Headaches from practice guidelines

Patient Safety Strategies in Psychiatry and How They Construct the Notion of Preventable Harm: A Scoping Review

OBJECTIVES

The literature on patient safety in psychiatry has not been explored systematically in terms of what interventions are used, how they are used, and what type of (preventable) harm is targeted. The aims of this scoping review are to explore patient safety strategies used in psychiatry and determine how they construct the notion of preventable harm.

METHOD

A scoping review of literature on patient safety in psychiatry published in English between 2000 and 2019 was conducted using Scopus, MEDLINE, PsycInfo, and CINAHL. Keywords of patient safety strategies and possible outcomes were coded from the results, discussion, or conclusion. Patient safety strategies were inductively categorized into themes according to the focus of the strategy.

RESULTS

The review introduces 7 focus areas of patient safety strategies identified within the psychiatric literature: "risk management," "healthcare practitioners," "patient observation," "patient involvement," "computerized methods," "admission and discharge," and "security." The result shows that patient safety strategies mainly aim to reduce suicide, self-harm, violence, and falls and present a large diversity of measures, often aimed at reducing variability while increasing standardization.

CONCLUSIONS

The strategies that are supported in the literature to achieve safer psychiatry mainly arise from linear cause-effect models and rely on staff performance, competence, and compliance. Contemporary safety science acknowledges the performance variability of everyday normal work and sees risk as the dynamic migration of these daily activities. The field of psychiatry has not yet included this view of safety in the strategic actions to reduce preventable harm.

Knowledge translation of the American College of Emergency Physicians' clinical policy on syncope using computerized clinical decision support

Aims

To influence physician practice behavior after implementation of a computerized clinical decision support system (CDSS) based upon the recommendations from the 2007 ACEP Clinical Policy on Syncope.

Methods

This was a pre-post intervention with a prospective cohort and retrospective controls. We conducted a medical chart review of consecutive adult patients with syncope. A computerized CDSS prompting physicians to explain their decision-making regarding imaging and admission in syncope patients based upon ACEP Clinical Policy recommendations was embedded into the emergency department information system (EDIS). The medical records of 410 consecutive adult patients presenting with syncope were reviewed prior to implementation, and 301 records were reviewed after implementation. Primary outcomes were physician practice behavior demonstrated by admission rate and rate of head computed tomography (CT) imaging before and after implementation.

Results

There was a significant difference in admission rate pre- and post-intervention (68.1% vs. 60.5% respectively, p = 0.036). There was no significant difference in the head CT imaging rate pre- and post-intervention (39.8% vs. 43.2%, p = 0.358). There were seven physicians who saw ten or more patients during the pre- and post-intervention. Subset analysis of these seven physicians’ practice behavior revealed a slight significant difference in the admission rate pre- and post-intervention (74.3% vs. 63.9%, p = 0.0495) and no significant difference in the head CT scan rate pre- and post-intervention (42.9% vs. 45.4%, p = 0.660).

Conclusions

The introduction of an evidence-based CDSS based upon ACEP Clinical Policy recommendations on syncope correlated with a change in physician practice behavior in an urban academic emergency department. This change suggests emergency medicine clinical practice guideline recommendations can be incorporated into the physician workflow of an EDIS to enhance the quality of practice.

ED Treatment of Migraine Headache: Factors Influencing Pharmacotherapeutic Choices

STUDY OBJECTIVE

To evaluate the factors that influence clinicians' choices of parenteral medications in the emergency department (ED) management of migraine headache.

BACKGROUND

Migraine headache is a common problem in the United States. Many migraineurs require periodic ED management. Though a large variety of parenteral medications are used by ED clinicians in the treatment of migraine, little research has been directed to the reasons why providers use the medications they do.

METHODS

This study used a self-administered questionnaire for providers from 3 geographically distinct EDs to evaluate their pharmacotherapeutic preferences in the treatment of uncomplicated migraine based on a fictitious scenario. Factors influencing medication choices were rated on a 5-point Likert scale and analyzed descriptively. Hypothetical practice patterns from the questionnaires were compared with actual practice patterns from a prior study from the same institutions.

RESULTS

Eighty-three percent of surveys were returned, the majority from attending physicians (71%), as their initial drugs-of-choice providers preferred dopaminergic antiemetics (93%) and parenteral NSAIDs (22%). If initial therapy failed, opioids (40%) with nonspecific antiemetics (24%) were preferred as second-line agents. Choice of therapy was influenced (in descending order) by medication availability and its antimigraine properties, the providers' training, current departmental practice patterns, and national practice guideline recommendations. Opioid use was influenced by patients' failure to respond to ED and outpatient alternatives and the presence of contraindications/intolerances to non-opioids. When these results were compared to a prior study of actual practice patterns, a range of discordance was observed, which varied significantly by institution.

CONCLUSION

Emergency clinicians report that a variety of factors influence their parenteral pharmacotherapy in the management of patients with migraine headache. The comparison of hypothetical practice patterns with actual practice patterns reveals a range of institution-specific discordance. There is discordance between providers' responses to a fictitious scenario and their previously recorded practice patterns with regional variation.

Variations among emergency departments in the treatment of benign headache

STUDY OBJECTIVE

The practice patterns of US emergency departments in the treatment of patients with isolated benign headache have been recently described. How treatment varies among EDs has not been reported. To assess institutional variability in the pharmacotherapy of patients with benign headache, we describe and analyze the practice patterns of 3 US EDs.

METHODS

This health records survey included a cohort sample of consecutive adult patients aged 16 to 65 years treated with parenteral medication for isolated benign headache at 3 nonaffiliated US EDs: a large, group-model health maintenance organization, a tertiary-care academic center, and a rural community hospital. Patients who underwent a diagnostic search for intracranial pathology, who had any nonheadache secondary diagnosis, or who had coexistent trauma, fever (temperature of > or =38.0 degrees C [100.4 degrees F]), or known pregnancy were excluded from study analysis. Demographic, clinical, and pharmacotherapeutic variables were collected for each ED visit. Descriptive analyses were performed; comparisons were made with t tests.

RESULTS

Of the 490 eligible patients treated during the 4-month study period, the mean age was 36.4 years, and 374 (76%) were women. During their 629 visits, 364 (58%) received a migraine diagnosis, and 258 (41%) received a nonspecific headache diagnosis. Polypharmacy was common: 515 (82%) received 2 or more medications, and 154 (25%) received 3 or more medications. Pharmacotherapy varied greatly among the EDs. Use of opioid agonists showed the widest variation (16% to 72%), although use of dihydroergotamine (5% to 16%), prochlorperazine (32% to 59%), and adjunct diphenhydramine with prochlorperazine (42% versus 88%) also varied.

CONCLUSION

Great institutional variability exists among US EDs in the parenteral treatment of patients with isolated benign headache.