Substance use during hospitalisation requiring an urgent clinical response: an opportunity for intervention.

BACKGROUND: There are few reports on drug use in patients while hospitalised and none regarding management or clinical outcomes. AIMS: To describe cases of drug use by inpatients requiring an urgent clinical response. METHODS: We retrospectively reviewed cases at a teaching hospital in Sydney, Australia, from February 2019 to March 2021. RESULTS: Thirty cases were identified, with no deaths. Two patient groups were identified: (i) substance use disorders, using illicit drugs and (ii) self-harm history, using prescribed or over-the-counter drugs. Management involved cardiac monitoring (40%), intensive care (30%), charcoal (20%), antidotes (20%) and intubation (13%). Discharge was planned in 22 of 30 patients, against medical advice in four and directed by medical staff in four. CONCLUSIONS: Inpatient drug use requiring an urgent clinical response was infrequently recognised but presents a risk of harm to patients and staff and increases service utilisation and costs. Both harm reduction and systematic approaches guided by institutional policy are recommended. Using these events as reachable moments to address driving factors may modify patients' risk from future events.

Reluctance to Accept Alcohol Treatment by Alcoholic Liver Disease Transplant Patients: A Qualitative Study.

BACKGROUND: Liver transplantation (LT) is the optimum treatment for patients with end-stage alcoholic liver disease (ALD). However, despite a recognized risk of relapse to harmful drinking, ALD transplant patients are reluctant to use speciality alcohol treatment to support their abstinence, even when offered within the LT context. This study aimed to understand and identify factors contributing to alcohol treatment reluctance by ALD patients undergoing transplantation. METHODS: We conducted an in-depth qualitative study of ALD transplant patients. Minimally structured face-to-face interviews explored participants' alcohol-related experiences and their reasons for not using alcohol treatment during the course of their transplantation. Thematic analysis was used to analyze and interpret interview data to understand treatment reluctance based on participants' experiences. RESULTS: Five major themes were identified among 3 subgroups of patients (pretransplant and posttransplant abstainers and posttransplant relapsers): (i) the "contract" of mandatory abstinence, (ii) the "gap in the program" involving the lack of candour between patient and staff about alcohol-related matters and the lack of addiction services, (iii) a preference by participants to self-manage their alcohol use disorder, (iv) social support as a facilitator of abstinence and the risk of relapse when social support is diminished, and (v) the fear of stigmatization. Each of these factors were dynamically interrelated and differed slightly for each subgroup. CONCLUSIONS: The LT services may benefit from the inclusion of integrated specialist addiction services in their model of care. Such an approach may enhance the acceptability of alcohol treatment and reduce the risk of relapse among ALD transplant participants, especially for those whose social supports have diminished.

Assessing and managing suicidal patients in the emergency department.

OBJECTIVE: The objective of this article is to set out consensus guidelines for the assessment and management of "suicidal patients" in the emergency department. CONCLUSIONS: Clinicians should be respectful and reassuring. They should review old notes, conduct a full history and examination, and talk to friends, family and any practitioners already involved in the patient's care. Management should be guided, where possible, by the patient's preferences, not by notions of risk. Every negotiated management plan and its rationale should be carefully documented.

Involuntary admissions under the Mental Health Act 2007 (New South Wales): a comparison of patients detained by ambulance officers, medical practitioners and accredited persons in an emergency department.

OBJECTIVE: The Mental Health Act (MHA) 2007 (New South Wales [NSW]) is used to transport to, detain and treat individuals in a mental health facility. Patients are frequently taken to EDs under the MHA or detained in the ED for a mental health assessment. In NSW, medical practitioners, accredited persons, police and more recently ambulance officers, are authorised to write certificates under the MHA. There is an absence of research on the use of the MHA in NSW EDs. The primary research question for this study was: 'What is the involuntary admission rate for persons detained under the MHA in an NSW tertiary referral ED?' METHODS: After gaining ethics approval, the research team prospectively collected the MHA certificates written for patients in the ED over a 3 month period from February to May 2011. The research team reviewed the MHA certificate and medical records to characterise demographics, outcome, length of stay in ED and certificate suitability. Outcomes of interest were involuntary psychiatric admission or any inpatient admission, and were compared between the different professional groups completing the certificate. RESULTS: The involuntary admission rate for patients certified by ambulance officers under the NSW MHA was 27%, compared with a 60% involuntary admission rate when certified by medical practitioners or accredited persons. The mean average length of stay in the ED for patients certified under the MHA was 10 h. Seventy-five per cent of patients presented out of hours. CONCLUSION: Ambulance officer certification was a poor predictor of involuntary psychiatric admission in the Royal Prince Alfred Hospital Emergency Department. ED physicians should have the authority to revoke the certificate if, following assessment and treatment, the patient no longer fulfils criteria for detention under the MHA.

