Adopting a Novel Approach to Prevent and Address Patient Mistreatment of Staff in a Community Mental Health Center.

Verbal mistreatment of staff by patients is common in health care settings. Experiencing or witnessing mistreatment can have harmful psychological impacts, affecting well-being and clinical practice. As part of an effort to become an antiracist organization, an academic community mental health center based in Connecticut developed an initiative to address verbal mistreatment. Training in the Expect, Recognize, Address, Support, Establish (ERASE) framework was provided to 140 staff members. This training and subsequent actions to enhance the culture of safety were perceived as helpful by staff. Further development of the initiative is proceeding as the center's primary performance improvement program.

The Implementation and Effectiveness of Digital Cognitive Behavioral Therapy for Insomnia in Primary Care: A Pilot Study.

Background: Digital interventions delivering Cognitive Behavioral Therapy for insomnia (Digital CBTi) may increase utilization of effective care for a common and serious condition. A low-intensity implementation strategy may facilitate digital CBTi use in healthcare settings. This pilot study assessed the feasibility of implementing a digital CBTi in Veterans Health Administration (VA) primary care through iterative modifications to a low-intensity implementation strategy, while evaluating clinical outcomes of a specific digital CBTi program. Methods: A self-directed digital CBTi was implemented in the primary care clinics of a single VA facility using a cohort trial design that iteratively modified an implementation strategy over three 8-month phases. The phase 1 implementation strategy included (1) provider education; (2) point-of-care information via pamphlets; and (3) provider referral to digital CBTi through phone calls or messages. Phases 2 and 3 maintained these activities, while (1) adding a clinic-based coach who performed initial patient education and follow-up support contacts, (2) providing additional recruitment pathways, and (3) integrating the referral mechanism into provider workflow. Implementation outcomes included provider adoption, patient adoption, and acceptability. Clinical outcomes (insomnia severity, depression severity, and sedative hypnotic use) were compared among enrollees at baseline and 10 weeks. Results: Across all phases 66 providers (48.9%) made 153 referrals, representing 0.38% of unique clinic patients. Of referrals, 77 (50.3%) enrolled in the study, 45 (29.4%) engaged in the program, and 24 (15.7%) completed it. Provider and patient adoption did not differ meaningfully across phases. Among enrollees, digital CBTi was acceptable and the Insomnia Severity Index decreased by 4.3 points (t = 6.41, p < 0.001) and 13 (18.6%) reached remission. The mean number of weakly sedative-hypnotic doses decreased by 2.2 (35.5%) (t = 2.39, p < 0.02). Conclusions: Digital CBTi implementation in VA primary care is feasible using low-intensity implementation strategy, resulting in improved clinical outcomes for users. However, iterative implementation strategy modifications did not improve adoption.The trial was registered at clinicaltrials.gov (NCT03151083).

Outcomes of Patients with Alcohol Withdrawal Syndrome Treated with High-Dose Sedatives and Deferred Intubation.

RATIONALE: High doses of sedating drugs are often used to manage critically ill patients with alcohol withdrawal syndrome. OBJECTIVES: To describe outcomes and risks for pneumonia and endotracheal intubation in patients with alcohol withdrawal syndrome treated with high-dose intravenous sedatives and deferred endotracheal intubation. METHODS: Observational cohort study of consecutive patients treated in the intensive care unit (ICU) of a university-affiliated, community hospital for alcohol withdrawal syndrome, where patients were not routinely intubated to receive high-dose or continuously infused sedating medications. MEASUREMENTS AND MAIN RESULTS: We studied 188 patients hospitalized with alcohol withdrawal syndrome from 2008 through 2012 at one medical center. The mean age (SD) of the subjects was 50.8 ± 9.0 years and their mean ICU admission APACHE (Acute Physiology and Chronic Health Evaluation) II score was 6.2 ± 3.4. Thirty subjects (16%) developed pneumonia, and 38 (20.2%) required intubation. All of the 188 patients received lorazepam (median total dose, 42.5 mg), and 170 of 188 received midazolam, all but 2 by continuous intravenous infusion (median total dose, 527 mg; all administered in ICU); 19 received propofol (median total dose, 6,000 mg); and 19 received dexmedetomidine (median total dose, 1,075 mg). Intubated patients received substantially more benzodiazepine (median total dose, 761 mg of lorazepam equivalent vs. 229 mg for subjects in the nonintubated group; P < 0.0001). Endotracheal intubation was associated with pneumonia and higher acuity of illness (APACHE II score, >10). Intubated patients had a longer duration of hospital stay (median, 15 d vs. 6 d; P ≤ 0.0001). One patient did not survive hospitalization. CONCLUSIONS: In this single-center, observational study, where endotracheal intubation was deferred until aspiration or cardiopulmonary decompensation, treatment of alcohol withdrawal syndrome with high-dose, continuously infused sedating medications was not associated with excess morbidity or mortality.

Effect of zoledronic acid on bone density and markers of bone turnover in a community clinic.

