Effects of Ending the Use of Seclusion and Mechanical Restraint in the Pennsylvania State Hospital System, 2011-2020.

The Pennsylvania State Hospital System's use of containment procedures has been studied for >30 years. This prospective study assessed the effects of ending the use of seclusion and mechanical restraint in the system's six civil hospitals and two forensic centers from 2011 to 2020. The study examined the effect of this change on key safety measures: physical restraint, assaults, aggression, and self-injurious behavior. In total, 68,153 incidents, including 9,518 episodes of physical restraint involving 1,811 individuals, were entered into a database along with patients' demographic and diagnostic information. All data were calculated per 1,000 days to control for census changes. During the study, mechanical restraint was used 128 times and seclusion four times. Physical restraint use decreased from a high of 2.62 uses per 1,000 days in 2013 to 2.02 in 2020. The average length of time a person was held in physical restraint was reduced by 64%, from 6.6 minutes in 2011 to 2.4 minutes in 2020 (p<0.001). All safety measures improved or were unchanged. Use of unscheduled medication did not change. The hospital system safely ended the use of mechanical restraint and seclusion by using a recovery approach and by following the six core strategies for seclusion and restraint reduction.

Alternatives to opioids for acute pain management after dental procedures: A Department of Veterans Affairs consensus paper.

BACKGROUND: Opioid misuse is a widespread public health problem, and opioids are often prescribed in the dental environment. These recommendations provide alternatives to opioids to reduce or eliminate dental procedure-related acute pain. METHODS: A multidisciplinary working group developed these clinical recommendations to specifically address procedure-related acute pain. These recommendations, which are based on published peer-reviewed research and guidelines, include therapies used before, during, and after dental procedures. When evidence is not definitive, the best practices, which are based on experts' consensus, are included. The recommendations are not intended to be exhaustive. RESULTS: These recommendations are a summary of the evidence and best practices for opioid alternatives to treat acute pain related to dental procedures. CONCLUSIONS: Dental providers should prioritize opioid stewardship when managing procedure-related pain with strategies such as thorough preprocedure pain assessment, minimally invasive techniques, preemptive analgesia, intraprocedure pain management, and appropriately selected postprocedure pharmacologic therapy. PRACTICAL IMPLICATIONS: These recommendations are a concise resource for clinical providers. It is important to address patients' procedure-related pain, using nonopioids whenever possible. Alternatives are outlined, allowing providers to make informed decisions.

Department of Veterans Affairs Consensus: Preradiation dental treatment guidelines for patients with head and neck cancer.

Few protocols have been published for the dental management of patients with head and neck cancer to prevent complications from head and neck radiation therapy. Radiation therapy not only affects the tumor cells targeted, but also the dentition, bone, salivary gland, and oral soft tissue structures. A comprehensive dental evaluation prior to head and neck radiation therapy can help prevent many complications. The following clinical guidelines were established by a workgroup of oral health providers within the Department of Veterans Affairs. This workgroup focused on developing a set of recommendations regarding dental care prior to the initiation of head and neck radiation therapy based on the best clinical evidence and expert consensus. A systematic algorithm was developed for the evaluation including pre-exam data gathering, examination, education, and treatment, followed by maintenance and postradiation dental follow-up. This document is evidence-based, patient-centered, consistent with accepted practices of care and safety, and in accordance with applicable statutes and regulations.

Tailoring spin mixtures by ion-enhanced Maxwell magnetic coupling in color-tunable organic electroluminescent devices.

In this work, we show that the spin dynamics of excitons can be dramatically altered by Maxwell magnetic field coupling, together with an ion-enhanced, low-internal-splitting-energy organic semiconducting emitter. By employing a unique, alternating current (AC)-driven organic electroluminescent (OEL) device architecture that optimizes this magnetic field coupling, almost complete control over the singlet-to-triplet ratio (from fluorescent to phosphorescent emission in a single device) is realized. We attribute this spin population control to magnetically sensitive polaron-spin pair intersystem crossings (ISCs) that can be directly manipulated through external driving conditions. As an illustration of the utility of this approach to spin-tailoring, we demonstrate a simple hybrid (double-layer) fluorescence-phosphorescence (F-P) device using a polyfluorene-based emitter with a strong external Zeeman effect and ion-induced long carrier diffusion. Remarkable control over de-excitation pathways is achieved by controlling the device-driving frequency, resulting in complete emission blue-red color tunability. Picosecond photoluminescence (PL) spectroscopy directly confirms that this color control derives from the magnetic manipulation of the singlet-to-triplet ratios. These results may pave the way to far more exotic organic devices with magnetic-field-coupled organic systems that are poised to usher in an era of dynamic spintronics at room temperature.

