Comparison of violence risk screening experiences of emergency department clinicians.

OBJECTIVE: Individuals commonly present to the emergency department (ED) for care after violence and many are also at risk for subsequent self or other-directed violence. Screening for violence risk represents an important part of ED care, but is challenging to implement effectively. Feedback from ED providers is needed to characterize differences across provider types in order to facilitate implementation of enhanced screening practices. METHODS: This qualitative focus group study examined the experiences of 6 psychiatric social workers, 16 emergency medicine physicians, and 15 psychiatric providers in conducting violence risk screening to elicit ideas about solutions and barriers. RESULTS: Eight themes emerged: Approach to Patient Assessment, High-Yield Clinical Data in Risk Assessment, Suicide Risk Screen, ED Clinician Resources, Analysis of Professional Risk, Affective Response of Clinician, ED Role and Scope, and Clinical Management. All clinician types discussed the themes from their professional perspectives and generated important knowledge of violence risk screening practices. CONCLUSIONS: The findings affirm the importance of interdisciplinary cooperation in addressing violence risk in the ED and emphasize the need for ongoing clinical education and feedback as well as the importance of optimizing efficiency.

Objective and Subjective Perspectives on Implementation of a Violence Risk Screening Program in an Emergency Department.

OBJECTIVE: The objective of this study was to use quantitative and qualitative data to gather information about emergency medicine and psychiatric provider perspectives regarding the evolution of a violence risk screening process including the simultaneous implementation of a universal suicide screening program. METHODS: A retrospective review of violence risk screening data for 496 patient encounters over a 2-year period and across 4 phases of implementation and improvement was completed. Four focus groups were conducted with emergency medicine and psychiatric providers using nondirective facilitation methods to gather data regarding provider perspectives about violence and suicide risk screening. The focus groups were recorded, transcribed, and analyzed for thematic content. RESULTS: Four of the 6 violence risk screening items were most strongly associated with high-risk stratification across all phases. There were no changes in proportions of positive responses for 3 of the items. The proportion of positive responses for the other items changed significantly after expert feedback and clarification of item wording. Only 3% of the focus group passages included discussion of the universal suicide screening program. CONCLUSIONS: The providers indicated that they believed the violence risk screening and suicide screening procedures helped improve clinical thoroughness and documentation. Ongoing feedback between providers and program developers was beneficial. The implementation of the universal suicide screening process was relatively seamless for these providers.

Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation).

Agitated patients presenting to the emergency department (ED) can escalate to aggressive and violent behaviors with the potential for injury to themselves, ED staff, and others. Agitation is a nonspecific symptom that may be caused by or result in a life-threatening condition. Project BETA (Best Practices in the Evaluation and Treatment of Agitation) is a compilation of the best evidence and consensus recommendations developed by emergency medicine and psychiatry experts in behavioral emergencies to improve our approach to the acutely agitated patient. These recommendations focus on verbal de-escalation as a first-line treatment for agitation; pharmacotherapy that treats the most likely etiology of the agitation; appropriate psychiatric evaluation and treatment of associated medical conditions; and minimization of physical restraint/seclusion. Implementation of Project BETA in the ED can improve our ability to manage a patient's agitation and reduce the number of physical assaults on ED staff. This article summarizes the BETA guidelines and recent supporting literature for managing the acutely agitated patient in the ED followed by a discussion of how a large county hospital integrated these recommendations into daily practice.

Suicide Risk Assessment and Management in the Psychiatry Emergency Service: Psychiatric Provider Experience and Perceptions.

The objective of this study was to explore suicide risk identification and flow of patients with differing suicide risk through the Psychiatric Emergency Service (PES) to their clinical dispositions. 3 focus groups (N = 15 psychiatric providers working in the PES of a large urban teaching hospital) discussing suicide risk assessment in the PES were conducted, followed by thematic analysis. A total of 7 themes were identified in 624 coded passages. In focus groups conducted to explore suicide risk assessment, discussions shifted to broader matters, e.g., frustrations with the system in which the providers worked. 4 main messages emerged: screening tools cannot replace clinical judgment; the existing electronic health record is not efficient and sufficiently informative; competing demands challenge PES psychiatrists; and post-discharge patient outcome data are needed. These concerns suggest directions for improving patient care.

Dysfunctional Closed Chest Drainage - Common Causative Factors and Recommendations for Prevention.

