Assessing the risk of ships striking large whales in marine spatial planning

Marine spatial planning provides a comprehensive framework for managing multiple uses of the marine environment and has the potential to minimize environmental impacts and reduce conflicts among users. Spatially explicit assessments of the risks to key marine species from human activities are a requirement of marine spatial planning. We assessed the risk of ships striking humpback (Megaptera novaeangliae), blue (Balaenoptera musculus), and fin (Balaenoptera physalus) whales in alternative shipping routes derived from patterns of shipping traffic off Southern California (U.S.A.). Specifically, we developed whale-habitat models and assumed ship-strike risk for the alternative shipping routes was proportional to the number of whales predicted by the models to occur within each route. This definition of risk assumes all ships travel within a single route. We also calculated risk assuming ships travel via multiple routes. We estimated the potential for conflict between shipping and other uses (military training and fishing) due to overlap with the routes. We also estimated the overlap between shipping routes and protected areas. The route with the lowest risk for humpback whales had the highest risk for fin whales and vice versa. Risk to both species may be ameliorated by creating a new route south of the northern Channel Islands and spreading traffic between this new route and the existing route in the Santa Barbara Channel. Creating a longer route may reduce the overlap between shipping and other uses by concentrating shipping traffic. Blue whales are distributed more evenly across our study area than humpback and fin whales; thus, risk could not be ameliorated by concentrating shipping traffic in any of the routes we considered. Reducing ship-strike risk for blue whales may be necessary because our estimate of the potential number of strikes suggests that they are likely to exceed allowable levels of anthropogenic impacts established under U.S. laws.

Asthma Control Assessment Tools

Both the National Asthma Education and Prevention Program Expert Panel Report 3 and the 2015 Global Initiative for Asthma guidelines identify achieving and maintaining asthma control as goals of therapy, and they emphasize periodic assessment of asthma control once treatment is established. Accurate assessment of asthma control is difficult due to the complexity of asthma control and due to the limitations in the traditional methods of assessment, such as lung function tests, physician assessment, and patients' self-assessment. Relying solely on the role of lung function tests is insufficient to reflect the status of asthma control, since patients with asthma may have normal spirometry between exacerbations. Clinicians often overestimate the level of asthma control. Similarly, it is not uncommon for patients to overestimate how well their asthma is controlled, and, therefore, they under-report asthma symptoms and fail to recognize the impact that asthma has on their daily life. As a result, several tools have been developed to quantify the level of asthma control, identify patients at risk, and evaluate the effect of asthma management. This review examines the commonly used asthma control assessment tools in terms of content, psychometric properties, methods of administration, limitations, and ability to reflect the overall status of asthma control, which can aid clinicians in selecting the most appropriate tool for their needs.

Effect of Race and Ethnicity on Pulmonary Function Testing Interpretation: An American College of Chest Physicians (CHEST), American Association for Respiratory Care (AARC), American Thoracic Society (ATS), and Canadian Thoracic Society (CTS) Evidence Review and Research Statement

BACKGROUND

Calls have been made to discontinue the routine use of race and ethnicity in medicine. Specific to respiratory medicine, the use of race- and ethnicity-specific reference equations for the interpretation of pulmonary function test (PFT) results has been questioned.

RESEARCH QUESTIONS

Three key questions were addressed: (1) What is the current evidence supporting the use of race- and ethnicity-specific reference equations for the interpretation of PFTs? (2) What are the potential clinical implications of the use or nonuse of race and ethnicity in interpreting PFT results? and (3) What research gaps and questions must be addressed and answered to understand better the effect of race and ethnicity on PFT results interpretation and potential clinical and occupational health implications?

STUDY DESIGN AND METHODS

A joint multisociety (American College of Chest Physicians, American Association for Respiratory Care, American Thoracic Society, and Canadian Thoracic Society) expert panel was formed to undertake a comprehensive evidence review and to develop a statement with recommendations to address the research questions.

RESULTS

Several assumptions and gaps, both in the published literature and in our evolving understanding of lung health, were identified. It seems that many past perceptions and practices regarding the effect of race and ethnicity on PFT results interpretation are based on limited scientific evidence and measures that lack reliability.

