Patient Satisfaction and Recommendations for Delivering a Group-Based Intensive Outpatient Program via Telemental Health During the COVID-19 Pandemic: Cross-sectional Cohort Study.

BACKGROUND: Although group-based intensive outpatient programs (IOPs) are a level of care commonly utilized by adults with serious mental illness, few studies have examined the acceptability of group-based IOPs that required rapid transition to a telemental health (TMH) format during the COVID-19 pandemic. OBJECTIVE: The aim of this study was to evaluate patient satisfaction and future recommendations for a group-based IOP that was transitioned to a TMH format during the COVID-19 pandemic. METHODS: A 17-item patient satisfaction questionnaire was completed by patients at discharge and covered 3 areas: IOP TMH satisfaction, future recommendations, and video technology challenges. Descriptive and content analyses were conducted for the quantitative and open-ended questions, respectively. RESULTS: A total of 76 patients completed the program in 2020. A subset of patients (n=40, 53%) responded to the survey at program discharge. The results indicated that the patients were satisfied overall with the TMH program format; 50% (n=20) of the patients preferred the program continue offering the TMH format, and the rest preferred returning to in-person formats after the pandemic. The patients indicated the elements of the program that they found most valuable and provided recommendations for future program improvement. CONCLUSIONS: Overall, adults with serious mental illness reported high satisfaction with the group-based IOP delivered via TMH. Health care systems may want to consider offering both TMH and in-person formats regardless of the state of the pandemic. Patients' feedback on future improvements should be considered to help ensure long-term success.

Feasibility and Initial Outcomes of a Group-Based Teletherapy Psychiatric Day Program for Adults With Serious Mental Illness: Open, Nonrandomized Trial in the Context of COVID-19.

BACKGROUND: In the context of the COVID-19 pandemic, many behavioral health services have transitioned to teletherapy to continue delivering care for patients with mental illness. Studies that evaluate the outcome of this rapid teletherapy adoption and implementation are pertinent. OBJECTIVE: This single-arm, nonrandomized pilot study aimed to assess the feasibility and initial patient-level outcomes of a psychiatric transitional day program that switched from an in-person group to a video teletherapy group during the COVID-19 pandemic. METHODS: Patients with transdiagnostic conditions who were at risk of psychiatric hospitalization were referred to the Adult Transitions Program (ATP) at a large academic medical center in the United States. ATP was a 3-week intensive outpatient program that implemented group teletherapy guided by cognitive and behavioral principles delivered daily for 3 hours per day. Feasibility was assessed via retention, attendance rate, and rate of securing aftercare appointments prior to ATP discharge. Patients completed standardized patient-reported outcome measures at admission and discharge to assess the effectiveness of the program for improving quality of mental health, depression, anxiety, and suicide risk. RESULTS: Patients (N=76) started the program between March and August of 2020. Feasibility was established, with 70 of the 76 patients (92%) completing the program and a mean attendance of 14.43 days (SD 1.22); also, 71 patients (95%) scheduled at least one behavioral health aftercare service prior to ATP discharge. All patient-level reported outcomes demonstrated significant improvements in depression (95% CI -3.6 to -6.2; Cohen d=0.77; P<.001), anxiety (95% CI -3.0 to -4.9; Cohen d=0.74; P<.001), overall suicide risk (95% CI -0.5 to -0.1; Cohen d=0.41; P=.02), wish to live (95% CI 0.3 to 1.0; Cohen d=0.39; P<.001), wish to die (95% CI -0.2 to -1.4; Cohen d=0.52; P=.01), and overall mental health (95% CI 1.5 to 4.5; Cohen d=0.39; P<.001) from admission to discharge. CONCLUSIONS: Rapid adoption and implementation of a group-based teletherapy day program for adults at risk of psychiatric hospitalization appeared to be feasible and effective. Patients demonstrated high completion and attendance rates and reported significant improvements in psychosocial outcomes. Larger trials should be conducted to further evaluate the efficacy and effectiveness of the program through randomized controlled trials.

Enhancing the patient and family experience during pediatric sleep studies.

