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Introduction: Access block is a pervasive problem, even during times of minimal boarding in the ED, suggesting suboptimal use of ED stretchers can contribute. A tracking board utility was embedded into the electronic health record in Calgary, AB, allowing MDs and RNs to consider patients who could be relocated from a stretcher to a chair. Objectives of this study were to evaluate the feature's impact on total stretcher time (TST) and ED length of stay (LOS) for patients relocated to a chair. We also sought to identify facilitators and barriers to the tool's use amongst ED MDs and RNs. Methods: A retrospective cohort design was used to compare TST between those where the tool was used and not used amongst patients relocated to a chair between September 1 2017 and August 15 2018. Each use of the location tool was time-stamped in an administrative database. Median TST and ED LOS were compared between patients where the tool was used and not used using a Mann-Whitney U Test. A cross sectional convenience sample survey was used to determine facilitators and barriers to the tool's use amongst ED staff. Response proportions were used to report Likert scale questions; thematic analysis was used to code themes. Results: 194882 patients met inclusion criteria. The tool was used 4301 times, with “Ok for Chairs” selected 3914(2%) times and “Not Ok for Chairs” selected 384(0.2%) times; 54462(30%) patients were moved to a chair without the tool's use. Mean age, sex, mode of arrival and triage scores were similar between both groups. Median (IQR) TST amongst patients moved to a chair via the prompt was shorter than when the prompt was not used [142.7 (100.5) mins vs 152.3 (112.3) mins, p < 0.001], resulting in 37574 mins of saved stretcher time. LOS was similar between both groups (p = 0.22). 125 questionnaires were completed by 90 ED nurses and 35 ED MDs. 95% of staff were aware of the tool and 70% agreed/strongly agreed the tool could improve ED flow; however, 38% reported only “sometimes” using the tool. MDs reported the most common barrier was forgetting to use the tool and lack of perceived action in relocating patients. Commonly reported nursing barriers were lack of chair space and increased workload. Conclusion: Despite minimal use of the tracking board utility, triggering was associated with reduced TST amongst ED patients eventually relocated to a chair. To encourage increased use, future versions should prompt staff to select a location.
Although financing represents a critical component of health system strengthening and also a defining concern of efforts to move towards universal health coverage, many countries lack the tools and capacity to plan effectively for service scale-up. As part of a multi-country collaborative study (the Emerald project), we set out to develop, test and apply a fully integrated health systems resource planning and health impact tool for mental, neurological and substance use (MNS) disorders.
A new module of the existing UN strategic planning OneHealth Tool was developed, which identifies health system resources required to scale-up a range of specified interventions for MNS disorders and also projects expected health gains at the population level. We conducted local capacity-building in its use, as well as stakeholder consultations, then tested and calibrated all model parameters, and applied the tool to three priority mental and neurological disorders (psychosis, depression and epilepsy) in six low- and middle-income countries.
Resource needs for scaling-up mental health services to reach desired coverage goals are substantial compared with the current allocation of resources in the six represented countries but are not large in absolute terms. In four of the Emerald study countries (Ethiopia, India, Nepal and Uganda), the cost of delivering key interventions for psychosis, depression and epilepsy at existing treatment coverage is estimated at US$ 0.06–0.33 per capita of total population per year (in Nigeria and South Africa it is US$ 1.36–1.92). By comparison, the projected cost per capita at target levels of coverage approaches US$ 5 per capita in Nigeria and South Africa, and ranges from US$ 0.14–1.27 in the other four countries. Implementation of such a package of care at target levels of coverage is expected to yield between 291 and 947 healthy life years per one million populations, which represents a substantial health gain for the currently neglected and underserved sub-populations suffering from psychosis, depression and epilepsy.
This newly developed and validated module of OneHealth tool can be used, especially within the context of integrated health planning at the national level, to generate contextualised estimates of the resource needs, costs and health impacts of scaled-up mental health service delivery.
The turkey (Meleagris gallopavo) was independently domesticated in Mesoamerica and the Southwest, the latter as the only case of Native American animal domestication north of Mexico. In the upland (non-desert) portion of the American Southwest, distinctive closely related mtDNA lineages belonging to haplogroup H1 (thought to indicate domestication) occur from ca. 1 A.D. (Basketmaker II period) through early historic times. At many sites, low frequencies of lineages belonging to haplogroup H2 also occur, apparently derived from the local Merriam’s subspecies. We report genetic, stable isotope, and coprolite data from turkey remains recovered at three early sites in SE Utah and SW Colorado dating to the Basketmaker II, III, and early Pueblo II periods. Evidence from these and other early sites indicates that both the H1 and H2 turkeys had a predominantly maize-based diet similar to that of humans; prior to late Pueblo II times, the birds were kept primarily to provide feathers for blankets and ritual uses; and ritualized burials indicate turkeys’ symbolic value. We argue that viewing individuals from the H1 and H2 haplogroups as “domestic” versus “wild” is an oversimplification.
