Reducing physical restraints in pediatrics: A quality improvement mixed-methods analysis of implementing a clinical debriefing process after behavioural health emergencies in a Children's Hospital.

INTRODUCTION: An increasing number of pediatric patients with mental and behavioral health (MBH) conditions present to Emergency Department (ED) and inpatient settings with behavioral events that require physical restraint (PR). PR usage is associated with adverse outcomes. Clinical debriefing (CD) programs have been associated with improved performance but have not been studied in this population. After implementing an MBH-CD program in our Children's Hospital, we aimed to decrease the baseline (7/2018-3/2021) rate of a second PR episode (2PR) by 50 % in the ED and inpatient settings over two years. METHODS: A multidisciplinary team implemented an MBH-CD process in April 2021 for hospital teams to use immediately after behavioral events. We included patients ≤18 years old, with an ED or inpatient discharge MBH diagnosis, between July 2018 and June 2023. Pre- and post-implementation secondary outcomes included the ED median duration of PR and the ED PR time per 1000 h of ED care. ED and inpatient mean length of stay (LOS) and mean monthly visits (MMV) in pre- and post-implementation were also compared. Qualitative analysis identified major themes. RESULTS: Post-implementation, the ED significantly decreased 2PR rate by 67 %; in inpatients, no significant change was demonstrated. Median duration of ED PR decreased from 112 to 71 min (p = 0.006) and ED PR time significantly decreased by 82 % (14.8 to 2.7 h per 1000 h). In the post-implementation period, mean LOS (ED and inpatient) and MMV (ED only) were significantly higher. Fifty-one percent of 494 behavioral alerts were debriefed. Median debriefing duration was 6 min (IQR 4,10). Common themes included cooperation and coordination (23 %) and clinical standards (14 %). DISCUSSION: Clinical debriefing implementation was associated with significant improvement in ED patient outcomes. Inpatient outcomes were unchanged, but debriefings in both settings should enable frontline teams to continuously identify opportunities to improve future outcomes.

Efficacy, safety, tolerability, and pharmacokinetics of long-acting injectable cabotegravir for HIV pre-exposure prophylaxis in transgender women: a secondary analysis of the HPTN 083 trial.

BACKGROUND: The HIV Prevention Trials Network (HPTN) 083 trial showed that long-acting injectable cabotegravir was more effective than tenofovir disoproxil fumarate plus emtricitabine in preventing HIV in cisgender men and transgender women who have sex with men. We aimed to characterise the cohort of transgender women included in HPTN 083. METHODS: HPTN 083 is an ongoing, phase 2b/3, randomised, multicentre, double-blind, double-dummy clinical trial done at 43 sites in seven countries (Argentina, Brazil, Peru, the USA, South Africa, Thailand, and Viet Nam). HIV-negative participants were randomly assigned (1:1) to receive injectable cabotegravir or tenofovir disoproxil fumarate plus emtricitabine. The study design and primary outcomes of the blinded phase of HPTN 083 have already been reported. An enrolment minimum of 10% transgender women was set for the trial. Here we characterise the cohort of transgender women enrolled from Dec 6, 2016, to May 14, 2020, when the study was unblinded. We report sociodemographic characteristics, use of gender affirming hormone therapy, and behavioural assessments of the transgender women participants. Laboratory testing and safety evaluations are also reported. The trial is registered at ClinicalTrials.gov, NCT02720094. FINDINGS: HPTN 083 enrolled 570 transgender women (304 tenofovir disoproxil fumarate plus emtricitabine; 266 injectable cabotegravir). Transgender women were primarily from Asia (225 [39%]) and Latin America (205 [36%]); 330 (58%) reported using gender affirming hormone therapy. Intimate partner violence was common (270 [47%] reported emotional abuse and 172 [30%] reported physical abuse) and 323 (57%) reported a history of childhood sexual abuse. 159 (28%) transgender women disagreed that they were at risk for HIV, and 142 (25%) screened positive for depressive symptoms. During study follow-up, incidence of syphilis was 16·25% (95% CI 13·28-19·69), rectal gonorrhoea was 11·66% (9·14-14·66), and chlamydia was 20·61% (17·20-24·49). Frequency of adverse events was similar between the treatment groups. Nine seroconversions occurred among transgender women during the blinded phase of the study (seven in the tenofovir disoproxil fumarate plus emtricitabine group and two in the injectable cabotegravir group); overall incidence was 1·19 per 100 person-years (95% CI 0·54-2·25): 1·80 per 100 person-years (0·73-3·72) in the tenofovir disoproxil fumarate plus emtricitabine group and 0·54 per 100 person-years (0·07-1·95) in the injectable cabotegravir group (hazard ratio 0·34 [95% CI 0·08-1·56]). Cabotegravir concentrations did not differ by gender affirming hormone therapy use. INTERPRETATION: HIV prevention strategies for transgender women cannot be addressed separately from social and structural vulnerabilities. Transgender women were well represented in HPTN 083 and should continue to be prioritised in HIV prevention studies. Our results suggest that injectable cabotegravir is a safe and effective pre-exposure prophylaxis option for transgender women. FUNDING: National Institute of Allergy and Infectious Diseases and ViiV Healthcare.

Implementation of an Intrahospital Transport Checklist for Emergency Department Admissions to Intensive Care.

