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  • 1
    Online Resource
    Online Resource
    Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice
    BMJ ; 2022
    In:  BMJ Open Vol. 12, No. 5 ( 2022-05), p. e059876-
    Details
    In: BMJ Open, BMJ, Vol. 12, No. 5 ( 2022-05), p. e059876-
    Abstract: Agitation, defined as excessive psychomotor activity leading to aggressive or violent behaviour, is prevalent in the emergency department (ED) due to rising behavioural-related visits. Experts recommend use of verbal de-escalation and avoidance of physical restraint to manage agitation. However, bedside applications of these recommendations may be limited by system challenges in emergency care. This qualitative study aims to use a systems-based approach, which considers the larger context and system of healthcare delivery, to identify sociotechnical, structural, and process-related factors leading to agitation events and physical restraint use in the ED. Design Qualitative study using a grounded theory approach to triangulate interviews of patients who have been physically restrained with direct observations of agitation events. Setting Two EDs in the Northeast USA, one at a tertiary care academic centre and the other at a community-based teaching hospital. Participants We recruited 25 individuals who experienced physical restraint during an ED visit. In addition, we performed 95 observations of clinical encounters of agitation events on unique patients. Patients represented both behavioural (psychiatric, alcohol/drug use) and non-behavioural (medical, trauma) chief complaints. Results Three primary themes with implications for systems-based practice of agitation events in the ED emerged: (1) pathways within health and social systems; (2) interpersonal contexts as reflections of systemic stressors on behavioural emergency care and (3) systems-based and patient-oriented strategies and solutions. Conclusions Agitation events represented manifestations of patients’ structural barriers to care from socioeconomic inequities and high burden of emotional and physical trauma as well as staff members’ simultaneous exposure to external stressors from social and healthcare systems. Potential long-term solutions may include care approaches that recognise agitated patients’ exposure to psychological trauma, improved coordination within the mental health emergency care network, and optimisation of physical environment conditions and organisational culture.
    Type of Medium: Online Resource
    ISSN: 2044-6055 , 2044-6055
    URL: Article
    DOI: 10.1136/bmjopen-2021-059876
    Language: English
    Publisher: BMJ
    Publication Date: 2022
    detail.hit.zdb_id: 2599832-8
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  • 2
    Online Resource
    Online Resource
    Improving patient and clinician safety during COVID-19 through rapidly adaptive simulation and a randomised controlled trial: a study protocol
    BMJ ; 2022
    In:  BMJ Open Vol. 12, No. 5 ( 2022-05), p. e058980-
    Details
    In: BMJ Open, BMJ, Vol. 12, No. 5 ( 2022-05), p. e058980-
    Abstract: COVID-19 required healthcare systems to iteratively adapt for safe and up-to-date care as knowledge of the disease rapidly evolved. Rates of COVID-19 infections continue to fluctuate and patients without COVID-19 increasingly return to the emergency department (ED) for care. This leads to new challenges and threats to patient and clinician safety as suspected patients with COVID-19 need to be quickly detected and isolated among other patients with non-COVID-19-related illnesses. At the front lines, emergency physicians also face continued personal safety concerns and increased work burden, which heighten stress and anxiety, especially given the prolonged course of the pandemic. Burnout, already a serious concern for emergency physicians due to the cumulative stresses of their daily practice, may present as a longer-term outcome of these acute stressors. Methods and analysis We will implement a rapidly adaptive simulation-based approach to understand and improve physician preparedness while decreasing physician stress and anxiety. First, we will conduct semi-structured qualitative interviews and human factor observations to determine the challenges and facilitators of COVID-19 preparedness and mitigation of physician stress. Next, we will conduct a randomised controlled trial to test the effectiveness of a simulation preparedness intervention on physician physiological stress as measured by decreased heart rate variability on shift and anxiety as measured by the State-Trait Anxiety Inventory. Ethics and dissemination The protocol was reviewed and approved by the Agency for Healthcare Research and Quality for funding, and ethics approval was obtained from the Yale University Human Investigation Committee in 2020 (HIC# 2000029370 and 2000029372). To support ongoing efforts to address clinician stress and preparedness, we will strategically disseminate the simulation intervention to areas most impacted by COVID-19. Using a virtual telesimulation and webinar format, the dissemination efforts will provide hands-on learning for ED and hospital administrators as well as simulation educators. Trial registration number NCT04614844 .
