Experiences of nursing home staff using the targeted interdisciplinary model for evaluation and treatment of neuropsychiatric symptoms (TIME) – a qualitative study

Background/Aims: Neuropsychiatric symptoms (NPS) in dementia pose great challenges for residents and staff in nursing homes. The Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) has recently in a randomized controlled trial demonstrated reductions in NPS. We explored the participating staff's experiences with the model and how it meets the challenges when dealing with the complexity of NPS.

Methods: Three to six months after the end of the intervention, we interviewed 32 of the caregivers, leaders, and physicians participating in the trial, in five focus groups. We used thematic content analysis.

Results: The analysis yielded two main themes: (1) a systematic reflection method enhanced learning at work; (2) the structure of the approach helped staff to cope with NPS in residents with dementia.

Conclusion: TIME shifts the way of learning for the staff from a traditional to a more innovative and reflection-based learning through a process of learning how to learn at work. The staff's experienced increased coping in their approach to complex problems. Our results emphasise the importance of a structured and biopsychosocial approach to NPS in clinical practice. Future research should explore models for integrating situated learning in daily routines in nursing homes.     

Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics

Background

Rapid treatment of agitation in the emergency department (ED) is critical to avoid injury to patients and providers. Treatment with intramuscular antipsychotics is often utilized, but there is a paucity of comparative effectiveness evidence available.

Symptomatic palliative care for children with neurodisability

Paediatric palliative care and neurodisability are two relatively new, evolving paediatric sub-specialities that have increasing relevance in the current paediatric landscape. For many people palliative care has been synonymous with end of life care, but in paediatrics it encompasses much more and is for all children with life-threatening or life-limiting conditions, from the point of diagnosis. This breadth of focus is demonstrated well through the interface between paediatric palliative care and paediatric neurodisability. In this article we explore this unique interface through the three domains of complex symptom management, advanced care planning and end of life care. We describe the practicalities involved in all three areas and highlight the importance of early referral and the process of “dual” or “parallel” planning. We cover in more depth the specific management of the symptoms: dystonia/abnormalities of muscle tone, seizures, pain, agitation, secretions, respiratory failure, and gut failure.     

The emergence of human Powassan virus infection in North America

Powassan virus (POWV) is a tickborne flavivirus discovered in Ontario, Canada in 1958 that causes long-term neurological sequelae in about half the reported cases and death in a little more than 10 % of cases. The incidence of POWV disease is rising in the United States but there is limited understanding of the scope and causes of recent changes in POWV epidemiology. We focus on quantifying the increase in human POWV disease incidence and infection prevalence in the United States. We also examine differences in the frequency of symptomatic cases and asymptomatic or mildly symptomatic cases, as well as limitations in national and state surveillance for POWV infection. We searched SCOPUS for all articles containing original POWV prevalence research, case studies, or literature reviews published in English. Case studies were supplemented by Morbidity and Mortality Weekly Report POWV data from the Centers for Disease Control and Prevention (CDC) and surveillance information from state health department websites. An increase in the number of POWV cases has been reported in the United States over the past 50 yr, and the geographic range of human POWV cases has expanded. The age distribution of symptomatic POWV cases has shifted, with significantly more individuals over 40 yr old being diagnosed after 1998. The emergence of POWV is due in large part to: (i) a change in transmission of POWV from a vector that rarely bites people (Ixodes cookei) to a new vector that often bites people (Ixodes scapularis) and has expanded its geographic range, (ii) enhanced surveillance efforts for arboviruses, and (iii) a greater awareness of POWV infection.     

家长陪同对口腔门诊患儿七氟烷全身麻醉苏醒期躁动的影响研究

 目的　研究家长陪同对口腔门诊患儿七氟烷全身麻醉苏醒期躁动的影响。方法　选取2017年6—12月于重庆医科大学附属口腔医院行七氟烷全身麻醉口腔治疗患儿120例，随机分为陪同组和未陪同组，每组60例。陪同组患儿在治疗前麻醉诱导期及治疗后苏醒期均有家长陪同，未陪同组患儿在麻醉诱导期及苏醒期均无家长陪同。采用小儿麻醉苏醒期躁动量化评分表（pediatric anesthesia emergence delirium scale，PAED）对患儿麻醉苏醒期躁动情况进行评分，并计算躁动发生率。结果　陪同组PAED评分为（9.18 ± 3.41）分，未陪同组PAED评分为（10.57 ± 3.62）分，两组PAED评分比较，差异有统计学意义（t = 2.04，P = 0.03）。陪同组躁动发生率（26.67%）明显低于非陪同组（50.00%），差异有统计学意义（χ2 = 6.91，P = 0.01）。结论　治疗前麻醉诱导期及治疗后苏醒期有家长陪同，可减少患儿躁动的发生，提高家长对口腔治疗的满意度，促进良好的医患关系。     

