ABSTRACT
Background: Fatigue is a symptom of many Rheumatology Conditions (1). Hewlett et al have shown that a Fatigue Management programme (FMP) is effective in reducing fatigue in Rheumatoid Arthritis patients (2). In 2019, a 7-week group-based FMP was developed using a cognitive behavioural approach for Rheumatology patients in NHS Lothian (Scotland). In 2020, due to COVID-19, the in person FMP was adapted for virtual delivery. Referral criteria included Visual Analogue Scale-Fatigue (VAS-F) of ≥6/10 and an infam-matory rheumatic disease diagnosis. The FMP participants recorded Patient Reported Outcome Measures (PROMs) prior to and on completion of the FMP. In August 2021 demand for the FMP far outweighed the capacity of the delivery team and therefore the original 7-week FMP was further adapted to a 4-week programme. This was achieved by focusing on four core elements (i) sleep, (ii) thoughts, emotions and behaviours, (iii) energy conservation, (iv) setbacks. Objectives: The primary objective was to evaluate whether the 4-week programme produced comparable PROMs results to the 7-week programme. In doing so, the aim was to maintain efficacy of the programme and provide increased capacity by offering more groups in the same timeframe. Methods: Fatigue Severity Scale (FSS) and VAS-F were selected for comparison between pre and post FMP PROMs results, these being the main indicators of improvement in fatigue management. Fisher's exact test was used to determine any difference between the PROMs results reported at the end of both programmes. Participants who reported that their PROMs result were the same, worse or who did not respond, were all placed into the category 'Other'. The FMP team recorded the average waiting time for those attending each group. The length of the waiting list at any one time was calculated by removing those who were not interested, had been referred elsewhere, or who did not respond to the invitation, from the total number of referrals received by the FMP team. Results: There was no signifcant difference in FSS and VAS-F results reported by the participants in both groups at the end of the FMPs as determined by Fisher's exact test (Table 1). Waiting list times reduced from 24 weeks in August 2021 to 6 weeks in December 2021 as a result of the adaptation of the FMP from a 7-week programme to a 4-week programme (Figure 1). Conclusion: A 4-week FMP is as effective at improving the management of fatigue in Rheumatology patients as a 7-week FMP and reduces patient waiting times. More research is required to bolster the evidence base to support this novel approach.
ABSTRACT
Background/Significance: Nationwide, the number of hospital emergency department (ED) visits has steadily increased over the past decade;since 2009, ED volumes have increased over 11%.1 The proportion of ED visits primarily involving psychiatric concerns (including substance use) has also been on the rise, from 6.6% of all visits in 2007 to 10.9% of all visits in 2016.2 A recent retrospective analysis of ED visit data from the National Emergency Department Sample examining the years 2010 through 2014 identified mental health concerns (including substance use) as the second-most frequent ED presentation, with abdominal pain ranking as the most frequent.3 Challenges to caring for patients with prominent psychiatric concerns in EDs include: prolonged lengths of stay (LOS),4 boarding and overcrowding,5 increased restraint use,6 financial sequelae,7 and safety implications for patients and staff.5 Many EDs have limited access to psychiatric expertise. Unique features of our innovative ED-based Psychiatry service line include: 1) joint administration by academic departments of Emergency Medicine and Psychiatry, and 2) concurrent, rather than consecutive, evaluations conducted by Emergency Medicine physicians and Psychiatrists for optimal efficiency and collaboration. Methods: The ED Psychiatry Program at Froedtert Hospital was implemented in 2019 to improve patient care, systems-based processes, and cross-specialty education. IRB approval was granted on 4/7/2020 to review data collected on all patients seen in the ED by the new ED Psychiatry service and compare metrics with primary psychiatric patients seen in the ED prior to program implementation. Patient care metrics from the first 12 months has been analyzed;cases in which the ED psychiatrist was involved total 382 (data from 5 patients seen during this period could not be reviewed due to erroneous recording of identifying information). 754 charts were reviewed in total—377 post-implementation (9/1/2019-8/31/2020) and 377 pre-implementation (9/1/2018-8/31/2019). The following metrics were recorded and analyzed using basic summary statistics: ED LOS, disposition, psychiatric diagnosis at discharge, medication class recommended, medication class administered, medication route recommended, and medication route administered. Statistical analysis was performed both on the 12-month groups in aggregate, as well as separately in 6-month groupings to assess for any COVID-19 related confounding effect. Results: Analysis of the first 12 months of data (n = 377 control and intervention patients) demonstrates statistically significant results across a number of domains, including disposition (decrease in hospital admissions and increases in transfers and ED discharges post-implementation), psychiatric diagnoses (increases in personality, intellectual developmental, and anxiety spectrum disorders post-implementation), and medication classes and administration routes utilized (decrease in benzodiazepine use and increases in both atypical antipsychotic use, as well as oral route of administration post-implementation). There were also notable decreases in ED LOS for patients being admitted and