ABSTRACT
Individuals experiencing intimate partner violence (IPV) and/or human trafficking (HT) are at increased risk of severe health consequences as a result of legislation criminalizing and/or restricting abortion, which is expected to increase as a result of the Supreme Court decision Dobbs v. Jackson. These risks are further stratified by race, socioeconomics, and other marginalizing demographic attributes. IPV and HT introduce barriers to maintaining physical and mental health, due to control of access to transportation and funds by the abuser, fear of retribution for seeking healthcare, and other barriers. Individuals experiencing IPV or HT often lack reproductive autonomy, as a result of facing reproductive coercion at the hands of their abusers. Following the Dobbs decision, these vulnerable patient populations will face further limitations on their reproductive autonomy and increased obstacles to obtaining an abortion if they medically need or desire one. This will likely result in more patients presenting to the emergency department due to complications from unsafe or unsupervised self-managed abortions, as well as patients being reluctant to report having obtained an unlawful abortion due to fear of legal consequences. This is particularly relevant to individuals experiencing IPV and HT, as they may be more likely to use these methods for obtaining an abortion due to numerous barriers. Emergency medicine clinicians are vital in providing care to these patients, as they frequently present to emergency departments. A multi-pronged approach to better support these patients is essential, involving an increased index of suspicion for IPV, HT or the complications of unsupervised abortion, improved organizational structures, specialized training for staff, improved screening methods, reflection on implicit bias, and recommendations for mindful documentation and legal considerations.
Subject(s)
Abortion, Induced , Abortion, Spontaneous , Intimate Partner Violence , Pregnancy , Female , Humans , Emotions , Emergency Service, HospitalABSTRACT
Background: The effectiveness of PPE in preventing self-contamination of healthcare workers (HCWs) and transmission of pathogens (airborne and contact) in the emergency department (ED) is highly dependent on consistent, appropriate use of and other interactions (eg, storing, cleaning, etc) with the PPE. Pre–COVID-19 studies focused primarily on individual HCW contributions to incorrect or suboptimal PPE use. We conducted an analysis of ED video recordings using a human-factors engineering framework (ie, The Systems Engineering Initiative for Patient Safety, SEIPS), to identify work-system–level contributions to inappropriate PPE usage by HCWs while they provide care in their actual clinical care environment. Methods: In total, 47 video sessions (each ~15 minute) were recorded between June 2020 and May 2021 using a GoPro camera in an 8-bed pod area, designated for persons under investigation (PUI) and confirmed COVID-19–positive patients, in an ED of a large, tertiary-care, academic medical center. These recordings captured a ‘landscape view': 2 video cameras were set up to capture the entire ED pod area and HCWs as they provided care. A team with hemorrhagic fever expertise, infection prevention and control expertise, and ED expertise reviewed each video together and extracted data using a semistructured form. Results: Guided by the 5 components of the SEIPS work system model, (ie, task, physical environment, person, organization, tools and technology), multiple work system failure points influencing HCWs appropriate use of PPE were identified. For example, under the task component, HCWs were observed not doffing and donning in recommended sequence. Also, inconsistencies with COVID-19 status signage on a patient's door and ambiguous labelling of work areas designated as clean (donning) and dirty (doffing) sites acted as a barrier to appropriate PPE use under the physical environment section. Conclusions: Human factors–based analysis of video recordings of actual ED work identified a variety of work system factors that impede appropriate or correct use of PPE by HCWs. Future efforts to improve appropriate PPE use should focus on eliminating or mitigating the effects of these work system factors.Funding: US CDCDisclosures: The authors gratefully acknowledge the CDC for funding this work. This material is based upon work supported by the Naval Sea Systems Command (under contract No. N00024-13-D-6400, Task Order NH076). Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the Naval Sea Systems Command (NAVSEA) or the US CDC.
ABSTRACT
BACKGROUND: Despite the growing evidence indicating the efficacy of digital cognitive behavioral interventions (dCBIs) for behavioral health (BH) treatment, broad and consistent use of such interventions has been limited by knowledge obtained in real-world settings, including factors that impact provider uptake/referral. Engaging providers early in the implementation process offers an opportunity to explore their needs and behaviors, integrate interventions into workflows, and better understand provider setting capabilities. OBJECTIVE: This study assessed providers' views on the feasibility and acceptability of delivering a cognitive behavioral therapy (CBT)-based mobile app in multiple care settings. METHODS: Participating providers included BH and physical health (PH) providers from a women's health center, an outpatient BH clinic, and both rural/urban primary care settings. All participating providers cocreated workflows through facilitated workshops, including establishing feedback loops between the project team and providers and identifying clinical champions at each site. Over a 12-week period, the providers referred adult patients experiencing anxiety or depression to a mobile app-based dCBI, RxWell, and provided other indicated treatments as part of usual care. Referrals were completed by the providers through the electronic medical record. To better understand facilitators of and challenges in integrating RxWell into routine practice and perceptions of sustainability, a series of qualitative interviews was conducted. Interview data were analyzed to identify major themes using an inductive content analysis approach. RESULTS: A total of 19 provider interviews were conducted to discover motivators and barriers for referring RxWell. The providers benefited from a focused discussion on how to incorporate the referral process into their workflow, and knowing the app content was rooted in evidence. Although the providers believed engaging in experiential learning was important, they indicated that more education on the digital health coach role and how to monitor patient progress is needed. The providers thought patient engagement may be impacted by motivation, a lack of comfort using a smartphone, or preference for in-person therapy. The providers also expressed enthusiasm in continuing to refer the app. They liked the ability to provide patients with support between sessions, to have an extra treatment option that teaches BH exercises, and to have a CBT treatment option that overcomes barriers (eg, wait times, copays, travel) to traditional therapy modalities. CONCLUSIONS: Digital intervention success in health care settings relies heavily on engagement of key stakeholders, such as providers, in both design and implementation of the intervention and focused evaluation within intended care setting(s). Scaling digital interventions to meet the mental health needs of patients in usual care settings leans on thoughtfully constructed and streamlined workflows to enable seamless referral of patients by providers. Our findings strongly suggest that providers are supportive of digital tool integration to support the mental health of patients and endorse its use within their routine workflow.
ABSTRACT
Antibiotic stewardship during the COVID-19 pandemic is an important part of a comprehensive strategy to improve patient outcomes and reduce long-term adverse effects secondary to rising antibiotic resistance. This report describes a quality improvement project which incorporates the use of procalcitonin (PCT) testing to rationalise antibiotic prescribing in patients with suspected or confirmed COVID-19 at Chesterfield Royal Hospital. Data were collected from 118 patients with a total of 127 PCT levels checked over a period of 20 days. Each PCT level was correlated with the subsequent antibiotic outcome as well as the result of the COVID-19 PCR swab. Results indicate that antibiotics were either never started or were stopped within 48 hours in 72% of COVID-confirmed cases with a PCT less than 0.25 µg/L. Our findings suggest that procalcitonin testing, when used in combination with thorough clinical assessment, is a safe, simple and sustainable way of reducing antibiotic use in COVID-19.