Fire Incidents in a Mental Health Setting: Effects of Implementing Smokefree Polices and Permitting the Use of Different Types of E-Cigarettes.

Comprehensive smokefree policies in health care settings can have a positive impact on patients' smoking behaviour, but implementation is impeded by concern that surreptitious smoking may increase fire incidents. We investigated the incidence of routinely reported fire and false alarm incidents in a large mental health organisation in England over an 81-month period when different elements of a smokefree policy were implemented. We used negative binomial regression models to test associations between rates of fire and false alarm incidents and three hospital smokefree policy periods with mutual adjustment for occupied bed days: (1) an indoor policy which allowed disposable e-cigarettes; (2) a comprehensive policy which allowed disposable e-cigarettes; and (3) a comprehensive policy with all e-cigarette types allowed. We identified 90 fires and 200 false alarms. Fires decreased (incidence rate ratio (IRR): 0.35, 95% CI: 0.17-0.72, p = 0.004) and false alarms increased (IRR: 1.67, 95% CI: 1.02-2.76, p = 0.043), each by approximately two-thirds, when all e-cigarette types were allowed, after adjusting for bed occupancy and the comprehensive smokefree policy. Implementation of smokefree policies in mental health care settings that support use of all types of e-cigarettes may reduce fire risks, though measures to minimise effects of e-cigarette vapour on smoke detector systems may be needed to reduce false alarm incidents.

An observational study of system-level changes to improve the recording of very brief advice for smoking cessation in an inpatient mental health setting.

BACKGROUND: Smoking prevalence among people with psychosis remains high. Providing Very Brief Advice (VBA) comprising: i) ASK, identifying a patient's smoking status ii) ADVISE, advising on the best way to stop and iii) ACT (OFFER), offering a referral to specialist smoking cessation support, increases quit attempts in the general population. We assessed whether system-level changes in a UK mental health organisation improved the recording of the provision of ASK, ADVISE, ACT (OFFER) and consent to referral to specialist smoking cessation support (ACT (CONSENT)). METHODS: We conducted a study using a regression discontinuity design in four psychiatric hospitals with patients who received treatment from an inpatient psychosis service over 52 months (May 2012-September 2016). The system-level changes to facilitate the provision of VBA comprised: A) financially incentivising recording smoking status and offer of support (ASK and ACT (OFFER)); B) introduction of a comprehensive smoke-free policy; C) enhancements to the patient electronic healthcare record (EHCR) which included C1) a temporary form to record the financial incentivisation of ASK and ACT (OFFER) C2) amendments to how VBA was recorded in the EHCR and C3) the integration of a new electronic national referral system in the EHCR. The recording of ASK, ADVISE, ACT (OFFER/CONSENT) were extracted using a de-identified psychiatric case register. RESULTS: There were 8976 admissions of 5434 unique individuals during the study period. Following A) financial incentive, the odds of recording ASK increased (OR: 1.56, 95%CI: 1.24-1.95). Following B) comprehensive smoke-free policy, the odds of recording ADVICE increased (OR: 3.36, 95%CI: 1.39-8.13). Following C1) temporary recording form, the odds of recording ASK (OR:1.99, 95%CI:1.59-2.48) and recording ACT (OFFER) increased (OR: 4.22, 95%CI: 2.51-7.12). Following C3) electronic referral system, the odds of recording ASK (OR:1.79, 95%CI: 1.31-2.43) and ACT (OFFER; OR: 1.09, 95%CI: 0.59-1.99) increased. There was no change in recording VBA outcomes following C2) amendments to VBA recording. CONCLUSIONS: Financial incentives and the recording of incentivised outcomes, the comprehensive smoke-free policy, and the electronic referral system, were associated with increases in recording individual VBA elements, but other changes to the EHCR were not. System-level changes may facilitate staff recording of VBA provision in mental health settings.

Smoking-related violence in a mental health setting following the implementation of a comprehensive smoke-free policy: A content analysis of incident reports.

