Outcomes and lessons learned from an interprofessional student training program in Screening, Brief Intervention, and Referral to Treatment (SBIRT) at an academic health sciences center.

BACKGROUND AND OBJECTIVES: Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a public health intervention to address overuse and risky use of alcohol and illegal substances. In order to increase SBIRT in clinical practice, training should start with future health care provider students and faculty. The main objective of this program was to improve and enhance the training of health professions students to provide competent screening, brief intervention and referral to treatment for persons who have or are at-risk for substance use disorder. This paper shares the results of an SBIRT training program at an academic health sciences center for undergraduate nursing, graduate nursing, and medical students. DESIGN, SETTING AND PARTICIPANTS: 1229 undergraduate and graduate nursing students, medical students, faculty and preceptors at an academic medical center completed SBIRT coursework integrated into their existing curriculum. Coursework utilized an online learning platform as well as in-person skills training experiences. METHODS: An interprofessional team collaborated to create an online SBIRT curriculum consisting of 5 primary modules (total 3 h) and an SBIRT Booster module (0.5 h). The team also developed pre- and post-module quizzes and satisfaction surveys to measure changes in knowledge, confidence, and satisfaction; as well as simulations, videos, a screening tool, a provider pocket card, and an online resource library to support learning. Faculty and preceptors were trained in the program to model skills and answer student questions. A motivational interviewing specialist provided the in-person skills training sessions. RESULTS: A sustainable interprofessional SBIRT training program demonstrated gains in knowledge, confidence, and skills across all programs. The team used clinical opportunities and simulation with education to promote clinical proficiency. CONCLUSIONS: Interprofessional training mirrors real world clinical situations and encourages all providers to implement SBIRT in practice and decrease poor outcomes associated with substance use disorders.

The Use of Simulation in Teaching.

Simulation-based medical education (SBME) provides experiential learning for medical trainees without any risk of harm to patients. Simulation is now included in most medical school and residency curricula. In psychiatric education, simulation programs are rapidly expanding and innovating. Major applications of SBME in psychiatry include achieving close observation of trainees with patients, preparing trainees for unstable patient scenarios, and exposing trainees to a broader range of psychopathology. This review article covers the history of SBME, simulation modalities, current use of SBME in psychiatry, a case study from one institution, and recommendations for incorporating simulation in psychiatry education.

Exposure Therapy and Simultaneous Repetitive Transcranial Magnetic Stimulation: A Controlled Pilot Trial for the Treatment of Posttraumatic Stress Disorder.

OBJECTIVES: This is a small preliminary but novel study assessing the feasibility of repetitive transcranial magnetic stimulation (rTMS) delivery to veterans with posttraumatic stress disorder (PTSD) while they simultaneously receive prolonged exposure (PE) therapy. METHODS: A prospective, randomized, double-blinded, active sham-controlled design combined weekly sessions of rTMS and standard PE at the Veterans Administration Hospital. Eight adult patients received a full course of protocol-driven PE therapy and were randomly assigned to receive either rTMS or sham rTMS. Repetitive transcranial magnetic stimulation was delivered to the right or left prefrontal cortex with a figure-eight solid core coil at 120% motor threshold, 10 Hz, 5-second train duration, and 10-second intertrain interval for 30 minutes (6000 pulses) weekly for 5 weeks (30,000 stimuli). RESULTS: Of the 12 veterans consented, 8 completed the study treatment protocol. The dropout rate was 34%, roughly equivalent to the pooled average dropout rates observed in traditional PE therapy with Operation Enduring Freedom/Operation Iraqi Freedom veterans with PTSD, suggesting that veterans had no difficulty tolerating the addition of rTMS to PE therapy and that this is a feasible study design for larger trials in the future. Clinician-Administered PTSD Symptom scores reflected a general nonsignificant trend toward improvement, and subjects with comorbid major depression appeared to experience significant antidepressant benefit with treatment despite the fact that the doses used in this protocol were much smaller than those used to treat patients with major depressive disorder. CONCLUSIONS: This pilot study demonstrates the safety and feasibility of rTMS delivery to PTSD patients while they simultaneously receive PE. This unique approach to the treatment of PTSD highlights the need for further studies with larger sample sizes to assess treatment outcomes.

