Optimizing the hospital discharge process to facilitate family-centered care for well newborns.

BACKGROUND: The perceptions of discharge readiness differ among caregivers and providers. An efficient planning process ensures timely attainment of discharge readiness. Our aim was to increase the percentage of discharge orders placed by 10 a.m. from 0.5% to 10% within 6 months thereby improving discharge readiness. METHODS: We conducted a quality improvement initiative in the newborn nursery between March 2021 and June 2022 (n = 2307). We implemented a physician-led early discharge huddle and standardized the newborn screen (NBS) and circumcision process. RESULTS: By 10 a.m., our primary outcome measure, discharge orders, improved from 0.5 to 19%. Our process measures also increased. NBS specimens collected improved from 56 % to 98 % and circumcision rates increased from 66 to 88%. Balancing measure of postpartum hospital days remained stable. CONCLUSIONS: Optimizing family-centered discharge processes by addressing key drivers is essential and can be achieved without an increase in postpartum hospital days.

The Department of Veterans' Affairs Depleted Uranium Cohort in the Time of COVID-19: Translating a Traditional Surveillance Protocol to a Telehealth Platform.

OBJECTIVE: In 2021, 37 members of a cohort of depleted uranium-exposed Gulf War I veterans were evaluated using a protocol tailored to accommodate COVID-19 safety practices on a telehealth platform. METHODS: Individual elements of the legacy protocol were reviewed for urgency and feasibility of inclusion in a modified, telehealth platform. RESULTS: The redesigned protocol included a participant readiness for telehealth assessment, nurse and physician telehealth visits, collection of usual health questionnaires, and urine collections for exposure monitoring for uranium and other fragment-related metal measures. CONCLUSIONS: Despite some limitations in scope, the telehealth platform permitted a visual "visit" with surveillance participants who expressed a high comfort level with the format. The telehealth platform has apparent utility for occupational surveillance and should be explored as a standard approach for surveillance outside of public health emergencies.

Surveillance of Depleted Uranium-exposed Gulf War Veterans: More Evidence for Bone Effects.

ABSTRACT: Gulf War I veterans who were victims of depleted uranium (DU) "friendly-fire" incidents have undergone longitudinal health surveillance since 1994. During the spring of 2019, 36 members of the cohort were evaluated with a monitoring protocol including exposure assessment for total and isotopic uranium concentrations in urine and a comprehensive review of health outcomes, including measures of bone metabolism and bone mineral density (BMD) determination. Elevated urine U concentrations were observed in cohort members with retained depleted uranium (DU) shrapnel fragments. In addition, a measure of bone resorption, N-telopeptide, showed a statistically significant increase in those in the high DU subgroup, a finding consistent with a statistically significant decrease in bone mass also observed in this high DU subgroup compared to the low DU subgroup. After more than 25 y since first exposure to DU, an aging cohort of military veterans continues to show few U-related health effects in known target organs of U toxicity. The new finding of impaired BMD in the high DU subgroup has now been detected in two consecutive surveillance visits. While this is a biologically plausible uranium effect, it is not reflected in other measures of bone metabolism in the full cohort, which have largely been within normal limits. However, ongoing accrual of the U burden from fragment absorption over time and the effect of aging further impairing BMD suggest the need for future surveillance assessments of this cohort.

Cleaning and Disinfection Perceptions and Use Practices Among Elastomeric Respirator Users in Health care.

BACKGROUND: Reusable elastomeric respirator use in health care may represent one solution to address N95 respirator shortages experienced during infectious disease outbreaks, but cleaning and disinfection requirements may limit their utility. Evidence of respirator cleaning and disinfection behaviors and practices by health care workers may inform guidance on reusable respirator use. METHODS: Medical system elastomeric respirator users were surveyed about respirator cleaning and disinfection practices and perceptions via an electronic survey. Respondents were subsequently classified based on reported compliance with their assigned respirator use. To explore whether respirator cleaning and disinfection issues affected compliance with assigned device use, responses were compared between user groups and adjusted for covariates. RESULTS: A total of 432 of 2,024 (21%) eligible elastomeric respirator users completed the survey. Most (>90%) reported that their respirator was clean, but only 52% reported that they always disinfect their respirators after use according to the hospital's expected practice. Only 40 respondents (9%) reported regularly cleaning the respirator with soap and water, in accordance with manufacturer recommendations. Reporting of suboptimal decontamination practice was not associated with assigned device compliance, however, except among providers and respiratory therapists. CONCLUSION/APPLICATION TO PRACTICE: Although perceptions of cleanliness and adherence to expected decontamination practices during routine use did not appear to influence compliance with assigned respirator use overall, this did predict compliance among providers and respiratory therapists, both of whom have nonfixed workstations. Practical and effective strategies to assure easy access to and availability of clean reusable respiratory protective devices are needed to facilitate their use in health care respiratory protection programs.