Smoke-free policies in mental health settings are important to protect health but are often impeded by staff concerns that physical violence may increase. We aimed to address the literature gap about the frequency, nature, and management of physical violence in relation to smoking. We compared the antecedents and containment of smoking-related incidents of physical violence over a two-year period, (12 months when an indoor-only smoke-free policy was in place, followed by 12 months after a new comprehensive smoke-free policy was introduced) using incident reports completed by staff in a large mental health organization in London, UK. Sixty-one smoking-related incidents occurred during the indoor-only smoke-free policy period; 32 smoking-related incidents occurred during the comprehensive smoke-free policy. We identified four antecedent categories for physical violence: i) patient request to smoke denied by staff; ii) during a supervised smoking break; iii) staff response to a patient breach of the smoke-free policy iv) asking for, trading or stealing smoking materials. The antecedent pattern changed across the two policy periods, with fewer incidents of denying a patient's request to smoke and a greater number of incidents involving staff responding to breaches occurring after the introduction of the comprehensive smoke-free policy. The prohibition of smoking breaks removed this source of violence. Timeout and PRN medication were the most common containment interventions. Understanding the context of smoking-related violence may inform clinical guidelines about its prevention and management.

Probing the Effects of Pyrimidine Functional Group Switches on Acyclic Fleximer Analogues for Antiviral Activity.

Due to their ability to inhibit viral DNA or RNA replication, nucleoside analogues have been used for decades as potent antiviral therapeutics. However, one of the major limitations of nucleoside analogues is the development of antiviral resistance. In that regard, flexible nucleoside analogues known as "fleximers" have garnered attention over the years due to their ability to survey different amino acids in enzyme binding sites, thus overcoming the potential development of antiviral resistance. Acyclic fleximers have previously demonstrated antiviral activity against numerous viruses including Middle East Respiratory Syndrome coronavirus (MERS-CoV), Ebola virus (EBOV), and, most recently, flaviviruses such as Dengue (DENV) and Yellow Fever Virus (YFV). Due to these interesting results, a Structure Activity Relationship (SAR) study was pursued in order to analyze the effect of the pyrimidine functional group and acyl protecting group on antiviral activity, cytotoxicity, and conformation. The results of those studies are presented herein.

The evolution of antiviral nucleoside analogues: A review for chemists and non-chemists. Part II: Complex modifications to the nucleoside scaffold.

This is the second of two invited articles reviewing the development of nucleoside analogue antiviral drugs, written for a target audience of virologists and other non-chemists, as well as chemists who may not be familiar with the field. As with the first paper, rather than providing a chronological account, we have chosen to examine particular examples of structural modifications made to nucleoside analogues that have proven fruitful as various antiviral, anticancer, and other therapeutics. The first review covered the more common, and in most cases, single modifications to the sugar and base moieties of the nucleoside scaffold. This paper focuses on more recent developments, especially nucleoside analogues that contain more than one modification to the nucleoside scaffold. We hope that these two articles will provide an informative historical perspective of some of the successfully designed analogues, as well as many candidate compounds that encountered obstacles.

The evolution of nucleoside analogue antivirals: A review for chemists and non-chemists. Part 1: Early structural modifications to the nucleoside scaffold.

This is the first of two invited articles reviewing the development of nucleoside-analogue antiviral drugs, written for a target audience of virologists and other non-chemists, as well as chemists who may not be familiar with the field. Rather than providing a simple chronological account, we have examined and attempted to explain the thought processes, advances in synthetic chemistry and lessons learned from antiviral testing that led to a few molecules being moved forward to eventual approval for human therapies, while others were discarded. The present paper focuses on early, relatively simplistic changes made to the nucleoside scaffold, beginning with modifications of the nucleoside sugars of Ara-C and other arabinose-derived nucleoside analogues in the 1960's. A future paper will review more recent developments, focusing especially on more complex modifications, particularly those involving multiple changes to the nucleoside scaffold. We hope that these articles will help virologists and others outside the field of medicinal chemistry to understand why certain drugs were successfully developed, while the majority of candidate compounds encountered barriers due to low-yielding synthetic routes, toxicity or other problems that led to their abandonment.

Predictors of adherence to a new erythropoiesis-stimulating agent inpatient ordering policy: A cross-sectional study.