INTERPRETATION

A need exists for more and better research that will inform our field about these many uncertainties and will serve as a foundation for future recommendations in this area. The identified shortcomings should not be discounted or dismissed because they may enable flawed conclusions, unintended consequences, or both. Addressing the identified research gaps and needs would allow a better-a more informed-understanding of the effects of race and ethnicity on PFT results interpretation.

Evaluating the Effectiveness of Written Dry Powder Inhaler Instructions and Health Literacy in Subjects Diagnosed With COPD

BACKGROUND

Improper inhaler use results in decreased drug deposition in the lungs. The impact of health literacy and poor vision on the patient's ability to learn inhaler technique by reading instructions has not been confirmed. This study evaluated the effectiveness of learning inhaler technique from written instructions and the impact of health literacy for patients diagnosed with COPD who used a dry powder inhaler (DPI).

METHODS

This pilot study recruited subjects diagnosed with COPD. A trained assessor scored subjects' inhaler technique before and after reading the appropriate American College of Chest Physicians handouts. Peak inspiratory flows (PIFs) were measured using an InCheck Dial. Health literacy was measured by the S-TOFHLA (Short Test of Functional Health Literacy in Adults), and visual acuity was measured by a Snellen chart. Associations between health literacy and visual acuity and changes in subjects' inhaler technique scores were assessed by Spearman's rho. Inhaler technique change scores were assessed by the Wilcoxon signed-rank test at P = .05.

RESULTS

Of the 24 participants enrolled, 63% were female, mean age was 65.6 y, and 83% were Global Initiative for Chronic Obstructive Lung Disease air-flow limitation 2 or 3. Wilcoxon scores were significant for improved total scores for both the Diskus and HandiHaler, with medians improving from 6.5 to 7.0 (interquartile range 6.0-7.8) (P = .047) and from 6.0 to 7.5 (interquartile range 7.0-9.0) (P = .002), respectively. The minimum required PIF was achieved by 93.8% of the Diskus and 94.4% of the HandiHaler groups. There were no associations detected between the handout intervention (Diskus and HandiHaler) and health literacy level and vision.

CONCLUSIONS

The educational handouts for DPIs helped participants already using a DPI to improve their inhaler technique. Stable participants diagnosed with COPD are able to generate appropriate PIFs to properly use DPIs. Neither vision nor health literacy was associated with the inability to learn inhaler technique from patient education inhaler device handouts.

Effective education parameters for trigger remediation in underserved children with asthma: A systematic review

OBJECTIVES

The prevalence of asthma is highest in minority children living in urban areas. Pediatric asthma research has focused on self-management education and trigger remediation using a multi-trigger, multi-component educational intervention approach. The purpose of this systematic review was to identify common educational parameters of these proposed interventions. The review also sought to identify which clinical outcomes improved with multi-trigger, multi-component educational interventions.

DATA SOURCES

PubMed, SCOPUS and ProQuest Dissertations were searched between 2000 to 2014 using the following terms: asthma; urban population or poverty area; environmental remediation; health education; allergens or dust mites or cockroaches or mold or mice or rats.

STUDY SELECTIONS

Studies were included if they met the following criteria: 1) participants were minority children identified as underserved; 2) there was a multi-trigger and multi-component intervention; 3) asthma severity was classified as persistent; and 4) asthma control was classified as not well controlled.

RESULTS

A total of 531 articles were retrieved of which 17 met the inclusion criteria. The interventions lacked consistency in their explanation. Most studies were vague in reporting pedagogical methods and educational content. Few studies reported a theoretical framework to guide their approach. Over half the studies did not report a learning assessment nor health literacy of the caregiver or the child with asthma. Yet all of the findings demonstrated statistically significant results in some or all of their primary outcomes.

CONCLUSION

Overall, the research lacked clarity in the approach to impact asthma outcomes and reduces the opportunity to substantiate the findings through replication.

