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Aims and Objectives: Studies have shown that the COVID-19 pandemic has taken a toll on individuals who interact with patients with SARS-CoV-2 but focused largely on clinicians in acute care settings. This qualitative descriptive study aimed to understand the experiences and well-being of essential workers across settings during the pandemic., Background: Multiple studies of the well-being of individuals who have cared for patients during the pandemic have included interviews of clinicians from acute care settings and revealed high levels of stress. However, other essential workers have not been included in most of those studies, yet they may also experience stress., Methods: Individuals who participated in an online study of anxiety, depression, traumatic distress, and insomnia, were invited to provide a free-text comment if they had anything to add. A total of 2,762 essential workers (e.g., nurses, physicians, chaplains, respiratory therapists, emergency medical technicians, housekeeping, and food service staff, etc.) participated in the study with 1,079 (39%) providing text responses. Thematic analysis was used to analyze those responses., Results: Four themes with eight sub-themes were: Facing hopelessness, yet looking for hope; Witnessing frequent death; Experiencing disillusionment and disruption within the healthcare system, and Escalating emotional and physical health problems., Conclusions: The study revealed major psychological and physical stress among essential workers. Understanding highly stressful experiences during the pandemic is essential to identify strategies that ameliorate stress and prevent its negative consequences. This study adds to the research on the psychological and physical impact of the pandemic on workers, including non-clinical support personnel often overlooked as experiencing major negative effects., Relevance to Clinical Practice: The magnitude of stress among all levels of essential workers suggests the need to develop strategies to prevent or alleviate stress across disciplines and all categories of workers., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Copel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: Feeling connected to nature, or nature relatedness (NR), can positively impact physical and psychological well-being. However, the relationship between NR and dietary behaviors has not been studied. This research examined the relationship between NR and dietary behaviors, including dietary diversity and fruit and vegetable intake., Design: Cross-sectional online survey study., Setting: Philadelphia, Pennsylvania., Subjects: Adults (n = 317) over 18 years who resided in Philadelphia, PA., Measures: The NR Scale was used to measure participants' connection to nature. It includes 21 items across three subscales: self, experience, and perspective (total and subscales range from 1 to 5). Dietary Diversity was assessed using the FAO's standardized tool (scores range from 0 to 9). To calculate dietary diversity, food groups reported were aggregated into nine food categories: starchy staples; dark green leafy vegetables; vitamin A rich fruits/vegetables; other fruits/vegetables; organ meat; meat/fish; eggs; legumes, nuts/seeds; and milk products. The NCI's 2-item CUP Fruit and Vegetable Screener was used to estimate daily fruit and vegetable intake (cups/day), and socio-demographic questions were asked., Analysis: Simple and multivariable regression models were used to examine associations between NR Total and subscale scores with dietary diversity scores and fruit and vegetable intake with NR Total scores and subscale scores. The multivariable models were adjusted for age, race, gender, and income., Results: People with higher NR Total ( P < .001), NR Self (P < .001), NR Perspective (P = .002), and NR Experience (P = .002) were more likely to report greater dietary diversity. Those with higher NR Total (P < .001), NR Self (P < .001), and NR Experience (P < .001) reported greater fruit and vegetable intake. Associations remained significant after adjusting for covariates., Conclusion: NR was associated with better dietary intake after accounting for socio-demographic indicators. These findings highlight the need for health promotion interventions that enhance NR, such as nature prescription initiatives, urban gardening and greening, and immersion in urban green spaces.