Achieving High Performance in AC-Field Driven Organic Light Sources.

Charge balance in organic light emitting structures is essential to simultaneously achieving high brightness and high efficiency. In DC-driven organic light emitting devices (OLEDs), this is relatively straight forward. However, in the newly emerging, capacitive, field-activated AC-driven organic devices, charge balance can be a challenge. In this work we introduce the concept of gating the compensation charge in AC-driven organic devices and demonstrate that this can result in exceptional increases in device performance. To do this we replace the insulator layer in a typical field-activated organic light emitting device with a nanostructured, wide band gap semiconductor layer. This layer acts as a gate between the emitter layer and the voltage contact. Time resolved device characterization shows that, at high-frequencies (over 40 kHz), the semiconductor layer allows for charge accumulation in the forward bias, light generating part of the AC cycle and charge compensation in the negative, quiescent part of the AC cycle. Such gated AC organic devices can achieve a non-output coupled luminance of 25,900 cd/m(2) with power efficiencies that exceed both the insulator-based AC devices and OLEDs using the same emitters. This work clearly demonstrates that by realizing balanced management of charge, AC-driven organic light emitting devices may well be able to rival today's OLEDs in performance.

Evaluation of Soil Manipulation to Prepare Engineered Earthen Waste Covers for Revegetation.

Seven ripping treatments designed to improve soil physical conditions for revegetation were compared on a test pad simulating an earthen cover for a waste disposal cell. The field test was part of study of methods to convert compacted-soil waste covers into evapotranspiration covers. The test pad consisted of a compacted layer of fine-textured soil simulating a barrier protection layer overlain by a gravelly sand bedding layer and a cobble armor layer. Treatments included combinations of soil-ripping implements (conventional shank [CS], wing-tipped shank [WTS], and parabolic oscillating shank with wings [POS]), ripping depths, and number of passes. Dimensions, dry density, moisture content, and particle size distribution of disturbance zones were determined in two trenches excavated across rip rows. The goal was to create a root-zone dry density between 1.2 and 1.6 Mg m and a seedbed soil texture ranging from clay loam to sandy loam with low rock content. All treatments created V-shaped disturbance zones as measured on trench faces. Disturbance zone size was most influenced by ripping depth. Winged implements created larger disturbance zones. All treatments lifted fines into the bedding layer, moved gravel and cobble down into the fine-textured protection layer, and thereby disrupted the capillary barrier at the interface. Changes in dry density within disturbance zones were comparable for the CS and WTS treatments but were highly variable among POS treatments. Water content increased in the bedding layer and decreased in the protection layer after ripping. The POS at 1.2-m depth and two passes created the largest zone with a low dry density (1.24 Mg m) and the most favorable seedbed soil texture (gravely silt loam). However, ripping also created large soil aggregates and voids in the protection layer that may produce preferential flow paths and reduce water storage capacity.

MetaRNA-Seq: An Interactive Tool to Browse and Annotate Metadata from RNA-Seq Studies.

The number of RNA-Seq studies has grown in recent years. The design of RNA-Seq studies varies from very simple (e.g., two-condition case-control) to very complicated (e.g., time series involving multiple samples at each time point with separate drug treatments). Most of these publically available RNA-Seq studies are deposited in NCBI databases, but their metadata are scattered throughout four different databases: Sequence Read Archive (SRA), Biosample, Bioprojects, and Gene Expression Omnibus (GEO). Although the NCBI web interface is able to provide all of the metadata information, it often requires significant effort to retrieve study- or project-level information by traversing through multiple hyperlinks and going to another page. Moreover, project- and study-level metadata lack manual or automatic curation by categories, such as disease type, time series, case-control, or replicate type, which are vital to comprehending any RNA-Seq study. Here we describe "MetaRNA-Seq," a new tool for interactively browsing, searching, and annotating RNA-Seq metadata with the capability of semiautomatic curation at the study level.

