Critical Access Research Articles

Does ridesourcing respond to unplanned rail disruptions? A natural experiment analysis of mobility resilience and disparity

Urban rail transit networks provide critical access to opportunities and livelihood in many urban systems. Ensuring that these services are resilient (that is, exhibiting efficient responses to and recovery from disruptions) is a key economic and social priority. Increasingly, the ability of urban rail systems to cope with disruptions is a function of a complex patchwork of mobility options, wherein alternative modes can complement and fill occurring service gaps. This study analyzes the role of ridesourcing in providing adaptive mobility capacity that could be leveraged to fill no-notice gaps in rail transit services, addressing the question of distributional impacts of resilience. Using a natural experiment, we systematically identify 28 major transit disruptions over the period of one year in Chicago and match them, both temporally and spatially, with ridesourcing trip data. Using multilevel mixed modeling, we quantify variation in the adaptive use of on-demand mobility across the racially and economically diverse city of Chicago. Our findings show that the gap-filling potential of adaptive ridesourcing during rail transit disruptions is significantly influenced by the station-, community-, and district-level factors. Specifically, greater shifts to ridesourcing occur during weekdays, nonholidays, and more severe disruptions, in community areas that have higher percentages of white residents and transit commuters, and in the more affluent North district of the city. These findings suggest that while ridesourcing appears to provide adaptive capacity during rail disruptions, its benefits do not appear to be equitable for lower-income communities of color that already experience limited mobility options. Research implications for mobility operator collaborations to support mobility as a service are discussed. This study builds a more comprehensive understanding of transit service resilience, variation in vulnerability, and the complementarity of ridesourcing to existing transport networks during disruptions.

Local and wide-scale livestock movement networks inform disease control strategies in East Africa

Livestock mobility exacerbates infectious disease risks across sub-Saharan Africa, but enables critical access to grazing and water resources, and trade. Identifying locations of high livestock traffic offers opportunities for targeted control. We focus on Tanzanian agropastoral and pastoral communities that account respectively for over 75% and 15% of livestock husbandry in eastern Africa. We construct networks of livestock connectivity based on participatory mapping data on herd movements reported by village livestock keepers as well as data from trading points to understand how seasonal availability of resources, land-use and trade influence the movements of livestock. In communities that practise agropastoralism, inter- and intra-village connectivity through communal livestock resources (e.g. pasture and water) was 1.9 times higher in the dry compared to the wet season suggesting greater livestock traffic and increased contact probability. In contrast, livestock from pastoral communities were 1.6 times more connected at communal locations during the wet season when they also tended to move farther (by 3 km compared to the dry season). Trade-linked movements were twice more likely from rural to urban locations. Urban locations were central to all networks, particularly those with potentially high onward movements, for example to abattoirs, livestock holding grounds, or other markets, including beyond national boundaries. We demonstrate how livestock movement information can be used to devise strategic interventions that target critical livestock aggregation points (i.e. locations of high centrality values) and times (i.e. prior to and after the wet season in pastoral and agropastoral areas, respectively). Such targeted interventions are a cost-effective approach to limit infection without restricting livestock mobility critical to sustainable livelihoods.

Durable self-healing coating system based on pH-responsive core-shell nanostructures

A critical access to high-efficiency anti-corrosion coatings is adding pH-responsive nanocontainers encapsulated with corrosion inhibitors into epoxy resin as it endows the composite coating with significant active long-term corrosion protection. Here, two self-healing coating systems (I-PBZ-EP and II-PBZ-EP) were constructed based on epoxy coating (EP) and benzotriazole-loaded zeolitic imidazolate framework (ZIF-8) encapsulated with polydopamine (PDA) by one-pot and two-pot methods, respectively. Electrochemical impedance spectroscopy (EIS) investigation shows that the low-frequency impedance modulus value (|Z|0.01Hz) of I-PBZ-EP still reaches 2.16 × 1010 Ω·cm2 which is the highest among all the coatings after 35 d of immersion. |Z|0.01Hz of the scratched I-PBZ-EP is 1.10 × 105 Ω·cm2 after 13 h of immersion in 3.5 wt% NaCl solution, which far surpasses |Z|0.01Hz of the scratched II-PBZ-EP, exhibiting its excellent self-healing properties. This is because I-PBZ can release more benzotriazole (BTA) (22.5 mg/L and 13.4 mg/L) than II-PBZ (15.8 mg/L and 9.4 mg/L) under acidic and basic conditions to repair the micro-defects. In short, by changing the loading mode of corrosion inhibitors, I-PBZ-EP with a simpler synthesis method manages to provide the long-term anticorrosion protection for the carbon steel substrate.

