Approximately half the world uses biomass fuel for domestic energy, resulting in widespread exposure to indoor air pollution (IAP) from biomass smoke. IAP has been associated with many respiratory diseases, though it is not clear what relationship exists between biomass use and pulmonary function. Four groups containing 20 households each were selected in Santa Ana, Ecuador based on the relative amount of liquid petroleum gas and biomass fuel that they used for cooking. Pulmonary function tests were conducted on each available member of the households 7 years of age. The pulmonary functions of both children (7-15 years) and women (16 years) were then compared between cooking fuel categories using multivariate linear regression, controlling for the effects of age, gender, height, and exposure to tobacco smoke. Among the 80 households, 77 children and 91 women performed acceptable and reproducible spirometry. In multivariate analysis, children living in homes that use biomass fuel and children exposed to environmental tobacco smoke had lower forced vital capacity and lower forced expiratory volume in 1s (P<0.05). However, no significant difference in pulmonary function was observed among women in different cooking categories. Results of this study demonstrate the harmful effects of IAP from biomass smoke on the lung function of children and emphasize the need for public health efforts to decrease exposure to biomass smoke.

Biomass fuel used for cooking results in widespread exposure to indoor air pollution (IAP), affecting nearly 3 billion people throughout the world. Few studies, however, have tested for an exposure-response relationship between biomass fuel and health outcomes. The aim of this study was to explore the relationship between biomass fuel, infant mortality, and children's respiratory symptoms. Eighty households in a rural community in Ecuador were selected based on their use of biomass fuel and questioned regarding a history of infant mortality and children's respiratory symptoms. Carbon monoxide (CO) and particulate matter (PM) were measured in a subset of these homes to confirm the relationship between biomass fuel use and IAP. Results showed a significant trend for higher infant mortality among households that cooked with a greater proportion of biomass fuel (P=0.008). Similar trends were noted for history of cough (P=0.02) and earache (P<0.001) among children living in these households.

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Background Burnout is a maladaptive response to work-related stress that is associated with negative consequences for patients, clinicians, and the health care system. Critical care nurses are at especially high risk for burnout. Previous studies of burnout have used survey methods that simultaneously measure risk factors and outcomes of burnout, potentially introducing common method bias. Objectives To evaluate the frequency of burnout and individual and organizational characteristics associated with burnout among critical care nurses across a national integrated health care system using data from an annual survey and methods that avoid common method bias. Methods A 2017 survey of 2352 critical care nurses from 94 sites. Site-level workplace climate was assessed using 2016 survey data from 2191 critical care nurses. Results Overall, one-third of nurses reported burnout, which varied significantly across sites. In multilevel analysis, workplace climate was the strongest predictor of burnout (odds ratio [OR], 2.20; 95% CI, 1.50-3.22). Other significant variables were overall hospital quality (OR, 1.44; 95% CI, 1.05-1.99), urban location (OR, 1.93; 95% CI, 1.09-3.42), and nurse tenure (OR, 2.11; 95% CI, 1.44-3.10). In secondary multivariable analyses, workplace climate subthemes of perceptions of workload and staffing, supervisors and senior leadership, culture of teamwork, and patient experience were each significantly associated with burnout. Conclusions Drivers of burnout are varied, yet interventions frequently target only the individual. Results of this study suggest that in efforts to reduce burnout, emphasis should be placed on improving local workplace climate.