STUDY OBJECTIVES: Pediatric polysomnography can result in suboptimal patient and provider (physician and advanced practice provider) experiences. We embarked on a project aimed at increasing the proportion of maximal satisfaction survey scores by a minimum of 10% in 1 year without adding personnel or major expenses. METHODS: We used a Six Sigma framework, define, measure, analyze, improve, and control (DMAIC), to conduct our analysis. For measurement, we designed a project-specific survey that was given to caregivers of children who underwent PSG in February 2018 and repeated the survey after interventions in February 2019. Lean and Six Sigma quality improvement tools were used to define important processes that influence patient satisfaction, including: supplier, input, process, output, customer, and requirements (SIPOC-R); journey mapping; 1-2-4-All brainstorming; and views solicited from our center's Patient and Family Advisory Council. We analyzed the relationships between identified processes and outcomes using usual descriptive statistics. We prioritized interventions using a Kano model and a quality function deployment (QFD) technique to rank priorities for interventions. Multiple opportunities to improve patient and family satisfaction before, during, and after a pediatric polysomnography were identified. Many were simple, one-step interventions and were implemented simultaneously. For those that required substantial training and/or scheduling changes, pilots were performed and plan, do, study, act (PDSA) cycles were used to check effectiveness. RESULTS: After implementation, top box scores rose 20%, from 51% (n = 47) in 2018 to 71% (n = 50) in 2019. CONCLUSIONS: Various quality improvement techniques employed in business, engineering, and manufacturing were used to identify and address areas of improvement in the pediatric polysomnography experience.

Improving 3-Hour Sepsis Bundled Care Outcomes: Implementation of a Nurse-Driven Sepsis Protocol in the Emergency Department.

PROBLEM: Sepsis, a life-threatening condition, can rapidly progress to death. The Hospital Inpatient Quality Reporting program has implemented bundled care metrics for sepsis care, but timely completion of these interventions is challenging. Best-practice interventions could improve patient outcomes and reimbursement. The purpose of this project was to improve the timeliness of sepsis recognition and implementation of bundled care interventions in the emergency department. METHODS: This evidence-based practice improvement project implemented a Detect, Act, Reassess, Titrate (DART)-based nursing protocol embedded within a checklist communication tool in the emergency department of a tertiary level-2 trauma center. Data comparisons between preintervention and post-DART protocol/checklist implementation included compliance with the individual Inpatient Quality Reporting 3-hour bundled elements, number of hospital days, and time to screen. Staff also completed a survey designed to assess their satisfaction with the DART algorithm/checklist. The Pearson χ2 test was used to assess bundled-care intervention variables. Wilcoxon rank sum tests were used to explore hospitalization outcomes. Staff satisfaction survey results were summarized. RESULTS: Improvement was statistically significant for lactate levels, blood cultures, and early antibiotic administration in the intervention period compared with baseline. Time to screen, ED length of stay, and number of hospital days improved between baseline and the intervention period, with an average number of hospital days decreasing by 2.5 days. Compliance with all Inpatient Quality Reporting metrics increased from 30% to 80%. DISCUSSION: When the nurse-driven protocol and communication tool were implemented, compliance with time-sensitive sepsis bundled interventions improved significantly. The outcomes suggest nurse-driven protocols can improve sepsis outcomes.

Examining the Frequency of Stimulant Misuse among Patients with Primary Disorders of Hypersomnolence: A Retrospective Cohort Study.

STUDY OBJECTIVES: Narcolepsy and idiopathic hypersomnia are commonly treated by sleep specialists and encountered by other medical providers. Although pharmacotherapy with modafinil and traditional stimulants is considered the mainstay of treatment, physicians are often uncomfortable with their prescription because of concerns regarding misuse. The goal of this study was to assess the frequency of stimulant misuse in this population. METHODS: A retrospective cohort study was performed evaluating patients 18 years and older diagnosed with narcolepsy with and without cataplexy and idiopathic hypersomnia with and without long sleep between 2003-2008. Patients were included if they obtained stimulant prescriptions from and had at least one follow-up visit subsequent to initial diagnosis at our center. Stimulant misuse was defined by multiple prescription sources or early refill requests, which are systematically entered into the record by nursing staff. RESULTS: A total of 105 patients met inclusion criteria for the study; 45 (42%) were male. Mean age at multiple sleep latency test was 42 (± 16). Twelve (11%) patients had a history of illicit substance misuse, and one (1%) patient demonstrated previous stimulant misuse. Fifty-seven (54%) patients carried psychiatric diagnoses, 88% of whom reported depression. Median duration of monitored stimulant therapy was 26 months (range 1-250). None of the 105 patients was found to have evidence of stimulant misuse. CONCLUSION: This study suggests that the frequency of stimulant misuse in patients with narcolepsy and idiopathic hypersomnia is extremely low. Concerns regarding drug misuse should not leverage decisions to provide long-term therapy.

