Technology-Enhanced Stepped Collaborative Care Targeting Posttraumatic Stress Disorder and Comorbidity After Injury: A Randomized Controlled Trial

Posttraumatic stress disorder (PTSD) and its comorbidities are endemic among injured trauma survivors. Previous collaborative care trials targeting PTSD after injury have been effective, but they have required intensive clinical resources. The present pragmatic clinical trial randomized acutely injured trauma survivors who screened positive on an automated electronic medical record PTSD assessment to collaborative care intervention (n = 60) and usual care control (n = 61) conditions. The stepped measurement-based intervention included care management, psychopharmacology, and psychotherapy elements. Embedded within the intervention were a series of information technology (IT) components. PTSD symptoms were assessed with the PTSD Checklist at baseline prerandomization and again, 1-, 3-, and 6-months postinjury. IT utilization was also assessed. The technology-assisted intervention required a median of 2.25 hours (interquartile range = 1.57 hours) per patient. The intervention was associated with modest symptom reductions, but beyond the margin of statistical significance in the unadjusted model: F(2, 204) = 2.95, p = .055. The covariate adjusted regression was significant: F(2, 204) = 3.06, p = .049. The PTSD intervention effect was greatest at the 3-month (Cohen's effect size d = 0.35, F(1, 204) = 4.11, p = .044) and 6-month (d = 0.38, F(1, 204) = 4.10, p = .044) time points. IT-enhanced collaborative care was associated with modest PTSD symptom reductions and reduced delivery times; the intervention model could potentially facilitate efficient PTSD treatment after injury.

Stepped Collaborative Care Targeting Posttraumatic Stress Disorder Symptoms and Comorbidity for US Trauma Care Systems: A Randomized Clinical Trial

Importance

To date, few multisite investigations have evaluated early interventions for injured patients with posttraumatic stress disorder (PTSD) symptoms.

Objective

To simultaneously assess the effectiveness and implementation of a brief stepped collaborative care intervention targeting PTSD and comorbidity.

Design, Setting, and Participants

A stepped-wedge cluster randomized clinical trial was conducted at 25 US level I trauma centers. Participants included hospitalized survivors of physical injury who underwent a 2-step evaluation for PTSD symptoms. Patients reporting high levels of distress on the PTSD Checklist (PCL-C) were randomized (N = 635) per the stepped-wedge protocol to enhanced usual care control (n = 370) or intervention (n = 265) conditions. The study was conducted from January 4, 2016, through November 2018. Data analysis was performed from November 4, 2019, to December 8, 2020.

Interventions

The Trauma Survivors Outcomes and Support collaborative care intervention included proactive injury case management that assisted patients transitioning from hospital inpatient to outpatient and community settings. The intervention also integrated evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD symptoms and comorbidity.

Main Outcomes and Measures

The primary study outcome was PTSD symptoms assessed with the PCL-C at baseline in the surgical ward and at 3, 6, and 12 months postinjury. Secondary outcomes included depressive symptoms, alcohol use, and physical function. Subgroup analyses examined the effect of baseline risk factors for enduring PTSD and quality of protocol implementation on study outcomes. Primary statistical analyses were conducted using the intent-to-treat sample.

Results

A total of 327 men (51.5%) were included in analysis; mean (SD) age was 39.0 (14.2) years. The investigation attained follow-up of 75% to 80% of the participants at 3 to 12 months. The intervention lasted a mean (SD) of 122 (132) minutes. Mixed model regression analyses revealed statistically significant changes in PCL-C scores for intervention patients compared with control patients at 6 months (difference, -2.57; 95% CI, -5.12 to -0.03; effect size, 0.18; P < .05) but not 12 months (difference, -1.27; 95% CI, -4.26 to 1.73; effect size, 0.08; P = .35). Subgroup analyses revealed larger PTSD treatment effects for patients with 3 or more baseline risk factors for enduring PTSD and for patients, including firearm injury survivors, treated at trauma centers with good or excellent protocol implementation. Intervention effects for secondary outcomes did not attain statistical significance.