Cultural Change: Implementation of a Recovery Program in a Veterans Health Administration Medical Center Inpatient Unit.

INTRODUCTION: The Freedom Commission's recommendations, Substance Abuse and Mental Health Services Administration's framework, and policy directives on recovery-oriented services have fueled the recovery transformation. Mental health recovery services have been implemented in a broad range of outpatient settings. However, psychiatric inpatient units remained embedded in the traditional model of care. AIMS: The purpose of this article is to describe an ongoing quality improvement implementation of recovery services in a Veterans Health Administration acute psychiatric inpatient unit. METHOD: An interprofessional Partnership for Wellness delivered 4 to 6 hours per day of evidence-based recovery and holistic population-specific health programs. Veteran, system, and program indicators were measured. RESULTS: Preliminary indicators over a 2-year period suggest that Veterans rated group content and relevance high, pre-post psychiatric rehospitalization rates decreased by 46%, and fidelity to recommended strategies was high. CONCLUSIONS: The project success reflects strong leadership, a partnership of committed staff, effective training, and an organizational culture exemplifying excellence in Veteran services and innovation.

A Year 3 Progress Report on Graduate Medical Education Expansion in the Veterans Access, Choice, and Accountability Act.

The VA has made progress in implementing mandates to expand medical residency programs to more rural and underserved locations and to increase access to family care providers, but some specialties, like geriatrics, remain underrepresented.

The Role of Amantadine Withdrawal in 3 Cases of Treatment-Refractory Altered Mental Status.

Amantadine, which was originally developed as an antiviral medication, functions as a dopamine agonist in the central nervous system and consequently is utilized in the treatment of Parkinson disease, drug-induced extrapyramidal reactions, and neuroleptic malignant syndrome. For reasons that are not entirely understood, abrupt changes in amantadine dosage can produce a severe withdrawal syndrome. Existing medical literature describes case reports of amantadine withdrawal leading to delirium, which at times has progressed to neuroleptic malignant syndrome. Amantadine withdrawal may be under-recognized by mental health clinicians, which has the potential to lead to protracted hospital courses and suboptimal outcomes. The goal of this case series is to highlight the role of amantadine withdrawal in the cases of 3 medically complex patients with altered mental status. In the first case, the cognitive side effects of electroconvulsive therapy masked acute amantadine withdrawal in a 64-year-old man with Parkinson disease. In the second case, a 75-year-old depressed patient developed a catatonic delirium when amantadine was discontinued. Finally, a refractory case of neuroleptic malignant syndrome in a 57-year-old patient with schizoaffective disorder rapidly resolved with the reintroduction of outpatient amantadine. These cases highlight several learning objectives regarding amantadine withdrawal syndrome: First, it may be concealed by co-occurring causes of delirium in medically complex patients. Second, its symptoms are likely to be related to a cortical and limbic dopamine shortage, which may be reversed with electroconvulsive therapy or reintroduction of amantadine. Third, its clinical presentation may occur on a spectrum and may include features suggestive of delirium, catatonia, or neuroleptic malignant syndrome.

Suicide-specific Safety in the Inpatient Psychiatric Unit.

In total, 75% of suicides reported to the Joint Commission as sentinel events since 1995, have occurred in psychiatric settings. Ensuring patient safety is one of the primary tasks of inpatient psychiatric units. A review of inpatient suicide-specific safety components, inclusive of incidence and risk; guidelines for evidence-based care; environmental safety; suicide risk assessment; milieu observation and monitoring; psychotherapeutic interventions; and documentation is provided. The Veterans Health Administration (VA) has been recognized as an exemplar system in suicide prevention. A VA inpatient psychiatric unit is used to illustrate the operationalization of a culture of suicide-specific safety. We conclude by describing preliminary unit outcomes and acknowledging limitations of suicide-specific inpatient care and gaps in the current inpatient practices and research on psychotherapeutic interventions, observation, and monitoring.