INTRODUCTION: Intrahospital transports (IHTs) are high-risk activities with the potential for adverse outcomes. Suboptimal care of a patient in our emergency department (ED) needing IHT to the pediatric intensive care unit (ICU) identified improvement opportunities. We describe implementing a novel checklist (Briefing ED-to-ICU Transport To Exit Ready: BETTER) for improving the IHT safety of pediatric ED patients admitted to the pediatric ICU. METHODS: A multidisciplinary team used the Model for Improvement to create a key driver diagram and process map. An evidence-based IHT checklist was implemented on July 23, 2019 after multiple plan-do-study-act checklist revisions. The specific aim was a ≥80% checklist completion rate for 6 months and maintaining that rate for 6 months. An anonymous, voluntary survey of ED nurses and physicians, 9 months postimplementation, evaluated perceived improvements in IHT safety. The outcome measure was the proportion of IHT-related incident reports, per ED-to-pediatric ICU admission, comparing baseline (2-year preimplementation) and intervention (1-year postimplementation) periods. Balancing measures included a quantitative assessment for any throughput measure delays and a survey question on perceived delays. RESULTS: From July 23, 2019 to July 22, 2020, 335 (84%) of 400 ED-to-ICU admissions had completed IHT checklists. Ninety percent of survey respondents (84% response rate) agreed that the checklist improved IHT safety. The incident report rate was lower in the intervention period (0.5% versus 2.3%; P = 0.03), with special cause improvement on T-chart analysis. Balancing measures did not indicate any delays secondary to checklist implementation. CONCLUSIONS: This IHT checklist was feasible and associated with improvements in perceived safety and incident event reporting. Further studies are needed to assess generalizability.

Acceptability of Long-Acting Injectable Cabotegravir (CAB LA) in HIV-Uninfected Individuals: HPTN 077.

Long-acting injectable PrEP could offer an alternative to daily oral PrEP, improve adherence and protection, if found acceptable, safe and effective. HPTN 077 evaluated injectable cabotegravir safety, tolerability and pharmacokinetics among HIV-uninfected males and females in sequentially-enrolled cohorts of two dosing strategies. We compared acceptability of product attributes, prevention preferences and future interest in injectable PrEP (FIIP) by region, sex-at-birth, arm and cohort and used multivariable analysis to identify FIIP determinants. Baseline injectable PrEP preferences were higher in non-U.S. sites and increased in both regions over time. In multivariable models, FIIP was most strongly associated with acceptability of product attributes, was higher in non-U.S. sites and more altruistic participants. Treatment arm and report of pain were not associated with FIIP. Injectable acceptability was highest in non-U.S. sites. Preferences for injectable versus other PrEP methods were higher among U.S. males than females, but higher among males and females in non-U.S. settings.

Simulation Training, Coaching, and Cue Cards Improve Delirium Care.

A quality improvement study supports the use of multimodal education to enhance clinical practice for care of patients with delirium.

Assessing Oral Hygiene in Hospitalized Older Veterans.

Poor oral health for all older adults can result in higher risk for heart disease, stroke, diabetes, and oral cancer. Findings from this study indicated older veterans needed to improve their oral hygiene habits but barriers to oral hygiene performance prevented them from receiving and performing oral hygiene measures.

Influenza vaccination knowledge and perceptions among Veterans Affairs nurses.

Flu vaccination among nurses in the Veterans Health Administration system is crucial in the prevention of influenza. Nurses working at a Veterans Administration Medical Center completed the Influenza Vaccination Knowledge and Perceptions Survey. The findings from this survey suggest the need for additional education for nurses as it relates to flu vaccination.

A survey of environmental service workers' knowledge and opinions regarding environmental cleaning.

Environmental service workers play an important role in the prevention of health care-associated infections. Environmental service workers working at a Veterans Administration Medical Center completed the Environmental Service Workers' Knowledge and Opinions Regarding Environmental Cleaning Survey. The findings from this survey suggest the need for further education of environmental service workers regarding the different types of pathogens that are spread by contaminated environmental surfaces and which of these are killed with bleach.

Bolting and flowering control in sugar beet: relationships and effects of gibberellin, the bolting gene B and vernalization.

BACKGROUND AND AIMS: Bolting, the first visible sign of reproductive transition in beets (Beta vulgaris), is controlled by the dominant bolting gene B (B allele), which allows for flowering under long days (LDs, >14 h light) without prior vernalization. The B-locus carries recessive alleles (bb) in sugar beet (Beta vulgaris L. spp. vulgaris), so that vernalization and LDs are required for bolting and flowering. Gibberellin growth hormones (GAs) control stem elongation and reproductive development, but their role during these processes in sugar beet is not defined. We aimed to investigate the involvement of GAs in bolting and flowering in sugar beet, and also its relationship with the vernalization requirement as defined by the B-gene. METHODOLOGY: Plants segregating for the B allele were treated with exogenous GA(4) under inductive (16 h light) and non-inductive (8 h light) photoperiods, with and without prior vernalization treatment. A co-dominant polymerase chain reaction (PCR) marker was used to genotype the B-gene locus. Bolting and flowering dates were scored, and bolt heights were measured as appropriate. Analysis of variance was used to determine the effects and interactions of GAs, the B allele and vernalization on bolting and flowering. The effects of the B allele on bolting were also verified in the field. PRINCIPAL RESULTS: Application of GAs or the B allele could initiate bolting independently. When the B allele was absent, the applied GAs promoted stem growth, but did so only in vernalized plants, irrespective of photoperiod. Under LDs, bolt height before flowering in plants carrying the B allele (BB; Bb) was not significantly influenced by GAs. The timing and frequency of flowering were influenced by the B allele without interactive effects from GAs. CONCLUSIONS: In sugar beet, GA acts independently of the B allele and photoperiod to induce bolting. Vernalization enables GA action independently of the B allele; hence, the dominant B allele may not directly participate in vernalization-induced bolting.