Efforts by critical access hospitals to increase health equity through greater engagement with social determinants of health.

Greater health care engagement with social determinants of health (SDOH) is critical to improving health equity. However, no national studies have compared programs to address patient social needs among critical access hospitals (CAHs), which are lifelines for rural communities. CAHs generally have fewer resources and receive governmental support to maintain operations. This study considers the extent to which CAHs engage in community health improvement, particularly upstream SDOH, and whether organizational or community factors predict involvement. Using descriptive statistics and Poisson regression, we compared 3 types of programs (screening, in-house strategies, and external partnerships) to address the patient social needs between CAHs and non-CAHs, independent of key organizational, county, and state factors. CAHs were less likely than non-CAHs to have programs to screen patients for social needs, address unmet social needs of patients, and enact community partnerships to address SDOH. When we stratified hospitals according to whether they endorsed an equity-focused approach as an organization, CAHs matched their non-CAH counterparts on all 3 types of programs. CAHs lag relative to their urban and non-CAH counterparts in their ability to address nonmedical needs of their patients and broader communities. While the Flex Program has shown success in offering technical assistance to rural hospitals, this program has mainly focused on traditional hospital services to address patients' acute health care needs. Our findings suggest that organizational and policy efforts surrounding health equity could bring CAHs in line with other hospitals in terms of their ability to support rural population health.

Factors associated with high influenza vaccination among healthcare workers in Tennessee acute-care hospitals, 2014–2022

Background: Healthcare workers (HCWs) are at increased risk of influenza exposure and represent a potential transmission source. The Department of Health and Human Services (HHS) set a goal for 2020 to have 90% of all HCWs in acute-care hospitals (ACHs) vaccinated. Vaccination against influenza decreases symptomatic illness and absenteeism and protects HCWs and their contacts. We assessed characteristics of facility intervention programs based on their success in meeting this benchmark. Methods: Data from the NHSN were utilized, including answers to the Annual Flu Survey for 2014–2022 and the rate of vaccine compliance by facility. Flu surveys detail facility-specific programs implemented for each influenza season, from October to March. We used SAS version 9.4 software for univariate analyses to determine factors significantly associated with meeting the HHS benchmark target of ≥90% vaccination among all HCWs, split into categories for employees, students or volunteers, and licensed independent practitioners. Facilities were excluded if they were not ACHs or Critical Access Hospitals (CAH), did not complete the Annual Flu Survey for at least 1 year, or required vaccination as a condition of employment. Results: From 2014 to 2022, 745 surveys were completed. Overall, 48.58% of respondents succeeded in meeting the HHS benchmark. Also, 306 surveys completed noted that their facility did not require influenza vaccination. Among those, only 19.93% respondents succeeded. Moreover, 80.33% of successful respondents for all HCWs required personal protective equipment (PPE) upon vaccination refusal compared to 34.29% of unsuccessful respondents (P < .0001). Furthermore, 98.36% successful respondents required documentation of offsite vaccination, compared to 89.39% of unsuccessful respondents (P = .027). For employees, 64.56% of successful respondents tracked vaccination rates in some or all units compared to 45.81% of unsuccessful respondents (P = .004). Also, 63.29% successful respondents had visible vaccination of leadership, compared to 43.61% of unsuccessful respondents (P = .003). Furthermore, 86.08% of successful respondents had mobile vaccination carts, compared to 73.57% unsuccessful respondents (P = .023). For the student- or volunteer-specific benchmark, 24.59% of successful respondents provided vaccination incentives compared to 14.63% of unsuccessful respondents (P = .035). Conclusions: Facilities with ≥90% vaccination among HCWs were more likely to require PPE after vaccination refusal and documentation for offsite vaccination. Other strategies for vaccination were differentially associated by employee type for Tennessee facilities. For future outreach, a multipronged approach is more likely to be successful in addressing vaccine uptake among employees with lagging rates. Strategies for influenza vaccine uptake could also improve other occupational vaccinations. More research is needed on the barriers to vaccination among HCWs specifically.Disclosures: None

(In)security alert! Who is guarding the airport?