三种不同时机下术前导尿配合手术室护理对全麻手术患者苏醒期躁动的影响

摘要 目的 观察三种不同时机下术前导尿配合手术室护理对全身麻醉（全麻）手术患者苏醒期躁动的影响。方法 选择2017年1月～2018年12月于我院行择期全麻手术的患者100例，根据术前导尿时机分为3组：A组（手术当日清晨在病房导尿，33例）、B组（麻醉前在手术室导尿，30例）、C组（麻醉平稳后在手术室导尿，37例）。记录并比较3组麻醉时间、术中输液量、术中出血量、苏醒时间及导尿前后收缩压（SBP）、舒张压（DBP）及心率（HR）变化，比较3组一次性导尿成功率、术后导尿管适应度及苏醒期躁动发生情况，采用自拟问卷调查患者护理满意度。结果 3组麻醉时间、术中输液量、术中出血量及苏醒时间比较，差异无统计学意义（P>0.05）；A组导尿后SBP、DBP、HR较导尿前均显著升高（P<0.05），B组和C组SBP、DBP、HR与导尿前比较，差异无统计学意义（P>0.05）；A组一次性导尿成功率显著低于B组和C组，术后导尿管适应度显著差于B组和C组（P<0.05）；A组苏醒期躁动发生率显著高于C组，苏醒期躁动分级显著高于C组P<0.05）；A组护理满意度评分显著低于B组和C组，差异有统计学意义（P<0.05）。结论 在麻醉前后于手术室进行导尿的效果明显优于手术当日清晨在病房导尿，配合手术室护理干预可有效提高患者术后对导尿管的适应度，降低苏醒期躁动发生率，提高患者护理满意度。     

Cost-Effectiveness of Midazolam Versus Haloperidol Versus Olanzapine for the Management of Acute Agitation in the Accident and Emergency Department

ObjectivesA multicenter randomized clinical trial in Hong Kong Accident and Emergency (A&E) departments concluded that intramuscular (IM) olanzapine is noninferior to haloperidol and midazolam, in terms of efficacy and safety, for the management of acutely agitated patients in A&E setting. Determining their comparative cost-effectiveness will further provide an economic perspective to inform the choice of sedative in this setting.MethodsThis analysis used data from a randomized clinical trial conducted in Hong Kong A&E departments between December 2014 and September 2019. A within-trial cost-effectiveness analysis comparing the 3 sedatives was conducted, from the A&E perspective and a within-trial time horizon, using a decision-analytic model. Sensitivity analyses were also undertaken.ResultsIn the base-case analysis, median total management costs associated with IM midazolam, haloperidol, and olanzapine were Hong Kong dollar (HKD) 1958.9 (US dollar [USD] 251.1), HKD 2504.5 (USD 321.1), and HKD 2467.6 (USD 316.4), respectively. Agitation management labor cost was the main cost driver, whereas drug costs contributed the least. Midazolam dominated over haloperidol and olanzapine. Probabilistic sensitivity analyses supported that midazolam remains dominant > 95% of the time and revealed no clear difference in the cost-effectiveness of IM olanzapine versus haloperidol (incremental cost-effectiveness ratio 667.16; 95% confidence interval ?770.89, 685.90).ConclusionsIM midazolam is the dominant cost-effective treatment for the management of acute agitation in the A&E setting. IM olanzapine could be considered as an alternative to IM haloperidol given that there is no clear difference in cost-effectiveness, and their adverse effect profile should be considered when choosing between them.     

地佐辛降低手术患者全麻苏醒期躁动的临床效果

目的 探讨地佐辛对全麻苏醒期躁动的影响。方法 选取全麻手术患者140例,根据病历单双号随机分为观察组(73例)和对照组(67例)。观察组患者在手术结束前30 min给予5 mg地佐辛静脉注射;对照组给予5 mL 0.9% NaCl溶液静脉滴注。对两组患者拔管前5 min、拔管时及拔管后5 min进行躁动评分和镇静评分;于拔管后10 min对两组患者舒适度进行评价;记录两组患者拔管时间、睁眼时间以及呼吸恢复时间。结果 拔管前5 min、拔管时以及拔管后5 min观察组患者躁动评分分别为(1.11±0.13)分、(1.13±0.11)分和(0.44±0.05)分,均明显低于对照组,差异有统计学意义(P < 0.05);观察组患者镇静评分分别为(1.82±0.14)分、(2.18±0.30)分及(2.63±0.21)分,均明显高于对照组,差异有统计学意义(P < 0.05)。拔管后10 min观察组患者Bcs舒适度得分为(2.73±0.21)分,明显高于对照组,两组比较差异有统计学意义(P < 0.05)。观察组患者拔管时间、睁眼时间以及呼吸恢复时间与对照组比较,差异无统计学意义(P > 0.05)。结论 术前给予地佐辛静脉注射可以有效降低手术患者全麻苏醒期躁动,提高患者舒适度,并且不会抑制患者的呼吸,临床应用安全。