Conclusions and Relevance

A brief stepped collaborative care intervention was associated with significant 6-month but not 12-month PTSD symptom reductions. Greater baseline PTSD risk and good or excellent trauma center protocol implementation were associated with larger PTSD treatment effects. Orchestrated efforts targeting policy and funding should systematically incorporate the study findings into national trauma center requirements and verification criteria.

Trial Registration

ClinicalTrials.gov Identifier: NCT02655354.

Sexual risk behaviors among teens at an urban emergency department: relationship with violent behaviors and substance use

PURPOSE

Data regarding sexual risk behaviors among adolescent patients presenting to urban emergency departments (EDs) are lacking. This article describes rates and correlates of sexual risk behaviors among adolescents screened in an urban ED.

METHODS

During a period of 1-year, a total of 1,576 patients aged 14-18 years, self-administered a computerized survey (57.6% female, 59.3% African American).

RESULTS

Among sexually active adolescents (60%), 12% reported four or more partners; of those, 45.3% reported using a condom all the time and 14.7% reported using substances before sex. Regression analyses examined correlates of sexual risk behaviors on the basis of demographics, violence, and substance use. Males and younger teens were more likely to report condom use than females and older teens. Participants with poor grades were more likely to have had sex and used substances before sex, and were less likely to report condom use. Participants reporting dating violence were more likely to have had sex and less likely to have used condoms, whereas participants reporting peer violence and weapon carriage were more likely to report substance use before sex. Binge drinking and marijuana use were associated with all sex risk behaviors.

CONCLUSIONS

The visit to an urban ED may provide an opportunity to deliver interventions to address sexual risk behaviors among adolescents.

A multifaceted intervention for infants with failure to thrive. A prospective study

OBJECTIVE

To determine whether a multifaceted intervention decreased the incidence of failure to thrive (FTT) in a group of preterm infants with low birth weights and improved the 3-year intelligence, health, growth, and behavior status of the children with FTT.

DESIGN

Three-year, prospective, randomized, clinical trial.

SETTING

Eight large university hospital sites throughout the United States.

SAMPLE

Nine hundred fourteen preterm infants with low birth weights who were born at the sites and met study criteria.

INTERVENTION

Home visits weekly during the first year of life and biweekly thereafter until the age of 3 years to provide family support and implement two curricula; and attendance at a child development center from 12 months until 3 years of age, 5 days a week, to deliver an early childhood educational intervention.

RESULTS

The incidence of FTT did not differ between the treatment and control groups (20% vs 22%). Overall, children with FTT in the treatment group were not different from children with FTT in the follow-up group on any of the outcome variables. However, after controlling for other factors, treatment group membership significantly contributed to the prediction model of 36-month IQ (P = .005) for the children with FTT. In addition, children with FTT in the intervention group with higher compliance demonstrated higher 3-year IQ and better behavior scores than the children with FTT in the low-compliance group.

CONCLUSIONS

The intervention did not change the incidence of FTT or the 3-year outcomes in this low-birth-weight, preterm cohort. After controlling for multiple independent variables, marked effects on 3-year IQ were noted. In addition, these beneficial effects were most pronounced in families that were most complaint with the intervention.

The relationship between cumulative risk and promotive factors and violent behavior among urban adolescents

Resiliency theory posits that some youth exposed to risk factors do not develop negative behaviors due to the influence of promotive factors. This study examines the effects of cumulative risk and promotive factors on adolescent violent behavior and tests two models of resilience-the compensatory model and the protective model-in a sample of adolescent patients (14-18 years old; n = 726) presenting to an urban emergency department who report violent behavior. Cumulative measures of risk and promotive factors consist of individual characteristics and peer, family, and community influences. Hierarchical multiple regression was used to test the two models of resilience (using cumulative measures of risk and promotive factors) for violent behavior within a sample of youth reporting violent behavior. Higher cumulative risk was associated with higher levels of violent behavior. Higher levels of promotive factors were associated with lower levels of violent behavior and moderated the association between risk and violent behaviors. Our results support the risk-protective model of resiliency and suggest that promotive factors can help reduce the burden of cumulative risk for youth violence.