Relationship Between Seclusion and Restraint Reduction and Assaults in Pennsylvania's Forensic Services Centers: 2001-2010.

OBJECTIVE: This prospective study assessed the use of seclusion and restraint in Pennsylvania forensic centers from 2001 through 2010. It also examined the correlation between declining use of containment procedures and patient-to-patient and patient-to-staff assaults. METHODS: The 2,741 episodes of restraint or seclusion involving 801 unique individuals served in state forensic centers during the study period were entered into a uniform database. Included in this data set were demographic and diagnostic data as well as the causes and injuries associated with each use of these procedures. These data were correlated with rates of patient-to-patient and patient-to-staff assaults with any injury for each month of this study. RESULTS: From 2001 to 2010, the rate of use of mechanical restraint significantly declined from 1.63 to .04 episodes per 1,000 days (p<.001), and the rate of use of seclusion significantly declined from .89 to .04 episodes per 1,000 days (p<.001). There was a nonsignificant decline in the use of physical restraint during this span. During this decade, the rate of patient-to-staff assaults declined, and the rate of patient-to-patient assaults was unaffected. CONCLUSIONS: Decreasing the use of containment procedures had a positive effect on reducing assaults. Leadership, data transparency, use of clinical alerts, workforce development, policy changes, and discontinuation of psychiatric use of PRN orders were all contributing factors. A philosophical change toward a recovery model of psychiatric care and services was the driving force behind this transformation.

Correlation between reduction of seclusion and restraint and assaults by patients in Pennsylvania's state hospitals.

OBJECTIVE: This prospective study assessed the use of seclusion and restraint in the Pennsylvania state hospital system from 2001 through 2010. It also examined the correlation between declining use of containment procedures and assaults by patients on other patients and staff. METHODS: The 12,900 anonymized records involving the 1,801 unique, civilly committed individuals who were physically or mechanically restrained and secluded in the nine civil hospitals during this study period were entered into a database. The data set included demographic and diagnostic information about the patients and the cause and effect of the procedures. These data were compared with rates of patient-to-patient and patient-to-staff assaults to determine any correlation between changes in use of containment and assaults. RESULTS: From 2001 to 2010, the use of mechanical restraint significantly declined from .37 to .08 episodes per 1,000 days (p<.018), and the use of seclusion significantly declined from .21 to .01 episodes per 1,000 days (p<.001). Persons with an axis I diagnosis of psychotic disorder accounted for 44% of containment procedures used during this study. Patient-to-patient assaults declined slightly, and patient-to-staff assaults were unaffected. CONCLUSIONS: Decreasing the use of containment procedures did not increase assaults. Better leadership, data transparency, use of clinical alerts, workforce development, policy changes, enhanced use of response teams, implementation of dialectical behavior therapy, and discontinuation of the psychiatric use of PRN orders contributed to the change in use of containment procedures. A philosophical change to a recovery model of psychiatric care and services was the driving force behind this transformation.

Frequency-dependent, alternating current-driven, field-induced polymer electroluminescent devices with high power efficiency.

A significant enhancement in power efficiency for alternating current-driven field-induced polymer electroluminescent devices is demonstrated by employing a high-k ferroelectric polymer dielectric through impedance matching of the device with the driving source. A peak power efficiency of 34.1 lm W(-1) at a frequency of 65 kHz is achieved, which is 2 to 12 times higher than the previous highest reports.

Dynamics of a wetting layer and Marangoni convection in microgravity.