Storage and Availability of Elastomeric Respirators in Health Care.

Use of reusable respirators, such as elastomeric half-face respirators (EHFRs), may serve as one solution to combating the problem of N95 respirator shortages experienced during infectious disease emergencies. To clarify whether logistical issues like respirator storage and availability are barriers to implementation of healthcare respiratory protection strategies that include EHFRs, this study aimed to evaluate the availability, storage, and respirator and filter replacement practices of EHFRs used in healthcare settings under routine use. Healthcare workers using EHFRs were surveyed about their use practices. To explore whether issues related to storage and availability of EHFRs affected compliance with assigned respirator use, responses were compared between concordant users and EHFR users who were assigned to use EHFRs but currently use different respirators ("discordant users"). Most concordant EHFR users reported that their respirator was always available when needed (63.8%). Almost two-thirds of concordant but only half of discordant users reported storing their EHFRs conveniently in the patient care area (p = <0.001). Among mobile workers, discordant users had higher odds (aOR = 3.2, 95% CI [1.4,7.5]) of reporting that their respirator was not stored in the patient care area, suggesting that storage location has a significant impact on compliance with expected practice, particularly in this group. Storage and access are barriers to optimal elastomeric respirator use in healthcare. Strategies to assure ready availability and storage of respirators will permit EHFR inclusion in pandemic and routine respiratory protection programs.

User acceptance of reusable respirators in health care.

BACKGROUND: Inclusion of reusable respirators, such as elastomeric half-face respirators (EHFRs) and powered air-purifying respirators (PAPRs), in hospital respiratory protection inventories may represent 1 solution to the problem of N95 respirator shortages experienced during pandemics. User acceptance of these devices is 1 potential barrier to implementing such a strategy in respiratory protection programs. METHODS: To assess user attitudes toward various respirators, health care workers enrolled in respiratory protection programs in a medical system using EHFRs, N95s, and PAPRs and completed an online questionnaire that addressed attitudes, beliefs, and respirator preferences under different risk scenarios. Responses were compared between user groups. RESULTS: Of 1,152 participants, 53% currently used N95s, 24% used EHFRs, and 23% used PAPRs. N95 users rated their respirators more favorably compared with EHFR and PAPR users (P < .001) regarding comfort and communication, however, EHFR users rated their respirators much more highly regarding sense of protection (P < .001). For all user groups, reusable respirators were significantly more likely (odds ratios 2.3-7.7) to be preferred over N95 filtering facepiece respirators in higher risk scenarios compared to "usual circumstance" scenarios. CONCLUSIONS: Despite somewhat less favorable ratings on comfort and communication, experienced EHFR and PAPR users still prefer reusable respirators over N95s in certain higher risk scenarios. This suggests that reusable respirators are an acceptable alternative to N95 respirators in health care and offer 1 viable solution to prevent pandemic-generated respirator shortages.

Surveillance results and bone effects in the Gulf War depleted uranium-exposed cohort.

A small group of Gulf War I veterans wounded in depleted uranium (DU) friendly-fire incidents have been monitored in a clinical surveillance program since 1993. During the spring of 2017, 42 members of the cohort were evaluated with a protocol which includes exposure monitoring for total and isotopic uranium concentrations in urine and a comprehensive assessment of health outcomes including measures of bone metabolism, and for participants >50 years, bone mineral density (BMD) determination. Elevated urine U concentrations were observed in cohort members with retained DU shrapnel fragments. Only the mean serum estradiol concentration, a marker of bone metabolism, was found to be significantly different for lower-vs- higher urine U (uU) cohort sub-groups. For the first time, a significant deficit in BMD was observed in the over age 50, high uU sub-group. After more than 25 years since first exposure to DU, an aging cohort of military veterans continues to exhibit few U-related adverse health effects in known target organs of U toxicity. The new finding of reduced BMD in older cohort members, while biologically plausible, was not suggested by other measures of bone metabolism in the full (all ages) cohort, as these were predominantly within normal limits over time. Only estradiol was recently found to display a difference as a function of uU grouping. As BMD is further impacted by aging and the U-burden from fragment absorption accrues in this cohort, a U effect may be clarified in future surveillance visits.