Sex differences in characteristics of adolescents presenting to the emergency department with acute assault-related injury

OBJECTIVES

Adolescents with a history of peer assault are known to report high rates of other risky behaviors. The characteristics of adolescents seeking care in the ED for acute assault-related injury are less well established. This knowledge deficit is particularly noticeable for adolescent female victims of peer assault. This study's objectives were: 1) to characterize the demographics and risk behaviors of youths presenting to the emergency department (ED) with acute assault-related injury and 2) to compare assaulted youths' demographic characteristics, past experiences with violence, and other risk behaviors by sex.

METHODS

A systematic sample of adolescents (ages 14 to 18 years) presenting to an urban ED with acute assault-related injury (excluding dating violence, sexual assault, and child abuse) was recruited. Consenting participants self-administered a computerized survey about demographics, history of peer and dating aggression, and theoretical correlates of violence (e.g., alcohol and other drug use, depressive symptoms, weapon carriage). Multivariate logistic regression was performed to identify factors that were differentially associated with presentation to the ED for acute assault-related injury for females versus males.

RESULTS

Of 3,338 adolescents completing a screening survey during the 36-month study period, 197 had presented to the ED with acute assault-related injuries; seven of these were excluded from this study due to being victims of dating violence. Most (n = 179, 94.2%) of these 190 acutely assaulted participants were discharged home. The majority reported a history of past-year peer aggression (n = 160, 84.2%) and past-year violent injury (n = 106, 55.8%). Similar rates of past-year peer aggression, past-year violent injury, alcohol use, and weapon carriage were observed for adolescent males and females presenting with acute assault-related injury. Males and females also reported similar age, race, socioeconomic status, and education levels. Compared to males, females were less likely to report living with a parent (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.08 to 0.84) and were more likely to report depressive symptoms (OR = 2.59, 95% CI = 1.23 to 5.48) and past-year dating aggression (OR = 2.23, 95% CI = 1.04 to 4.82).

CONCLUSIONS

Male and female adolescents with acute assault-related injuries were very similar. Both reported extremely high rates of past year peer violence, assault-related injury, and substance use. The greater prevalence of some risk factors among adolescent females, such as depressive symptoms, dating aggression, and independent living status, should be further investigated.

Substance use and posttraumatic stress disorder symptoms in trauma center patients receiving mandated alcohol screening and brief intervention

In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N=878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n=166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of college policy targeting integrated substance abuse treatment at trauma centers.

Prescription opioid use among addictions treatment patients: nonmedical use for pain relief vs. other forms of nonmedical use

BACKGROUND

Differences between those who engage in nonmedical prescription opioid use for reasons other than pain relief and those who engage in nonmedical use for reasons related to pain only are not well understood.

METHODS

Adults in a residential treatment program participated in a cross-sectional self-report survey. Participants reported whether they used opioids for reasons other than pain relief (e.g., help sleep, improve mood, or relieve stress). Within those with past-month nonmedical opioid use (n=238), logistic regression tested differences between those who reported use for reasons other than pain relief and those who did not.

RESULTS

Nonmedical use of opioids for reasons other than pain relief was more common (66%) than nonmedical use for pain relief only (34%), and those who used for reasons other than pain relief were more likely to report heavy use (43% vs. 11%). Nonmedical use for reasons other than pain relief was associated with having a prior overdose (odds ratio [OR]=2.54, 95% CI: 1.36-4.74) and use of heroin (OR=4.08, 95% CI: 1.89-8.79), barbiturates (OR=6.44, 95% CI: 1.47, 28.11), and other sedatives (OR=5.80, 95% CI: 2.61, 12.87). Individuals who reported nonmedical use for reasons other than pain relief had greater depressive symptoms (13.1 vs. 10.5) and greater pain medication expectancies across all three domains (pleasure/social enhancement, pain reduction, negative experience reduction).

CONCLUSIONS

Among patients in addictions treatment, individuals who report nonmedical use of prescription opioids for reasons other than pain relief represent an important clinical sub-group with greater substance use severity and poorer mental health functioning.

Factors Associated With Follow-Up Attendance Among Rape Victims Seen in Acute Medical Care

OBJECTIVE

Rape is associated with posttraumatic stress disorder (PTSD) and related comorbidities. Most victims do not obtain treatment for these conditions. Acute care medical settings are well positioned to link patients to services; however, difficulty engaging victims and low attendance at provided follow-up appointments is well documented. Identifying factors associated with follow-up can inform engagement and linkage strategies.