Introduction Dysfunctional closed chest drainage unit (CDU) dysfunction is a common but serious clinical problem associated with tube thoracostomy and results in a significant rise in morbidity, prolonged hospital stays, and increased economic burden. This observational study examines the proximate factors of closed CDU dysfunction in addition to their relative frequency. Based on our findings, we suggest logical recommendations for preventing the factors that contribute to closed chest drainage unit dysfunction. Method The study target population consists of all those individuals who had experienced tube thoracostomy for any pathology related to the chest cavity treated in the Department of Thoracic Surgery, Nishter Medical University, Multan, Pakistan, from February 2015 to January 2017. The study population was not restricted by age or gender. Of the 727 examined cases, only those patients who had experienced tube thoracostomy and had significant failure in draining the pleural collection were included in the study. Detailed histories were collected, and thorough physical examinations were carried out for each participant. Chest x-rays and, if needed, computed tomography (CT) scans were obtained to properly examine the placement of the chest tubes and detect the causative factor of the closed CDU dysfunction. Results A total of 139 cases were included in the study. The most common cause of closed CDU dysfunction was the use of the wrong CDU connection (n = 24, 17.3%). Other common problems included inadequate prime fluid use, loose connections, kinked tubes, and overly full bottles. Conclusion Closed CDU dysfunction may be prevented by adopting and following proper protocols for tube thoracostomy.

Evaluating psychiatric readmissions in the emergency department of a large public hospital.

INTRODUCTION: Hospital emergency departments (EDs) around the country are being challenged by an ever-increasing volume of patients seeking psychiatric services. This manuscript describes a study performed to identify internal and external factors contributing to repeated psychiatric patient admissions to the hospital main ED. METHODS: Data from ED visits of patients who were admitted to the Parkland Memorial Hospital ED (the community hospital for Dallas County, TX, USA) with a psychiatric complaint more than once within a 30-day period were evaluated (n=202). A 50-item readmission survey was used to collect information on demographic and clinical factors associated with 30-day readmission, as well as to identify quality improvement opportunities by assessing related moderating factors. An analysis of acute readmission visits (occurring within 3 days of previous discharge) was also performed. RESULTS: Patients readmitted to the ED commonly present with a combination of acute psychiatric symptoms, substance use (especially in the case of acute readmission), and violent or suicidal behavior. The vast majority of cases reviewed found that readmitted patients had difficulties coordinating care outside the ED. A number of moderating factors were identified and targeted for quality improvement including additional support for filling prescriptions, transportation, communication with family and outside providers, drug and alcohol treatment, intensive case management, and housing. CONCLUSION: Many of the resources necessary to reduce psychiatric patient visits to hospital EDs are available within the community. There is no formal method of integrating and insuring the continuity of community services that may reduce the demand for psychiatric and related services in the ED. While agreements between community service providers may be challenging and require considerable vigilance to maintain equitable agreements between parties, this route of improving efficiency may be the only available method, given the current and projected patient care needs.

Development and Implementation of a Universal Suicide Risk Screening Program in a Safety-Net Hospital System.

BACKGROUND: Many individuals who die by suicide present for nonbehavioral health care prior to death. The risk is often undetected. Universal suicide screening in health care may improve risk recognition. A quality improvement project involving a universal suicide screening program was designed and developed in a large safety-net health care system. METHODS: The steps in developing and implementing this quality improvement program were gathering intelligence, examining resources, designing the screening program, creating a clinical response, constructing an electronic health record screening protocol, clinical workforce education, and program implementation. This project used the Columbia-Suicide Severity Rating Scale, Clinical Practice Screener-Recent, and a preliminary clinical decision support system. RESULTS: Prevalence data on suicide risk levels are provided for 328,064 adult encounters from the first six months of the screening program. Approximately half of the screens were completed in the outpatient clinics, more than 40% in the emergency department (ED), and slightly less than 5% in the hospital inpatient units. In the ED, 6.3% of the screens were positive, as were 1.6% in the inpatient units, and 2.1% in the outpatient clinics. The odds of a positive suicide screening in the ED was 4.29 times higher than the inpatient units and 3.13 times higher than the outpatient clinics. CONCLUSION: A new quality improvement program for universal suicide screening was successfully implemented in a large safety-net health care system. The burden to the system from universal screening was not overwhelming and was managed effectively through thoughtful allocation of clinical resources.

Suicide Risk Assessment and Management: Real-World Experience and Perceptions of Emergency Medicine Physicians.

