Evaluation of a primary care-based post-discharge phone call program: keeping the primary care practice at the center of post-hospitalization care transition.

BACKGROUND: The post-hospitalization period is a precarious time for patients. Post-discharge nurse telephone call programs aiming to prevent unnecessary readmissions have had mixed results. OBJECTIVE: Describe a primary-care based program to identify and address problems arising after hospital discharge. DESIGN: A quality improvement program embedding registered nurses in a primary care practice to call patients within 72 h of hospital discharge and route problems within the practice for real-time resolution. PARTICIPANTS: Adult patients with a primary care provider in the general internal medicine practice at the University of California San Francisco who were discharged home from the Medicine service. MAIN MEASURES: Patients reached directly by phone had a 'full-scripted encounter;' those reached only by voice-mail had a 'message-scripted encounter;' those not reached despite multiple attempts had a 'missed encounter.' Among patients with full-scripted encounters, we identified and cataloged problems arising after hospital discharge and measured the proportion of calls in which a problem was uncovered. For the different encounter types, we compared follow-up appointment attendance and 30-day readmission rates. KEY RESULTS: Of 790 eligible discharges, 486 had a full-scripted, 229 a message-scripted and 75 a missed encounter. Among the 486 full-scripted encounters, nurses uncovered at least one problem in 371 (76 %) discharges, 25 % of which (n = 94) included new symptoms, and 47 % (n = 173) included medication issues. Discharges with full-scripted and message-scripted encounters were associated with higher follow-up appointment attendance rates compared with those with missed encounters (60.1 %, 58.5 %, 38.5 % respectively p = 0.004). There was no significant difference in 30-day readmission rates (12.8 %, 14.8 %, 14.7 %; p = 0.72). CONCLUSIONS: Our results suggest that centering a post-discharge phone call program within the primary care practice improves post-hospital care by identifying clinical and care-coordination problems early. With the new Medicare transitional care payment, such programs could become an important, self-sustaining part of the patient-centered medical home.

Field testing the transferability of behavioural science knowledge on promoting vaccinations.

As behavioural science is increasingly adopted by organizations, there is a growing need to assess the robustness and transferability of empirical findings. Here, we investigate the transferability of insights from various sources of behavioural science knowledge to field settings. Across three pre-registered randomized controlled trials (RCTs, N = 314,824) involving a critical policy domain-COVID-19 booster uptake-we field tested text-based interventions that either increased vaccinations in prior field work (RCT1, NCT05586204), elevated vaccination intentions in an online study (RCT2, NCT05586178) or were favoured by scientists and non-experts (RCT3, NCT05586165). Despite repeated exposure to COVID-19 vaccination messaging in our population, reminders and psychological ownership language increased booster uptake, replicating prior findings. However, strategies deemed effective by prediction or intention surveys, such as encouraging the bundling of COVID-19 boosters and flu shots or addressing misconceptions, yielded no detectable benefits over simple reminders. These findings underscore the importance of testing interventions' transferability to real-world settings.

Touch displays: the effects of palm rejection technology on productivity, comfort, biomechanics and positioning.

Direct touch displays can improve the human-computer experience and productivity; however, the higher hand locations may increase shoulder fatigue. Palm rejection (PR) technology may reduce shoulder loads by allowing the palms to rest on the display and increase productivity by registering the touched content and fingertips through the palms rather than shoulders. The effects of PR were evaluated by having participants perform touch tasks while posture and reaction force on the display were measured. Enabling PR, during which the subjects could place the palms on the display (but were not required to), resulted in increased wrist extension, force applied to the display and productivity, and less discomfort, but had no effect on the self-selected positioning of the display. Participants did not deliberately place their palms on the display; therefore, there was no reduction in shoulder load and the increased productivity was not due to improved hand registration. The increased productivity may have been due to reduced interruptions from palm contacts or reduced motor control demands.

Supplements Are Not a Synonym for Safe: Suspected Liver Injury From Ashwagandha.

Background: As patients look more to alternative herbal and dietary supplements to boost energy and mood, reports are increasing of unintended adverse effects, particularly to the liver. Case Presentation: We report a case of a 48-year-old man with a history of severe alcohol use disorder who presented to the emergency department with a cholestatic pattern of liver injury in the setting of alcohol and use of a testosterone-boosting supplement containing ashwagandha. Conclusions: Drug-induced liver damage should be considered in patients with alcohol use disorder who present with a cholestatic pattern of liver injury. Although many natural substances are well tolerated, others can have unanticipated and harmful adverse effects and drug interactions. Future research should identify not only potentially harmful substances, but also which patients may be at greatest risk.

A 1-Year Review of a Nationally Led Intervention to Improve Suicide Prevention Screening at a Large Homeless Veterans Clinic.

BACKGROUND: Suicide is a national public health concern and veterans are a particularly vulnerable population. The Veterans Health Administration (VHA) Office of Mental Health and Suicide Prevention implemented a national, standardized process for suicide risk screening in October 2018, which was instituted at the West Los Angeles Veterans Affairs Medical Center Homeless Patient Aligned Care Team (HPACT) clinic. METHODS: This article examines the results of the screening initiative after implementation, describes difficulties faced in implementation, and suggests strategies that might be used to overcome those challenges. RESULTS: Over 1 fiscal year (October 1, 2018 to September 30, 2019) the HPACT clinic had 2932 unique veterans assigned to its care; 1876 (64%) received a primary screen of suicide risk, 523 (18%) were not screened, and 533 (18%) were exempt from screening by protocol. Of the 523 (18%) unscreened patients, 331 (11%) patients had no HPACT visit and 132 (5%) did not visit any VHA site during the period. There were 192 (7%) patients who visited but were not screened of which 19 (1%) declined screening. CONCLUSIONS: Most missed screening opportunities were due to patients being lost to follow-up. There were 5 challenges identified for screening implementation, including health record factors, communication, clinician buy-in, system factors, and patient factors. Thus, promoting interprofessional collaboration, visualizing effective process flows, establishing clear lines of communication and roles for involved staff, and opening avenues for continuous feedback and troubleshooting were all effective in increasing comfort with suicide assessment and screening rates.

Use of Phenobarbital in Delirium Tremens.

The standard of care for alcohol withdrawal centers on the use of escalating doses of benzodiazepines until clinical improvement is achieved. However, there is no established standard in the care of patients with severe alcohol withdrawal and delirium tremens that is refractory to benzodiazepine therapy. One potential therapy that is gaining traction is the use of phenobarbital, which may be mechanistically superior to benzodiazepines in treating delirium tremens because of its effects on GABA and N-methyl-D-aspartate receptors. The dosing of phenobarbital and its subsequent taper, however, is still unclear and the side effect profile is not well characterized. In this case report, we present the case of a 37-year-old Hispanic male who presented with alcohol withdrawal and subsequent delirium tremens who was treated with phenobarbital with positive clinical response and minimal side effects.