METHOD

Administrative, patient self-report, and provider observational data from Harborview Medical Center were combined for the analysis. Using logistic regression, we examined factors associated with follow-up health service utilization after seeking services for rape in the emergency department.

RESULTS

Of the 521 diverse female (n = 476) and male (n = 45) rape victims, 28% attended the recommended medical/counseling follow-up appointment. In the final (adjusted) logistic regression model, having a developmental or other disability (OR = 0.40, 95% CI = 0.21-0.77), having a current mental illness (OR = 0.25, 95% CI = 0.13-0.49), and being assaulted in public (OR = 0.50, 95% CI = 0.28-0.87) were uniquely associated with reduced odds of attending the follow-up. Having a prior mental health condition (OR = 3.02, 95% CI = 1.86-4.91), a completed Sexual Assault Nurse Examiner's (SANE) examination (OR = 2.97, 95% CI = 1.84-4.81), and social support available to help cope with the assault (OR = 3.54, 95% CI = 1.76-7.11) were associated with an increased odds of attending the follow-up.

CONCLUSIONS

Findings point to relevant characteristics ascertained at the acute care medical visit for rape that may be used to identify victims less likely to obtain posttraumatic medical and mental health services. Efforts to improve service linkage for these patients is warranted and may require alternative service delivery models that engage rape survivors and support posttraumatic recovery.

Correlates of depressive symptoms among at-risk youth presenting to the emergency department

OBJECTIVE

The study's objective was to identify correlates of depressive symptoms among at-risk youth in an urban emergency department (ED).

METHOD

A systematic sample of adolescents (ages 14-18) in the ED were recruited as part of a larger study. Participants reporting past-year alcohol use and peer aggression self-administered a survey assessing: demographics, depressive symptoms and risk/protective factors. Logistic regression identified factors associated with depressive symptoms.

RESULTS

Among 624 adolescents (88% response rate) meeting eligibility criteria, 22.8% (n=142) screened positive for depressive symptoms. In logistic regression, depressive symptoms were positively associated with female gender [odds ratio (OR): 2.84, 95% confidence interval (CI): 1.78-4.51], poor academic performance (OR: 1.57, 95% CI: 1.01-2.44), binge drinking (OR: 1.88, 95% CI: 1.21-2.91), community violence exposure (OR: 2.25, 95% CI: 1.59-3.18) and dating violence (OR: 2.14, 95% CI: 1.36-3.38) and were negatively associated with same-sex mentorship (OR: 0.52, 95% CI: 0.29-0.91) and older age (OR: 0.55, 95% CI 0.34-0.89). Including gender interaction terms did not significantly change findings.

CONCLUSIONS

Screening and intervention approaches for youth in the urban ED should address the co-occurrence of depressive symptoms with peer and dating violence, alcohol and nonmarijuana illicit drug use.

Implementation Facilitation to Promote Emergency Department-Initiated Buprenorphine for Opioid Use Disorder

Importance

Emergency department (ED)-initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused.

Objective

To evaluate whether provision of ED-initiated buprenorphine with referral for OUD increased after implementation facilitation (IF), an educational and implementation strategy.

Design, Setting, and Participants

This multisite hybrid type 3 effectiveness-implementation nonrandomized trial compared grand rounds with IF, with pre-post 12-month baseline and IF evaluation periods, at 4 academic EDs. The study was conducted from April 1, 2017, to November 30, 2020. Participants were ED and community clinicians treating patients with OUD and observational cohorts of ED patients with untreated OUD. Data were analyzed from July 16, 2021, to July 14, 2022.

Exposure

A 60-minute in-person grand rounds was compared with IF, a multicomponent facilitation strategy that engaged local champions, developed protocols, and provided learning collaboratives and performance feedback.

Main Outcomes and Measures

The primary outcomes were the rate of patients in the observational cohorts who received ED-initiated buprenorphine with referral for OUD treatment (primary implementation outcome) and the rate of patients engaged in OUD treatment at 30 days after enrollment (effectiveness outcome). Additional implementation outcomes included the numbers of ED clinicians with an X-waiver to prescribe buprenorphine and ED visits with buprenorphine administered or prescribed and naloxone dispensed or prescribed.