A two-site pilot randomized 3 day trial of high dose left prefrontal repetitive transcranial magnetic stimulation (rTMS) for suicidal inpatients.

BACKGROUND: Suicide attempts and completed suicides are common, yet there are no proven acute medication or device treatments for treating a suicidal crisis. Repeated daily left prefrontal repetitive transcranial magnetic stimulation (rTMS) for 4-6 weeks is a new FDA-approved treatment for acute depression. Some open-label rTMS studies have found rapid reductions in suicidality. DESIGN: This study tests whether a high dose of rTMS to suicidal inpatients is feasible and safe, and also whether this higher dosing might rapidly improve suicidal thinking. This prospective, 2-site, randomized, active sham-controlled (1:1 randomization) design incorporated 9 sessions of rTMS over 3 days as adjunctive to usual inpatient suicidality treatment. The setting was two inpatient military hospital wards (one VA, the other DOD). PATIENTS: Research staff screened approximately 377 inpatients, yielding 41 adults admitted for suicidal crisis. Because of the funding source, all patients also had either post-traumatic stress disorder, mild traumatic brain injury, or both. TMS METHODS: Repetitive TMS (rTMS) was delivered to the left prefrontal cortex with a figure-eight solid core coil at 120% motor threshold, 10 Hertz (Hz), 5 second (s) train duration, 10 s intertrain interval for 30 minutes (6000 pulses) 3 times daily for 3 days (total 9 sessions; 54,000 stimuli). Sham rTMS used a similar coil that contained a metal insert blocking the magnetic field and utilized electrodes on the scalp, which delivered a matched somatosensory sensation. MAIN OUTCOME MEASURE: Primary outcomes were the daily change in severity of suicidal thinking as measured by the Beck Scale of Suicidal Ideation (SSI) administered at baseline and then daily, as well as subjective visual analog scale measures before and after each TMS session. Mixed model repeated measures (MMRM) analysis was performed on modified intent to treat (mITT) and completer populations. RESULTS: This intense schedule of rTMS with suicidal inpatients was feasible and safe. Minimal side effects occurred, none differing by arm, and the 3-day retention rate was 88%. No one died of suicide within the 6 month followup. From the mITT analyses, SSI scores declined rapidly over the 3 days for both groups (sham change -15.3 points, active change -15.4 points), with a trend for more rapid decline on the first day with active rTMS (sham change -6.4 points, active -10.7 points, P = 0.12). This decline was more pronounced in the completers subgroup [sham change -5.9 (95% CI: -10.1, -1.7), active -13 points (95% CI: -18.7, -7.4); P = 0.054]. Subjective ratings of 'being bothered by thoughts of suicide' declined non-significantly more with active rTMS than with sham at the end of 9 sessions of treatment in the mITT analysis [sham change -31.9 (95% CI: -41.7, -22.0), active change -42.5 (95% CI: -53.8, -31.2); P = 0.17]. There was a significant decrease in the completers sample [sham change -24.9 (95% CI: -34.4, -15.3), active change -43.8 (95% CI: -57.2, -30.3); P = 0.028]. CONCLUSIONS: Delivering high doses of left prefrontal rTMS over three days (54,000 stimuli) to suicidal inpatients is possible and safe, with few side effects and no worsening of suicidal thinking. The suggestions of a rapid anti-suicide effect (day 1 SSI data, Visual Analogue Scale data over the 3 days) need to be tested for replication in a larger sample. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01212848, TMS for suicidal ideation.

Systematic investigation of initiatives to reduce seclusion and restraint in a state psychiatric hospital.

