Improving Emergency Medicine Clinician Awareness of Prehospital-Administered Medications.

Background/problem: Information transfer between emergency medical services (EMS) and emergency medicine (EM) is at high risk for omissions and errors. EM awareness of prehospital medication administration affects patient management and medication error. In April 2020, we surveyed emergency physicians and emergency department nurse practitioners (NPs) and physician assistants (PAs) regarding the EMS handoff process. Emergency physicians and NPs/PAs endorsed knowing what medications were given, or having received direct verbal handoff from EMS "Often" or "Always" only 20% of the time (n = 71), identifying a need to improve the written handoff process. To assess rates of medication error due to lack of awareness of prehospital administered medications, we measured glucocorticoid redosing in the emergency department (ED) following prehospital dexamethasone administration. In 2020, glucocorticoids were redosed 30% of the time, and our aim was to reduce glucocorticoid redosing to 10% by June 2022. Intervention: We developed and implemented a system innovation where prehospital-administered medications documented in a nursing flowsheet during verbal handoff are pulled directly into the triage note where they are more likely to be reviewed by receiving EM clinicians. Results: Shewhart p-charts were used to evaluate for statistical process change in the process measure of triage note documentation of prehospital medication administration and the outcome measure of glucocorticoid redosing. While the frequency of prehospital dexamethasone administration in the triage note increased, no statistical process change outcome measure of glucocorticoid redosing was observed. However, on repeat survey of EM clinicians in July 2022, 50% now indicated they were aware of prehospital medication administration "Often" or "Always" (n = 61, p = 0.003), 87% maintained they use the triage note as the main source of information regarding prehospital medication administration, and 81% "Always" review the triage note. Conclusions: Innovations that improve accessibility of written documentation of prehospital medication administration were associated with improved subjective assessment of EM clinician awareness of prehospital medications, but not the outcome measure of medication error. Effective error reduction likely requires better system integration between prehospital and EM records.

Hypomanic-like experiences and spontaneous emotional mental imagery.

BACKGROUND: Bipolar spectrum disorders (BPSD) are associated with frequent and emotional mental imagery, theorized to play a role in mood instability. However, we lack methods for measuring tendency to experience emotional mental imagery in daily life. The current study developed such a measure and evaluated the hypothesis that a high tendency to experience emotional imagery in daily life would be associated with higher levels of hypomanic-like experiences. METHODS: We conducted two rounds of studies to develop and refine a measure of spontaneous emotional imagery (E-SUIS) using factor analysis. We conducted a third study to test the relationship between E-SUIS score and hypomanic-like experiences. Participants (total N = 554, age 18-25) comprised an unselected community sample. RESULTS: First, factor analysis indicated a unidimensional factor structure and excellent reliability (α=0.87) of our novel measure of spontaneous emotional mental imagery. Second, higher scores on a hypomanic-like experiences scale related to higher use of both spontaneous emotional imagery and spontaneous non-emotional imagery. Spontaneous emotional mental imagery significantly improved the prediction of hypomanic-like experiences over non-emotional mental imagery. LIMITATIONS: Only two mental imagery measures were included. To determine discriminant validity of the E-SUIS requires additional imagery measures or interviews. CONCLUSIONS: Levels of hypomanic-like experiences were related to the tendency to use emotional imagery in daily life. Additionally, spontaneous use of emotional imagery appears to be a better predictor of hypomanic-like experiences in the general population compared to spontaneous use of non-emotional imagery.

The role of mental imagery in mood amplification: An investigation across subclinical features of bipolar disorders.

Vivid emotional mental imagery has been identified across a range of mental disorders. In bipolar spectrum disorders - psychopathologies characterized by mood swings that alternate between depression and mania, and include irritability and mixed affect states - mental imagery has been proposed to drive instability in both 'positive' and 'negative' mood. That is, mental imagery can act as an "emotional amplifier". The current experimental study tested this hypothesis and investigated imagery characteristics associated with mood amplification using a spectrum approach to psychopathology. Young adults (N = 42) with low, medium and high scores on a measure of subclinical features of bipolar disorder (BD), i.e., hypomanic-like experiences such as overly 'positive' mood, excitement and hyperactivity, completed a mental imagery generation training task using positive picture-word cues. Results indicate that (1) mood amplification levels were dependent on self-reported hypomanic-like experiences. In particular, (2) engaging in positive mental imagery led to mood amplification of both positive and negative mood in those participants higher in hypomanic-like experiences. Further, (3) in participants scoring high for hypomanic-like experiences, greater vividness of mental imagery during the experimental task was associated with greater amplification of positive mood. Thus, for individuals with high levels of hypomanic-like experiences, the generation of emotional mental imagery may play a causal role in their mood changes. This finding has implications for understanding mechanisms driving mood amplification in bipolar spectrum disorders, such as targeting imagery vividness in therapeutic interventions.