Security at airports represents a major risk exposure. Poorly paid and underappreciated staff are tasked with controlling critical access points to ground and airside facilities. This paper describes a review of security services at a major North American airport, based on interviews conducted with management and personnel of a contracted service provider. It also evaluates service quality, contract compliance and the business processes involved in the delivery of those services. The review identified significant problems with staff turnover, training and performance; all factors that could lead to compromised security. It also examined the value received for money spent on delivering security services, considering their: (i) economy; (ii) efficiency and (iii) effectiveness. While this review was confined to a single airport, it is expected that the methodology adopted, as well as the problems noted, will apply to other aviation facilities.

In-depth assessment of critical access hospital stewardship program adherence to the CDC Core elements in Iowa and Nebraska

Background: Critical-access hospitals (CAHs) are required to meet the CDC 7 Core Elements of antimicrobial stewardship programs (ASPs). CAHs have lower adherence to the core elements than larger acute-care hospitals, and literature defining which core-element deficiencies exist within CAHs as well as barriers to adherence is lacking. Methods: We evaluated 21 CAH ASPs (5 in Nebraska and 15 in Iowa) that self-identified as potentially deficient in the Core Elements, via self-assessment followed by in-depth interviews with local ASP team members to assess adherence to the CDC Core Elements for ASPs. Core-element compliance was rated as either full (1 point), partial (0.5), or deficient (0), with a maximum score of 7 per ASP. High-priority recommendations to ensure core-element compliance were provided to facilities as written feedback. Self-reported barriers to implementation were thematically categorized. Results: Among the 21 CAH ASPs, none fully met all 7 core elements (range, 2.5–6.5), with a median of 5 full core elements met (Fig. 1). Only 6 ASPs (28.6%) had at least partial adherence to each of the 7 core elements. Action (21 of 21, 100%) and leadership commitment (16 of 21, 76.2%) were the core elements with the highest adherence, and accountability (4 of 21, 19%) and education (9 of 21, 42.9%) were the lowest. The most frequent high-priority recommendations were to provide physician and pharmacist leader ASP training (19 of 21, 90.5%), to track antimicrobial stewardship interventions (12 of 21, 57.1%), and to provide or track educational activities (12 of 21, 57.1%) (Fig. 2). One-third of programs were recommended to establish a physician leader. The most commonly self-identified barriers to establishing and maintaining an ASP were a lack of dedicated resources such as time of personnel (15 of 20, 75%), lack of infectious diseases expertise and training (8 of 20, 40%), and electronic medical record limitations (5 of 20, 25%) (Fig. 3). Conclusions: CAH ASPs demonstrate several critical gaps in achieving adherence to the CDC Core Elements, primarily in training for physician and pharmacist leaders and providing stewardship-focused education. Further resources and training customized to the issues present in CAH ASPs should be developed.Disclosures: None

Using Two Statewide Medical Operations Coordination Centers to Load Balance in Pediatric Hospitals During a Severe Respiratory Surge in the United States.

