AMPlifying metabolic screening for inpatients on antipsychotic medications with a nurse-driven protocol.

INTRODUCTION: Patients on antipsychotic medications are at higher risk of developing metabolic syndrome; nevertheless, metabolic screening for patients on antipsychotics is suboptimal. METHODS: This project developed and implemented AMP (Antipsychotic Metabolic screening Protocol), a nurse-driven protocol on inpatient psychiatric units that allowed nursing staff to collect all components of a metabolic screening. Nurses working on units with AMP were surveyed pre- and post-implementation on perception of AMP and empowerment. RESULTS: AMP significantly increased overall metabolic screening as well as the most frequently missing component (lipid panel). The screening rates pre-intervention were similar to those found in the literature (on average, only two-thirds of patients were screened). However, AMP improved the rate such that nine out of every ten patients on the units were screened. Nurses had a negative perception and no change in empowerment from AMP implementation. CONCLUSIONS: AMP can be used to increase metabolic screening for patients on antipsychotics. Further research is needed to better understand adoptability of nurse-driven protocols in the psychiatric inpatient setting as well as other applications, such as smoking cessation or safety sitters.

The Aggressive Incidents in Medical Settings (AIMS) Study: Advancing Measurement to Promote Prevention of Workplace Violence.

BACKGROUND: Rates of aggressive events and workplace violence (WPV) exposure are often represented by proxy measures (restraint, incident, injury reports) in health care settings. Precise measurement of nurse and patient care assistant exposure rates to patient aggression on inpatient medical units in acute care hospitals advances knowledge, promoting WPV prevention and intervention. METHODS: This prospective, multisite cohort study examined the incidence of patient and visitor aggressive events toward patient care staff on five inpatient medical units in a community hospital and an academic hospital setting in the northeastern United States. Data were collected with event counters, Aggressive Incident and Management Logs (AIM-Logs), and demographic forms over a 14-day period in early 2017. RESULTS: Participants recorded a total of 179 aggressive events using event counters, resulting in a rate of 2.54 aggressive events per 20 patient-days. Patient verbal aggression rates (2.00 events per 20 patient-days) were higher compared to physical aggression rates (0.85 events per 20 patient-days). The staff aggression exposure rate was 1.17 events per 40 hours worked (verbal aggression exposure rate: 0.92 events per 40 hours; physical aggression exposure rate: 0.39 events per 40 hours). The most common precipitants included medication administration (18.6%), waiting for care (17.2%), and delivering food/drinks (15.9%). Most events were managed with verbal de-escalation (75.2%). The number of patients assigned to patient care staff was significantly greater during a shift when an aggressive event occurred compared to when no event occurred (6.3 vs. 5.7, t = -2.12, df = 201.6, p = 0.0348). CONCLUSION: Event counters and AIM-Logs offer greater information about patterns of aggression and preventive interventions used and provide information on the need for debriefing and worker support after aggressive events. Additional studies of this methodology in other settings are needed to evaluate the value of this technology for improving worker and patient safety.

Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice.

OBJECTIVES: Agitation, defined as excessive psychomotor activity leading to aggressive or violent behaviour, is prevalent in the emergency department (ED) due to rising behavioural-related visits. Experts recommend use of verbal de-escalation and avoidance of physical restraint to manage agitation. However, bedside applications of these recommendations may be limited by system challenges in emergency care. This qualitative study aims to use a systems-based approach, which considers the larger context and system of healthcare delivery, to identify sociotechnical, structural, and process-related factors leading to agitation events and physical restraint use in the ED. DESIGN: Qualitative study using a grounded theory approach to triangulate interviews of patients who have been physically restrained with direct observations of agitation events. SETTING: Two EDs in the Northeast USA, one at a tertiary care academic centre and the other at a community-based teaching hospital. PARTICIPANTS: We recruited 25 individuals who experienced physical restraint during an ED visit. In addition, we performed 95 observations of clinical encounters of agitation events on unique patients. Patients represented both behavioural (psychiatric, alcohol/drug use) and non-behavioural (medical, trauma) chief complaints. RESULTS: Three primary themes with implications for systems-based practice of agitation events in the ED emerged: (1) pathways within health and social systems; (2) interpersonal contexts as reflections of systemic stressors on behavioural emergency care and (3) systems-based and patient-oriented strategies and solutions. CONCLUSIONS: Agitation events represented manifestations of patients' structural barriers to care from socioeconomic inequities and high burden of emotional and physical trauma as well as staff members' simultaneous exposure to external stressors from social and healthcare systems. Potential long-term solutions may include care approaches that recognise agitated patients' exposure to psychological trauma, improved coordination within the mental health emergency care network, and optimisation of physical environment conditions and organisational culture.

