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The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates’ mental health and patient outcomes.
Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15–20 min modules, totaling 1.5–2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments.
Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = −0.41), peritraumatic distress (d = −0.24), and experiential avoidance (d = −0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = −0.94), depression (d = −0.23), anxiety (d = −0.29), and experiential avoidance (d = −0.30).
Significance of results
Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.
Emergency physicians evaluate over 12 million patients with wounds in emergency departments (EDs) each year. They provide a wide spectrum of wound care, including laceration repair. This chapter addresses wound assessment and modalities of laceration repair.
As the body's largest and the most exposed organ, the skin is subject to a variety of external forces encountered in daily activities. The skin's anatomic structure and layers must be considered when planning a repair (Figure C.1).
Lacerations penetrating only the epidermis are minor and may not warrant major repair. The underlying dermis is one to several millimeters thick depending on its location on the body. The repair of this layer provides structural integrity for a healing wound. In some cases, especially wounds under tension, a separate deep dermal layer of closure may be required. The dermis rests on subcutaneous tissue which contains adipose and other loose connective tissue. The repair of subcutaneous tissue does not contribute to final wound strength. Re-approximation of subcutaneous tissue can eliminate potential spaces, thereby decreasing risk of infection in selected wounds.
Wound healing and the final cosmetic outcome of a laceration repair depend on many factors, including dynamic and static tension. Static tension is determined by intrinsic skin factors such as collagen concentration. Anatomic determinants such as underlying bone, tendon, muscle and location over a joint space impact the dynamic tension of the repaired laceration. Natural lines of tension exist all over the body (Figure C.2).
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