OBJECTIVES: This study used an experimental design to examine the effect of systematic implementation of behavioral interventions on the rate of seclusion and restraint in an inpatient psychiatric hospital. METHODS: With a variant of the multiple-baseline design, a model designed to reduce seclusion and restraint was implemented at a large state-funded hospital in the southeastern United States. The implementation schedule was established such that each of five inpatient units was randomly assigned to implement the intervention components in a different order, and each unit served as its own control. Participants were patients and staff, for a total of 89,783 patient-days over a 3.5-year period from January 2005 through June 2008. The components included trauma-informed care training, changes to unit rules and language, changes to the physical characteristics of the therapeutic environment, and involvement of patients in treatment planning. The rate of inpatient psychiatric seclusion and restraint (per patient day) was tracked continuously during the 3.5-year period. RESULTS: A significant reduction of 82.3% (p=.008) in the rate of seclusion and restraint was observed between the baseline phase (January 2005 through February 2006) and the follow-up, postintervention phase (April 2008 through June 2008). After control for illness severity and nonspecific effects associated with an observation-only phase, changes to the physical environment were uniquely associated with a significant reduction in rate of seclusion and restraint during the intervention rollout period. CONCLUSIONS: These data suggest that substantial reductions in use of seclusion and restraint are possible in inpatient psychiatric settings and that changes to the physical characteristics of the therapeutic environment may have a significant effect on use of seclusion and restraint.

Malignant catatonia in a patient with bipolar disorder, B12 deficiency, and neuroleptic malignant syndrome: one cause or three?

A Case is presented of a 23-year-old woman with progressive onset of paranoid psychosis and catatonia, who was ultimately found to have both vitamin B12 deficiency and a family history of bipolar disorder. The patient was initially diagnosed with schizophrenia and treated with the antipsychotic medication ziprasidone. Her condition rapidly worsened to a state consistent with either neuroleptic malignant syndrome or malignant catatonia. Work-up then revealed vitamin B12 deficiency and a family history of bipolar disorder. Her symptoms improved rapidly but partially with benzodiazepines and electrocon-vulsive therapy, and completely with addition of valproic acid, vitamin B12 replacement, and re-introduction of antipsychotic medication in the form of olanzapine. The authors discuss the differential diagnosis of catatonia as reflecting a high likelihood of underlying mood disorder; the evaluation and management of malignant catatonia and malignant neuroleptic syndrome; and the role of vitamin B12 deficiency in precipitating psychotic symptoms. The case also illustrates the problems of diagnosing and managing a multifactorial disorder with psychiatric, general medical, and perhaps iatrogenic components.

Psychiatry clerkship students' preparation, reflection, and results on the NBME Psychiatry Subject Exam.

OBJECTIVE: Psychiatry clerkship training involves many learning components, one of which is acquisition of scholarly knowledge. The authors investigate the reading materials and learning methods used by clinical clerks in their preparation for the National Board of Medical Examiners (NBME) Psychiatry Subject Exam (PSE). METHODS: Clerkship students from six U.S. medical schools who had recently completed their psychiatry clerkship and PSE were surveyed regarding reading material use, teaching methods encountered, and other relevant resources which may have influenced their PSE scores. RESULTS: The most frequently used PSE preparation material was a "step-or-prep" book, followed by practice questions, handouts, and assigned texts. No single preparation material type or combination proved significantly different in influencing PSE scores. The didactic methods used in clerkships did differ significantly in their influence on PSE scores. Students in the top quartile used slightly more books and different combinations of books than students in the bottom quartile. CONCLUSION: Students exhibited several trends in their preparation for the PSE. The most striking findings were the heavy student reliance on step-or-prep books over other learning resources and that step-or-prep books did not demonstrate significance as a superior preparation resource for the PSE. These trends in third-year psychiatric rotations have important implications for medical student education.

Enhancing patient safety in psychiatric settings.