A Model Program to Manage Behavioral Emergencies and Support Nurses in the Medical Setting.

Medically hospitalized individuals have high rates of comorbid psychiatric, substance abuse, and behavioral disorders. Disruptive and sometimes aggressive behaviors may arise when mental health needs of patients go unrecognized or are inadequately addressed. Health care workers experience the most workplace violence compared with other professions, with nurses and nursing aides at highest risk. A Behavioral Emergency Support Team (BEST) model can be an effective approach to providing a customized response to a patient's agitation through identification of underlying clinical and environmental contributors to the onset of aggression as well as to provide behavioral education and support of nursing staff. Results from 2 years of BEST model use resulted in 124 events among 96 patients of whom 19 had repeated events. The most common reasons for codes were aggression (79%) and elopement threat/attempt (45%), and the most frequent patient diagnosis was cognitive impairment (54%). Development of a BEST model provides support to nurses that is not otherwise available for events that are disruptive to care in inpatient medical settings and help minimize the occurrence of workplace violence.

Staff perceptions of risk factors for violence and aggression in ambulatory care.

BACKGROUND: Management of violent acts of patients and their visitors in psychiatric and hospital settings has been studied. However, violence has not yet been addressed in the ambulatory care environment. OBJECTIVE: To identify potential risk factors for patient and visitor violence [PVV] and staff perceptions of the impact of these risk factors in ambulatory care. METHODS: A review of psychiatric inpatient research was conducted examining violence and aggression including risk factors for PVV. Identified risk factors for violence were incorporated into a survey tool and distributed to staff in a community clinic asking for their perception of the impact of these risk factors on aggression in their work environment. RESULTS: Risk factors for violence and aggression were categorized as static or dynamic or as related to characteristics of staff or the environment of care. All of the risk factors were identified as possible contributors to PVV by the staff while items related to substance abuse and the clinic environment were selected by the staff as "highly likely" to contribute to PVV in their setting. CONCLUSIONS: Continued research is needed in this area to better understand risk factors for PVV and develop appropriate safety interventions and crisis training for ambulatory care settings.

A randomized study on the effect of modified behavioral activation treatment for depressive symptoms in rural left-behind elderly.

OBJECTIVE: To evaluate the effectiveness of a modified behavioral activation treatment (MBAT) intervention on reducing depressive symptoms in rural left-behind elderly. METHOD: This is a randomized study registered in Chinese Clinical Trial Registry (ChiCTR-IOR-17011289). Eighty rural left-behind elderly people who had a Geriatric Depression Scale (GDS) score between 11 and 25 were randomly assigned to the intervention (n = 40) and control group (n = 40). The intervention group received both MBAT and regular treatment for 8 weeks while the control group received regular treatment. Both groups were assessed with the GDS, Beck Anxiety Inventory (BAI), and Oxford Happiness Questionnaire (OHQ) at baseline, immediately post-intervention, and at 3 months post-intervention. RESULTS: There were a total of 73 participants that completed the intervention. The scores of GDS and BAI decreased significantly, but the scores of OHQ increased significantly in the intervention group after 8 sessions of MBAT (P < .01). The reduction in depression symptoms after the intervention was maintained at the 3-month follow-up. Significant differences in GDS, BAI, and OHQ scores were observed between the intervention group and the control group (P < .01). CONCLUSION: MBAT produced a significantly greater reduction in depressive symptoms than regular care in rural left-behind elderly. Clinical or methodological significance of this article: A modified behavioral activation (BA) psychotherapy can significantly reduce the recurrence and seriousness of depression symptoms in the left-behind elderly with mild to moderate depression. This study also suggests that further study of the MBAT as an intervention will provide a direction for the management of mental health in rural left-behind elders.

