Use of quality improvement methods to enhance implementation of a mental health care bundle in a pediatric emergency department.

OBJECTIVES: We used quality improvement methods to implement a care bundle for children presenting to a pediatric emergency department (ED) with mental health concerns. A bundle novelty was that it included an option for assessment in a partnered clinic, not in the ED, to families of children assessed as having no medical or safety concerns. The primary aim of this study was to establish successful implementation of the bundle prior to studying its impact. METHODS: The bundle included the Ask Suicide-Screening Questions to standardize risk assessment at triage, the HEADS-ED (Home, Education, Activities/Peers, Drug/Alcohol, Suicidality, Emotions/Behavior, Discharge Resources) tool for brief, scored mental health assessments, and offering an urgent appointment within 96 h for low-risk children as an alternative to ED-based assessment or as a follow-up option for patients assessed in the ED. We developed aims, driver diagrams, and outcome measures for each bundle element. Each element was introduced with small tests of change using iterative plan-do-study-act cycles. Run charts were used to determine successful completion of aims. RESULTS: Rules for special cause were met through detection of shifts in performance 5 months after bundle implementation for the Ask Suicide-Screening Questions and HEADS-ED. These bundle elements were consistently used with ≥ 80% of eligible patients, representing aim achievement. During the 6 months of providing urgent appointments, 89.3% of 159 referred families received an appointment within 96 h. CONCLUSIONS: Using quality improvement methods, we were able to successfully ensure reliable implementation of a new care bundle for pediatric patients presenting to the ED with mental health concerns and allow eligible low-risk patients to receive full assessments in a partnered clinic instead of the ED.

RéSUMé: OBJECTIFS: Nous avons utilisé des méthodes d'amélioration de la qualité pour mettre en œuvre un ensemble de soins (bundle) pour les enfants qui se présentent à un service d'urgence pédiatrique avec des problèmes de santé mentale. Une nouveauté de ce bundle était qu'il comprenait une option d'évaluation dans une clinique partenaire, et non au service des urgences, pour les familles d'enfants évalués comme n'ayant aucun problème médical ou de sécurité. L'objectif premier de cette étude était d'assurer la réussite de la mise en œuvre du bundle avant d'en étudier l'impact. MéTHODES: Le bundle comprenait le questionnaire Ask Suicide-Screening Questions pour normaliser l'évaluation du risque au triage, l'outil HEADS-ED (Home, Education, Activities/Peers, Drug/Alcohol, Suicidality, Emotions/Behavior, Discharge Resources) pour des évaluations brèves et notées de la santé mentale, et l'offre d'un rendez-vous urgent dans les 96 heures pour les enfants à faible risque comme alternative à l'évaluation à l'urgence ou comme option de suivi pour les patients évalués à l'urgence. Nous avons élaboré des objectifs, des diagrammes de pilotage et des mesures de résultats pour chaque élément du bundle. Chaque élément a été introduit avec de petits tests de changement en utilisant des cycles itératifs planifier-faire-étudier-agir. Des diagrammes de progression ont été utilisés pour déterminer la réussite des objectifs. RéSULTATS: Les règles relatives à la cause spéciale ont été respectées grâce à la détection de changements dans les performances 5 mois après la mise en œuvre de bundle pour les questions de dépistage du suicide et HEADS-ED. Ces bundles ont été systématiquement utilisés avec plus de 80 % des patients éligibles, ce qui représente un objectif atteint. Au cours des six mois pendant lesquels des rendez-vous urgents ont été proposés, 89,3 % des 159 familles référées ont obtenu un rendez-vous dans les 96 heures. CONCLUSIONS: En utilisant des méthodes d'amélioration de la qualité, nous avons réussi à assurer une mise en œuvre fiable d'un nouveau bundle de soin pour les patients pédiatriques se présentant aux urgences avec des problèmes de santé mentale et à permettre aux patients à faible risque éligibles de recevoir des évaluations complètes dans une clinique partenaire plutôt qu'aux urgences.

"The Feeling of Failure Is Immense": A Qualitative Analysis of the Experiences of Unmatched Residency Applicants Using Reddit.

PURPOSE: The increasing number of applicants who do not match to a residency program has been identified as an issue in Canada and the United States, yet the experiences of those individuals going unmatched have remained largely unexplored. By better understanding such experiences, medical schools will be better equipped to support unmatched graduates. The authors sought to understand the shared experiences of unmatched residency applicants, including those who did not match to American residency programs. METHOD: The authors turned to the social media platform Reddit as their source of data to further understand the experiences of unmatched residency applicants, using a thematic analysis of comments posted on the subreddit r/medicalschool. The subreddit was searched for comments containing the term unmatched on August 16, 2021. A total of 206 comments containing content about first-person experiences of going unmatched were included in the thematic analysis. RESULTS: The 206 comments were authored by 124 unique usernames between the years of 2012 and 2021. Two primary themes emerged in the analysis: perceptions of insufficient return for investments made in medical education and concern about the possibility of going unmatched again in the future. Subthemes identified for the first theme were regret for pursuing medical school, perceptions of failure, and considering an alternative career. Subthemes identified for the second theme were perceived lack of transparency and fairness in the match process and desire to improve future applications, which sometimes involved considering applying to other specialties. CONCLUSIONS: The results of this study suggest unmatched applicants are prone to a range of negative cognitive and emotional reactions. In light of these findings, medical schools should ensure effective supports are being offered to unmatched applicants in a timely and nonjudgmental manner. Future work should focus on investigating the outcomes of interventions for supporting unmatched applicants.