Utilizing Respiratory Therapists to Reduce Costs of Care

INTRODUCTION

Changes to the reimbursement of respiratory care services over the past 26 years make it imperative that respiratory therapists (RTs) demonstrate cost savings to establish their value. Therefore, this systematic review evaluated the cost-related impacts from utilizing RTs to deliver care when compared to other care providers.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to guide the search process. The study addressed articles across all age groups and care settings that compared the cost of care provided by RTs to a comparison group. Studies were excluded if they were not written in English, described care provided outside of the United States, did not provide quantitative data, or lacked a comparison group.

RESULTS

A total of 4,120 articles emerged from the search process, of which 60 qualified for a full text review. Cost savings were evaluated for the 28 articles included in this review, noting the study design, the specific respiratory care practice, use of protocols, clinical setting, and age group. The most frequently studied topic was mechanical ventilation, which along with disease management represented by the most randomized, controlled trials for the study design. The clinical practice area notably absent was home care.

CONCLUSIONS

Although cost comparisons across studies could not be made due to the inconsistent manner in which data were reported, evidence demonstrated that care provided by RTs yielded both direct and indirect cost reductions, which were achieved through protocol utilization, specialized expertise, and autonomous decision making. The care provided was consistent with care provided by other disciplines. It is critical for the respiratory care profession to highlight key clinical practice areas for future research, to establish uniform reporting measures for outcomes, and to foster the development of future respiratory care researchers to affirm the value that respiratory therapists add to patient care.

Relationship Between Respiratory Muscle Strength, Handgrip Strength, and Muscle Mass in Hospitalized Patients

BACKGROUND

Minimal information is available to validate measurement of respiratory muscle strength (RMS) in the clinical setting. The purpose of this study was to determine the correlation between maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and sniff nasal inspiratory pressure (SNIP) with handgrip strength (HGS) and cross sectional muscle area obtained via diagnostic abdominal computed tomography (CT).

MATERIALS AND METHODS

Measures of MIP, MEP, SNIP, and HGS were obtained from individuals that participated in a previously published study; individuals who had an abdominal CT completed with (±)7 days of obtaining RMS measures were included. Both RMS and HGS were measured within 48-72 hours of admission; for RMS, the highest absolute (cm H₂ O) and percent predicted values were recorded, and the average of 3 HGS measurements (kg) was documented. Cross-sectional muscle area (cm² ) at the third lumbar region was recorded. Spearman's correlation coefficient was used to assess the relationship between variables.

RESULTS

A total of 35 participants were included. HGS was correlated to absolute MIP (r_s = 0.62, r_s = 0.61), MEP (r_s = 0.74, r_s = 0.73), and SNIP (r_s = 0.58, r_s = 0.54) for males and females, respectively. Crosss-sectional muscle area was correlated with absolute MIP (r_s = 0.66), MEP (r_s = 0.58), and SNIP (r_s = 0.783) for men and absolute SNIP (r_s = 0.56) among women.

CONCLUSION

Measures of RMS represent a promising assessment of muscle mass and function among hospitalized patients.

Predicting Respiratory Therapists' Intentions to Use the Modified Early Warning Score by Using an Enhanced Technology Acceptance Model

BACKGROUND

The modified early warning score (MEWS) is used to detect early clinical deterioration and to escalate care as needed. Respiratory therapists (RTs) usually do not use the MEWS even when it is implemented as a default in the electronic health record system. This study explored whether the technology acceptance model could predict the intentions of RTs to use the MEWS.

METHODS

A validated survey that uses a pretest/posttest design was used to determine the effect of an educational intervention (lecture and interactive small group session) on RTs' MEWS knowledge. We also measured key determinants of the intention by RTs to use the MEWS based on the constructs of the technology acceptance model. The survey was distributed to 75 RTs employed at a Midwestern academic medical center.

RESULTS

There was a 61% survey response rate. Statistical analysis of the survey data demonstrated that the educational intervention increased the MEWS knowledge score from 2.0 before education to 4.0 after education (P < .001). Moreover, there was a statistically significant increase in the behavioral intention score, from 3.0 before education to 4.0 after education (P < .001). Partial least squares structural equation modeling revealed that MEWS knowledge influenced perceived ease of use, which influenced attitude, which influenced behavioral intention.

