Implementing an Alcohol Withdrawal Protocol: A Quality Improvement Project.

This quality improvement project evaluates the effectiveness of implementing an evidence-based alcohol withdrawal protocol in an acute care setting. Patient outcomes, length of stay, and nurses' knowledge and satisfaction with care are compared pre- and postimplementation. Implementation resulted in significant reduction of restraint use, transfers to critical care, 1:1 observation, and length of stay, whereas no reduction was seen in rapid response calls. Nurses' knowledge post-alcohol withdrawal protocol education increased and satisfaction with patient care improved.

Quality improvement and cost savings with multicomponent delirium interventions: replication of the Hospital Elder Life Program in a community hospital.

OBJECTIVE: Delirium is a common problem associated with increased morbidity, mortality, and healthcare costs in the hospitalized elderly, yet there is little research outside of academic medical centers exploring methods to prevent its onset. The authors adapted the Hospital Elder Life Program (HELP) for use in a community hospital and assessed its impact on delirium rate, length of stay (LOS) and healthcare costs in elderly patients. METHODS: Delirium episodes and duration, total patient-days with delirium and LOS were assessed in 595 patients 70 years of age or older admitted to a general medical floor at a community hospital. Pre-intervention outcomes were assessed on the medical floor for 4 months. Interventions adapted from HELP occurred over 9 months and included daily visits, therapeutic activities, and assistance with feeding, hydration, sleep, and vision/hearing impairment. Delirium was assessed on a daily basis with the Confusion Assessment Method (CAM). RESULTS: The rate of episodes of delirium decreased from 20% in the pre-intervention group to 12% in the intervention group, a relative 40% reduction (P = 0.019). Total patients days with delirium decreased from 8% in the usual care group to 6% in the intervention group (P = 0.005). LOS among all patients enrolled in the intervention group decreased by 2 days (P < 0.001). Interventions resulted in $841,000 cost savings over 9 months. CONCLUSIONS: HELP can be successfully adapted for implementation in a community hospital setting to decrease delirium episodes, total patient-days with delirium and LOS, and generate substantial cost savings.

Alcohol use and congestive heart failure: incidence, importance, and approaches to improved history taking.

Alcohol use, abuse, and dependence have the potential to result in alcoholic cardiomyopathy (ACM). This distinct form of congestive heart failure (CHF) is responsible for 21-36% of all cases of nonischemic dilated cardiomyopathy in Western society. Without complete abstinence, the 4-year mortality for ACM approaches 50%. Therefore, accurate and detailed assessment of alcohol use in congestive heart failure is essential. The prevalence of problematic alcohol use is unrecognized by many clinicians. Clinical assessment of alcohol intake is often reduced to a simple question such as, "Do you drink?" Denial and minimization are hallmarks of alcohol abuse, with many individuals underreporting their use of alcohol. Clinicians can overcome these hurdles by implementing practical history taking measures to improve the accuracy of self-reported alcohol use. The data regarding the dangers of ongoing alcohol use in individuals with ACM make attempts to engage individuals in treatment to support abstinence essential. Suggestions for detailed and accurate assessment are discussed.

Symptom perception in CHF: (why mind matters).

Symptoms utilized in the clinical care of heart failure as markers of disease severity include, dyspnea, insomnia, low energy, fatigue, poor appetite, and diminished memory. This is despite the fact that physiologic variables such as cardiac ejection fraction and oxygen consumption do not accurately predict functional state in individuals with congestive heart failure (CHF). Distress (anxiety and depression) may amplify symptom complaints without associated physiologic aberration. Personality traits and psychiatric illness, such as mood, anxiety, and psychotic illnesses may also alter perception of somatic symptoms that are associated with this chronic illness. The impact of distress and its treatment on functional performance and CHF symptom reporting deserve additional attention. The need to screen for distress in all with serious symptomatic heart failure is certain.

Treating persistent depressive symptoms in post-ACS patients: the project COPES phase-I randomized controlled trial.

