Treating Latent Tuberculosis Infection in Newly Arriving Refugees: An Advanced Practice Nurse Initiative at the University of Louisville Global Health Center

Background: A review of newly arriving refugees referred to the local health department for latent tuberculosis infection (LTBI) treatment during 2013-2015 revealed a treatment gap of 73%, supporting the need to identify new approaches to treat vulnerable populations and mirrored results in the literature. Objectives: 1) Describe an advanced practice registered nurse (APRN) led alternative approach to LTBI treatment in the refugee population; and 2) evaluate the impact of a 12-week regimen for LTBI on treatment acceptance, adherence and completion. Methods: During the initial health screening visit, treatment options were provided for those identified with LTBI consisting of either a 12-week regimen requiring weekly directly observed therapy (DOT) or the traditional 9-month treatment. Results: During March-December 2016, 50 refugees were referred and 24/50 were offered a 12-week regimen of Rifapentine and Isoniazid, administered with DOT. 23 of the 24 or 96% completed the entire treatment course. Conclusions: The new LTBI clinic process resulted in an increase in treatment acceptance and completion compared with the historic rate of 27%. Implications for Nursing: APRN initiatives such as this can result in positive benefits to patients and communities while serving to advance the nursing profession in all practice setting

Use of Emergency Department for Care Access by Refugees Resettling in Kentucky, 2015: Findings from the University of Louisville Global Health Center

Background: Kentucky is one of the largest rural resettlement areas for refugees in the US welcoming more than 3,000 refugees and other entrants during 2015. Refugees arrive with a number of chronic health conditions that require ongoing management in a healthcare system where they lack knowledge and ability to navigate. This may encourage them to seek care that is easy to access but episodic and fragmented. The objective of this study was to determine the frequency and reasons for accessing care via a local emergency department by resettling refugees during their first twelve months of resettlement. Methods: Using data from domestic health screening, crossmatching was done with the Emergency Department (ED) database of a local university medical center. Records were reviewed to determine If the ED was accessed for care, day and time care was accessed, chief complaint at the time of ED arrival, discharge diagnosis and final disposition. Results: Of 2616 refugees seen for health screening during 2011-2015, 77 (3%) sought care in the ED at least one time during the twelve months following their arrival, encompassing a total of 96 unique ED visits. Of the 96 ED visits, 83 (86%) were seen and discharged with the remaining 13 (14%) being admitted to ULH or referred for admission to another facility (e.g., mental health). Of the 83 discharged visits, 51 (61%) were determined to be preventable ED visits. Care was accessed more frequently on Monday (19%), Sunday (18%) and Thursday (17%). 57 of the 83 discharged visits (69%) occurred during hours that reflect those common for routine business in a clinic setting (8 AM - 4 PM). Of ED visits during those routine business hours, 34 (60%) were determined to be preventable ED visits. Discussion: This study represents the first published data regarding ED use by refugees resettling into a single community. These data provide insight into the use of an ED as a point of care access and the role that access plays in refugee healthcare, especially during the earliest phase of resettlement. Conclusions: These data may serve to inform development of a refugee-centered medical home with the objective to improve access to coordinated and comprehensive care

Recommendations for change in infection prevention programs and practice

Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future

Support needs and barriers to accessing support:Baseline results of a mixed-methods national survey of people bereaved during the COVID-19 pandemic

BACKGROUND: The COVID-19 pandemic is a mass bereavement event which has profoundly disrupted grief experiences. Understanding support needs and access to support among people bereaved at this time is crucial to ensuring appropriate bereavement support infrastructure. AIM: To investigate grief experiences, support needs and use of formal and informal bereavement support among people bereaved during the pandemic. DESIGN: Baseline results from a longitudinal survey. Support needs and experiences of accessing support are reported using descriptive statistics and thematic analysis of free-text data. SETTING/PARTICIPANTS: 711 adults bereaved in the UK between March and December 2020, recruited via media, social media, national associations and community/charitable organisations. RESULTS: High-level needs for emotional support were identified. Most participants had not sought support from bereavement services (59%, n = 422) or their General-Practitioner (60%, n = 428). Of participants who had sought such support, over half experienced difficulties accessing bereavement services (56%, n = 149)/General-Practitioner support (52%, n = 135). About 51% reported high/severe vulnerability in grief; among these, 74% were not accessing bereavement or mental-health services. Barriers included limited availability, lack of appropriate support, discomfort asking for help and not knowing how to access services. About 39% (n = 279) experienced difficulties getting support from family/friends, including relational challenges, little face-to-face contact and disrupted collective mourning. The perceived uniqueness of pandemic bereavement and wider societal strains exacerbated their isolation. CONCLUSIONS: People bereaved during the pandemic have high levels of support needs alongside difficulties accessing support. We recommend increased provision and tailoring of bereavement services, improved information on support options and social/educational initiatives to bolster informal support and ameliorate isolation

