Background: Healthcare providers are encouraged to prepare their practice to effectively manage the care of mild to moderate adolescent depression. Cost-effective screening, diagnostic, and newly developed pediatric primary care depression management guidelines have been established. To integrate guidelines into practice, primary care providers (PCPs) must document effectively to ensure a complete treatment plan is in place in the patient’s electronic health record (EHR).

Intervention: Elements from a flowsheet were implemented into the EHR to promote thorough assessment and documentation of care delivered to adolescents with depression.

Methods: An initial chart review was completed on patients diagnosed with depression. An updated depression template was implemented within the EHR for six weeks. A follow-up chart review was completed post-intervention to determine if documentation of elements from the adolescent depression guidelines improved after the EHR update. Pre-intervention and post- intervention surveys were delivered to PCP’s to understand their perspective on adolescent depression management.

Outcomes: The chart review revealed that baseline PHQ-9 screenings were documented in 91% (n=43) of the charts reviewed in the pre-intervention timeframe. Only 78% (n=7) of the charts reviewed during post-intervention included PHQ-9 screenings. Early intervention treatment options documented in the pre-intervention timeframe included education 100% (n=47), medication prescriptions 53% (n=25), and psychotherapy referrals 18% (n=18). During post- intervention, education 100% (n=9), medication prescriptions 78% (7), and psychotherapy referrals 22% (n=7) were documented by the PCPs.

Recommendation: The quality improvement project focused heavily on documentation completed over a one year pre-intervention timeframe compared to a six-week post-intervention timeframe. Further evaluation and chart review over the next year will provide a more adequate comparison of documentation within primary care practice.

Disease burden is higher in the United States than in comparable countries. The Patient Self Determination Act of 1990 requires healthcare facilities to provide Advance Care Planning (ACP) information to all Medicare patients. The healthcare staffs’ (n=7) commitment to 3-days of ACP training increase ACP rates in the primary care setting. The Medicare Incentive Program is the platform for this initiative. This quantitative project used a valid and reliable pre and posttest design that consisted of 27 items on a Likert-scale. A 3.5-month chart audit (n=91) was conducted to assess the completion rate. Descriptive statistics was used to describe the demographic data.

The results of the two-tailed Wilcoxon signed rank test were significant based on an alpha value of 0.05, V = 0.00, z = -2.37, p = .018. There was a significant increase in the post-readiness to change average scores. A Mann Whitney test was used to analyze the statistically significant difference between the averages in two ACP types and electronic health record documentation (EHR). Staff did not always code (Mdn = 0.00) but they documented in the EHR (Mdn =1.00; 512.00, p = 0.003). ACP discussion was performed 63% of the time during Annual Wellness Visits (AWV), and there was a 49% increase in the EHR documentation. Trained staff are key stakeholders in guiding ACP conversations. They understand the barriers, impact, and consequences related to the lack of advance directives.

Background: Extreme heat is a public health challenge. The scarcity of directly comparable studies on the association of heat with morbidity and mortality and the inconsistent identification of threshold temperatures for severe impacts hampers the development of comprehensive strategies aimed at reducing adverse heat-health events.

Objectives: This quantitative study was designed to link temperature with mortality and morbidity events in Maricopa County, Arizona, USA, with a focus on the summer season.

Methods: Using Poisson regression models that controlled for temporal confounders, we assessed daily temperature–health associations for a suite of mortality and morbidity events, diagnoses, and temperature metrics. Minimum risk temperatures, increasing risk temperatures, and excess risk temperatures were statistically identified to represent different “trigger points” at which heat-health intervention measures might be activated.

Results: We found significant and consistent associations of high environmental temperature with all-cause mortality, cardiovascular mortality, heat-related mortality, and mortality resulting from conditions that are consequences of heat and dehydration. Hospitalizations and emergency department visits due to heat-related conditions and conditions associated with consequences of heat and dehydration were also strongly associated with high temperatures, and there were several times more of those events than there were deaths. For each temperature metric, we observed large contrasts in trigger points (up to 22°C) across multiple health events and diagnoses.

Conclusion: Consideration of multiple health events and diagnoses together with a comprehensive approach to identifying threshold temperatures revealed large differences in trigger points for possible interventions related to heat. Providing an array of heat trigger points applicable for different end-users may improve the public health response to a problem that is projected to worsen in the coming decades.