Results

A total of 394 patients were enrolled during the baseline evaluation period and 362 patients were enrolled during the IF evaluation period across all sites, for a total of 756 patients (540 [71.4%] male; mean [SD] age, 39.3 [11.7] years), with 223 Black patients (29.5%) and 394 White patients (52.1%). The cohort included 420 patients (55.6%) who were unemployed, and 431 patients (57.0%) reported unstable housing. Two patients (0.5%) received ED-initiated buprenorphine during the baseline period, compared with 53 patients (14.6%) during the IF evaluation period (P < .001). Forty patients (10.2%) were engaged with OUD treatment during the baseline period, compared with 59 patients (16.3%) during the IF evaluation period (P = .01). Patients in the IF evaluation period who received ED-initiated buprenorphine were more likely to be in treatment at 30 days (19 of 53 patients [35.8%]) than those who did not 40 of 309 patients (12.9%; P < .001). Additionally, there were increases in the numbers of ED clinicians with an X-waiver (from 11 to 196 clinicians) and ED visits with provision of buprenorphine (from 259 to 1256 visits) and naloxone (from 535 to 1091 visits).

Conclusions and Relevance

In this multicenter effectiveness-implementation nonrandomized trial, rates of ED-initiated buprenorphine and engagement in OUD treatment were higher in the IF period, especially among patients who received ED-initiated buprenorphine.

Trial Registration

ClinicalTrials.gov Identifier: NCT03023930.

The projected costs and benefits of a supervised injection facility in Seattle, WA, USA

BACKGROUND

As one strategy to improve the health and survival of people who inject drugs, the King County Heroin & Opioid Addiction Task Force recommended the establishment of supervised injection facilities (SIF) where people can inject drugs in a safe and hygienic environment with clinical supervision. Analyses for other sites have found them to be cost-effective, but it is not clear whether these findings are transferable to other settings.

METHODS

We utilized local estimates and other data sources deemed appropriate for our setting to implement a mathematical model that assesses the impact of a hypothetical SIF on overdose deaths, non-fatal overdose health service utilization, skin and soft tissue infections, bacterial infections, viral infections, and enrollment in medication assisted treatment (MAT). We estimated the costs and savings that would occur on an annual basis for a small-scale pilot site given current overdose rates, as well as three other scenarios of varying scale and underlying overdose rates.

RESULTS

Assuming current overdose rates, a hypothetical Seattle SIF in a pilot phase is projected to annually reverse 167 overdoses and prevent 6 overdose deaths, 45 hospitalizations, 90 emergency department visits, and 92 emergency medical service deployments. Additionally, the site would facilitate the enrollment of 41 SIF clients in medication assisted treatment programs. These health benefits correspond to a monetary value of $5,156,019. The annual estimated cost of running the SIF is $1,222,332. The corresponding cost-benefit ratio suggests that the pilot SIF would generate $4.22 for every dollar spent on SIF operational costs. The pilot SIF is projected to save the healthcare system $534,453. If Seattle experienced elevated overdose rates and Seattle SIF program were scaled up, the health benefits and financial value would be considerably greater.

CONCLUSION

This analysis suggests that a SIF program in Seattle would save lives and result in considerable health benefits and cost savings.

A factor analytic study of the infant-toddler and early childhood versions of the HOME Inventory administered to white, black, and Hispanic american parents of children born preterm

Factor analyses were performed on the Infant-Toddler and the Early Childhood versions of the HOME Inventory for 3 groups (blacks, whites, and Hispanics) of premature, low-birthweight children. Participants lived in 8 different U.S. cities. On the IT-HOME, 5 factors were originally retained for each group using the principal factors method of extraction. Factor structures for blacks and whites were similar, accounting for 85% and 75% of the variance, respectively. The structure for Hispanics was somewhat different; a 7-factor solution accounting for 65% of the variance was most interpretable. For the EC-HOME, 6 factors were retained for both black and white groups, accounting for 80% and 73% of the variance, respectively. For Hispanics, an 8-factor solution accounted for 59% of the variance. The factor structures for blacks and whites were largely in agreement with the current organization of items into subscales. The fit for Hispanics was not quite as good, but most factors also corresponded to current subscales.