OBJECTIVE: This study aims to document the efficacy of zoledronic acid by comparing bone densities and markers of bone turnover, in patients with osteoporosis. METHODS: Bone mineral density (BMD) and urinary N-telopeptide, a marker of bone turnover, were compared before and after treatment with intravenous zoledronic acid. RESULTS: 52 participants had atleast two doses of zoledronic acid over 36 months. Significant increases in BMD were found in the spine (t=4.38, P<0.01) and decrease in bone turnover marker N-telopeptide (t=3.30, P=0.002). Small but significant correlations were determined between prior steroid use and change in BMD in the spine (r=0.35, P<0.05), and family history of osteoporosis and change in BMD in the right femur (r=0.38, P<0.05). CONCLUSION: Annual infusions of zoledronic acid for at least two years, revealed a significant increase in bone density at the spine and a decrease in urinary N-telopeptide in patients treated at our center.

ß-blocker withdrawal among patients presenting for surgery from home.

OBJECTIVE: This study sought to measure the prevalence of perioperative ß-blocker noncompliance by patients who were prescribed long-term ß-blocker therapy and presented for surgery from home. The effect of patient noncompliance on the presenting heart rate on the day of surgery also was examined. DESIGN: Prospective observational study with outcome data obtained from reviews of medical records. SETTING: The preoperative clinic and operating rooms of a Veterans Administration hospital. PARTICIPANTS: Patients on long-term ß-blocker therapy who presented from home for surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic and comorbidity data and data on self-reported compliance to ß-blocker therapy, vital signs on the initial day of surgery, and recent ambulatory vital signs were collected. Ten of 50 subjects (20%; 95% confidence interval, 9-31) reported not taking their ß-blocker on the day of surgery. These self-reported nonadherers exhibited a higher presenting heart rate on the day of surgery than adherent subjects (median, 78 v 65 beats/min; p = 0.02 by Wilcoxon rank-sum test). The difference-in-difference analysis in heart rate between baseline primary care and the day of surgery also was statistically significant between compliant and noncompliant subjects (-7 v + 12.5 beats/min; p < 0.00001). CONCLUSIONS: Patient self-report and physiologic data documented a failure to take ß-blockers and possible ß-blocker withdrawal in 20% of patients who presented for surgery from home. If these findings are confirmed in larger studies, improved patient understanding of and compliance with medication instructions during preoperative visits should be a focus of future quality improvement initiatives.

The relationship between preoperative and primary care blood pressure among veterans presenting from home for surgery: is there evidence for anesthesiologist-initiated blood pressure referral?

BACKGROUND: American College of Cardiology/American Heart Association guidelines describe the perioperative evaluation as "a unique opportunity to identify patients with hypertension"; however, factors such as anticipatory stress or medication noncompliance may induce a bias toward higher blood pressure, leaving clinicians unsure about how to interpret preoperative hypertension. Information describing the relationship between preoperative intake blood pressure and primary care measurements could help anesthesiologists make primary care referrals for improved blood pressure control in an evidence-based fashion. We hypothesized that the preoperative examination provides a useful basis for initiating primary care blood pressure referral. METHODS: We analyzed retrospective data on 2807 patients who arrived from home for surgery and who were subsequently evaluated within 6 months after surgery in the primary care center of the same institution. After descriptive analysis, we conducted multiple linear regression analysis to identify day-of-surgery (DOS) factors associated with subsequent primary care blood pressure. We calculated the sensitivity, specificity, and positive and negative predictive value of different blood pressure referral thresholds using both a single-measurement and a 2-stage screen incorporating recent preoperative and DOS measurements for identifying patients with subsequently elevated primary care blood pressure. RESULTS: DOS systolic blood pressure (SBP) was higher than subsequent primary care SBP by a mean bias of 5.5 mm Hg (95% limits of agreement + 43.8 to -32.8). DOS diastolic blood pressure (DBP) was higher than subsequent primary care DBP by a mean bias of 1.5 mm Hg (95% limits of agreement +13.0 to -10.0). Linear regression of DOS factors explained 19% of the variability in primary care SBP and 29% of the variability in DBP. Accounting for the observed bias, a 2-stage SBP referral screen requiring preoperative clinic SBP ≥140 mm Hg and DOS SBP ≥146 mm Hg had 95.9% estimated specificity (95% confidence interval [CI] 94.4 to 97.0) for identifying subsequent primary care SBP ≥140 mm Hg and estimated sensitivity of 26.8% (95% CI 22.0 to 32.0). A similarly high specificity using a single DOS SBP required a threshold SBP ≥160 mm Hg, for which estimated specificity was 95.2% (95% CI 94.2 to 96.1). For DBP, a presenting DOS DBP ≥92 mm Hg had 95.7% specificity (95% CI 94.8 to 96.4) for subsequent primary care DBP ≥90 mm Hg with a sensitivity of 18.8% (95% CI 14.4 to 24.0). CONCLUSION: A small bias toward higher DOS blood pressures relative to subsequent primary care measurements was observed. DOS factors predicted only a small proportion of the observed variation. Accounting for the observed bias, a 2-stage SBP threshold and a single-reading DBP threshold were highly specific though insensitive for identifying subsequent primary care blood pressure elevation.