Implementing and Sustaining Team-Based Telecare for Bipolar Disorder: Lessons Learned from a Model-Guided, Mixed Methods Analysis

BACKGROUND

Telemental health interventions have empirical support from clinical trials and structured demonstration projects. However, their implementation and sustainability under less structured clinical conditions are not well demonstrated.

INTRODUCTION

We conducted a follow-up analysis of the implementation and sustainability of a clinical video teleconference-based collaborative care model for individuals with bipolar disorder treated in the Department of Veterans Affairs to (a) characterize the extent of implementation and sustainability of the program after its establishment and (b) identify barriers and facilitators to implementation and sustainability.

MATERIALS AND METHODS

We conducted a mixed methods program evaluation, assessing quantitative aspects of implementation according to the Reach, Efficacy, Adoption, Implementation, and Maintenance implementation framework. We conducted qualitative analysis of semistructured interviews with 16 of the providers who submitted consults, utilizing the Integrated Promoting Action on Research Implementation in the Health Services implementation framework.

RESULTS

The program demonstrated linear growth in sites (n = 35) and consults (n = 915) from late 2011 through mid-2016. Site-based analysis indicated statistically significant sustainability beyond the first year of operation. Qualitative analysis identified key facilitators, including consult content, ease of use via electronic health record, and national infrastructure. Barriers included availability of telehealth space, equipment, and staff at the sites, as well as the labor-intensive nature of scheduling.

DISCUSSION

The program achieved continuous growth over almost 5 years due to (1) successfully filling a need perceived by providers, (2) developing in a supportive context, and (3) receiving effective facilitation by national and local infrastructure.

CONCLUSION

Clinical video teleconference-based interventions, even multicomponent collaborative care interventions for individuals with complex mental health conditions, can grow vigorously under appropriate conditions.

Team-Based Telecare for Bipolar Disorder

INTRODUCTION

Numerous randomized controlled trials indicate that collaborative chronic care models improve outcome in a wide variety of mental health conditions, including bipolar disorder. However, their spread into clinical practice is limited by the need for a critical mass of patients and specialty providers in the same locale. Clinical videoconferencing has the potential to overcome these geographic limitations.

MATERIALS AND METHODS

A videoconference-based collaborative care program for bipolar disorder was implemented in the Department of Veterans Affairs. Program evaluation assessed experience with the first 400 participants, guided by five domains specified by the American Telemedicine Association: treatment engagement, including identification of subpopulations at risk for not being reached; participation in treatment; clinical impact; patient safety; and quality of care.

RESULTS

Participation rates resembled those for facility-based collaborative care. No participant characteristics predicted nonengagement. Program completers demonstrated significant improvements in several clinical indices, without evidence of compromise in patient safety. Guideline-based quality of care assessment after 1 year indicated increased lithium use, decreased antidepressant use, and increased prazosin use in individuals with comorbid post-traumatic stress disorder, but no impact on already high rates of lithium serum level monitoring.

DISCUSSION

Clinical videoconferencing can extend the reach of collaborative care models for bipolar disorder. The next step involves assessment of the videoconference-based collaborative care for other serious mental health conditions, investigation of barriers and facilitators of broad implementation of the model, and evaluation of the business case for deployment and sustainability in clinical practice.

Serum interleukin-10 in ICU patients with severe acute central nervous system injuries

RATIONALE

IL-10, the main anti-inflammatory cytokine, may play a pivotal role in cerebral inflammation implicated in the development of brain edema and secondary brain damage after injury.

AIM OF THE STUDY

1) Determining absolute IL-10 serum level and its pattern in critically ill patients with traumatic and non-traumatic acute brain injury. 2) Assessment of prognostic value of serum IL-10 in those patients.

MATERIALS AND METHODS

Serum IL-10 levels in 46 adults (multi-profile ICU, teaching hospital) with traumatic brain injury (TBI, N = 18), nontraumatic intracranial hemorrhage (SAH, N = 11) and polytrauma with concomitant brain injury (POL, N = 17) were measured using ELISA. Relationship of IL-10 and initial diagnosis, clinical state, outcome and risk of infection development was evaluated.

RESULTS

IL-10 was detectable in the serum of all but one patient on ICU admission (56.6 +/- 91.9 pg/ml; mean +/- SD). No statistically significant differences in IL-10 between TBI, SAH and POL groups as well as between survivors and non-survivors on any day were found. No correlation between IL-10 and GCS or SAPS II was seen. Significant fall in serum IL-10 during the first 4 days of injury in patients of all subgroups was observed. Patients with initial serum IL-10 below 77 pg/ml were at significantly higher risk of development of any infection within the first week of injury.

CONCLUSIONS

After acute brain injury, serum IL-10 in adults is detectable independent of CNS lesion type. Its systemic release is strongly individualized. Serum IL-10 on ICU admission may have some prognostic value to predict development of infection in patients with CNS lesions.