OBJECTIVE: There is growing national consensus that use of institutional measures of control, such as seclusion, restraint, enforced medications, and hand-cuffed transport, within psychiatric hospitals is all too common and is potentially counter-therapeutic. Unfortunately, little is known about how to reduce such measures of last resort. This article reviews the available literature and describes a proposed research agenda involving a behavioral effort, the Engagement Model, for reducing seclusion and restraint procedures and enhancing patient safety in psychiatric settings. METHODS: Using Medline and PsychInfo, we reviewed studies that specifically evaluated efforts to reduce seclusion and restraint on psychiatric units. Key search terms included seclusion, restraint, reduc*, psychiatric patient safety, psychiatric safety, psychiatric sanctuary, and quality of care psychiatry. RESULTS: Only very limited data are available on reducing measures of last resort and improving the safety of psychiatric settings, and virtually no controlled data are available concerning the effectiveness of specific behavioral efforts on subsequent reduction of seclusion and restraint events. In light of the paucity of data, we describe efforts to incorporate and evaluate such a model in a large academic psychiatric hospital using a multiple baseline times-series design and review principles for and obstacles to implementing this model. CONCLUSIONS: It is hoped this discussion will stimulate research on this understudied topic and provide a framework for improving patient safety in psychiatric settings.

Evaluating initiatives to reduce seclusion and restraint.

The use of institutional measures of control such as seclusion and restraint within psychiatric hospitals is common and arguably countertherapeutic; however, little is known about how best to reduce the use of these measures. The development and implementation of new institutional strategies to reduce the use of seclusion and restraint are important. Although traditional performance improvement (PI) project methodology might seem well-suited to helping managers and administrators identify effective hospital-wide interventions to decrease seclusion and restraint rates, the Logic of the standard PI model precludes managers from making valid inferences about which interventions actually cause change. This article presents a model (derivative of the multiple baseline time-series design with randomization) for testing individual elements of a Large-scale PI project to reduce the use of seclusion and restraint in a behavioral healthcare organization. The proposed model is flexible, accommodates overlapping organizational initiatives, and simultaneously allows for meaningful inferences to be made about the active components of the interventions. The ability to make meaningful inferences is important because, if the initiatives to reduce seclusion and restraint rates work, other healthcare organizations would benefit from knowing Key Words which specific interventions actually Lead engagement model to change and which interventions have multiple baseline design Little impact on secLusion and restraint performance improvement rates. Early experiences with this model psychiatry from a hospital manager's perspective sanctuary trauma are discussed, along with the costs and benefits of using it.

How unusual are the "unusual events" detected by control chart techniques in healthcare settings?

Statistical process control (SPC) charts have become widely implemented tools for quality monitoring and assurance in healthcare settings across the United States. SPC methods have been successfully used in industrial settings to track the quality of products manufactured by machines and to detect deviations from acceptable Levels of product quality. However, problems may arise when SPC methods are used to evaluate human behavior. Specifically, when human behavior is tracked over time, the data stream generated usually exhibits periodicity and gradualism with respect to behavioral changes over time. These tendencies can be quantified and are recognized in the statistical field as autocorrelation. When autocorrelation is present, conventional SPC methods too often identify events as "unusuaL" when they really should be understood as products of random fluctuation. This article discusses the concept of autocorrelation and demonstrates the negative impact of autocorrelation on traditional SPC methods, with a specific focus on the use of SPC charts to detect unusual events.

An autocorrelation-corrected nonparametric control chart technique for health care quality applications.

Recently, Alemi proposed a nonparametric control chart technique (Tukey's control chart) for quality management applications when few data points are available and when data do not conform to the assumptions of traditional control chart techniques. Borckardt et al then published an empirical evaluation of the technique and concluded that the presence of autocorrelation in control-chart data negatively impacted the technique's ability to help managers make accurate decisions about the presence of special-cause variation in their data. Thus, there is still a need for control chart techniques that appropriately handle short data streams that do not necessarily conform to the assumptions of traditional control chart techniques but are not negatively impacted by autocorrelation in the data. In this article, the authors empirically evaluate a modified version of the technique presented by Alemi that is designed to account for autocorrelation. Empirical analyses indicate that the modified technique demonstrates superior false-positive performance with very little degradation of power compared with the original technique proposed by Alemi.