Outcomes from the evaluation of an emergency department-based mental health nurse practitioner outpatient service in Australia.

PURPOSE: To evaluate an emergency department (ED)-based mental health nurse practitioner (MHNP) outpatient service in Sydney, Australia. DATA SOURCES: Data collection incorporated waiting times for follow-up outpatient appointments, two brief self-report measures (the K-10 measure of psychological distress and the General Self-Efficacy Scale), a satisfaction tool, and interviews conducted with a random selection of outpatients and a stratified, purposive sample of ED staff. CONCLUSIONS: Over 60% of outpatients were followed up within 5 days of their initial presentation. The mean K-10 score at baseline was 32 (very high psychological distress, n = 101) but this had decreased by two categories to 24 at follow-up (moderate psychological distress, n = 51). There was a modest association between decreased psychological distress and an increase in perceived self-efficacy. Participant satisfaction with aspects of the outpatient service was generally rated as high to very high. Interviewed outpatients (n = 23) were particularly positive about the accessibility, immediacy, and flexibility of the service and overall therapeutic benefits. Emergency staff (n = 20) considered the outpatient service enhanced service provision by facilitating access to a population of patients who were previously underserved. IMPLICATIONS FOR PRACTICE: The ED-based MHNP role enhances access to specialized mental health care and also supports emergency staff.

An emergency department-based mental health nurse practitioner outpatient service: part 2, staff evaluation.

The nurse practitioner role incorporates enhancing access to health-care services, particularly for populations that are underserved. This entails working collaboratively with colleagues across multidisciplinary teams and emphasizing a nursing model of practice within the nurse practitioner role. In Australia, the added value associated with establishing mental health nurse practitioner (MHNP) positions based in the emergency department (ED) is emerging. This paper presents qualitative findings from a study using a mixed-method design to evaluate an ED-based MHNP outpatient service in Sydney, Australia. One component of the evaluation involved semistructured interviews conducted with a random selection of study participants and a stratified sample of ED staff. This is the second of a two-part paper that presents an analysis of the qualitative data derived from the staff interviews (n = 20). Emergency staff were very supportive of the outpatient service, and perceived that it enhanced overall service provision and improved outcomes for patients. Moreover, staff expressed interest in receiving more formal feedback on the outcomes of the service. Staff also felt that service provision would be enhanced through additional mental health liaison nurses working in the department, especially after hours. An ED-based MHNP outpatient service expedites access to follow up to individuals with a broad range of problems, and supports ED staff in the provision of safe, effective, and more holistic care.

An emergency department-based mental health nurse practitioner outpatient service: part 1, participant evaluation.

The mental health liaison nurse role in the emergency department (ED) has demonstrated a range of positive outcomes for both consumers and staff. In Australia, the added value associated with establishing mental health nurse practitioner (MHNP) positions based on this model is emerging. This paper presents qualitative findings from a study using a mixed-method design to evaluate an ED-based MHNP outpatient service in Sydney, Australia. In evaluating this new service, semistructured interviews were conducted with a random selection of study participants and a stratified sample of ED staff. This is the first of a two-part paper that presents an analysis of qualitative data from interviews conducted with study participants (n = 23). Participants reported numerous therapeutic benefits from the service, such as support, understanding, and a focus on solutions rather than problems, and high levels of satisfaction with the accessibility of the service and follow up. Suggestions for improving the service were also offered. Participants emphasized that overall ED service provision would be enhanced through additional resources, especially an extension of operating hours. Findings from these participant interviews provide strong support for an ED-based MHNP outpatient service.

Multidisciplinary CKD care enhances outcomes at dialysis initiation.

In 2003, the Nephrology Section at Dartmouth-Hitchcock Medical Center embraced a new concept for providing care that included a continuing care manager and a nephrologist working together with the patient to introduce stage-based education and clinical interventions. This study compares the outcomes of patients initiating hemodialysis or peritoneal dialysis who received CKD care using a multidisciplinary care model (n = 89) with those who received traditional nephrology care (n = 82). Overall, the findings in this study support the use of the multidisciplinary clinic as a method for improving care of the patient with CKD initiating dialysis, and reducing hospital admissions and costs. The care coordination provided in the multidisciplinary setting improved the number of fistulas placed (60.7% vs. 21%, p < 0.001), the number of fistulas used for dialysis initiation (40.4% vs. 12.3, p < 0.001), and the management of anemia with higher hemoglobin levels prior to dialysis initiation (10.9 g/dL vs. 10.0 g/dL, p = 0.003). Patients receiving multidisciplinary care were 42% less likely to be admitted to the hospital for dialysis initiation, had significantly fewer days hospitalized (p = 0.001), fewer admissions (p = 0.005), and reduced charges for a 90-day period (p = 0.003) after dialysis initiation.

Introducing a new model of emergency department-based mental health care.

This article highlights the importance of the three-phase process used to develop and implement an emergency department-based, mental health nurse practitioner (MHNP) outpatient service in a teaching hospital in Sydney. Australia. The project included a feasibility study and a model refinement phase followed by implementation and pilot evaluation. Support for the initiative was secured through early engagement with relevant stakeholders, from exploring the potential for the proposal through to pilot evaluation. Preliminary findings from the pilot study are presented. The authors propose that the project succeeded by emphasising a nursing model of practice.

Dominantly inherited ataxia and dysphonia with dentate calcification: spinocerebellar ataxia type 20.