BACKGROUND: Erythropoiesis-stimulating agents (ESAs) are recommended for treating anemia in patients with chronic kidney disease and end-stage renal disease. However, misappropriate and over-use of these agents can be costly and unnecessary in some settings. OBJECTIVE: The primary aim was to identify predictors of adherence to a newly approved ESA inpatient ordering policy. The secondary aims were to evaluate the impact of a 5-day delay in the initiation of ESA therapy on ESA usage, hemoglobin (Hb) levels, and costs. METHODS: This retrospective observational record review included a sample of adult patients admitted to four tertiary care hospitals from November 1, 2013 to August 31, 2014. Multivariable logistic and linear regression analyses were used to calculate the odds of adherence to the new ESA inpatient ordering policy and the impact of this policy on discharge Hb level, respectively. RESULTS: A total of 242 patients were included. The majority of the prescribers (77%) adhered to the new ESA ordering policy. Hemoglobin (OR = 1.306; 95% CI: 1.03-1.65) and ferritin (OR = 3.91; 95% CI: 1.23-12.51) levels at admission and length of hospital stay were positively correlated with the odds of patients receiving ESAs after day 5 (OR = 1.12; 95% CI:1.05-1.20). Furthermore, adherence to the new policy did not have a significant impact on discharge Hb level (ß = 0.02349; P = 0.895). CONCLUSIONS: Prescribers were adherent to a 5-day delay in the initiation of ESA therapy policy which resulted in a reduction in ESA usage, did not impact the discharge Hb levels, and was proven to be cost effective.

Effect of implementation of a smoke-free policy on physical violence in a psychiatric inpatient setting: an interrupted time series analysis.

BACKGROUND: Smoke-free policies are important to protect health and reduce health inequalities. A major barrier to policy implementation in psychiatric hospitals is staff concern that physical violence will increase. We aimed to assess the effect of implementing a comprehensive smoke-free policy on rates of physical assaults in a large UK mental health organisation. METHODS: We did an interrupted time series analysis of incident reports of physical assault 30 months before and 12 months after the implementation of the policy in the inpatient wards of South London and Maudsley National Health Service Foundation Trust, London, UK. We used a quasi-Poisson generalised additive mixed model to model the monthly incidence of physical assaults as a function of several explanatory variables. FINDINGS: 4550 physical assaults took place between April 1, 2012, and Sept 30, 2015; 225 (4·9%) of which were smoking-related. After adjustment for temporal and seasonal trends and key confounders (sex, age, schizophrenia or related disorders, or having been sectioned under the Mental Health Act), there was a 39% reduction in the number of physical assaults per month after the policy introduction compared with beforehand (incidence rate ratio 0·61, 95% CI 0·53-0·70; p<0·0001). INTERPRETATION: Introduction of a comprehensive smoke-free policy appeared to reduce the incidence of physical assaults. Adequately resourced smoke-free policies could be part of broader violence reduction strategies in psychiatric settings. FUNDING: National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South London (King's College Hospital NHS Foundation Trust).

Time to Smoke: Facilitating Smoking Breaks in Mental Health Inpatient Settings.

INTRODUCTION: Prevalence of smoking in mental health patients is up to three times higher than in the general population, with the highest rates seen in inpatient settings. In many countries, smoke-free policies in inpatient settings prohibit smoking in buildings but allow supervised smoking breaks. We aimed to estimate staff resources dedicated to such breaks. METHODS: A cross sectional survey was conducted with a convenience sample of inpatient mental health staff from four hospitals in London, England. Staff were asked about the number of designated supervised smoking breaks and their duration, per day, on their ward. We calculated the opportunity cost of the time allocated to supervising smoking. RESULTS: The survey was completed by 67 staff from 25 inpatient wards across four hospital sites. Eighteen wards had designated daily supervised smoking breaks; the average number of breaks per ward was 7.6 (SD 3.9), with an average of 2 hours, 23 minutes a day of clinical time dedicated to supervising smoking. We estimated the opportunity cost of supervising smoking was between £50 to £238 per ward per day or £18 250 to £86 870 per ward per year, depending on the seniority of staff supervising smoking breaks. CONCLUSIONS: Considerable time and resources is being used to facilitate smoking in mental health hospitals with smoke-free policies which allow smoking in hospital grounds. This resource could be redirected to provide evidence-based care that improves health and wellbeing, such as tobacco dependence treatment. IMPLICATIONS: This study is the first to estimate the time and opportunity costs of facilitating smoking across different wards in a mental health setting in the United Kingdom. Health care resources are scarce, including staff time. Every time staff facilitate smoking, clinical time is diverted away from therapeutic activities that contribute to improved patient health. Rather than suggesting any financial savings can be made through the introduction of smoke-free services, we present one metric of the value to mental health service providers of the hours of clinical time that could be released to provide therapeutic care.