Background: mHealth apps have been not been well tested among childhood cancer survivors (CCSs) to track physical and psychosocial functioning for improved self-management of post-treatment needs., Objectives: This pilot study had 3 aims: (1) assess the usage of the Health Storylines mHealth app; (2) examine its effect in improving self-efficacy in managing survivorship healthcare needs, health-related quality of life, and perceived illness; and (3) determine if app usage moderated the effects on the above patient-reported outcome measures among female CCSs., Methods: Study participants accessed the Health Storylines mHealth app on their own personal device. This single-group, pilot study included 3 measurement points: baseline and 3 and 6 months after initiation of using the app., Results: Use of the mHealth app ranged from 0 times to 902 times. Every study participant who used the app (n = 26) also used the mental health app component of the Health Storylines app. Generalized estimating equations were fit to examine the effect of the mHealth app use on self-efficacy, perceived illness, and health-related quality of life, between baseline, 3-month follow-up, and 6-month follow-up. No statistically significant changes were evident, on average, from baseline to 3- or 6-month follow-up on any outcome. Subsequent testing of effect moderation showed differential trends for high versus low users., Conclusions: Studies are needed among this clinical population to determine who will benefit and who will perceive the app as a useful aspect of their survivorship care., Implications for Practice: Sharing mental health functioning tracked on mhealth apps with healthcare providers may inform needed interventions for young adult female CCSs., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To evaluate the effect of providing early attending physician involvement via telemedicine to improve the decision process of rapid response teams., Design: Quasi-experimental; three pairs of control/intervention months: June/July; August/October; November/December., Setting: Single-center, urban, quaternary academic children's hospital with three-member rapid response team: critical care fellow or nurse practitioner, nurse, respiratory therapist. Baseline practice: rapid response team leader reviewed each evaluation with an ICU attending physician within 2 hours after return to ICU., Subjects: 1) Patients evaluated by rapid response team, 2) rapid response team members., Interventions: Implementation of a smartphone-based telemedicine platform to facilitate early co-assessment and disposition planning between the rapid response team at the patient's bedside and the attending in the ICU., Measurements and Main Results: As a marker of efficiency, the primary provider outcome was time the rapid response team spent per patient encounter outside the ICU prior to disposition determination. The primary patient outcome was percentage of patients requiring intubation or vasopressors within 60 minutes of ICU transfer. There were three pairs of intervention/removal months. In the first 2 pairs, the intervention was associated with the rapid response team spending less time on rapid response team calls (June/July: point estimate -5.24 min per call; p < 0.01; August/October: point estimate -3.34 min per call; p < 0.01). During the first of the three pairs, patients were significantly less likely to require intubation or vasopressors within 60 minutes of ICU transfer (adjusted odds ratio, 0.66; 95 CI, 0.51-0.84; p < 0.01)., Conclusions: Early in the study, more rapid ICU attending involvement via telemedicine was associated with rapid response team providers spending less time outside the ICU, and among patients transferred to the ICU, a significant decrease in likelihood of patients requiring vasopressors or intubation within the first 60 minutes of transfer. These findings provide evidence that early ICU attending involvement via telemedicine can improve efficiency of rapid response team evaluations.

Background: Deviations (DEVs) from resuscitation guidelines are associated with worse outcomes after adult in-hospital cardiac arrest (IHCA), but impact during pediatric IHCA is unknown., Methods: Retrospective cohort study of prospectively collected data from the American Heart Association's Get With The Guidelines-Resuscitation registry. Children who had an index IHCA of ≥1 min from 2000 to 2014 were included. DEVs are defined by the registry by category (airway, medications, etc.) A composite measure termed circulation DEV(C-DEV), defined as at least one process deviation in the following categories: medications, defibrillation, vascular access, or chest compressions, was the primary exposure variable. Primary outcome was survival to hospital discharge. Mixed-effect models with random intercept for each hospital assessed the relationship of DEVs with survival to hospital discharge. Robustness of findings was assessed via planned secondary analysis using propensity score matching., Results: Among 7078 eligible index IHCA events, 1200 (17.0%) had DEVs reported. Airway DEVs (466; 38.8%) and medication DEVs (321; 26.8%) were most common. C-DEVs were present in 629 (52.4%). Before matching, C-DEVs were associated with decreased rate of ROSC (aOR = 0.53, CI95: 0.43-0.64, p < 0.001) and survival to hospital discharge (aOR = 0.71, CI95: 0.60-0.86, p < 0.001). In the matched cohort (C-DEV n = 573, no C-DEV n = 1146), C-DEVs were associated with decreased rate of ROSC (aOR 0.76, CI95 0.60-0.96, p = 0.02), but no association with survival to hospital discharge (aOR 1.01, CI95 0.81-1.25, p = 0.96)., Conclusions: DEVs were common in this cohort of pediatric IHCA. In a propensity matched cohort, while survival to hospital discharge was similar between groups, events with C-DEVs were less likely to achieve ROSC., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Eating disorders are a serious, life-threating condition impacting adolescents and young adults. Providers in primary care settings have an important role in identifying disordered eating (DE) symptoms. Unfortunately, symptoms go undetected in 50% of patients in medical settings. Using the behavioral health screen, this study identified DE risk profiles in a sample of 3620 female adolescents and young adults (ages 14-24), presenting in primary care. A latent class analysis with twenty psychosocial factors identified three DE risk groups. The group at highest risk for DE was characterized by endorsement of internalizing symptoms and a history of trauma. The next risk group consisted of those with externalizing symptoms, particularly substance use. The group at lowest risk for DE reported more time spent with friends compared to their peers. Primary care providers and psychiatric teams can benefit from knowing the psychosocial risk patterns affiliated with DE, and using brief, comprehensive screening tools to identify these symptoms.