Aerostat-lofted instrument and sampling method for determination of emissions from open area sources.

An aerostat-borne instrument and sampling method was developed to characterize air samples from area sources, such as emissions from open burning. The 10 kg battery-powered instrument system, termed "the Flyer", is lofted with a helium-filled aerostat of 4m nominal diameter and maneuvered by means of one or two tethers. The Flyer can be configured variously for continuous CO2 monitoring, batch sampling of semi-volatile organic compounds (SVOCs), volatile organic compounds (VOCs), black carbon, metals, and PM by size. The samplers are controlled by a trigger circuit to avoid unnecessary dilution from background sampling when not within the source plume. The aerostat/Flyer method was demonstrated by sampling emissions from open burning (OB) and open detonation (OD) of military ordnance. A carbon balance approach was used to derive emission factors that showed excellent agreement with published values.

On call: a survey of Wisconsin obstetric groups.

OBJECTIVE: The purpose of this study was to identify patterns of obstetric call in order to identify areas of focus for future evaluation of "best practices." STUDY DESIGN: A telephone survey of obstetricians in Wisconsin was conducted, attempting to sample 1 physician from each group or call pool in every hospital in the state. RESULTS: Sixty-six physicians responded to this survey. The range in size of call pools was 1 to 11, with the median being 5. The duration of call is usually 24 hours. All have other nondelivery responsibilities while on call. In-house call is almost always limited to hospitals with residencies (6/8). Twenty-three percent of groups have formalized back-up systems, and 26% of groups have recovery provisions after call. CONCLUSION: There is no standard call system. Practicing obstetricians are commonly on call for longer hours and have less time off after call than is now mandated for obstetric residents, though work intensity may vary.

Predictors of relapse to harmful alcohol after orthotopic liver transplantation.

BACKGROUND: End-stage alcoholic liver disease (ALD) is a common indication for liver transplantation. Outcomes may be limited by return to harmful drinking. Previous studies have identified few predictors of drinking relapse. AIM: This study examined novel postulated predictors of relapse to drinking. METHOD: The case notes of all patients transplanted for ALD at the Royal Prince Alfred Hospital from 1987-2004 were reviewed. Pre-transplant characteristics were rated by a psychiatrist independent of the transplant team, blind to the outcome. Outcomes were rated by a second independent alcohol treatment specialist also blind to the pre-transplant ratings. RESULTS: Of 100 patients, 6 died before discharge from hospital, 4 had <6 months follow-up, 18 relapsed to harmful drinking, 10 drank below harmful levels, and 62 remained abstinent after a mean of 5.6 years follow-up. Univariate analyses identified six potential pre-transplant predictors of return to harmful drinking. These were a diagnosis of mental illness (of which all cases were of depression), the lack of a stable partner, grams per day consumed in the years before assessment for transplant, reliance on 'family or friends' for post-transplant support, tobacco consumption at time of assessment, and lack of insight into the alcohol aetiology. Duration of pre-transplant abstinence and social class by occupation did not predict relapse. A multivariate model based on the above characteristics correctly predicted 89% of the outcomes. CONCLUSION: A model based on readily defined behaviours and psychosocial factors predicted relapse to harmful drinking after transplant for ALD. This model may improve assessment and post-transplant management of patients with advanced ALD.

Quantitative and qualitative differences between handout and mailed patient satisfaction surveys.

BACKGROUND: Patient satisfaction surveys are widely used to measure patients' opinions of the quality of the health care they have received. There are a variety of methods for distributing patient satisfaction surveys. Different distribution methods may yield significantly different satisfaction ratings. OBJECTIVE: We sought to compare survey ratings obtained via 2 distribution methods: handout versus mailed. DESIGN: Patients were randomized to receive either a handout survey or a mailed survey. SUBJECTS: Patients who had an appointment with a family practice provider in one of the regional outpatient centers of a large medical clinic during a 3-week period. MEASURES: An 11-item visit-specific patient satisfaction survey was used to survey patient satisfaction. RESULTS: Handout surveys yielded higher satisfaction scores than mailed surveys. The response rate was higher with handout surveys than with mailed surveys. However, handout surveys were returned with more skipped questions, a lower variation in ratings, and fewer written comments than the mailed surveys. CONCLUSIONS: Both quantitative and qualitative differences between the 2 distribution methods were revealed. Attempts to compare data obtained from the 2 different distribution methods need to be approached with caution.