Report on the use of two statewide Medical Operations Coordination Centers (MOCCs) to manage a rapid surge in pediatric acute and critical care patient needs. Brief report. The states of Washington and Oregon during the pediatric respiratory surge in November 2022/December 2022 which overwhelmed existing pediatric acute and critical care hospital capacity. Pediatric patients requiring hospitalization in Washington and Oregon. Adaptations to the use of two existing statewide MOCCs to provide pediatric patient load balancing through surveillance, modifications of existing referral agreements, coordinated expansion of resources, activation of regional crisis standards of care, and integration of pediatric critical care physicians from Harborview Medical Center as subject matter experts (SMEs). The Washington and Oregon MOCCs managed 183 pediatric requests from hospitals unable to transfer pediatric patients between November 1, 2022, and December 14, 2022. Sixteen percent of requests were for children younger than 3 months and 37% were for children between 3 months and 1 year; most had acute viral respiratory disease. Requests for children older than 13 years old were primarily intentional drug ingestions. Fifty-eight percent were for critically ill children and 17% originated from critical access hospitals. Washington's SMEs were utilized in nearly a quarter of cases with the disposition changing in 38% of these. Washington and Oregon statewide MOCCs have leveraged centralized coordination to effectively load balance a surge in pediatric patients which has overwhelmed existing pediatric hospital resources. Centralized coordination and surveillance informed pediatric hospitals and policy makers of unmet clinical needs and facilitated rapid expansion of clinical capacity and modifications to referral processes. Integration of pediatric SMEs enabled efficient triage of these resources. MOCCs provide an adaptable centralized resource for addressing surge and have been effective in managing overwhelmed pediatric hospital resources in Washington and Oregon.

Effects of Medicaid Expansion on Perceived Community Health Needs: Comparing and Contrasting the Content of CAH CHNAs Nationwide

The Patient Protection and Affordable Care Act (ACA) of 2010 included a requirement that every nonprofit hospital complete a Community Health Needs Assessment (CHNA) every three years. At the same time, the ACA offered significant financial incentives for states to broaden access to their Medicaid programs. Not all states took advantage of the Medicaid expansion incentives. Critical access hospitals (CAH) are deemed “critical” because they are the sole hospital in a geographic area. Such facilities are deeply enmeshed with the social determinants of health and other health-related challenges experienced by their communities. Their CHNA reports provide insight into the healthcare challenges community members cope with. The question explored in this study is: Do critical access hospital community health needs assessments in Medicaid expansion states report different community health care needs than those in non-expansion states? Both descriptive and analytic statistics indicate there are some differences between states, but there are also universal concerns in rural communities served by CAHs nationwide, regardless of Medicaid expansion status.

The impact of supply chain drivers on the performance of Ministry of Health pharmacies in Jordan

For most companies, supply chains have become the most crucial factor in their competition rather than individual competition, enabling any company to gain a competitive advantage against another organization through efficient and effective supply chain management. Supply chain drivers have become one of the most critical potential valuable access to a competitive advantage by enhancing and improving organizational performance. This study aims to explore the impact of the drivers of the supply chain on the performance of pharmacies of the Ministry of Health in Jordan. The study used the descriptive analytical approach and simple random sampling. 300 electronic questionnaires were designed via Google Sheets and sent via email and social media to employees in the Jordanian Ministry of Health pharmacies. The study retrieved 252 questionnaires valid for analysis. SPSS was employed to analyze the data and test the hypotheses. The results showed that the Beta-value is 0.849, T-value is 25.370, at a significance value of 0.000, which means that supply chain drivers affected the Ministry of Health pharmacy’s performance. The estimated regression equation means that any one-unit increase in the level of supply chain drivers will lead to an increase in Ministry of Health pharmacies’ performance by 0.789. Furthermore, the performance of the supply chain drivers was moderate, and the general performance was high. The study recommended that pharmacies focus on employing software and modern technology in inventory control.

Efficacy of analgesic and sub-dissociative dose ketamine for acute pain in the emergency department