Improving sleep: outcomes from a worksite healthy sleep program.

OBJECTIVE: Unhealthy and inadequate sleep is a common and significant problem impacting absenteeism, presenteeism, health, and productivity. This study aimed at analyzing the effect of a worksite-based healthy sleep program. METHODS: Retrospective analysis of 53 adult members of a worksite wellness center who participated in an 8-week healthy sleep program and completed pre- and postintervention health behavior questionnaires. RESULTS: Following the intervention participants felt significantly more rested, more confident in their ability to deal with sleep problems, and more knowledgeable about sleep. In addition, they reported a reduction in their stress level, improved quality of life, and increase energy level. CONCLUSIONS: These results support the effectiveness of worksite programs designed to promote healthy sleep. Future randomized studies are needed to further investigate the effectiveness and optimal delivery of healthy sleep promotion.

Cataplexy Emotional Trigger Questionnaire (CETQ)--a brief patient screen to identify cataplexy in patients with narcolepsy.

STUDY OBJECTIVES: This pilot study explored the sensitivity and specificity of a brief survey to determine the presence of cataplexy. We hypothesized that the brief questionnaire could provide a quick, sensitive, and specific screening tool to identify those patients with cataplexy, which would result in more timely referrals for further diagnostic testing. DESIGN: The pilot study utilized a brief questionnaire that was developed by including 5 questions that were found to be strong positive predictors of cataplexy from a previous 51-item cataplexy questionnaire. SETTING: Participants with a laboratory-confirmed diagnosis completed the questionnaire via mail correspondence or at the time of scheduled appointments in the Mayo Clinic Sleep Disorder Center, Rochester, Minn. PARTICIPANTS: Seventy-eight patients with narcolepsy and cataplexy and 78 patients with obstructive sleep apnea completed the questionnaire. INTERVENTIONS: NA. MEASUREMENTS AND RESULTS: The sensitivity, specificity, area under the curve, positive predictive value, and negative predictive value/were computed for each question individually, along with appropriate 95% confidence intervals. CONCLUSIONS: The first item of the cataplexy emotional trigger questionnaire (CETQ) discriminates patients with cataplexy from controls with excellent sensitivity and specificity. The addition of the other 4 questions, in the context of question 1, did not improve specificity, area under the curve, positive predictive value, or negative predictive value but did provide useful confirmatory data. Thus, a single question provides a brief practical tool that could improve the recognition of cataplexy in the clinical setting. Depending on the circumstance, users may be interested in utilizing 1 or all 5 questions.

Characterizing the emotions that trigger cataplexy.

Cataplexy is an intriguing example of how emotions can trigger muscle weakness by activating neural pathways. When associated with excessive daytime sleepiness, cataplexy is considered pathognomonic of narcolepsy. A questionnaire was administered to 55 patients with narcolepsy-cataplexy and 47 comparison subjects with obstructive sleep apnea. The area under the receiver-operating curve was 0.94 for the combination of muscle weakness with laughter and ability to hear during the episode. A 51-item questionnaire succeeds in identifying cataplexy in narcolepsy-cataplexy patients measured up against a comparison group. In the future, an abbreviated survey with these two questions should identify cataplexy with high sensitivity and specificity. These selected questions could subsequently be included into screening tools for use with different patient populations.

Obstructive sleep apnea-hypopnea syndrome.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is characterized by repetitive episodes of airflow reduction (hypopnea) or cessation (apnea) due to upper airway collapse during sleep. Increasing recognition and a greater understanding of the scope of this condition have substantially affected the practices of many clinicians. This review provides practical information for physicians assessing patients with OSAHS. It discusses complications, clinical recognition, the polysomnographic report, and treatment of OSAHS, including strategies for troubleshooting problems associated with continuous positive airway pressure therapy.