Aggressive Event Incidence using the Staff Observation of Aggression Scale-Revised (SOAS-R): A Longitudinal Study.

The aim of this study was to identify aggressive event incidence rates in the inpatient psychiatric setting, describe characteristics of events and differences based on aggression target and type (verbal vs. physical). A longitudinal study was carried out of aggressive events identified by workers in four inpatient psychiatric units using the Staff Observation of Aggression Scale-Revised (SOAS-R) over 6 weeks. A total of 113 aggressive events were recorded resulting in a rate of 13.27 events per bed per year. Verbal aggression was demonstrated in 86 % and physical aggression in 57 % of events. Most events (70.8 %, n = 81) targeted a worker. Compared to other targets, workers were 3.4 times more likely to feel threatened (95 % CI 1.2-9.6, χ2 = 5.08, p = 0.0242), and less likely to have a visible injury (OR 0.15, 95 % CI 0.04-0.6; χ2 = 7.1, p = 0.0078). Event severity ranged from 0 to 21 with a mean of 9.5(SD = 5.1), with 20 % considered severe. Verbal events had lower mean severity of 6.5(SD = 3.8) versus physical events with a severity of 11.8(SD = 4.8; t = 6.5, df = 111, p < 0.0001). In 57.5 % of events there was no consequence to the victim. For most events (76 %) resolution included workers talking to the patient, while 54 % involved use of medication. Restrictive measures (physical hold, seclusion or physical restraint) were involved in 24.8 % of events. Aggression incidence was similar to incidence found in other studies. Workers were the target of most aggressive events and many were identified as having no understandable provocation. Further understanding of event characteristics will promote more effective prevention and management of aggressive events.

Evaluation of Motivational Interviewing to Improve Psychotropic Medication Adherence in Adolescents.

PROBLEM: Medication adherence rates in adolescents are poor. The World Health Organization identified that those at greatest risk were nonwhite adolescents with depression. Medication nonadherence results in poorer mental health outcomes. OBJECTIVE: The first aim of the study was to investigate if two motivational interviewing (MI) sessions would improve medication adherence in adolescents taking antidepressants and mood stabilizers. The second aim was to evaluate if attitudes toward medication correlated with adherence. The third aim was to determine if self-reported adherence scores were similar to electronic adherence data collected. METHODS: The quasi-experimental study contained an MI intervention, including a baseline and postintervention assessment of adherence over 30 days. A total of 48 adolescents, ranging in age from 12 to 18 years, were recruited from a university mental health center to participate in the study; 41 completed the study. Four nurse practitioners and two child psychiatrists mastered the MI techniques evaluated with standardized measures. The Medication Electronic Monitoring System (MEMS) was the primary measure of medication adherence. The Drug Attitude Inventory (DAI) was used as a secondary measure. Finally, participants completed the client evaluation of MI and a satisfaction survey of MI. RESULTS: At endpoint, 70.7% of the participants were taking their medications between 80% and 100% of the time, as measured over 30 days, compared with 43.9% of participants at baseline. Mean adherence scores significantly improved by 17% after two MI sessions. Mean baseline adherence scores were 63.7%, whereas mean endpoint adherence scores were 80.6% (p < 0.0001). The effect size was 0.65, demonstrating moderate effect. Participants (n = 29) who demonstrated 80% or greater adherence had DAI mean scores of 16.48, whereas those below 80% had a DAI mean of 15.5 (p = 0.73), demonstrating no significant difference on drug attitudes between the two groups at endpoint. DAI baseline mean scores were 14.2, whereas endpoint mean scores were 16.2. There was a significant difference between self-rated adherence and objective data collected from the MEMS caps as participants over-reported medication adherence by an average of 18.4% at baseline (t = 6.84, df = 40, p < 0.001). Participants reported a high degree of satisfaction with MI. CONCLUSIONS: MI is a promising intervention for adolescents to improve psychotropic medication adherence.