BackgroundAcute pain accounts for over 70% of Emergency Department (ED) visits. Sub-dissociative dose ketamine (0.1–0.6 mg/kg) is safe and effective for the management of acute pain in the ED. However, the optimal dose of intravenous ketamine that provides effective analgesia and minimizes the risk of adverse effects has yet to be identified. The objective of this study was to describe an effective analgesia dose range of IV ketamine for acute pain in the ED. MethodsThis multi-center, retrospective cohort study evaluated adult patients who received analgesic and sub-dissociative dose ketamine for the management of acute pain between May 5, 2018, and August 30, 2021, in 21 emergency departments at academic, community, and critical access hospitals across four states. Patients were excluded if they received ketamine for an indication other than pain, such as procedural sedation or intubation, or for whom there was incomplete documentation for the primary outcome. Patients who received a ketamine dose <0.3 mg/kg were stratified into the low-dose group, and those who received a dose of 0.3 mg/kg or higher to the high-dose group. The primary outcome was change in pain scores within 60 min using a standard 11-point numeric rating scale (NRS). Secondary outcomes included incidence of adverse effects and use of rescue analgesics. Continuous variables were compared between dose groups using student t-test or Wilcoxon Rank-Sum test. Linear regression was used to assess the association between the change in NRS pain scores within 60 min and dose after adjusting for baseline pain, requiring an additional dose of ketamine, and receiving an opioid. ResultsFrom 3796 patient encounters screened for receipt of ketamine, 384 patients met inclusion criteria including 258 in the low-dose group, and 126 in the high-dose group. The primary reason for exclusion was incomplete documentation of pain scores, or ketamine used for sedation. Median baseline pain scores were 8.2 in the low-dose group and 7.8 in the high-dose group (difference 0.5; 95% CI 0 to 1, p = 0.04). Both groups demonstrated significant reductions in their mean NRS pain scores within 60 min following the first administration of IV ketamine. There were no differences in the change in pain scores between both groups (−2.2 vs −2.6, mean difference 0.4, 95% CI -0.4 to 1.1, p = 0.34). Use of rescue analgesics (40.7% vs 36.5%, p = 0.43) and adverse effects were similar between groups, including early discontinuation of the ketamine infusion (37.2% vs. 37.3%, p = 0.99). Overall, the most common adverse effects were agitation (7.3%) and nausea (7.0%). ConclusionThe analgesic efficacy and safety of high-dose sub-dissociative ketamine (≥0.3 mg/kg) was not superior to low-dose (< 0.3 mg/kg) for the management of acute pain in the ED. Low-dose ketamine <0.3 mg/kg is an effective and safe pain management strategy in this population.

Interoperability among hospitals treating populations that have been marginalized.

To test whether differences in hospital interoperability are related to the extent to which hospitals treat groups that have been economically and socially marginalized. Data on 2393 non-federal acute care hospitals in the United States from the American Hospital Association Information Technology Supplement fielded in 2021, the 2019 Medicare Cost Report, and the 2019 Social Deprivation Index. Cross-sectional analysis. We identified five proxy measures related to marginalization and assessed the relationship between those measures and the likelihood that hospitals engaged in all four domains of interoperable information exchange and participated in national interoperability networks in cross-sectional analysis. In unadjusted analysis, hospitals that treated patients from zip codes with high social deprivation were 33% less likely to engage in interoperable exchange (Relative Risk = 0.67, 95% CI: 0.58-0.76) and 24% less likely to participate in a national network than all other hospitals (RR = 0.76; 95% CI: 0.66-0.87). Critical Access Hospitals (CAH) were 24 percent less likely to engage in interoperable exchange (RR = 0.76; 95% CI: 0.69-0.83) but not less likely to participate in a national network (RR = 0.97; 95% CI: 0.88-1.06). No difference was detected for 2 measures (high Disproportionate Share Hospital percentage and Medicaid case mix) while 1 was associated with a greater likelihood to engage (high uncompensated care burden). The association between social deprivation and interoperable exchange persisted in an analysis examining metropolitan and rural areas separately and in adjusted analyses accounting for hospital characteristics. Hospitals that treat patients from areas with high social deprivation were less likely to engage in interoperable exchange than other hospitals, but other measures were not associated with lower interoperability. The use of area deprivation data may be important to monitor and address hospital clinical data interoperability disparities to avoid related health care disparities.

Policy implications of fixed-to-total-cost ratio variation across rural and urban hospitals.

Hospitals with lower fixed-to-total-cost ratios may be better positioned to remain financially viable when reducing service volumes required by many value-based payment systems. We assessed whether hospitals in rural areas have higher fixed-to-total-cost ratios, which would tend to create a systematic disadvantage in such an environment. Our observational study used a mixed-effects, repeated-measures model to analyze Medicare Hospital Cost Report Information System data for 2011-2020. We included all 4,953 nonfederal, short-term acute hospitals in the United States that are present in these years. After estimating the relationship between volume (measured in adjusted patient days) and patient-care costs in a model that controlled for a small number of hospital characteristics, we calculated fixed-to-total-cost ratios based on our model's estimates. We found that nonmetropolitan hospitals tend to have higher average fixed-to-total-cost ratios (0.85-0.95) than metropolitan hospitals (0.73-0.78). Moreover, the degree of rurality matters; hospitals in micropolitan counties have lower ratios (0.85-0.87) than hospitals in noncore counties (0.91-0.95). While the Critical Access Hospital (CAH) designation is associated with higher average fixed-to-total-cost ratios, high fixed-to-total-cost ratios are not exclusive to CAHs. Overall, these results suggest that hospital payment policy and payment model development should consider hospital fixed-to-total-cost ratios particularly in settings where economies of scale are unattainable, and where the hospital provides a sense of security to the community it serves.