    Type of Medium: Online Resource
    ISSN: 2044-6055 , 2044-6055
    URL: Article
    DOI: 10.1136/bmjopen-2021-058980
    Language: English
    Publisher: BMJ
    Publication Date: 2022
    detail.hit.zdb_id: 2599832-8
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  • 3
    Online Resource
    Online Resource
    Study protocol for the ACT response pilot intervention: development, implementation and evaluation of a systems-based Agitation Code Team (ACT) in the emergency department
    BMJ ; 2020
    In:  BMJ Open Vol. 10, No. 6 ( 2020-06), p. e036982-
    Details
    In: BMJ Open, BMJ, Vol. 10, No. 6 ( 2020-06), p. e036982-
    Abstract: Emergency department (ED) visits for behavioural conditions are rising, with 1.7 million associated episodes of patient agitation occurring annually in acute care settings. When de-escalation techniques fail during agitation management, patients are subject to use of physical restraints and sedatives, which are associated with up to 37% risk of hypotension, apnoea and physical injuries. At the same time, ED staff report workplace violence due to physical assaults during agitation events. We recently developed a theoretical framework to characterise ED agitation, which identified teamwork as a critical component to reduce harm. Currently, no structured team response protocol for ED agitation addressing both patient and staff safety exists. Methods and analysis Our proposed study aims to develop and implement the agitation code team (ACT) response intervention, which will consist of a standardised, structured process with defined health worker roles/responsibilities, work processes and clinical protocols. First, we will develop the ACT response intervention in a two-step design loop; conceptual design will engage users in the creation of the prototype, and iterative refinement will occur through in situ simulated agitated patient encounters in the ED to assess and improve the design. Next, we will pilot the intervention in the clinical environment and use a controlled interrupted time series design to evaluate its effect on our primary outcome of patient restraint use. The intervention will be considered efficacious if we effectively lower the rate of restraint use over a 6-month period. Ethics and dissemination Ethical approval by the Yale University Human Investigation Committee was obtained in 2019 (HIC #2000025113). Results will be disseminated through peer-reviewed publications and presentations at scientific meetings for each phase of the study. If this pilot is successful, we plan to formally integrate the ACT response intervention into clinical workflows at all EDs within our entire health system.
    Type of Medium: Online Resource
    ISSN: 2044-6055 , 2044-6055
    URL: Article
    DOI: 10.1136/bmjopen-2020-036982
    Language: English
    Publisher: BMJ
    Publication Date: 2020
    detail.hit.zdb_id: 2599832-8
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  • 4
    Online Resource
    Online Resource
    31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016): part two : National Harbor, MD, USA. 9-13 November 2016
    BMJ ; 2016
    In:  Journal for ImmunoTherapy of Cancer Vol. 4, No. S1 ( 2016-11)
    Details
    In: Journal for ImmunoTherapy of Cancer, BMJ, Vol. 4, No. S1 ( 2016-11)
    Type of Medium: Online Resource
    ISSN: 2051-1426
    URL: Article
    DOI: 10.1186/s40425-016-0173-6
    Language: English
    Publisher: BMJ
    Publication Date: 2016
    detail.hit.zdb_id: 2719863-7
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  • 5
    Online Resource
    Online Resource
    International recommendations for a vascular access minimum dataset: a Delphi consensus-building study
    BMJ ; 2021
    In:  BMJ Quality & Safety Vol. 30, No. 9 ( 2021-09), p. 722-730
    Details
    In: BMJ Quality & Safety, BMJ, Vol. 30, No. 9 ( 2021-09), p. 722-730
    Abstract: Data regarding vascular access device use and outcomes are limited. In part, this gap reflects the absence of guidance on what variables should be collected to assess patient outcomes. We sought to derive international consensus on a vascular access minimum dataset. Methods A modified Delphi study with three rounds (two electronic surveys and a face-to-face consensus panel) was conducted involving international vascular access specialists. In Rounds 1 and 2, electronic surveys were distributed to healthcare professionals specialising in vascular access. Survey respondents were asked to rate the importance of variables, feasibility of data collection and acceptability of items, definitions and response options. In Round 3, a purposive expert panel met to review Round 1 and 2 ratings and reach consensus (defined as ≥70% agreement) on the final items to be included in a minimum dataset for vascular access devices. Results A total of 64 of 225 interdisciplinary healthcare professionals from 11 countries responded to Round 1 and 2 surveys (response rate of 34% and 29%, respectively). From the original 52 items, 50 items across five domains emerged from the Delphi procedure.Items related to demographic and clinical characteristics (n=5; eg, age), device characteristics (n=5; eg, device type), insertion (n=16; eg, indication), management (n=9; eg, dressing and securement), and complication and removal (n=15, eg, occlusion) were identified as requirements for a minimum dataset to track and evaluate vascular access device use and outcomes. Conclusion We developed and internally validated a minimum dataset for vascular access device research. This study generated new knowledge to enable healthcare systems to collect relevant, useful and meaningful vascular access data. Use of this standardised approach can help benchmark clinical practice and target improvements worldwide.
    Type of Medium: Online Resource
    ISSN: 2044-5415 , 2044-5423
    URL: Article
    DOI: 10.1136/bmjqs-2020-011274
    Language: English
    Publisher: BMJ
    Publication Date: 2021
    detail.hit.zdb_id: 2592912-4
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