Cefepime versus imipenem-cilastatin for treatment of nosocomial pneumonia in intensive care unit patients: a multicenter, evaluator-blind, prospective, randomized study

In a randomized, evaluator-blind, multicenter trial, we compared cefepime (2 g three times a day) with imipenem-cilastatin (500 mg four times a day) for the treatment of nosocomial pneumonia in 281 intensive care unit patients from 13 centers in six European countries. Of 209 patients eligible for per-protocol analysis of efficacy, favorable clinical responses were achieved in 76 of 108 (70%) patients treated with cefepime and 75 of 101 (74%) patients treated with imipenem-cilastatin. The 95% confidence interval (CI) for the difference between these response rates (-16 to 8%) failed to exclude the predefined lower limit for noninferiority of -15%. In addition, therapy of pneumonia caused by an organism producing an extended-spectrum beta-lactamase (ESBL) failed in 4 of 13 patients in the cefepime group but in none of 10 patients in the imipenem group. However, the clinical efficacies of both treatments appeared to be similar in a secondary intent-to-treat analysis (95% CI for difference, -9 to 14%) and a multivariate analysis (95% CI for odds ratio, 0.47 to 1.75). Furthermore, the all-cause 30-day mortality rates were 28 of 108 (26%) patients in the cefepime group and 19 of 101 (19%) patients in the imipenem group (P = 0.25). Rates of documented or presumed microbiological eradication of the causative organism were similar with cefepime (61%) and imipenem-cilastatin (54%) (95% CI, -23 to 8%). Primary or secondary resistance of Pseudomonas aeruginosa was detected in 19% of the patients treated with cefepime and 44% of the patients treated with imipenem-cilastatin (P = 0.05). Adverse events were reported in 71 of 138 (51%) and 62 of 141 (44%) patients eligible for safety analysis in the cefepime and imipenem groups, respectively (P = 0.23). Although the primary end point for this study does not exclude the possibility that cefepime was inferior to imipenem, some secondary analyses showed that the two regimens had comparable clinical and microbiological efficacies. Cefepime appeared to be less active against organisms producing an ESBL, but primary and secondary resistance to imipenem was more common for P. aeruginosa. Selection of a single agent for therapy of nosocomial pneumonia should be guided by local resistance patterns.

[Spinal reflexes in the determination of brain death]

The authors present the results of spinal cord function evaluation in organ donors by examination of reflexes. The knee reflex and ankle jerk, as well as abdominal reflex and foot withdrawal reaction were tested in 31 donors. At least one of the above was seen in 25 individuals. It is suggested on the basis of data obtained not to hamper the transplant procedure in cases of tested reflex persistency when brain death is revealed on relevant examination.

[Evaluation of the usefulness of the laryngeal mask for general anesthesia in eye microsurgery--preliminary results]

PURPOSE

This prospective study was designed to compare intraocular pressure changes and haemodynamic response to insertion of either a laryngeal mask or an orotracheal tube during general anaesthesia for cataract surgery.

MATERIAL AND METHODS

The effect of techniques (tracheal tube-TT, laryngeal mask airway-LMA) securing a clear upper airway on the heart rate changes (HR), arterial pressure (SAP, DAP), oxygen saturation (SpO2), end-tidal carbon-dioxide pressure (Et-CO2), intraocular pressure (IOP) and the incidence of coughing, stridor and sore throat was analysed in 60 patients undergoing cataract surgery during general anaesthesia.

RESULTS

The mean values for HR, SAP, DAP and IOP measured before and after induction of anaesthesia were not different in both groups. After securing a clear airway, mean HR increased in TT group to 95.5/min and decreased to 75.7/min in LMA group. SAP increased in TT group to 131 mmHg, DAP to 82.6 mmHg, whilst in LMA group both values decreased to 98.6 mmHG and 66.3 mmHg, respectively. The significant difference in IOP values was observed after intubation or using laryngeal mask. In TT group, intraocular pressure increased to 15 mmHg in healthy eye and to 13.6 mmHg in ill eye whilst there was a decrease in LMA group to 5.5 and 7.43 mmHg, respectively. Furthermore, a greater incidence of such complications as coughing, stridor and sore throat in TT group was observed.

CONCLUSION

The results show that using LMA in microsurgery during general anaesthesia is more advantageous and safer for patients in comparison with tracheal intubation.

[Phage and serological types of bacteria infecting patients in anesthesiology and intensive therapy (1988-1990)]

1736 of biological materials, being taken from 264 patients, were investigated since 1988 to 1990. 1410 kinds of microorganisms were cultured from 999 biological materials, in which the growth of bacterial flora was noticed. Following species were isolated most frequently: Pseudomonas aeruginosa 15.39%, Proteus mirabilis 12.91%, Klebsiella pneumoniae 10.43% and Staphylococcus aureus 10.43%. The most frequent serological type according to Fisher's scheme was Pseudomonas aeruginosa--immunotype T 3.7 and according to Habs scheme--immunotype P 16. Strains of Staphylococcus aureus were most frequently sensitive to phages the group II. In case of Klebsiella sp. bacilli, the most predominant strains were not typed either by basic or extended phage sets.