Analysis of Telestroke Usage in Rural Critical Access Emergency Departments.

Introduction: Telestroke is an effective strategy to increase appropriate stroke treatments among patients in resource-limited environments. Despite the well-documented benefits of telestroke, there is limited literature regarding its utilization. The purposes of this study are: (1) determine the percentage of potential stroke patients who generate a telestroke consult in rural critical access hospitals (CAHs) and (2) validate an electronic medical record (EMR)-derived report as a stroke screen. Methods: This retrospective chart review analyzed patients presenting between September 1, 2020 and February 1, 2021 to three CAHs. Visits with triage complaints suggesting acute ischemic stroke (AIS)/transient ischemic attack (TIA) were pooled for analysis using an EMR-derived report. Patients with confirmed AIS/TIA at discharge over this period were used to validate the EMR tool. Results: The EMR report pooled 252 possible AIS/TIA visits out of 12,685 emergency department visits for analysis. It had a specificity of 98.78% and sensitivity of 58.06%. Of the 252 visits, 12.7% met telestroke criteria and 38.89% received telestroke evaluation. Among these, a definite diagnosis of AIS/TIA was made in 92.86%. Of the remaining population who met criteria but didn't undergo consultation, 61.11% were diagnosed with AIS/TIA at discharge. Conclusion: This study provides novel characterization of stroke presentations and telestroke in rural CAHs. The EMR-derived report is a reasonable tool to concentrate potential AIS/TIA cases for review and resource allocation but is not sensitive enough to detect stroke as a stand-alone tool. The majority (56%) of eligible patients did not undergo telestroke consultation. Future studies are critical to further understand reasons contributing to this.

Quality Indicators in Critical Access Hospitals, Small Rural, and Urban Hospitals

Purpose: Critical Access Hospitals (CAHs) have served their rural communities since they were created in the 1990s. CAHs have been exempt from the multiple organizational performance-based approaches that use financial incentives and thus quality indicators targeting CAHs specifically do not exist. Reports have suggested indicators that are appropriate for rural hospitals and CAHs but none have included all types of quality indicators - structures, work processes, outcomes, and quality improvement (QI) activities. Using a subset of the National Database of Nursing Quality Indicators® (NDNQI®) we assessed whether existing indicators for the work environment (structure), patient - and nurse outcomes are appropriate for CAHs. Methods: Using 2017 NDNQI® data on 16 structure and outcome indicators (8 work environment, 6 patient- and 2 nurse outcomes) were extracted. Employing bootstrapped confidence intervals CAHs were compared to other small (less than 50 beds) rural and urban hospitals. Findings: 103 CAHs, 63 small rural hospitals and 91 small urban hospitals had data on at least one indicator (range 87-239 for each indicator). There were no differences between CAHs and other small rural and urban hospitals for 15 of the 16 quality indicators. CAHs had fewer bachelor prepared nurses compared to urban hospitals. Conclusion: Our results suggest that quality indicators for structure and outcomes currently used in approximately 2000 hospitals are also applicable for CAHs. Whether they apply to all 1350 CAHs and can be used to guide benchmarking and QI in CAHs needs further study. Keywords: Critical Access Hospitals, Quality Indicators, National Database of Nursing Quality Indicators®DOI: https://doi.org/10.14574/ojrnhc.v23i1.733

Improving Hand Hygiene in a Rural Critical Access Hospital

Improving Hand Hygiene in a Rural Critical Access Hospital

Adapting Obstetric-Capacity Assessments to a Rural Context to Drive System Improvements [ID: 1375979

