The rapid stabilization pathway: impact of a brief inpatient intervention on the length of stay and readmissions among psychiatrically hospitalized adolescents.

BACKGROUND: Suicide is the second leading cause of death among adolescents in the United States (Centers for Disease Control and Prevention [CDC], 2017, Death rates due to suicide and homicide among persons age 10-24: United States, 2000-2017) constituting a significant public health crisis. The demand for psychiatric emergency services and inpatient beds is increasing, while the number of beds available decreases or remains static (National Association of State Mental Health Program Directors, 2017, Trend in psychiatric inpatient capacity, United States and Each State, 1970-2014. www.nasmhpd.org/sites/default/files/TACPaper.2.Psychiatric-Inpatient-Capacity_508C.pdf) leading to delays in treatment and exacerbation of symptoms for some adolescents awaiting care. This pilot project describes the development, feasibility, and acceptability of a creative, values-based safety planning intervention for adolescents hospitalized on an acute inpatient psychiatric unit and the impact of this intervention on length of stay and readmissions to acute psychiatric care. METHODS: Thirty patients experiencing a suicidal crisis participated in the Rapid Stabilization Pathway (RSP) during their inpatient psychiatric admission. RESULTS: Results indicate that, compared to patients who underwent inpatient treatment as usual (TAU), RSP patients were discharged after a significantly shorter length of stay (4 vs. 6.1 weekdays respectively, p < .001). Further, there was no significant difference in readmission to the inpatient unit or to the psychiatric emergency room among RSP and TAU patients at 30, 60, and 90 days postdischarge. CONCLUSIONS: These findings have significant implications for acute inpatient programming. The RSP intervention treated patients in a shorter amount of time without any increase in re-admissions. Further, the shortened length of stay allowed for more patients to be treated on the inpatient unit and a significant cost savings. Future directions for programming and outcome research are discussed.

Innovative Strength-Based Care in Child and Adolescent Inpatient Psychiatry.

PROBLEM: Child and adolescent psychiatric units serve the highest risk, most vulnerable populations in the mental health delivery system. This article describes the integration of a strength-based approach with a traditional, medical model of psychiatric care on an acute inpatient unit. A strength-based framework allows for increased focus on exploring patients' goals, strengths, relationships, skills, and family communication within the hospital setting. METHODS: The process of integration of strength-based care is described, followed by discussion of the implementation and evaluation of interventions, including mindfulness, family movie, narrative, and animal-assisted therapies. FINDINGS: Innovative interventions led to improvement in patient symptoms, unit culture, and patient, family, and staff satisfaction. CONCLUSION: A strong emphasis on strength-based, multidisciplinary treatment has enhanced patient care, as the goals of acute inpatient admission are broadened to include more than diagnosis and medication management.

Enhanced task-oriented training in a person with dementia with Lewy bodies.

Despite the inevitable loss of function seen in people with progressive dementias, interventions for reversing or minimizing functional loss are understudied. Research supports task-oriented training, but practical gaps in how to best evaluate clients for this training and how to implement it in clinical settings may be thwarting translation to occupational therapy practice. We structured an intervention model called STOMP (Skill-building through Task-Oriented Motor Practice) using a unique blend of task-oriented training and motor-learning principles. In this article, we describe through a case study the process and outcome of using STOMP to improve functional skills in a woman with moderate dementia with Lewy bodies. Our findings suggest that STOMP has the potential to serve as a structure for the evaluation and treatment of occupational performance deficits in people with dementia and that this model warrants further investigation.

Qualitative analysis of medical student impressions of a narrative exercise in the third-year psychiatry clerkship.

PURPOSE: Clinical clerkship directors and faculty undertake the challenge of teaching patient-centered communication to students who face the enormous doctor-centered task of learning diagnostic medicine. The authors examined students' written reactions to the narrative exercise, which, drawing from narrative medicine and narrative therapy, challenges students to be more patient-centered by writing a patient's life story and sharing it with that patient. METHOD: During one-half of an academic year (2008-2009), the authors used qualitative methods to explore the range of medical student experiences with the narrative exercise in the psychiatry clerkship. RESULTS: During the study period, 46 medical students completed the exercise, and 44 (96%) submitted 367 comments for the research team to analyze. Four broad categories emerged: (1) communication, (2) insight, (3) hope, and (4) mixed or negative reactions. The most common theme was improved communication, which comprised the subcategories of enhanced active listening, opening up, and relationship building. Improved insights included student insights into their patients, as well as the facilitation of patient insights into themselves, especially regarding their own strengths and relationships. The exercise was well received by students: Only five comments were categorized as negative, and all of these related to difficulties selecting patients. CONCLUSIONS: Students reported many examples of improved patient-centered communication facilitated by the exercise. The narrative exercise may also promote a greater understanding of patients as complete human beings rather than diagnostic entities. The approach may be useful in educational settings beyond the psychiatry clerkship.

Relationship between nonlinear properties of sacral skin blood flow oscillations and vasodilatory function in people at risk for pressure ulcers.