To examine gaps in effective self-directed violence risk assessments by emergency medicine physicians. Four focus groups (N = 16 physicians) were conducted, followed by thematic analysis. Eight themes were identified in 1,293 coded passages. Participants discussed the practical ways they deal with the challenges of assessing and managing self-directed violence in low-resource settings. Emergency medicine physicians find mechanistic suicide screenings problematic, especially when intervention options are scarce; they find patient rapport, clinical experience, and corroboration from colleagues to be valuable in addressing the complex challenges of suicide risk assessment and management.

Development and testing of procedures for violence screening and suicide risk stratification on a psychiatric emergency service.

OBJECTIVE: The objective was to examine the relationship between violence screening items, suicide risk stratification, and disposition in a psychiatric emergency service setting. METHODS: A retrospective review of electronic health record data for 286 patient encounters was performed. RESULTS: Four of the 6 violence risk screening items were significantly associated with both involuntary presentation to the psychiatric emergency service and high-risk stratification. These 4 items were also associated with psychiatric hospital disposition in bivariate analysis, however, only indirectly through their association with high-risk stratification, which in turn was directly associated with psychiatric hospital disposition. CONCLUSION: Violence screening items inform disposition but only through the use of risk stratification, supporting the need for additional research into the predictive value of standardized suicide risk stratification definitions to inform clinical practice.

The training of psychodynamic psychiatrists: the concept of "psychodynamic virtue".

Competence as a psychodynamic psychiatrist requires more than the acquisition of a body of theoretical knowledge and a set of technical skills. It calls for the acquisition of a set of virtues--attitudes of mind and heart--that are embedded in the character and person of the developing resident. The authors enumerate and explore these psychodynamic virtues. They discuss how residency training can best serve to develop these virtues in residents.

L-shell x-ray fluorescence measurements of lead in bone: accuracy and precision.

This study aimed to quantify the accuracy and precision of a method for in vivo measurements of lead in bone using L-shell x-ray fluorescence (LXRF), the former via comparison with independent measurements of lead in bone obtained using electrothermal atomic absorption spectrometry (AAS) following acid digestion. Using LXRF. the lead content of adult human cadaver tibiae was measured, both as intact legs and as dissected tibiae with overlying tissue removed, the latter at several proximal-distal locations. After LXRF, each tibia was divided into nine cross-sectional segments, which were further separated into tibia core and surface samples for AAS measurement. The proximal-distal variability of AAS-measured core and surface tibia lead concentrations has been described elsewhere (the lead concentration was found to decrease towards both ends of the tibia). The subjects of this paper are the proximal-distal variability of the LXRF-measured lead concentrations, the measurement uncertainty and the statistical agreement between LXRF and AAS. There was no clear proximal-distal variability in the LXRF-measured concentrations; the degree of variability in actual tibia lead concentrations is far less than the LXRF measurement uncertainty. Measurement uncertainty was dominated by counting statistics and exceeded the estimate of lead concentration in most cases. The agreement between LXRF and AAS was reasonably good for bare bone measurements but poor for intact leg measurements. The variability of the LXRF measurements was large enough, for both bare bone and intact leg measurements, to yield grave concerns about the analytical use of the technique in vivo.

Measurements of lead in human tibiae. A comparison between K-shell x-ray fluorescence and electrothermal atomic absorption spectrometry.

The aim of this study was to validate 109Cd-based K-shell x-ray fluorescence measurements against atomic absorption spectrometry (AAS) measurements of core and surface tibia lead. The lead content of nine adult human cadaver tibiae was measured using 109Cd-based K-shell x-ray fluorescence (XRF) spectrometry and the results compared to measurements obtained using electrothermal atomization atomic absorption spectrometry following acid digestion. Each tibia was divided into nine cross-sectional segments, which were further separated into tibia core and surface samples for the AAS analytical measurements. Proximal-distal variability in tibia lead concentration as determined by AAS was previously described for both surface and core segments and was found to decrease towards the ends of the tibia, in contrast to XRF in which lead was found to increase towards the tibia ends. The effect of this contrasting behaviour on the agreement between XRF and AAS measurements was examined. Lead concentrations determined by AAS ranged from 3 to 19 microg of lead per gram of dry weight bone (microg g(-1)) for tibia core and from 5 to 32 microg g(-1) for tibia surface. Lead concentrations determined by XRF ranged from 2 to 35 microg g(-1) dry weight. No statistically significant difference was found between mean XRF-measured concentrations and mean surface lead concentrations measured by AAS, but XRF significantly overestimated tibia core lead concentrations by between 5 and 8 microg g(-1).