Outcomes following suicidal crisis among hazardous and harmful alcohol users in the Crisis Resolution Team

Despite associations between alcohol use and suicidal acts, little research measures prognoses of alcohol-using patients treated by Crisis Resolution Teams (CRTs), an intensive community-based intervention. We estimated the association of alcohol use amongst patients accepted following suicidal acts or ideation in four London-based Crisis Resolution Teams, with death-by-any-cause or recontact with crisis care. We analysed the electronic health records of 1615 CRT patients accepted following suicidal acts or ideation over 38 months, following STROBE guidelines. Using logistic regression we estimated the association of alcohol use (indicated by risk-assessment, AUDIT, or ICD-10 diagnosis) with death-or-recontact at (i) 30-days and (ii) 1-year after treatment start, adjusted for age, sex, ethnicity, psychiatric diagnosis, and severity of need. Hazardous, harmful, or dependent drinking was identified in 270 cases at baseline (16.7%); 73 (4.5%) were alcohol dependent. By 1-year, 622 patients (38.5%) had recontacted crisis care or died. After adjustment, alcohol use at a hazardous, harmful, or dependent level was not associated with increased odds of death-or-recontact at 30-days (AOR 1.17, 95%CI 0.73, 1.88) or 1-year (AOR 1.17, 95%CI 0.85, 1.60). Patients with hazardous, harmful, and dependent alcohol use are a small proportion of CRT patients, despite being more commonly encountered in emergency settings from which patients may be referred to CRTs, indicating a potential gap in provision. Those who are included in CRTs are not at increased risk of death-or-recontact within 1 year of treatment, suggesting that their inclusion can work, at least in a sample with predominantly hazardous or harmful alcohol use.     

Creating an environment to implement and sustain evidence based practice: A developmental process

Background

Elements of evidence based practice (EBP) are well described in the literature and achievement of EBP is frequently being cited as an organisational goal. Despite this, the practical processes and resources for achieving EBP are often not readily apparent, available or successful.

Purpose

To describe a multi-dimensional EBP program designed to incorporate evidence into practice to lead to sustainable improvement in patient care and ultimately patient outcome.

Implementation strategies

A multi-dimensional EBP program incorporating EBP champions and mentors, provision of resources, creation of a culture to foster EBP and use of practical EBP strategies was implemented in a 22-bed intensive care unit (ICU) in a public, tertiary hospital in Brisbane, Australia. The practical EBP strategies included workgroups, journal club and nursing rounds.

Achievements

The multi-dimensional EBP program has been successfully implemented over the past three years. EBP champions and mentors are now active and two EBP workgroups have investigated specific aspects of practice, with one of these resulting in development of an associated research project. Journal club is a routine component of the education days that all ICU nurses attend. Nursing rounds is now conducted twice a week, with between one and seven short-term issues identified for each patient reviewed in the first 12 months.

Conclusions

A multi-dimensional program of practice change has been implemented in one setting and is providing a forum for discussion of practice-related issues and improvements. Adaptation of these strategies to multiple different health care settings is possible, with the potential for sustained practice change and improvement.     

The Triad of Impairment in Autism Revisited

TOPIC:  The triad of impairment referred to at present in the autism-related literature is a behavioral triad. This paper extends this thinking of the triad of impairment to the triad that underlies the behavioral manifestation. The real triad of impairment.
PURPOSE:  This paper considers the thinking and information processing style of autism and takes the next transitional step in understanding the triad of impairment.
SOURCES USED:  Contemporary literature on autism and information processing.
CONCLUSIONS:  Exceptional pioneering work in the late 1970s gave rise to the concept of the triad of impairments as the central plank of the construct of autism: impaired communication; impaired social skills; and a restricted and repetitive way of being-in-the-world. This clear articulation of the structures of the phenomena allowed a new way for professionals and families to see and understand autism, and to relate to those with autism. Like the evolution of many concepts, this was a transitional idea. The original triad of impairments described the behavioral manifestation; the actual triad of impairments is at the level of cognitive processing. The actual triad of impairment is static and ubiquitous unlike the variable and fluctuating behavioral manifestation. The actual triad of impairment in autism is visual as opposed to linguistic processing, impaired abstraction, and lack of theory of mind. The actual triad is central to all diagnosis that together makes up the autism spectrum.     