School Closures and Social Anxiety During the COVID-19 Pandemic.

In their recent systematic review, Loades et al.1 reported on the effects that social isolation and loneliness may have on children and adolescents during the global 2019 novel coronavirus disease (COVID-19) pandemic, with their findings suggesting associations between social anxiety and loneliness/social isolation. While this is undoubtedly true for many children and adolescents, it is also worth commenting on the subset of children and youths with social phobia for whom a temporary lessening of distress may be observed while schools are closed owing to a lack of exposure to anxiety-provoking situations in the school environment.

Assessment of Aggressive Behaviour in a Patient with Autism Spectrum Disorder Requiring General Anesthesia.

OBJECTIVE: To consider the utility of general anesthesia in the assessment of aggressive behaviour associated with autism spectrum disorder (ASD). METHODS: We describe the case of an adolescent male exhibiting violent behaviour with a previous diagnosis of ASD and review medical literature relevant to the assessment of aggression in the context of ASD. RESULTS: A 16-year-old male with a prior diagnosis of ASD, who was non-verbal, was admitted to an inpatient psychiatry ward with the presenting issue of violent behaviour. The patient had not received routine medical or dental care for several years due to agitation and aggression when attempts to physically examine him were made. General anesthesia was necessary to assess for medical conditions that may be contributory to his behavioural changes. While under general anesthesia, he was physically examined by several consulting services, received brain imaging, and laboratory specimens were drawn. CONCLUSIONS: Aggressive behaviour is a common issue for patients with ASD. When a patient's behaviour precludes examination and investigations, general anesthesia may be beneficial to facilitate the assessment process. This case illustrates the importance of a multidisciplinary approach in the assessment and management of a minimally verbal patient presenting with behavioural changes. To the knowledge of the authors, this represents the first published case report of a patient with ASD requiring general anesthesia for the assessment of aggressive behaviour.

OBJECTIF: Estimer l'utilité d'une anesthésie générale dans l'évaluation du comportement agressif associé au trouble du spectre de l'autisme (TSA). MÉTHODES: Nous décrivons le cas d'un adolescent masculin présentant un comportement violent avec un diagnostic précédent de TSA, et révisons la littérature médicale traitant de l'évaluation de l'agressivité dans le contexte du TSA. RÉSULTATS: Un jeune homme de 16 ans ayant un diagnostic précédent de TSA, qui était non verbal, a été hospitalité dans une unité d'hospitalisation psychiatrique alors qu'il présentait un problème de comportement violent. Le patient n'avait pas reçu de soins médicaux ou dentaires réguliers depuis plusieurs années en raison de l'agitation et de l'agressivité qu'il manifestait quand on tentait de l'examiner physiquement. L'anesthésie générale était nécessaire pour évaluer les affections médicales qui pouvaient contribuer à ces changements de comportement. Quand il fut sous anesthésie générale, il a été physiquement examiné par plusieurs services de consultation, il a reçu une imagerie cérébrale et des échantillons de laboratoire ont été prélevés. CONCLUSIONS: Le comportement agressif est un problème commun chez les patients souffrant du TSA. Quand le comportement d'un patient empêche l'examen et les investigations, l'anesthésie générale peut être bénéfique pour faciliter le processus d'évaluation. Ce cas illustre l'importance d'une approche multidisciplinaire dans l'évaluation et la prise en charge d'un patient minimalement verbal qui présente des changements de comportement. À la connaissance des auteurs, ceci représente la première étude de cas publiée d'un patient souffrant du TSA nécessitant une anesthésie générale pour évaluer un comportement agressif.

Low molecular weight thrombin inhibitors with excellent potency, metabolic stability, and oral bioavailability.

Modification of lead compound 1 by reducing lipophilicity in the P3 group produced a series of low molecular weight thrombin inhibitors with excellent potency in functional assays, metabolic stability, and oral bioavailability. These modifications led to the identification of two optimized compounds, 14 and 16.

Unexpected enhancement of thrombin inhibitor potency with o-aminoalkylbenzylamides in the P1 position.

Thrombin inhibitors incorporating o-aminoalkylbenzylamides in the P1 position were designed, synthesized and found to have enhanced potency and selectivity in several different structural classes. X-ray crystallographic analysis of compound 24 bound in the alpha-thrombin-hirugen complex provides an explanation for these unanticipated results.

Nanomolar Inhibitors for Two Distinct Biological Target Families from a Single Synthetic Sequence: A Next Step in Combinatorial Library Design?

One common synthetic route creates small-molecule libraries directed toward two functionally distinct target families. The novel structural template 1 can independently display the necessary pharmacophore patterns for inhibition of members of two different biomolecular target families, the matrix metalloproteinases (MMPs) or the phosphodiesterases (PDEs). The incorporation of multiple target family directed design elements into combinatorial library design could help expedite the pharmaceutical lead discovery process. Z=OR' (PDE4), H (MMPs).