INTRODUCTION: As part of its Health Resources and Services Administration Maternal Health Innovation, Centers for Disease Control and Prevention (CDC) ERASE MM, and the American College of Obstetricians and Gynecologists Alliance for Innovation on Maternal Health (AIM) awards, Montana assessed capacity to provide risk-appropriate care in Montana's hospitals with labor and delivery (L&amp;D) units as well as critical access hospitals (CAHs) without L&amp;D units that serve remote communities in maternity care deserts. METHODS: Montana conducted the CDC LOCATe assessment in 96% (N=25) of hospitals with an L&amp;D and adapted an assessment used internationally by the World Health Organization to assess emergency obstetric capacity in 94% of CAHs without an L&amp;D. Surveys were conducted in REDCap, and the research team provided facilities with technical support in their completion of the assessments. RESULTS: While half of CAHs without L&amp;D reported an emergency delivery in the last 2 years, just one reported capacity to perform all services necessary to safely manage emergency deliveries. Two-thirds of facilities without L&amp;D units did not have a written transport protocol. In hospitals with L&amp;D who conducted the LOCATe assessment, nearly half (48%) overestimated the level of maternal health care that they were able to provide. Ultrasound and maternal-fetal medicine were the most common capacity insufficiencies. CONCLUSION: The system assessments revealed specific interventions that can expand capacity for quality obstetric care in a rural state like Montana, such as simulation training, adoption of AIM safety bundles through the perinatal quality collaborative, and enhanced access to ultrasound and maternal-fetal medicine services through telemedicine. National assessments like LOCATe should be adapted for the rural context to facilitate targeted resource investments.

Principles of Screening for Disease and Health Risk Factors in the Emergency Department.

The emergency department serves as a critical access point to the health system for many patients, especially those with limited resources. Screening for disease or risk factors for poor health outcomes can potentially improve both individual and population health. Screening initiatives should focus on evidence-based strategies and take local epidemiology and ED capacity into consideration. Initiatives should strive for community support and transparency with patients. They should also be financially sustainable for those involved. Screening can identify patients who can then be counseled, provided with prophylaxis or treatment, or referred to external resources. Through screening and intervention, the ED can serve as a vital contributor to individual and population health.

The role of telehealth in pediatric emergency care.

In 2006, the Institute of Medicine published a report titled "Emergency Care for Children: Growing Pains," in which it described pediatric emergency care as uneven at best. Since then, telehealth has emerged as one of the great equalizers in care of children, particularly for those in rural and underresourced communities. Clinicians in these settings may lack pediatric-specific specialization or experience in caring for critically ill or injured children. Telehealth consultation can provide timely and safe management for many medical problems in children and can prevent many unnecessary and often long transport to a pediatric center while avoiding delays in care, especially for time-sensitive and acute interventions. Telehealth is an important component of pediatric readiness of hospitals and is a valuable tool in facilitating health care access in low resourced and critical access areas. This paper provides an overview of meaningful applications of telehealth programs in pediatric emergency medicine, discusses the impact of the COVID-19 pandemic on these services, and highlights challenges in setting up, adopting, and maintaining telehealth services.

Availability and Accessibility of Mental Health Services for Youth: A Descriptive Survey of Safety-Net Health Centers During the COVID-19 Pandemic.

Community Mental Health Centers (CMHCs) and Federally Qualified Health Centers (FQHCs) are critical access points for families with adolescents needing mental health care, especially those enrolled in Medicaid. However, barriers exist which may reduce their accessibility. This study aims to describe the availability and accessibility of outpatient mental health services for children and adolescents at safety-net health centers in a large metropolitan county. Approximately one year after the COVID-19 pandemic began in the U.S., a comprehensive sample of 117 CMHCs and 117 FQHCs were called and administered a 5-minute survey. Approximately 10% of health centers were closed, and 20% (28.2% of FQHCs and 7.7% of CMHCs) reported not offering outpatient mental health services. Despite CMHCs having 5.4 more clinicians on staff on average, reported wait times were longer at CMHCs than FQHCs. These findings indicate that online directories intended to be a comprehensive and accessible resource, such as the SAMHSA Treatment Locator, are often inaccurate or out-of-date.