Depression and sub-syndromal depressive symptoms are important predictors of morbidity and mortality after acute coronary syndrome (ACS). Prior trials of depression treatment in post-ACS patients have demonstrated no improvement for event-free survival, and only modest improvement in depression symptoms. These trials have raised a number of important issues regarding timing of depression intervention, acceptability of depression treatment to ACS patients, and safety for subsets of the treated population. This article describes Project COPES (Coronary Psychosocial Evaluation Studies), a multi-center Phase-I randomized clinical trial. Project COPES uses a patient preference depression treatment that has previously been found acceptable to medical patients, and a 3-month pre-randomization observation period to insure depression status. The study sample will include 200 post-ACS patients. The primary outcome is patient satisfaction with depression care. Secondary, exploratory aims include the acceptability of depression treatment, reduction in depressive symptoms, and the effects of treatment on two key pathways--medication adherence and inflammation--hypothesized to link depression to post-ACS prognosis. These analyses will provide important data to inform subsequent clinical trials with this population.

Psychological and social factors that correlate with dyspnea in heart failure.

Dyspnea is a common symptom of heart failure frequently relied upon to assess clinical functioning. The purpose of this study is to explore a broad range of medical, psychological, and social factors that correlate with dyspnea in heart failure patients. Seventy-six participants ranged from well-compensated, ambulatory subjects to those with recent hospitalization for acutely decompensated heart failure. The sample was predominantly male, mean age of 63.5 years, with mild depressive symptoms in 25%. Correlation analysis revealed that dyspnea significantly correlated with depression, fatigue, and overall health perception. Standard regression analyses indicated that depression, fatigue, and overall health perception uniquely contributed to dyspnea, explaining 38.0% of the total variance. The present study confirms that dyspnea is multifactorial, with links to psychological distress and overall health perception.

Complicated hypertension related to the abuse of ephedrine and caffeine alkaloids.

Ephedra containing products (ECPs), which most often contain additional sources of caffeine alkaloids, may be an under-recognized cause of hypertension. ECPs, especially when used in combination or at higher than recommended doses, can cause life-threatening cardiovascular and neurological complications. We present a case of hypertensive encephalopathy with new onset generalized tonic-clonic seizure secondary to concomitant use of two OTC supplements containing a mixture of ephedrine and caffeine alkaloids.

Psychiatric symptoms masking pituitary adenoma in Spanish speaking immigrants.

Barriers to clear communication, such as culture, language, and other aspects of self-presentation may have an important impact on the doctor-patient relationship. When not addressed, cultural and linguistic issues can result in unreliable clinical histories, noncompliance with medical treatment, misinterpretation of data, poor continuity of care, less preventive screening, miscommunication, and inadequate analgesia. Lack of access to competent interpreters and failure to take a full history may result in inaccurate assessment of presenting complaints leading to a delay in initiating necessary treatment. In addition, the presence of psychiatric symptoms can interfere with the medical diagnostic process, leading sometimes to premature closure of the differential diagnosis and attributing all presenting complaints to psychiatric illness. When both language barriers and psychotic symptoms present together, the risk of inaccurate diagnosis is multiplied. We report two Spanish-speaking patients with primary central nervous system tumors who had delayed diagnosis and treatment due to triage personnel focusing on presenting psychiatric complaints without attention to co-morbid medical symptoms. In each case, the patients initially presented to non-Spanish-speaking medical providers who did not have access to trained interpreter services. Physician attention to primary psychiatric symptoms led to referral for psychiatric care, delaying treatment for obvious neuro-endocrinologic problems.

Psychiatric assessment in transplantation

A implementaçäo da figura do doador presumido e as recentes mudanças na regulamentaçäo do transplante no Brasil iräo aumentar a disponibilidade de órgäos no país. O avanço no cuidado de doentes portadores de insuficiência grave de órgäos, por sua vez, irá aumentar a demanda por esses mesmos órgäos. Há considerável literatura apoiando o envolvimento de psiquiatras no processo de seleçäo dos candidatos ao transplante. Pesquisas mostram que fatores psicossociais influenciam na adesäo ao tratamento e, conseqüentemente, no prognóstico destes pacientes. A partir de uma revisäo da literatura existente, articula-se os componentes e lógicas de uma avaliaçäo psicossocial abrangente, propondo sua inserçäo na avaliaçäo pré-operatória dos pacientes para o recebimento de órgäo