The purposes of this study were to quantify the nonlinear properties of sacral skin blood flow oscillations (BFO) and to explore their relationships with impaired vasodilatory function in people at risk for pressure ulcers. A total of 25 people with various levels of vasodilatory functions were studied, 10 people with normal vasodilatory function (Biphasic thermal index, BTI (5.5, 4.5, 10.1)), 10 people with slight impaired vasodilatory function (BTI (3.7, 3.2, 6.7)), and 5 people with severe impaired vasodilation (BTI (2.4, 1.7, 4.5)). A non-painful fast heating protocol was applied to the sacral region to induce biphasic vasodilation, axon reflex mediated and nitric oxide mediated. Biphasic thermal index is defined as ratios of first peak, nadir, and second peak to baseline blood flow. Laser Doppler flowmetry was used to record the BFO signals. Nonlinear properties of BFO were quantified based on self-similarity using Hurst exponent (HE) and detrended fluctuation analysis (DFA), regularity using sample entropy (SampEn), complexity using correlation dimension (CD), and chaotic behavior using largest Lyapunov exponent (LLE). The Wilcoxon signed rank tests were used to examine the differences between groups. Our results showed that local heating reduces the self-similarity and increases complexity of skin blood flow oscillations. Vasodilatory function has an inverse relationship with nonlinear properties in sacral skin baseline BFO. Nonlinear indexes, including HE, DFA, CD, and LLE, are appropriate tools to quantify nonlinear properties of BFO to study the microvascular dysfunction (p<0.05), and that SampEn may not be appropriate for this purpose (p>0.05). Our study supports the use of nonlinear indexes to predict the vasodilatory function, which can complement current analysis of blood flow control mechanisms using spectral (wavelet) analysis.

Treatment settings for adolescent psychiatric conditions.

The intensive psychiatric treatment settings, including inpatient hospitalization, day programs and residential care, are valuable options for clinicians caring for adolescents with serious mental health problems. The availability of these setting may be limited by geographic, insurance, or financial restraints, but providers should stay informed about the treatment settings available in their area and be prepared to advocate for their adolescent patients' psychiatric needs. Although little evidence-based practice is available to guide clinicians taking care of adolescents in need of the most intensive psychiatric treatment settings, certain elements of care have proven most essential, including especially the successful engagement of families in treatment. Good outcomes for the most complicated adolescents follow from successful collaborations with families and the various providers that intersect in their multidisciplinary care.

Effects of Transcutaneous Electrical Nerve Stimulation (TENS) Electrode Placement on Spontaneous and Noxiously Evoked Dorsal Horn Cell Activity in the Cat.

The objectives of this study were to examine the effects of ipsilateral vs. contralateral as well as simultaneous placement of transcutaneous electrical nerve stimulation (TENS) electrodes in somatic receptive fields on spontaneous and noxiously evoked dorsal horn cell activity in anesthetized cats. Recordings were made from cells in the left gray matter of lumbosacral segments. In this study ipsilateral means left and contralateral means right. Results showed that mean cell activity decreased significantly (p < 0.001) when electrodes were placed in somatic receptive fields of either the contralateral (right) or ipsilateral (left) lower extremity. When comparing contralateral vs. ipsilateral effects, the most significant reduction (p < 0.004) in mean cell activity occurred with ipsilateral (left) placement of the electrodes. For bilateral application (simultaneous ipsilateral and contralateral) of TENS electrodes, 66% of the cells demonstrated a significant additive effect in reducing spontaneous and noxiously evoked cell activity. Clinically, the results might suggest that analgesia can result from bilateral placement of electrodes or by placement of electrodes in the contralateral dermatome (somatic field) when certain clinical conditions may prevent the placement of electrodes on the same side (ipsilateral) as the perceived pain.

Decreased activity of spontaneous and noxiously evoked dorsal horn cells during transcutaneous electrical nerve stimulation (TENS).

The purpose of this study was to examine the effects of TENS application to somatic receptive fields on spontaneous and noxiously evoked dorsal horn cell activity in alpha-chloralose-anesthetized cat. Carbon-filament microelectrodes were used to record extracellular action potentials from 83 spontaneously discharging cells. Using a commercial TENS unit (Medtronic Eclipse Model 7723), spontaneous cell activity was decreased in 54% (65%) of the cells. Twenty-five (30%) did not respond and 4 (5%) increased activity. It was also shown that for 36 cells which were evoked with either manual pinch (19 cells) or manual clamp (17 cells), cell activity decreased during TENS application. This study shows that dorsal horn neurons which can potentially transmit noxious information to supraspinal levels, can have their cell activity decreased during TENS application to somatic receptive fields. This is consistent with the concept of the 'gate control theory of pain' in that less noxious information would be involved in the pain perception process.

Viscerosomatic convergence onto feline spinal neurons from esophagus, heart and somatic fields: effects of inflammation.

One objective of this study was to examine a mechanism for the inability of patients to distinguish esophageal pain from cardiac pain. Patients with esophageal disease and angina pectoris often perceive pain as originating from the same somatic fields. Another objective was to compare the effect of esophageal distension between animals with a non-inflamed or with an inflamed esophagus. For this study in anesthetized cats, we recorded extracellular action potentials from T2-T7 spinal neurons that responded to intraluminal distension of an untreated or a turpentine-inflamed distal esophagus. Threshold distension volumes were compared between these 2 groups of animals. Neurons also were examined for effects of intracardiac bradykinin injection and somatic stimuli. Results showed that spinal neurons responded to a smaller threshold distension volume when cells in animals with an inflamed distal esophagus were compared to cells in animals with a non-inflamed distal esophagus. Spinal neurons that received input from the distal esophagus also received convergent input from the heart and somatic fields. Our data supported the hypotheses that (1) referred pain from the distal esophagus resulted from activation of the same spinal neurons by visceral and somatic input, (2) pain originating from the distal esophagus and heart might be difficult to distinguish because of viscerosomatic and viscerovisceral convergence onto the same spinal neurons, and (3) an inflamed distal esophagus might be more sensitive to distension than a non-inflamed esophagus.