transferred from the ED;however, these differences were not statistically significant. Discussion: Analysis of the first year of service data suggests program efficacy and overall value to the health system, with relevant metrics including shorter ED LOS, improved diagnostic accuracy, increased provision of pharmacological treatment interventions in the ED setting and upon discharge, and more resource-appropriate dispositions for patients presenting to the ED with psychiatric concerns. Future directions for further study include: 1) review of the total data set, numbering over 1300 patients in 2 years;2) de-duplication of the data set to eliminate repeat patient encounters as a potential source of confounding;3) collaboration with a faculty biostatistician team for further statistical analysis;and 4) collection and analysis of additional relevant metrics, including restraint use (both f equency and duration), utility of 1:1 observers, patient insurance status (to aid in quantifying possible financial impact), additional patient demographic data (including age, race, gender, ethnicity), and time of patient presentation to the ED. Conclusion/Implications: Integration of psychiatric care into medical settings has been widespread in outpatient environments, but acute models are lacking. Complex psychiatric presentations impede ED workflows and often lead to inadequate care for this vulnerable population. Our jointly administered program that embeds CL Psychiatrists into our academic ED care team has improved and enhanced the care of ED patients presenting with psychiatric concerns as well as operational efficiencies within the department. References: 1. Agency for Healthcare Research and Quality. (2021, April). HCUP Fast Stats. Retrieved from Healthcare Cost and Utilization Project (HCUP): www.hcup-us.ahrq.gov/faststats/national/inpatienttrendsED.jsp 2. Theriault, K., Rosenheck, R., & Rhee, T. (2020). Increasing Emergency Department Visits for Mental Health Conditions in the United States. J Clin Psychiatry, 20m13241. 3. Hooker, E. A., Mallow, P. J., & Oglesby, M. M. (2019). Characteristics and trends of emergency department visits in the United States (2010-2014). J Emerg Med, 344-351. 4. Ding, R., McCarthy, M., Desmond, J., Lee, J., Aronsky, D., & Zeger, S. (2010). Characterizing waiting room time, treatment time, and boarding time in the emergency room using quantile regression. Acad Emerg Med, 813-823. 5. American College of Emergency Physicians. (2014). Polling Survey Results. 6. Zeller, S., Calma, N., & Stone, A. (2014). Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med, 1-6. 7. Nicks, B. A., & Manthey, D. M. (2012). The impact of psychiatric patient boarding in emergency departments. Emerg Med Int.
ABSTRACT
Objective: Despite the high prevalence of pediatric traumatic brain injury (TBI) in children under 5 years of age, there has been limited research about early family support and interventions for this age group. Given that TBI can disrupt parent-child interactions and parent-child interactions are central for child development, we developed an online parenting skills intervention (Gaining Real Life Skills over the Web;GROW) to improve TBI recovery. The online parenting skills program aims to improve caregiver functioning and increase positive parenting behaviors. The purpose of this pilot study was to examine feasibility, acceptability, and preliminary efficacy of the program. Methods: Parents learned strategies for responsive parenting while integrating stress management and self-care techniques by reviewing online content and videos and practicing parenting skills with therapist feedback over 8 weeks. The online content consisted of 5 core modules with the option for 1 supplemental session. Primary study outcomes were feasibility, acceptability, and efficacy of the GROW program to improve caregiver functioning and positive parenting behaviors. Qualitative interviews and satisfaction questionnaires will be analyzed to identify common themes and suggestions across participants. Results: To date, of 63 potentially eligible parents: 23 agreed to participate (36.5%), 19 declined (30.2%), and 21 are currently being recruited (33.3%). Of the 23 who agreed to participate: 10 completed baseline visits (43.5%), 5 are scheduled (21.7%), and 8 are being rescheduled (34.7%). Four parents have completed the program thus far and rated the program as both helpful and enjoyable, finding the coaching to be particularly valuable. Preliminary findings also trend toward an increase in caregiver functioning and positive parenting behaviors. Suggestions for improving the program were oriented towards shortening the program length. Families acknowledged the difficulty in dedicating time to review web content, complete homework, and meet with the therapist weekly. Families with very young children are busy;a challenge made even more difficult amid the influence of COVID and its added stressors. Final pilot data will be presented at the time of the conference. Conclusion: Despite promising feedback about the value of the program, low rates of participation underscore the challenges of engaging parents of very young children. Disruptions due to the COVID-19 pandemic likely made uptake even lower. Assuming that preliminary evidence for acceptability and efficacy are confirmed, next steps include working with stakeholders to preserve key content while redesigning the program to minimize barriers (e.g., shorten modules) and increase engagement. Efforts to identify and target the unique stressors associated with parenting a very young child will be essential to promote uptake. Ultimately, a larger-scale randomized control trial is needed in order to examine the relative efficacy of the program in relation to a comparison group.