CONCLUSIONS

Numerous studies have demonstrated that a change in behavioral intention is a good predictor of change in behavior. The increase in the RTs' knowledge, attitude, and behavioral intention scores after MEWS education indicated that these RTs may be more inclined to use the MEWS if they were educated about its clinical relevance and if their attitude toward using it were favorable. Analysis of the study results also indicated that the technology acceptance model could serve as a framework to guide respiratory care managers in the development of strategies to successfully implement new systems or processes that are intended to be used by RTs.

A guideline-based approach to asthma management

The management of asthma has dramatically improved in recent years because of a better understanding of the disease and an organized approach to therapy. All of the various components and tools for evaluating individuals with asthma may be found in the Expert Panel Report Guidelines by the National Heart, Lung, and Blood Institute, initially published in 2007. These comprehensive guidelines help health care professionals care for individuals with asthma throughout their lifespan. This article will assist the health care provider to use these evidence-based guidelines.

Variations in FVC and FEV1 Biologic Quality Control Measures in a Global Multi-Center Clinical Trial

BACKGROUND

Although quality control standards are recommended to ensure accurate test results, the coefficient of variation for the FVC and FEV₁ biologic quality control (BioQC) is not specified. The primary aim of this study was to evaluate variations in spirometry BioQCs in a large and diverse cohort of individuals to determine an acceptable standard for the coefficient of variation.

METHODS

The FVC and FEV₁ biologic control data were secondary analyses from an inhaled medication trial that was conducted over 3 y ending in 2018 that included 114 laboratories. Results were sent to a central repository for expert review. The FVC and FEV₁ coefficients of variation were based upon a minimum of 10 spirometry values annually separated by at least 5 d. A second method of computing the coefficient of variation used 10 values within 28 d. Descriptive statistics were computed. Wilcoxon signed-rank tests were conducted to compare whether the median coefficient of variation values between the 2 methods differed, tested at α = 0.05 using SPSS.

RESULTS

Of 249 biologic control participants, 170 met the first year's inclusion criteria. The coefficient of variation for the 5-d separated method was < 5% for 94.1% of FVC and 93.5% of FEV₁ values in the first year. By year 3, 90% of FVC and FEV₁ coefficient of variation values were < 4%. The medians for the 5-d separated and the 28-d measure showed no difference for either FVC coefficient of variation or FEV₁ coefficient of variation, Z = -1.764, P = .78, and Z = -0.980, P = .33, respectively.

CONCLUSIONS

Interlab biologic control variation values of < 4% for FVC and FEV₁ are achievable; however, individual labs should strive to attain lower values. Acceptable coefficients of variation can be achieved within 28 d.

Methods to improve teaching interdisciplinary teamwork through computer conferencing

This study evaluated how initiatives that oriented students to the virtual classroom and faculty feedback that promoted increased student interaction affected teaching teamwork skills in a 6-week, interdisciplinary health professions module. Outcomes from a control group were compared with those from an experimental group that had greater technical support, a print-based study guide, enhanced faculty guidance, and weekly grades rewarding student interaction. Two researchers independently recorded the number of messages each student wrote and coded faculty message content. A t test compared the difference in students' pretest and posttest scores on the Interdisciplinary Education Perception Scale (IEPS) between groups. Fisher exact test was used to compare the total student messages, total faculty messages per team, and faculty message content between modules. The experimental group had greater IEPS belief changes and more faculty messages per team but no difference in total student postings. Faculty messages in the experimental group contained fewer vague messages and more messages containing introductions, restated assignments, reinforcement, and technical information. Providing students with resources to aid their orientation to the virtual classroom and coaching faculty to increase student interaction improved learning outcomes. Faculty messages that restated assignments and contained reinforcement, introductions, and technical information impacted student participation the most.

