Implementation of a Children's Hospital Acute Care Behavior Response Team.

BACKGROUND: Pediatric patients with behavioral needs are frequently admitted to the hospital for medical care; when behavioral crises occur, patients and staff are at risk for injury. Our aim was to implement a behavior response team (BRT) to increase the days between employee injury due to aggressive patient interactions on the inpatient medical units from 99 to 150 over 1 year. METHODS: A multidisciplinary team used quality improvement methods to design and implement the BRT system that includes 2 options: huddle to proactively plan for patients exhibiting early signs of escalation and STAT for immediate help for patients with imminent risk of harm to self or others. Using run and statistical process control charts, we tracked events per month, days between Occupational Safety & Health Administration-recordable events, and violent restraint use over time for 1 year after implementation. Staff pre and postimplementation surveys were compared to assess staff perception of safety and support provided by the BRT intervention. RESULTS: The BRT was implemented across the inpatient system in July 2020, with an average number of 13 events per month. Days between Occupational Safety & Health Administration-recordable events remained stable with a maximum of 134 days. Restraint use remained stable at 0.74 per 1000 patient days. The perception of behavioral support available to staff increased significantly pre to postsurvey. CONCLUSIONS: The implementation of a BRT can improve staff perception of support and confidence in safely caring for patients with behavior needs on the inpatient medical unit, although additional provider- and system-level improvements are needed to prevent employee injuries.

Should Tactile Defensiveness Exclude a Life-Sustaining Intervention in an Adolescent With Autism?

This Ethics Rounds considers the benefits and burdens of a potentially temporary tracheostomy in an adolescent with autism and severe tactile defensiveness.

The Respiratory Therapy Practice-Based Outcomes Initiative (RT-PBOI): Developing a framework to explore the value added by respiratory therapists to health care in Alberta.

BACKGROUND: There exists a political imperative to have access to data that meets the needs of health care administrators, governments, and funding bodies to support evidence-informed decision making. It is incumbent upon respiratory therapists to examine how they can deliver the highest-quality patient care, but also that they add value to health systems that ensure the benefits of health innovations are shared equitably among all members of our communities. PURPOSE: To explore the perceived value contributed by the respiratory therapy profession to health care and the health care system in the Province of Alberta at patient, team, and system levels. RESEARCH METHODS: An interpretive descriptive approach was adopted, including the formation of a description and exploration of possible associations, relationships, and patterns within a field of practice. CONCLUSIONS: The qualitative data analysis uncovered a framework that could inform research efforts of the respiratory therapy community in a way that contributes to the proposed mechanisms by which the profession generates value for the organization and patients. The RT-PBOI Conceptual Model identified five key concepts relating to the value contributed by respiratory therapists to health care: technical skills, practice across settings, strategic expertise, tools that leverage capacity, and growing value into the future.

Clozapine for Drug-Refractory Irritability in Individuals with Developmental Disability.

OBJECTIVES: In this case series, we describe the acute clinical impact and tolerability of rapid titration of clozapine for treatment of refractory irritability in five hospitalized youth with developmental disability. We offer this descriptive report in an effort to expand the evidence base guiding treatment of refractory aggression in this population. METHODS: Five youth with developmental disability and severe irritability were admitted to a 10-bed psychiatric crisis stabilization unit where they received thorough psychiatric and medical evaluation. Informed consent was obtained in each case, and each patient underwent rapid titration onto clozapine. Clozapine monitoring guidelines were followed for all patients throughout treatment, and clinical severity at baseline and improvement with treatment was measured by use of the Clinical Global Impressions-Severity scale (CGI-S) and the Clinical Global Impressions-Improvement scale (CGI-I). RESULTS: One female and four males diagnosed with developmental disability and at least one other psychiatric diagnosis, mean age of 13.1 ± 2.1 years, and mean CGI-S at baseline of 5.8, each received clozapine treatment by rapid titration. The mean therapeutic total daily dose of clozapine was 380 ± 200 mg. All patients demonstrated acute clinical improvement with the mean final CGI-I of 2.0, or "much improved." CONCLUSION: These initial results support the potential utility of clozapine rapid titration for treatment of severe refractory irritability in youth with developmental disability. These patients tolerated clozapine treatment in the short term. Future studies are needed to thoroughly evaluate the long-term safety of clozapine treatment in this population.

Autism spectrum disorders.

Autism spectrum disorders are being diagnosed with increasing frequency. The likelihood that a primary care provider will see a patient with autism spectrum disorder in their clinic is high. In this article, current diagnostic criteria and expected changes in DSM criteria, as well as prevalence rates and epidemiologic studies are reviewed. Recommendations for screening, including early warning signs, and best practices for diagnosis are discussed. Comprehensive evidence based intervention for ASD as well as the findings of the National Standards Project are reviewed. Medication management is also described, as are the roles of other treating professionals.