-adjusted and grouped by year, sex, and race/ethnicity. RESULTS: From 1990 to 2003, opioid-related fatal poisoning rates increased by 529% from 1.4 per 100,000 in 1990 to 8.8 per 100,000 in 2003. The proportion of total poisoning deaths associated with opioids rose from 28% in 1990 to 69% in 2003. CONCLUSIONS: Massachusetts experienced a significant increase in opioid-related poisoning death rates. To guide future public health interventions, further investigation is necessary to better delineate the specific opioids involved, the circumstances surrounding these deaths, and the medical and behavioral health care options available.