This research evaluates the climatic summertime representation of the diurnal cycle of near-surface temperature using the Weather Research and Forecasting System (WRF) over the rapidly urbanizing and water-vulnerable Phoenix metropolitan area. A suite of monthly, high-resolution (2 km grid spacing) simulations are conducted during the month of July with both a contemporary landscape and a hypothetical presettlement scenario. WRF demonstrates excellent agreement in the representation of the daily to monthly diurnal cycle of near-surface temperatures, including the accurate simulation of maximum daytime temperature timing. Thermal sensitivity to anthropogenic land use and land cover change (LULCC), assessed via replacement of the modern-day landscape with natural shrubland, is small on the regional scale. The WRF-simulated characterization of the diurnal cycle, supported by previous observational analyses, illustrates two distinct and opposing impacts on the urbanized diurnal cycle of the Phoenix metro area, with evening and nighttime warming partially offset by daytime cooling. The simulated nighttime urban heat island (UHI) over this semiarid urban complex is explained by well-known mechanisms (slow release of heat from within the urban fabric stored during daytime and increased emission of longwave radiation from the urban canopy toward the surface). During daylight hours, the limited vegetation and dry semidesert region surrounding metro Phoenix warms at greater rates than the urban complex. Although prior work has suggested that daytime temperatures are lower within the urban complex owing to the addition of residential and agricultural irrigation (i.e., “oasis effect”) we show that modification of Phoenix's surrounding environment to a biome more representative of temperate regions eliminates the daytime urban cooling. Our results indicate that surrounding environmental conditions, including land cover and availability of soil moisture, play a principal role in establishing the nature and evolution of the diurnal cycle of near-surface temperature for the greater Phoenix, Arizona, metropolitan area relative to its rural and undeveloped counterpart.

Maricopa County, Arizona, anchor to the fastest growing megapolitan area in the United States, is located in a hot desert climate where extreme temperatures are associated with elevated risk of mortality. Continued urbanization in the region will impact atmospheric temperatures and, as a result, potentially affect human health. We aimed to quantify the number of excess deaths attributable to heat in Maricopa County based on three future urbanization and adaptation scenarios and multiple exposure variables.

Two scenarios (low and high growth projections) represent the maximum possible uncertainty range associated with urbanization in central Arizona, and a third represents the adaptation of high-albedo cool roof technology. Using a Poisson regression model, we related temperature to mortality using data spanning 1983–2007. Regional climate model simulations based on 2050-projected urbanization scenarios for Maricopa County generated distributions of temperature change, and from these predicted changes future excess heat-related mortality was estimated. Subject to urbanization scenario and exposure variable utilized, projections of heat-related mortality ranged from a decrease of 46 deaths per year (− 95%) to an increase of 339 deaths per year (+ 359%).

Projections based on minimum temperature showed the greatest increase for all expansion and adaptation scenarios and were substantially higher than those for daily mean temperature. Projections based on maximum temperature were largely associated with declining mortality. Low-growth and adaptation scenarios led to the smallest increase in predicted heat-related mortality based on mean temperature projections. Use of only one exposure variable to project future heat-related deaths may therefore be misrepresentative in terms of direction of change and magnitude of effects. Because urbanization-induced impacts can vary across the diurnal cycle, projections of heat-related health outcomes that do not consider place-based, time-varying urban heat island effects are neglecting essential elements for policy relevant decision-making.

Public transit systems have been identified as a critical component to reducing energy use and greenhouse gas emissions associated with the transportation sector to mitigate future climate change impacts. A unique aspect of public transit is its use almost always necessitates environmental exposure and the design of these systems directly influences rider exposure via rider ingress, egress, and waiting. There is a tension between policies and programs which promote transit use to combat climate change and the potential impact an uncertain climate future may have on transit riders.

In the American Southwest, extreme heat events, a known public health threat, are projected to increase between 150 and 840% over the next decade, and may be a health hazard for transit riders. There are opportunities to incorporate rider health risks in the overall planning process and develop alternative transit schedules during extreme heat events to minimize these risks. Using Los Angeles Metro as a case studies, we show that existing transit vehicles can be reallocated across the system to significantly reduce exposure for riders who are more vulnerable to heat while maintaining a minimum level of service across the system. As cities continue to invest in public transit it is critical for them to understand transit use as an exposure pathway for riders and to develop strategies to mitigate potential health risks.

Climate change is predicted to increase the intensity and negative impacts of urban heat events, prompting the need to develop preparedness and adaptation strategies that reduce societal vulnerability to extreme heat. Analysis of societal vulnerability to extreme heat events requires an interdisciplinary approach that includes information about weather and climate, the natural and built environment, social processes and characteristics, interactions with stakeholders, and an assessment of community vulnerability at a local level. In this letter, we explore the relationships between people and places, in the context of urban heat stress, and present a new research framework for a multi-faceted, top-down and bottom-up analysis of local-level vulnerability to extreme heat. This framework aims to better represent societal vulnerability through the integration of quantitative and qualitative data that go beyond aggregate demographic information. We discuss how different elements of the framework help to focus attention and resources on more targeted health interventions, heat hazard mitigation and climate adaptation strategies.

Extreme heat is a natural hazard that could rapidly increase in magnitude in the 21st century. The combination of increasingurbanization, growing numbers of vulnerable people, and the evidence of global warming indicate an urgent need for improved heat-wavemitigation and response systems. A review of the literature on heat-wave impacts in urban environments and on human health revealsopportunities for improved synthesis, integration, and sharing of information resources that relate to the spatial and temporal nature ofthreats posed by extreme heat. This paper illustrates how geospatial technologies can aid in the mitigation of urban heat waves.