Self-reported sleep disturbance (SD) is a distressing symptom in patients with advanced cancer. There are limited data on the treatment of SD and predictors to response of SD to outpatient supportive care clinic (OPC) consultation. The aims of our study was to determine the frequency, intensity, and correlates of SD as assessed with the Edmonton Symptom Assessment System (ESAS) sleep item at the time of initial consultation and identify the predictors of improvement in SD at follow-up.
We reviewed the records of consecutive patients with advanced cancer presenting to the OPC. ESAS scores were obtained at the initial and subsequent visits between January 2008 and February 2010. All patients underwent screening for SD (0–10 scale: 0 = best sleep, presence of SD defined as ≥3) and interdisciplinary assessment and treatment, including drug review, counseling, sleep hygiene review, and drug therapy. A response was defined as a 1-point improvement at the follow-up visit on the Edmonton Symptom Assessment Scale (ESAS) sleep item score. Baseline patient characteristics, medication use, and ESAS scores were analyzed to determine their association with response.
The median age was 58 years, and 53% of patients were men. The most common cancer type was head and neck or lung (36%). Of the 442 patients, 330 had baseline SD (score ≥3/10, 75%). Median and mean (standard deviation) baseline SD scores were 5 and 5.1 (2.9). The multivariable regression model found the intensity of baseline ESAS sleep item scores to be associated with baseline sedative use, baseline ESAS pain scores, baseline ESAS fatigue scores, baseline ESAS feeling of well-being scores, and sedative use (R2 = 0.22). Sleep disturbance response at first follow-up was seen in 196 of 330 patients (59%). Moderate to high SD score and anxiety at initial visit with odds ratios (OR) of 2.53 (p = 0.0007) and 1.59 (p = 0.048), respectively, were associated with a response.
Significance of results:
Both the frequency and severity of SD were high. Response to supportive care consultation was substantial. The severity of SD and anxiety at the initial visit predicted a response at first follow-up. Further research is needed.
Cannabis use has been reported to be associated with an earlier onset of symptoms in patients with first-episode psychosis, and a worse outcome in those who continue to take cannabis. In general, studies have concentrated on symptoms of psychosis rather than mania. In this study, using a longitudinal design in a large naturalistic cohort of patients with first-episode psychosis, we investigated the relationship between cannabis use, age of presentation to services, daily functioning, and positive, negative and manic symptoms.
Clinical data on 502 patients with first-episode psychosis were collected using the MiData audit database from seven London-based Early Intervention in psychosis teams. Individuals were assessed at two time points – at entry to the service and after 1 year. On each occasion, the Positive and Negative Syndrome Scale, Young Mania Rating Scale and Global Assessment of Functioning Scale disability subscale were rated. At both time points, the use of cannabis and other drugs of abuse in the 6 months preceding each assessment was recorded.
Level of cannabis use was associated with a younger age at presentation, and manic symptoms and conceptual disorganization, but not with delusions, hallucinations, negative symptoms or daily functioning. Cannabis users who reduced or stopped their use following contact with services had the greatest improvement in symptoms at 1 year compared with continued users and non-users. Continued users remained more symptomatic than non-users at follow-up.
Effective interventions for reducing cannabis use may yield significant health benefits for patients with first-episode psychosis.
While bipolar disorder (BD) is a leading cause of disability, and an important contributor to disability in BD is cognitive impairment, there is little systematic research on the longitudinal course of cognitive function and instrumental activities of daily living (IADLs) in late-life. In this report, we characterize the 2-year course of cognitive function and IADLs in older adults with BD.
We recruited non-demented individuals 50 years and older with BD I or BD II (n = 47) from out-patient clinics or treatment studies at the University of Pittsburgh. Comparator subjects (‘controls’) were 22 individuals of comparable age and education with no psychiatric or neurologic history, but similar levels of cardiovascular disease. We assessed cognitive function and IADLs at baseline, 1- and 2-year time-points. The neuropsychological evaluation comprised 21 well-established and validated tests assessing multiple cognitive domains. We assessed IADLs using a criterion-referenced, performance-based instrument. We employed repeated-measures mixed-effects linear models to examine trajectory of cognitive function. We employed non-parametric tests for analysis of IADLs.
The BD group displayed worse cognitive function in all domains and worse IADL performance than the comparator group at baseline and over follow-up. Global cognitive function and IADLs were correlated at all time-points. The BD group did not exhibit accelerated cognitive decline over 2 years.
Over 2 years, cognitive impairment and associated functional disability of older adults with BD appear to be due to long-standing neuroprogressive processes compounded by normal cognitive aging rather than accelerated cognitive loss in old age.