RT education and COVID-19 pneumonia discharge quality

Background

There is a lack of data assessing the influence of respiratory therapist (RT) education on clinical outcomes. The primary objective of this study was to evaluate the impact of RTs holding advanced degrees or completing adult critical care competencies on discharge outcomes of patients with COVID-19 pneumonia.

Study Design and Methods

This retrospective, cross-sectional study included adults with confirmed COVID-19 admitted to the hospital for at least three days between March-May 2020. The academic degree held by each RT was considered advanced (baccalaureate or higher) or associate degree. Discharge outcomes were considered good, compromised, or poor when subjects' hospital discharge was directly to home, long-term care facility/rehabilitation center, or hospice/died, respectively. A time-to-event multi-state regression model was used to determine the impact of RT academic degree and adult critical care competencies on discharge outcomes using α=0.05.

Results

A total of 260 subjects (median age 59 y; 166 males) received clinical care from 132 RTs. RT median professional experience was six y (IQR 3-11), 70.8% had an advanced degree, and 70.8% completed adult critical care competencies. The time-to-event multi-state regression model showed that patients with >85% exposure to RTs with advanced degrees transitioned 3.72 times more frequently to good outcomes than RTs without advanced degrees (p=.001). Similarly, patients with >85% exposure to RTs with adult critical care competencies transitioned 5.10 times more frequently to good outcomes than RTs without adult critical care competencies (p<.001).

Conclusion

Patients with COVID-19 pneumonia who received greater than 85% of their care by RTs who earned advanced degrees or completed adult critical care competencies had improved discharge outcomes. This preliminary work suggests that advancing education for the respiratory therapist workforce may improve the discharge quality of patients with acute respiratory failure and should be further explored.

Respiratory care managers' preferences regarding baccalaureate and master's degree education for respiratory therapists

OBJECTIVE

Determine respiratory care managers' preferences regarding baccalaureate and master's degree education for practicing respiratory therapists (RTs).

METHODS

A survey was mailed to 1,444 members of the Management Section of the American Association for Respiratory Care. Managers were asked about their preferences for RTs who hold or are pursuing baccalaureate degrees, the value of various courses of study (majors), and degrees earned via distance learning. Demographic data and attitudes about distance learning, content, and target audiences for master's degree programs were also collected.

RESULTS

Twenty-six percent of those polled responded. Thirty-four percent of respondents preferred baccalaureate degree over associate degree for entry-level RTs, 28% had no preference, and 38% no opinion. Regarding hiring of experienced RTs, 70% of respondents preferred RTs with baccalaureate degrees. Regarding baccalaureate completion degree majors, advanced respiratory care practice was most highly valued. Sixty percent thought that a degree earned via distance learning was equivalent to one earned in the traditional classroom setting; 23% thought a distance learning degree was of less value; 3% thought a distance learning degree was of greater value; and 14% were uncertain. The respondents thought graduate degrees were valuable for managers, clinical specialists, educators, and supervisors. Although 95% of managers would recommend graduate programs that have some distance learning courses, only 75% would recommend programs offered solely via distance learning.

CONCLUSIONS

For RTs who plan to complete a baccalaureate degree, majoring in advanced respiratory care practice is potentially valuable. Managers showed preference for hiring experienced RTs with baccalaureate degrees but did not prefer entry-level therapists with baccalaureate degrees. Graduate degrees are supported for managers, clinical specialists, educators, and supervisors. Most managers supported some use of distance learning for graduate degrees.

Prediction of Hospital Readmission Using the CORE and CORE+ Scores in Persons With COPD