Near the liquid-vapor critical point in pure fluids, material and thermal properties vary considerably with temperature. In a series of microgravity experiments, sulfur hexafluoride (SF6) was heated ∼1 K above its critical temperature, then quenched below the critical temperature in order to form gas and liquid domains. We found a power law exponent of 0.389 ± 0.010 for the growth of the wetting layer thickness during the intermediate stage of phase separation. Full and microscopic view images of the sample cell unit were analyzed to determine the changes in the size distribution of liquid droplets inside the gas phase over time. We found that the distribution of diameters for liquid droplets always contains a fraction of very small droplets, presumably due to a continuous nucleation process. At the same time, the size distribution flattens over time and rapidly includes large-size droplets, presumably generated through a coalescence mechanism. By following both a large gas bubble over two hours of video recordings, we found periodic and synchronous motion of the gas bubble along both the x and y directions. By following a large liquid droplet embedded into the large gas bubble, we found periodic, out of phase motions, which we related to Marangoni convection. The experimentally measured velocity of the liquid droplet is in good agreement with the theoretical predicted velocity of ∼0.386 µm/s obtained from Young's thermocapillary effect.

Psychiatric use of unscheduled medications in the Pennsylvania state hospital system: effects of discontinuing the use of P.R.N. orders.

The objective of this prospective study was to assess patient exposure to the psychiatric use of unscheduled medications at all nine Pennsylvania state hospitals and to unify practice guidelines in this regard. In August 2004, a decision was made to discontinue the use of p.r.n. orders for psychiatric indications. All unscheduled medications, (p.r.n. and STAT physician's order) administered for psychiatric indications were entered into a uniform database. A total of 46,913 unscheduled medications were administered to people served in the hospital system throughout this 15 month study. During March 2004, 87.7 unscheduled medications per 1,000 days-of-care were administered in the hospital system. During the last month of this study, May 2005, this rate had decreased to 17 per 1,000 days-of-care. Many hospital safety measures significantly improved as a result of this change. Cessation of p.r.n. medication use for psychiatric indications has significantly decreased patient exposure to unnecessary psychotropic medications and has resulted in a safer hospital system.

Expanding a professional dental care system: experiences of Task Force 261 Multifunctional Medical Battalion during Operation Iraqi Freedom 07-09.

During Operation Iraqi Freedom 07-09, Task Force 261 Multifunctional Medical Battalion managed an extensive dental care system stretching throughout the Iraq theater of operations. We illustrate several of the unique challenges faced by Task Force 261's headquarters and its dental and area support companies, and describe the remedies emplaced by the Task Force. Personnel structure, the evacuation chain, supply and facility management, dental civil-military operations, detainee care, information technology applications, and public health initiatives are discussed in detail.

Pennsylvania State Hospital system's seclusion and restraint reduction program.

OBJECTIVES: This study examined the use of seclusion and mechanical restraint from 1990 to 2000 and the rate of staff injuries from patient assaults from 1998 to 2000 in a state hospital system. METHODS: Records of patients older than 18 years who were civilly committed to one of the nine state hospitals in Pennsylvania were included in the analyses. Two databases were used in each of the nine hospitals: one identified date, time, duration, and justification for each episode of seclusion or restraint and the other identified when a patient was hospitalized and the demographic characteristics and the diagnosis of the patient. Rate and duration of seclusion and restraint were calculated. Reports from compensation claims were used to determine staff injuries from patient assaults. RESULTS: The rate and duration of seclusion and mechanical restraint decreased dramatically during this period. From 1990 to 2000, the rate of seclusion decreased from 4.2 to .3 episodes per 1,000 patient-days. The average duration of seclusion decreased from 10.8 to 1.3 hours. The rate of restraint decreased from 3.5 to 1.2 episodes per 1,000 patient-days. The average duration of restraint decreased from 11.9 to 1.9 hours. Patients from racial or ethnic minority groups had a higher rate and longer duration of seclusion than whites. Seclusion tended to be less likely, but longer, during the night shift. Patients were restrained less often during the night shift, but for a longer duration. The rate of restraint was higher during the week than during weekends and holidays. Younger patients were more likely to be secluded and restrained, but older patients remained secluded and restrained longer. No significant changes were seen in rates of staff injuries from 1998 to 2000. CONCLUSIONS: Many factors contributed to the success of this effort, including advocacy efforts, state policy change, improved patient-staff ratios, response teams, and second-generation antipsychotics.