Improving patient privacy and confidentiality in one regional Emergency Department – A quality project

Background

Patient privacy and confidentiality (PPaC) is an important consideration for nurses and other members of the health care team. Can a patient expect to have confidentiality and in particular privacy in the current climate of emergency health care? Do staff who work in the Emergency Department (ED) see confidentiality as an important factor when providing emergency care? These questions are important to consider.

Methods

This is a two phased quality improvement project, developed and implemented over a six month period in a busy regional, tertiary referral ED.

Results

Issues identified for this department included department design and layout, overcrowding due to patient flow and access block, staff practices and department policies which were also impacted upon by culture of the team, and use of space.

Conclusions

Changes successful in improving this issue include increased staff awareness about PPaC, intercom paging prior to nursing handover to remove visitors during handover, one visitor per patient policy, designated places for handover, allocated bed space for patient reviews/assessment and a strategy to temporarily move the patient if procedures would have been undertaken in shared bed space. These are important issues when considering policy, practice and department design in the ED.     

Reshaping curricula: Culture and mental health in undergraduate health degrees

Australia is a country rich in cultural diversity, with Indigenous Australians having specific cultural values and a variety of spoken languages. In addition, the increasing number of people from migrant and refugee backgrounds requires that health professionals be able to communicate effectively with people from a wide range of cultural backgrounds. This is particularly relevant when undertaking a mental health assessment, because members of diverse communities often face the dual vulnerability of marginalization and stigmatization. This paper reports on the development and evaluation of a virtual teaching and learning resource that prepares health students to be culturally competent in mental health assessment. Four online interprofessional learning journeys were developed. Evaluation of the learning resources was conducted across three participating Australian universities. Quantitative evaluation involved pre‐ and post‐testing using an empathy scale, the Mental Health Nursing Clinical Confidence Scale, and the Cultural Competence Questionnaire informed by the theory of planned behaviour. Qualitative data from focus group interviews explored participants’ experiences of using the guided learning journey. Participants reported changes from pretest to post‐test in their empathy and attitudes towards culturally and linguistically diverse consumers with significant positive changes in cultural competence, empathy, and attitudes. There was strong satisfaction with the learning materials, indicating that participants valued this ‘real world’ learning experience. Results require cautious interpretation, given recruitment difficulties in the evaluation phase. However, these learning journeys appear to have potential to be an effective way to challenge attitudes and perceptions, as well as increase cultural competence towards culturally and linguistically diverse consumers.     

The sensitivity of 38 heart rate variability measures to the addition of artifact in human and artificial 24‐hr cardiac recordings

Background

Artifact is common in cardiac RR interval data derived from 24‐hr recordings and has a significant impact on heart rate variability (HRV) measures. However, the relative impact of progressively added artifact on a large group of commonly used HRV measures has not been assessed. This study compared the relative sensitivity of 38 commonly used HRV measures to artifact to determine which measures show the most change with increasing increments of artifact. A secondary aim was to ascertain whether short‐term and long‐term HRV measures, as groups, share similarities in their sensitivity to artifact.

Methods

Up to 10% of artifact was added to 20 artificial RR (ARR) files and 20 human cardiac recordings, which had been assessed for artifact by a cardiac technician. The added artifact simulated deletion of RR intervals and insertion of individual short RR intervals. Thirty‐eight HRV measures were calculated for each file. Regression analysis was used to rank the HRV measures according to their sensitivity to artifact as determined by the magnitude of slope.

Results

RMSSD, SDANN, SDNN, RR triangular index and TINN, normalized power and relative power linear measures, and most nonlinear methods examined are most robust to artifact.

Conclusion

Short‐term time domain HRV measures are more sensitive to added artifact than long‐term measures. Absolute power frequency domain measures across all frequency bands are more sensitive than normalized and relative frequency domain measures. Most nonlinear HRV measures assessed were relatively robust to added artifact, with Poincare plot SD1 being most sensitive.