Background: Identifying persons with COPD at high risk for hospital readmission provides opportunities for efficient and appropriate care to lower readmission risk. This study examined 30-d and 60-d hospital readmission prediction of the COPD-readmission (CORE) score and a newly developed CORE+ score. The relationship between CORE and CORE+ scores and ICU admission, endotracheal intubation, and in-hospital noninvasive ventilation (NIV) use was explored. Methods: A retrospective cohort study evaluated participants with spirometry-confirmed COPD from 2 Midwestern academic hospitals. The CORE score variables included eosinophil blood count, FEV1/FVC (<0.70) and FEV1 (≤40% of predicted), triple inhaler therapy, previous hospitalization, and presence of neuromuscular disease. Out-of-hospital NIV use and Charlson comorbidity index were added to compose the CORE+ score. Researchers assessed associations between variables and outcomes with chi-square test or Fisher exact test, compared results of CORE and CORE+ scores with Wilcoxon signed-rank test, assessed each score's 30-d and 60-d readmission predictive power with multiple logistic regression, and evaluated predictive accuracy with AUC of receiver operating characteristic using alpha < 0.05. Results: Of 391 participants, the study found a 22% 30-d, all-cause readmission rate and a 16% 60-d, all-cause readmission rate. CORE+ score had better predictive accuracy than the CORE score for 30-d readmission (area under the curve 0.81 [95% CI 0.76-0.86]; AUC 0.73 [95% CI 0.66-0.79], P < .001) and 60-d readmission (AUC 0.77 [95% CI 0.71-0.83]; AUC 0.75 [95% CI 0.69-0.81], P < .001). Participants who used in-hospital NIV had higher median CORE+ scores (P = < .001). Conclusions: CORE and CORE+ scores demonstrated good to very good predictive accuracy for 30-d and 60-d readmission, respectively. Moreover, this study demonstrated a linear relationship between in-hospital NIV use and CORE+ score.

Communication of Career Pathways Through Associate Degree Program Web Sites: A Baseline Assessment

BACKGROUND

The American Association for Respiratory Care sponsored a series of conferences that addressed the competency of the future workforce of respiratory therapists (RTs). Based upon the findings from those conferences, several initiatives emerged that support RTs earning a baccalaureate (or bachelor's) degree. The objective of this study was to identify the ways that associate degree programs communicate career pathways toward a baccalaureate degree through their Web sites.

METHODS

This cross-sectional observational study used a random sample of 100 of the 362 associate degree programs approved by the Commission on Accreditation for Respiratory Care. Data were collected from 3 specific categories: demographic data, baccalaureate completion information, and the Web page location for the program. The presence of statements related to any pathway toward a bachelor's degree, transfer credits, articulation agreements, and links for baccalaureate completion were recorded. The descriptive statistics in this study were reported as total numbers and percentages.

RESULTS

Of the 100 programs in the random sample, only 89 were included in the study. Only 39 (44%) programs had links on their program Web site that had any content related to bachelor's degrees, 16 (18%) identified college transfer courses toward a bachelor's degree, and 26 (29%) programs included baccalaureate articulation agreements on their Web site.

CONCLUSIONS

A minority of associate degree programs communicated career pathway information to their prospective and current students through program Web sites. An informative Web site would make the path more transparent for entry-level students to meet their future educational needs as their careers progress.

Development and psychometric evaluation of the asthma Action plan questionnaire (AAPQ)

OBJECTIVE

To develop a practical and psychometrically sound tool to evaluate caregiver knowledge of their child's asthma action plan (AAP).

METHODS

A pilot study was conducted in a sample of 40 caregivers of children with asthma to assess the content validity, item difficulty, and item discrimination of the Asthma Action Plan Questionnaire (AAPQ). The inter-rater and intra-rater agreement of the AAPQ's scoring rubric were also examined. Subsequently, a large-scale study was conducted in a sample of 80 caregivers of children with asthma and 40 caregivers of children without current asthma and no prior exposure to patients with asthma to evaluate the internal consistency, test-retest reliability, and known-groups validity of the AAPQ.

RESULTS

The 7-item AAPQ demonstrated acceptable content validity (a scale-content validity index of 0.98) and internal consistency (Cronbach's alpha =.63 and mean inter-item correlation coefficient of .20) and very strong test-retest reliability over a two-to-four-week period (r = .88, p < .001). The AAPQ discriminated between caregivers of children with asthma and caregivers of children without asthma (M ± SD 8.3 ± 1.6 vs. 4.3 ± 1.7, p < .001, respectively).

CONCLUSION

The AAPQ is a valid and reliable questionnaire that provides an assessment of caregivers' knowledge of their child's AAP and can guide educational interventions by healthcare providers.