The U.S. Department of Veterans' Affairs depleted uranium exposed cohort at 25 Years: Longitudinal surveillance results.

BACKGROUND: A small group of Gulf War I veterans wounded in depleted uranium (DU) friendly-fire incidents have been monitored for health changes in a clinical surveillance program at the Veterans Affairs Medical Center, Baltimore since 1994. METHODS: During the spring of 2015, an in-patient clinical surveillance protocol was performed on 36 members of the cohort, including exposure monitoring for total and isotopic uranium concentrations in urine and a comprehensive assessment of health outcomes. RESULTS: On-going mobilization of U from embedded fragments is evidenced by elevated urine U concentrations. The DU isotopic signature is observed principally in participants possessing embedded fragments. Those with only an inhalation exposure have lower urine U concentration and a natural isotopic signature. CONCLUSIONS: At 25 years since first exposure to DU, an aging cohort of military veterans continues to show no U-related health effects in known target organs of U toxicity. As U body burden continues to accrue from in-situ mobilization from metal fragment depots, and increases with exposure duration, critical tissue-specific U concentration thresholds may be reached, thus recommending on-going surveillance of this veteran cohort.

Biologic monitoring and surveillance results for the department of veterans affairs' depleted uranium cohort: Lessons learned from sustained exposure over two decades.

BACKGROUND: A small group of Gulf War I veterans wounded in depleted uranium (DU) friendly fire incidents have been monitored in a clinical surveillance program at the Veterans Affairs Medical Center, Baltimore since 1994. METHODS: An in-patient clinical surveillance protocol was performed on 35 members of the cohort, including exposure monitoring for total and isotopic uranium concentrations in urine and a comprehensive assessment of health outcomes. RESULTS: Although urine U concentrations continue to be elevated in this group, illustrating on-going in situ mobilization of U from embedded fragments, no consistent U-related health effects have been observed. CONCLUSIONS: Now more than 20 years since first exposure to DU, an aging cohort of military veterans continues to show no U-related health effects in known target organs of U toxicity. As tissue concentrations continue to accrue with exposure duration, critical tissue-specific U concentration thresholds may be reached, thus recommending on-going surveillance of this veteran cohort.

Chromosome 5 and 7 abnormalities in oncology personnel handling anticancer drugs.

OBJECTIVE: To determine the frequency of "signature" chromosomal abnormalities in oncology workers handling anticancer drugs. METHODS: Peripheral blood from health care personnel (N = 109) was examined with probes for targets on chromosomes 5, 7, and 11. The effect of drug-handling frequency on chromosome abnormalities was assessed. RESULTS: An excess of structural (0.18 vs 0.02; P = 0.04) and total abnormalities (0.29 vs 0.04; P = 0.01) of chromosome 5 was observed in the high-exposure group compared with the unexposed. Increased incidence rate ratios (IRRs) for abnormalities of chromosome 5 (IRR = 1.24; P = 0.01) and for either chromosome 5 or 7 (IRR = 1.20; P = 0.01) were obtained at 100 handling events. Effect sizes were augmented 2- to 4-fold when alkylating agent handling alone was considered. CONCLUSIONS: Biologically important exposure to genotoxic drugs is apparently occurring in oncology work settings despite reported use of safety practices.

Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers.

OBJECTIVE: This study evaluated health care worker exposure to antineoplastic drugs. METHODS: A cross-sectional study examined environmental samples from pharmacy and nursing areas. A 6-week diary documented tasks involving those drugs. Urine was analyzed for two specific drugs, and blood samples were analyzed by the comet assay. RESULTS: Sixty-eight exposed and 53 nonexposed workers were studied. Exposed workers recorded 10,000 drug-handling events during the 6-week period. Sixty percent of wipe samples were positive for at least one of the five drugs measured. Cyclophosphamide was most commonly detected, followed by 5-fluorouracil. Three of the 68 urine samples were positive for one drug. No genetic damage was detected in exposed workers using the comet assay. CONCLUSIONS: Despite following recommended safe-handling practices, workplace contamination with antineoplastic drugs in pharmacy and nursing areas continues at these locations.