Health status of preterm low-birth-weight infants. Comparison of maternal reports

BACKGROUND

Developers of measures of child health status have documented acceptable reliability and some validity, but less attention has been paid to the concurrent and predictive validity of these measures.

METHODS

We examined the concurrent and predictive validity of the RAND General Health Rating Index, the Stein-Jessop Functional Status II-R, and the mother's global assessment of her child's health on a 5-point scale, in a sample of preterm low-birth-weight children (n = 608) who were followed up as controls in the Infant Health and Development Program. We compared maternal-reported measures assessed at 24 months with other measures of growth, morbidity, functioning, and health care utilization assessed concurrently and at 36 months in bivariate and multivariate analyses.

RESULTS

After controlling for other factors, the RAND General Health Rating Index and the Stein-Jessop Functional Status II-R were unrelated to the growth, utilization, or functioning measures. The RAND General Health Rating Index was significantly, but weakly, related to future morbidity. The mother's global perception of health was significantly related to outpatient utilization and behavior problems.

CONCLUSIONS

Clinicians may find that maternal assessment of overall child health is a sensitive but nonspecific indicator of the mother's concern. For researchers, none of these measures seems likely to serve as a proxy for health care utilization or morbidity in studies of other phenomena, or as an indicator of detailed health outcomes.

Home environment and adaptive social behavior among premature, low birth weight children: alternative models of environmental action

Used data from 465 premature, low birth weight children representing three major sociocultural groups (Caucasian, African American, Hispanic) to examine the relation between children's home environments and their adaptive social behavior. Results showed low to moderate associations between scores on the HOME Inventory at 1 and 3 years and scores on two measures of adaptive social behavior at 30 to 36 months, the Adaptive Social Behavior Inventory, and observations of mother-child interaction in a structured laboratory situation. Results indicated that responsive, nurturant care at both 1 and 3 years are related to child adaptive social behavior, as are cognitively stimulating experiences and materials. However, canonical correlational analysis indicated that only Acceptance and Variety of Experience, measured at age 3, and Variety of Experience measured at age 1 accounted for independent amounts of variance in adaptive social behavior as perceived by mothers. Also, only sociocultural group status and Learning Materials at 36 months contributed to the prediction of persistence and enthusiasm as observed in the laboratory setting.

Use of Amphetamine-Type Stimulants Among Emergency Department Patients With Untreated Opioid Use Disorder

STUDY OBJECTIVE

Concurrent use of amphetamine-type stimulants among individuals with opioid use disorder can exacerbate social and medical harms, including overdose risk. The study evaluated rates of amphetamine-type stimulant use among patients with untreated opioid use disorder presenting at emergency departments in Baltimore, MD; New York, NY; Cincinnati, OH; and Seattle, WA.

METHODS

Emergency department (ED) patients with untreated opioid use disorder (N=396) and enrolled between February 2017 and January 2019 in a multisite hybrid type III implementation science study were evaluated for concurrent amphetamine-type stimulant use. Individuals with urine tests positive for methamphetamine, amphetamine, or both were compared with amphetamine-type stimulant-negative patients.

RESULTS

Overall, 38% of patients (150/396) were amphetamine-type stimulant positive; none reported receiving prescribed amphetamine or methamphetamine medications. Amphetamine-type stimulant-positive versus -negative patients were younger: mean age was 36 years (SD 10 years) versus 40 years (SD 12 years), 69% (104/150) versus 46% (114/246) were white, 65% (98/150) versus 54% (132/246) were unemployed, 67% (101/150) versus 49 (121/246) had unstable housing, 47% (71/150) versus 25% (61/245) reported an incarceration during 1 year before study admission, 60% (77/128) versus 45% (87/195) were hepatitis C positive, 79% (118/150) versus 47% (115/245) reported drug injection during 1 month before the study admission, and 42% (62/149) versus 29% (70/244) presented to the ED for an injury. Lower proportions of amphetamine-type stimulant-positive patients had cocaine-positive urine test results (33% [50/150] versus 52% [129/246]) and reported seeking treatment for substance use problems as a reason for their ED visit (10% [14/148] versus 19% [46/246]). All comparisons were statistically significant at P<.05 with the false discovery rate correction.