Communicating with colleagues and patients about acute bipolar disorder.

Patients with bipolar disorder require a collaborative care approach involving primary care doctors, psychiatrists, nurses, social workers, therapists, and other support to manage their illness. Psychiatric mental health nurses and advanced practice nurses provide important psychoeducation to patients regarding their diagnosis, medications, and other treatment strategies. Communication among the care team is critical to ensure that patients are adhering to treatment, being monitored for symptoms and adverse effects, and receiving follow-up and support to improve their functioning.

Recognizing signs and symptoms of bipolar disorder.

Psychiatric mental health nurses and advanced practice nurses play an important role in the assessment and care of patients with bipolar disorder. Using appropriate rating scales and diagnostic criteria can aid in the assessment of patients who present with a variety of symptoms. In this game-based CME activity, you will assume the role of a psychiatric mental health advanced practice nurse who must recognize the signs and symptoms of bipolar disorder and select appropriate treatment for a 20-year-old patient with suicidal thoughts.

Measurement and monitoring of health care worker aggression exposure.

Aggression exposure is highly prevalent in healthcare workers, and is a complex problem that negatively impacts patient and worker safety and health. Typically only events of high severity (e.g., use of physical restraint or incident reports) are monitored in healthcare settings. Unfortunately, these events are likely a small fraction of all aggressive events that range from verbal to physical. Improved measurement and monitoring of healthcare worker aggression exposure may lead to improved patient and worker safety and health. This article provides an overview of aggression exposure in healthcare and reviews the measurement of aggression, including challenges and common measures. Discussion of a pilot study presents insights gained from using a novel measure of aggression, handheld counters. The conclusion offers implications for research and clinical practice.

Correlation between levels of conflict and containment on acute psychiatric wards: the city-128 study.

OBJECTIVE Attainment of safe, calm inpatient psychiatric wards that are conducive to positive therapeutic care is crucial. On such wards, rates of coerced medication, seclusion, manual restraint and other types of containment are comparatively low, and, usually, rates of conflict-for example, aggression, substance use, and absconding-are also low. Sometimes, however, wards maintain low rates of containment even when conflict rates are high. This study investigated wards with the counterintuitive combination of low containment and high conflict or high containment and low conflict. METHODS The authors conducted a secondary analysis of cross-sectional data collected from 136 acute psychiatric wards across England in 2004-2005. The wards were categorized into four groups on the basis of median splits of containment and conflict rates: high conflict and high containment, high conflict and low containment, low conflict and low containment, and low conflict and high containment. Features significantly associated with these ward types were identified. RESULTS Among the variables significantly associated with the various typologies, some-for example, environmental quality-were changeable, and others-such as social deprivation of the area served-were fixed. High-conflict, low-containment wards had higher rates of male staff and lower-quality environments than other wards. Low-conflict, high-containment wards had higher numbers of beds. High-conflict, high-containment wards utilized more temporary staff as well as more unqualified staff. No overall differences were associated with low-conflict, low-containment wards. CONCLUSIONS Wards can make positive changes to achieve a low-containment, nonpunitive culture, even when rates of patient conflict are high.

Psychopharmacology of pediatric bipolar disorder.

This comprehensive literature review incorporates research studies evaluating the effectiveness of psychotropic medications in children and adolescents with pediatric bipolar disorder. Research articles were obtained using Medline. Open-label studies, prospective and retrospective chart reviews and randomized controlled trials evaluating the effectiveness of medication in pediatric bipolar disorder with greater than ten subjects are included in this article. Antipsychotics, anticonvulsants and lithium as monotherapy, as well as their use in combination treatment, were evaluated to determine their effectiveness in pediatric bipolar disorder. Clinical recommendations of medication and management strategies are made from a synthesis of the data. In addition, adherence concerns caused by adverse effects and nonresponse as they impact physical and mental health are addressed.