Randomized trials of pulmonary vasodilators in pulmonary hypertension (PH) due to left heart disease (Group 2) and lung disease (Group 3) have demonstrated potential for harm. Yet these therapies are commonly used in practice. Little is known of the effects of treatment outside of clinical trials. We aimed to establish outcomes of vasodilator treatment for Groups 2/3 PH in real-world practice. We conducted a retrospective cohort study of 132,552 Medicare-eligible Veterans with incident Groups 2/3 PH between 2006-2016, and a secondary nested case-control study. Our primary outcome was a composite of death by any cause or selected acute organ failures. In our cohort analysis, we calculated adjusted risks of time to our outcome using Cox proportional hazards models with facility-specific random effects. In our case-control analysis, we used logistic mixed-effects models to estimate the effect of any past, recent, and cumulative exposure on our outcome. From our cohort study, 3,249 (2.5%) Veterans were exposed to pulmonary vasodilators. Exposure to vasodilators was associated with increased risk of our primary outcome, in both Group 3 (HR 1.58 [95% CI 1.37-1.82]) and Group 2 (HR 1.26 [1.12-1.41]) PH patients. The case-control study determined odds of our outcome increased by 11% per year of exposure (OR 1.11 [1.07-1.16]). Treating Groups 2/3 PH with vasodilators in clinical practice is associated with increased risk of harm. This extension of trial findings to a real-world setting offers further evidence to limit use of vasodilators in Groups 2/3 PH outside of clinical trials.

Background Critical care nurses have a burnout rate among the highest of any nursing field. Nurse burnout may impact care quality. Few studies have considered how temporal patterns may influence outcomes. Objective To test a longitudinal model of burnout clusters and associations with patient and clinician outcomes. Methods An observational study analyzed data from annual employee surveys and administrative data on patient outcomes at 111 Veterans Health Administration intensive care units from 2013 through 2017. Site-level burnout rates among critical care nurses were calculated from survey responses about emotional exhaustion and depersonalization. Latent trajectory analysis was applied to identify clusters of facilities with similar burnout patterns over 5 years. Regression analysis was used to analyze patient and employee outcomes by burnout cluster and organizational context measures. Outcomes of interest included patient outcomes (30-day standardized mortality rate and observed minus expected length of stay) for 2016 and 2017 and clinician outcomes (intention to leave and employee satisfaction) from 2013 through 2017. Results Longitudinal analysis revealed 3 burnout clusters among the 111 sites: low (n = 37), medium (n = 68), and high (n = 6) burnout. Compared with sites in the low-burnout cluster, those in the high-burnout cluster had longer patient stays, higher employee turnover intention, and lower employee satisfaction in bivariate models but not in multivariate models. Conclusions In this multiyear, multisite study, critical care nurse burnout was associated with key clinician and patient outcomes. Efforts to address burnout among nurses may improve patient and employee outcomes.

The views expressed here are solely those of the authors and do not necessarily represent the position of the Veterans Health Administration, United States government, or authors' respective academic institutions.

Reducing seclusion and restraint use is a prominent focus of efforts to improve patient safety in inpatient psychiatry. This study examined the poorly understood relationship between seclusion and restraint rates and organizational climate and clinician morale in inpatient psychiatric units.Methods: Facility-level data on hours of seclusion and physical restraint use in 111 U.S. Department of Veterans Affairs (VA) hospitals in 2014 to 2016 were obtained from the Centers for Medicare & Medicaid Services. Responses to an annual census survey were identified for 6646 VA inpatient psychiatry clinicians for the same period. We examined bivariate correlations and used a Poisson model to regress hours of seclusion and restraint use on morale and climate measures and calculated incident rate ratios (IRRs). Results:The average physical restraint hours per 1000 patient hours was 0.33 (SD, 1.27; median, 0.05). The average seclusion hours was 0.31 (SD, 0.84; median, 0.00). Physical restraint use was positively associated with burnout (IRR, 1.76; P = 0.04) and negatively associated with engagement (IRR, 0.22; P = 0.01), psychological safety (IRR, 0.48; P < 0.01), and relational climate (IRR, 0.69; P = 0.04). Seclusion was positively associated with relational climate (IRR, 1.69; P = 0.03) and psychological safety (IRR, 2.12; P = 0.03). Seclusion use was also nonsignificantly associated with lower burnout and higher engagement. Conclusions:We found significant associations between organizational climate, clinician morale, and use of physical restraints and seclusion in VA inpatient psychiatric units. Health care organization leadership may want to consider implementing a broader range of initiatives that focus on improving organizational climate and clinician morale as one way to improve patient safety.