We describe a pedigree of Anglo-Celtic origin with a phenotypically unique form of dominantly inherited spinocerebellar ataxia (SCA) in 14 personally examined affected members. A remarkable observation is dentate nucleus calcification, producing a low signal on MRI sequences. Unusually for an SCA, dysarthria is typically the initial manifestation. Mild pyramidal signs and hypermetric saccades are noted in some. Its distinguishing clinical features, each present in a majority of affected persons, are palatal tremor, and a form of dysphonia resembling spasmodic dysphonia. Repeat expansion detection failed to identify either CAG/CTG or ATTCT/AGAAT repeat expansions segregating with the disease in this family. The testable SCA mutations have been excluded. On linkage analysis, the locus maps to chromosome 11, which rules out all the remaining mapped SCAs except for SCA5. While locus homogeneity with SCA5 is not formally excluded, we consider it rather unlikely on phenotypic grounds, and propose that this condition may represent an addition to the group of neurogenetic disorders subsumed under the rubric SCA. The International Nomenclature Committee has made a provisional assignment of 'SCA20', although firm designation will have to await a definite molecular distinction from SCA5.

A clinical measure for the assessment of problem solving in brain-injured adults.

Rapid Assessment of Problem Solving (RAPS) is a clinical test of verbal problem-solving skills for brain-injured persons. This modification of F. A. Mosher and J. R. Hornsby's (1966) Twenty Questions Test (20Q) reduces the memory demands of the test for brain-injured clients. This article provides background on the 20Q Test and modifications made for RAPS. It describes RAPS materials, administration, and scoring procedures and reports RAPS results for 70 normal participants. Normal participants solved RAPS problems with an average of 5 questions. Questions were predominantly constraint seeking and focused on semantic categories or features. Normal participants also reflected substantial variability in their performance on RAPS. This appeared to be related to 2 metacognitive abilities associated with problem solving, planning, and shifting set. The performance of 3 chronic traumatically brain injured individuals is also described and compared to the normal sample to illustrate clinical applications of RAPS.

Problem-solving by traumatically brain injured and neurologically intact subjects on an adaptation of the twenty questions test.

PRIMARY OBJECTIVE: RAPS (Rapid Assessment of Problem-Solving) is a clinical measure for assessing verbal problem-solving in hard-to-test patients or those that may not be able to tolerate a longer, more detailed assessment. The design of the test is based on Mosher and Hornsby's Twenty Question test, but RAPS contains several modifications to facilitate its use with brain-injured individuals. This study used RAPS to compare the verbal problem-solving ability of subjects that were neurologically intact and subjects that had chronic traumatic brain injuries. METHODS AND PROCEDURES: Twenty-one adults that were neurologically intact (NI) and 21 adults that had incurred a traumatic brain injury (TBI) matched for age, gender and education took part in the study. Before being tested with RAPS, participants signed an IRB-approved consent form and completed a battery of neurocognitive measures. RAPS entailed the solving of three verbal problems. Each problem involved an array of 32 pictures of common objects (e.g. football) arranged in a 4x 8 grid. The subjects were instructed to ask yes/no questions to determine which picture the examiner was 'thinking of '. Three scores were computed for each problem solved: number of questions asked, percentage of constraint-seeking questions, and question-asking efficiency scores for the first four questions. OUTCOMES: No learning effects across the problems were found for any of the RAPS measures. Scores were averaged across the three problems to determine group effects. Groups of TBI and NI subjects did not differ significantly in the number of questions asked in solving RAPS problems. Members of the NI group asked significantly more constraint-seeking questions (e.g. Is it an animal?) than those in the TBI group, and the subjects that had incurred brain injuries did more guessing than the NI group. Over 70% of the time, guessing took place after the semantic category containing the target picture was known to the subject. Guesses took the form of pseudo-constraint questions (e.g. Is it the animal with a long neck?) rather than frank guesses (e.g. Is it the giraffe?). These trends were seen for both groups. Question-asking efficiency scores, computed for the first four questions of each problem, reflected the amount of information gained by the subjects' questions. It was anticipated that subjects' questioning strategies would target larger rather than smaller number of pictures and systematically reduce the number of total pictures under consideration. Question-asking efficiency scores were significantly higher for the group of NI subjects. Both groups increased question-asking efficiency scores across the first four questions, and there was no significant group x question interaction. Further analysis of the question-asking efficiency scores revealed that questions from the group of NI subjects tended to target multiple categories of pictures and larger single semantic categories of pictures on the 32-item problem-solving board, whereas those from the group of TBI subjects often targeted smaller categories or portions of categories. CONCLUSIONS: Two meta-cognitive functions, planning and strategy shifting, appeared to explain most of the differences in the verbal problem-solving performance between the groups. Both groups, however, demonstrated a range of abilities on RAPS. Until a larger normative database for RAPS is available, it behooves clinicians using the test to analyse results on an individual basis, to consider the subject's pre-morbid problem-solving ability and to weigh those factors associated with brain injury that could affect RAPS performance.

Moving forward way: Medicare prescription drug coverage.

Nursing is multidimensional, interactive, interdisciplinary, and complex. Almost anything that can be said about nursing can be said another way. Some things worth being said and heard will not follow the norms of journal presentation. A forum accommodates the emerging voice, the new format, the innovative approach. Nursing Forum, in an effort to honor the independent voice in nursing, presents here the voice who elects to enter the dialogue, but who does so "in another way."