Coming in: an examination of people with co-occurring substance use and serious mental illness exiting chronic homelessness.

Despite national efforts, the number of people who are chronically homeless in our cities remains high. People with serious mental illness and substance abuse problems continue to represent the majority of those experiencing long-term homelessness. Traditional shelters have difficulty engaging and addressing the needs of this group; however, there are an increasing number of alternative models, including the Safe Haven shelter program, developed to better meet their needs. In this article, the authors examine responses from 28 qualitative interviews conducted with 16 residents of a Safe Haven shelter serving chronically homeless people, at 3 and 9 months after entry. All had a severe mental illness and were actively substance abusing. The importance of a model that respects personhood, a place that feels like home, and challenges faced by residents as they "come in" are emphasized.

Utility of the PRE-DELIRIC delirium prediction model in a Scottish ICU cohort.

The PREdiction of DELIRium for Intensive Care (PRE-DELIRIC) model reliably predicts at 24 h the development of delirium during intensive care admission. However, the model does not take account of alcohol misuse, which has a high prevalence in Scottish intensive care patients. We used the PRE-DELIRIC model to calculate the risk of delirium for patients in our ICU from May to July 2013. These patients were screened for delirium on each day of their ICU stay using the Confusion Assessment Method for ICU (CAM-ICU). Outcomes were ascertained from the national ICU database. In the 39 patients screened daily, the risk of delirium given by the PRE-DELIRIC model was positively associated with prevalence of delirium, length of ICU stay and mortality. The PRE-DELIRIC model can therefore be usefully applied to a Scottish cohort with a high prevalence of substance misuse, allowing preventive measures to be targeted.

STOP: Can We Minimize OR Traffic?

Perioperative nurses at our institution voiced concerns about the amount of traffic in the ORs. We formed a workgroup consisting of perioperative nurses, educators, and leaders and initiated a quality improvement (QI) project to identify the amount of OR traffic that occurs during a procedure. The workgroup developed a check sheet to record door swings, staff classifications, reasons for opening the door, and the number of people in the OR at 15-minute intervals. Baseline results showed that average door swings ranged from 33 per hour in general surgery to 54 per hour in cardiac surgery. Nurses accounted for the most traffic, citing retrieving supplies as the main reason. Interventions focused on decreasing nurse traffic for retrieval of supplies in general surgery. Follow-up observations showed that average door swings increased to 41 per hour in general surgery, but nurse traffic decreased. Monitoring and limiting traffic could positively affect patient safety and outcomes.

ICU delirium: a survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit.

BACKGROUND: Delirium is an independent predictor of mortality and morbidity in the intensive care unit and is associated with a prolonged hospital and intensive care unit stay. National guidelines suggest that intensive care unit delirium is screened for daily using the confusion assessment method for the intensive care unit validated screening tool. Research suggests that there is a lack of knowledge on intensive care unit delirium, its screening tools and that it is inadequately screened for. AIMS: The aim of the study is to assess nursing and medical staff knowledge, understanding and management of intensive care unit delirium and assess the perceived barriers associated with intensive care unit delirium screening using a validated screening tool. RESEARCH DESIGN AND SETTING: A survey design was used and a questionnaire designed to collect the data. The sample consisted of 149 nursing and medical staff working in three district intensive care units within the United Kingdom. RESULTS: The data yielded reveals that 44% (n = 33) of the respondents were not educated on ICU delirium. Furthermore the confusion assessment method for the intensive care unit was only being used in one out of the three sites surveyed and this was found to be at best sporadic, this fails to adhere to current delirium guidelines (NICE, 2010). Those using a non structured way of detecting delirium observed for hallucinations and agitation. Common associated barriers quoted in the literature such as time restraints did not appear to be an issue in this study. CONCLUSION: This study has shown that despite national guidelines screening with a validated delirium screening tool is not being performed in two of the intensive care unit surveyed and one site employs the confusion assessment method for the intensive care however screening is sporadic. This study contributes to the evidence base suggesting that intensive care unit delirium is under recognised and screened for despite current guidelines.

Subfossil leaves reveal a new upland hardwood component of the pre-European Piedmont landscape,Lancaster County, Pennsylvania.

Widespread deforestation, agriculture, and construction of milldams by European settlers greatly influenced valley-bottom stream morphology and riparian vegetation in the northeastern USA. The former broad, tussock-sedge wetlands with small, anastomosing channels were converted into today's incised, meandering streams with unstable banks that support mostly weedy, invasive vegetation. Vast accumulations of fine-grained "legacy" sediments that blanket the regional valley-bottom Piedmont landscape now are being reworked from stream banks, significantly impairing the ecological health of downstream water bodies, most notably the Chesapeake Bay. However, potential restoration is impaired by lack of direct knowledge of the pre-settlement riparian and upslope floral ecosystems. We studied the subfossil leaf flora of Denlingers Mill, an obsolete (breached) milldam site in southeastern Pennsylvania that exhibits a modern secondary forest growing atop thin soils, above bedrock outcrops immediately adjacent to a modified, incised stream channel. Presumably, an overhanging old-growth forest also existed on this substrate until the early 1700s and was responsible for depositing exceptionally preserved, minimally transported subfossil leaves into hydric soil strata, which immediately underlie post-European settlement legacy sediments. We interpret the eleven identified species of the subfossil assemblage to primarily represent a previously unknown, upland Red Oak-American Beech mixed hardwood forest. Some elements also appear to belong to a valley-margin Red Maple-Black Ash swamp forest, consistent with preliminary data from a nearby site. Thus, our results add significantly to a more complete understanding of the pre-European settlement landscape, especially of the hardwood tree flora. Compared with the modern forest, it is apparent that both lowland and upslope forests in the region have been modified significantly by historical activities. Our study underscores that generally overlooked subfossil leaves can provide important, local, temporally constrained paleoecological data, with much potential value in this case for stream and wetland restoration decisions in the mid-Atlantic region.

The BMC ACCESS project: the development of a medically enhanced safe haven shelter.

This paper describes the development and implementation of the Boston Medical Center (BMC) Advanced Clinical Capacity for Engagement, Safety, and Services Project. In October 2002, the BMC Division of Psychiatry became the first such entity to open a Safe Haven shelter for people who are chronically homeless, struggling with severe mental illness, and actively substance abusing. The low-demand Safe Haven model targets the most difficult to reach population and serves as a "portal of entry" to the mental health and addiction service systems. In this paper, the process by which this blended funded, multi-level collaboration, consisting of a medical center, state, city, local, and community-based consumer organizations, was created and is maintained, as well as the clinical model of care is described. Lessons learned from creating the Safe Haven Shelter and the development and implementation of the consumer-informed evaluation are discussed as well as implications for future work with this population.