Factors associated with higher levels of grief and support needs among people bereaved during the pandemic: results from a national online survey

We identified factors associated with higher levels of grief and support needs among 711 people bereaved during the COVID-19 pandemic in the UK (deaths 16 March 2020-2 January 2021). An online survey assessed grief using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36), and practical and emotional support needs in 13 domains. Participants’ mean age was 49.5 (SD 12.9); 628 (88.6%) female. Mean age of deceased 72.2 (SD 16.1). 311 (43.8%) deaths were from confirmed/suspected COVID-19. High overall levels of grief and support needs were observed; 28.2% exhibited severe vulnerability (IOV ≥ 24). Grief and support needs were higher for close relationships with the deceased (versus more distant) and reported social isolation and loneliness (P < 0.001), and lower with age of deceased above 40-50. Other associated factors were place of death and health professional support post-death (P < 0.05

Levels of grief, support needs and risk factors among people bereaved during the Covid-19 pandemic: baseline results from a longitudinal UK online survey

Background The COVID-19 pandemic has had a detrimental impact on millions of people’s experiences of bereavement. Traumatic end-of-life experiences and disruptions to support networks increase chances of poor bereavement outcomes. Aim To examine grief and support needs, and identify associated risk factors. Methods Mixed-methods survey of people bereaved in the UK from March 2020-January 2021, disseminated via media, social media, national associations, community/charitable organisations. Practical and emotional support needs were assessed in 13 domains, and grief intensity using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0–36). Results 711 participants, mean age 49.5 (SD 12.9); 88.6% female; 95.3% white. Mean age of deceased 72.2 (SD 16.1); 58% died in hospital; 44% from COVID-19. Mean IOV was 20.41 (95% CI = 20.06 to 20.77), i.e. high vulnerability in grief overall. 28.2% exhibited extreme levels of vulnerability (i.e., IOV ≥ 24). In six support domains, all relating to psycho-emotional support, 50% to 60% of respondents reported high/fairly high levels of need. Increased levels of perceived support from health professionals led to significantly (P < 0.001) lower levels of grief and support need (small/medium effect, P < 0.001). Bereaved participants who were socially isolated/lonely experienced higher levels of grief and support needs than those who were not (P < 0.001). Grief and support needs were much higher for close family members compared with other groups (P < 0.05). Levels of grief and support needs were slightly higher for COVID deaths compared with non-COVID (P < 0.01), although this was not significant in a mixed model. Conclusions People bereaved during the pandemic experience high levels of grief and emotional support needs, with social isolation/loneliness and death of a close family member particular risk factors. Healthcare professionals’ support is associated with better bereavement experiences

Prolonged grief during and beyond the pandemic: factors associated with levels of grief in a four time-point longitudinal survey of people bereaved in the first year of the COVID-19 pandemic

BackgroundThe COVID-19 pandemic has been a devastating and enduring mass-bereavement event, with uniquely difficult sets of circumstances experienced by people bereaved at this time. However, little is known about the long-term consequences of these experiences, including the prevalence of Prolonged Grief Disorder (PGD) and other conditions in pandemic-bereaved populations.MethodsA longitudinal survey of people bereaved in the UK between 16 March 2020 and 2 January 2021, with data collected at baseline (n = 711), c. 8 (n = 383), 13 (n = 295), and 25 (n = 185) months post-bereavement. Using measures of Prolonged Grief Disorder (PGD) (Traumatic Grief Inventory), grief vulnerability (Adult Attitude to Grief Scale), and social support (Inventory of Social Support), this analysis examines how participant characteristics, characteristics of the deceased and pandemic-related circumstances (e.g., restricted visiting, social isolation, social support) are associated with grief outcomes, with a focus on symptoms of PGD.ResultsAt baseline, 628 (88.6%) of participants were female, with a mean age of 49.5 (SD 12.9). 311 (43.8%) deaths were from confirmed/suspected COVID-19. Sample demographics were relatively stable across time points. 34.6% of participants met the cut-off for indicated PGD at c. 13 months bereaved and 28.6% at final follow-up. Social isolation and loneliness in early bereavement and lack of social support over time strongly contributed to higher levels of prolonged grief symptoms, while feeling well supported by healthcare professionals following the death was associated with reduced levels of prolonged grief symptoms. Characteristics of the deceased most strongly associated with lower levels of prolonged grief symptoms, were a more distant relationship (e.g., death of a grandparent), an expected death and death occurring in a care-home. Participant characteristics associated with higher levels of prolonged grief symptoms included low level of formal education and existence of medical conditions.ConclusionResults suggest higher than expected levels of PGD compared with pre-pandemic times, with important implications for bereavement policy, provision and practice now (e.g., strengthening of social and specialist support) and in preparedness for future pandemics and mass-bereavement events (e.g., guidance on infection control measures and rapid support responses)