Objectives: Estimate the inter-rater reliability of critical care nurses performing a pediatric modification of the Glasgow Coma Scale in a contemporary PICU., Design: Prospective observation study., Setting: Large academic PICU., Patients/subjects: All 274 nurses with permanent assignments in the PICU were eligible to participate. A subset of 18 nurses were selected as study registered nurses. All PICU patients were eligible to participate., Interventions: None., Measurements and Main Results: PICU nurses were educated and demonstrated proficiency on a pediatric modification of the Glasgow Coma Scale we created to make it more applicable to a diverse PICU population that included patients who are sedated, mechanically ventilated, and/or have developmental disabilities. Each study registered nurse observed a sample of nurses perform the Glasgow Coma Scale, and they independently scored the Glasgow Coma Scale. Patients were categorized as having developmental disabilities if their preillness Pediatric Cerebral Performance Category score was greater than or equal to 3. Fleiss' Kappa (κ), intraclass correlation coefficient, and percent agreement assessed inter-rater reliability for each Glasgow Coma Scale component (eye, verbal, motor) and age-specific scale (≥ 2 and < 2-yr-old). The overall percent agreement between study registered nurses and nurses was 89% for the eye, 91% for the verbal, and 79% for the motor responses. Inter-rater reliability ranged from good (intraclass correlation coefficient = 0.75) to excellent (intraclass correlation coefficient = 0.96) for testable patients. Agreement on the motor response was significantly lower for children with developmental disabilities (< 2 yr: 59% vs 95%; p = 0.0012 and ≥ 2 yr: 55% vs 91%; p = 0.0012). Agreement was significantly worse for intermediate range Glasgow Coma Scale motor responses compared with responses at the extremes (e.g., motor responses 2, 3, 4 vs 1, 5, 6; p < 0.05)., Conclusions: A pediatric modification of the Glasgow Coma Scale performed by trained PICU nurses has excellent inter-rater reliability, although reliability was reduced in patients with developmental disabilities and for intermediate range Glasgow Coma Scale responses. Further research is needed to determine the effectiveness of this Glasgow Coma Scale modification to detect clinical deterioration.

Context: Teaching faculty cannot reliably distinguish between satisfactory and unsatisfactory resident performances and give non-specific feedback., Objectives: This study aimed to test whether a novel rating form can improve faculty accuracy in detecting unsatisfactory performances, generate more rater observations and improve feedback quality., Methods: Participants included two groups of 40 internal medicine residency faculty staff. Both groups received 1-hour training on how to rate trainees in the mini-clinical evaluation exercise (mini-CEX) format. The intervention group was given a new rating form structured with prompts, space for free-text comments, behavioural anchors and fewer scoring levels, whereas the control group used the current American Board of Internal Medicine Mini-CEX form. Participants watched and scored six scripted videotapes of resident performances 2-3 weeks after the training session., Results: Intervention group participants were more accurate in discriminating satisfactory from unsatisfactory performances (85% versus 73% correct; odds ratio [OR] 2.13, 95% confidence interval [CI] 1.16-3.14, P = 0.02) and yielded more correctly identified unsatisfactory performances (96% versus 52% correct; OR 25.35, 95% CI 9.12-70.46), but were less accurate in identifying satisfactory performances (73% versus 95% correct; OR 0.15, 95% CI 0.05-0.39). Intervention group participants averaged one fewer declared intended feedback item (4.7 versus 5.7) and showed no difference in the amount of feedback that was above minimal in quality. Intervention group participants generated more written evaluative observations (10.8 versus 5.7). Inter-rater agreement improved with the new form (Fleiss' kappa, 0.52 versus 0.30)., Conclusions: Modifying the currently used direct observations process may produce more recorded observations, increase inter-rater agreement and improve overall rater accuracy, but it may also increase severity error.