CONCLUSION

Amphetamine-type stimulant use among ED patients with untreated opioid use disorder was associated with distinct sociodemographic, social, and health factors. Improved ED-based screening, intervention, and referral protocols for patients with opioid use disorder and amphetamine-type stimulant use are needed.

Experiences and Insights from the Early US COVID-19 Epicenter: A Rapid Assessment Procedure Informed Clinical Ethnography Case Series

OBJECTIVE

The Coronavirus disease (COVID-19) outbreak has evolved into a pandemic crisis, with King County in Washington State emerging as the early US epicenter. A literature review revealed few reports providing front-line clinical and research teams guidance related to multilevel, rapidly evolving COVID-19 directives.

METHOD

The Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) method was used to develop a clinical case series and conduct participant observation during an ongoing comparative effectiveness trial of peer-integrated, patient-centered interventions after traumatic injury. Participants were patients enrolled in the intervention arm of the ongoing trial, as well as front-line clinicians, patient peer interventionists, and clinical research team members implementing the trial. All participants were exposed to the Washington State COVID-19 outbreak.

RESULTS

Primary and secondary COVID-19 prevention strategies were feasibly integrated into ongoing care coordination and behavioral interventions for at-risk patients. Beyond the compilation of case studies, as an iterative method, RAPICE data collection naturalistically evolved to include observations of intervention team activity occurring within the larger pandemic epicenter context. A daily clinical research team huddle that flexibly accommodated virtual participation was also feasibly implemented.

CONCLUSIONS

Primary and secondary COVID-19 prevention strategies can be feasibly integrated into ongoing clinical interventions during the pandemic. Routine, proactive clinical and research team communication that transparently addresses ethical tensions and health-sustaining activities may promote well-being for providers grappling with rapidly evolving pandemic directives. Proactive assessments of individual provider vulnerabilities for severe COVID-19 related respiratory illness may also be a crucial element of the health care system pandemic responses.

Rapid ethnographic assessment of the COVID-19 pandemic April 2020 'surge' and its impact on service delivery in an Acute Care Medical Emergency Department and Trauma Center

OBJECTIVES

Assess the impacts of the COVID-19 pandemic on service delivery by frontline healthcare providers in acute care medical and emergency department settings and identify strategies used to cope with pandemic-related physical and mental health demands.

DESIGN

Rapid clinical ethnography of patient-provider encounters during an initial pandemic 'surge' conducted by a team of clinician-researchers using a structured protocol for qualitative data collection and analysis.

SETTING

Level 1 trauma centre at Harborview Hospital in Seattle Washington in April 2020.

PARTICIPANTS

Frontline clinical providers serving as participant observers during performance of their clinical duties recorded observations and summaries of conversations with other providers and patients.

RESULTS

We identified four different kinds of impacts: procedural, provider, patient and overall. Each impact highlighted two or more levels of a socioecological model of services delivery: (1) the epidemiology of COVID-19, (2) outer setting, (3) inner or organisational setting and (4) individual patient and provider. Despite significant changes in procedures that included COVID-19 screening of all admitted patients, social distancing and use of personal protective equipment, as well as changes in patient and provider behaviour, the overall impact of the pandemic on the emergency department and acute care service delivery was minimal. This is attributed to having a smaller surge than expected, a quick response by the healthcare system to anticipated demands for service delivery and protection of patients and providers, adequate supplies and high provider morale.

CONCLUSIONS

Although limited to one setting in one healthcare system in one community, the findings offer some important lessons for healthcare systems that have yet to be impacted as well as systems that have been more severely impacted. Each of the socioecological framework levels was found to impact service delivery to patients, and variations at each of these levels account for variations in that quality of care globally.

A comparative effectiveness trial of an information technology enhanced peer-integrated collaborative care intervention versus enhanced usual care for US trauma care systems: Clinical study protocol

Annually approximately 2-3 million Americans are so severely injured that they require inpatient hospitalization. The study team, which includes patients, clinical researchers, front-line provider and policy maker stakeholders, has been working together for over a decade to develop interventions that target improvements for US trauma care systems nationally. This pragmatic randomized trial compares a multidisciplinary team collaborative care intervention that integrates front-line trauma center staff with peer interventionists, versus trauma team notification of patient emotional distress with mental health consultation as enhanced usual care. The peer-integrated collaborative care intervention will be supported by a novel emergency department exchange health information technology platform. A total of 424 patients will be randomized to peer-integrated collaborative care (n = 212) and surgical team notification (n = 212) conditions. The study hypothesizes that patient's randomized to peer integrated collaborative care intervention will demonstrate significant reductions in emergency department health service utilization, severity of patient concerns, post traumatic stress disorder symptoms, and physical limitations when compared to surgical team notification. These four primary outcomes will be followed-up at 1- 3-, 6-, 9- and 12-months after injury for all patients. The Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) method will be used to assess implementation processes. Data from the primary outcome analysis and implementation process assessment will be used to inform an end-of-study policy summit with the American College of Surgeons Committee on Trauma. The policy summit will facilitate acute care practice changes related to patient-centered care transitions over the course of a single 5-year funding cycle. Trial registration: (Clinicaltrials.govNCT03569878).

Caloric requirement for refeeding inpatients with anorexia nervosa: the contribution of anxiety exercise, and cigarette smoking

BACKGROUND

Refeeding inpatients with anorexia nervosa (AN) is costly, stressful, and can precipitate the refeeding syndrome. Caloric intake is usually increased gradually from a low starting point until a steady weight gain is achieved. There is no reliable equation that predicts the number of calories required for a weight gain. It was our clinical suspicion that anxiety, exercise, and cigarette smoking might increase the caloric need for refeeding.

METHOD

We conducted an observational cohort study of 17 females with AN admitted to an inpatient eating disorder unit for refeeding. We estimated the energy intake by observation, the caloric expenditure due to exercise with a triaxial accelerometer, the number of cigarettes smoked by history, and the anxiety by the Beck Anxiety Inventory (BAI).

RESULTS

Neither anxiety, exercise, or cigarette smoking predicted the caloric requirement for refeeding, individually or in combination.

DISCUSSION

Our data suggest that the caloric requirement for weight gain during refeeding is not predicted by the patient's anxiety, exercise or smoking habits. The standard methods of estimating caloric requirements for refeeding remain indirect calorimetry and previous history.

Use of the HOME Inventory with Families of Young Visually Impaired Children

The study reported here examined the usefulness of the Infant-Toddler and the Early Childhood forms of the HOME Inventory as applied to children who are visually impaired. The results indicated that families of children with visual impairments scored about the same as did families in the norm groups.

Catalyzing the Translation of Patient-Centered Research Into United States Trauma Care Systems: A Case Example

BACKGROUND

The expedient translation of research findings into sustainable intervention procedures is a longstanding health care system priority. The Patient-Centered Outcomes Research Institute (PCORI) has facilitated the development of "research done differently," with a central tenet that key stakeholders can be productively engaged throughout the research process. Literature review revealed few examples of whether, as originally posited, PCORI's innovative stakeholder-driven approach could catalyze the expedient translation of research results into practice.

OBJECTIVES

This narrative review traces the historical development of an American College of Surgeons Committee on Trauma (ACS/COT) policy guidance, facilitated by evidence supplied by the PCORI-funded studies evaluating the delivery of patient-centered care transitions. Key elements catalyzing the guidance are reviewed, including the sustained engagement of ACS/COT policy stakeholders who have the capacity to invoke system-level implementation strategies, such as regulatory mandates linked to verification site visits. Other key elements, including the encouragement of patient stakeholder voice in policy decisions and the incorporation of end-of-study policy summits in pragmatic comparative effectiveness trial design, are discussed.

CONCLUSIONS

Informed by comparative effectiveness trials, ACS/COT policy has expedited introduction of the patient-centered care construct into US trauma care systems. A comparative health care systems conceptual framework for transitional care which incorporates Research Lifecycle, pragmatic clinical trial and implementation science models is articulated. When combined with Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE), employed as a targeted implementation strategy, this approach may accelerate the sustainable delivery of high-quality patient-centered care transitions for US trauma care systems.