The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) project: An open-label pragmatic randomised control trial comparing the efficacy of differing therapeutic agents for primary care detoxification from either street heroin or methadone [ISRCTN07752728]

BACKGROUND: Heroin is a synthetic opioid with an extensive illicit market leading to large numbers of people becoming addicted. Heroin users often present to community treatment services requesting detoxification and in the UK various agents are used to control symptoms of withdrawal. Dissatisfaction with methadone detoxification [8] has lead to the use of clonidine, lofexidine, buprenorphine and dihydrocodeine; however, there remains limited evaluative research. In Leeds, a city of 700,000 people in the North of England, dihydrocodeine is the detoxification agent of choice. Sublingual buprenorphine, however, is being introduced. The comparative value of these two drugs for helping people successfully and comfortably withdraw from heroin has never been compared in a randomised trial. Additionally, there is a paucity of research evaluating interventions among drug users in the primary care setting. This study seeks to address this by randomising drug users presenting in primary care to receive either dihydrocodeine or buprenorphine. METHODS/DESIGN: The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) project is a pragmatic randomised trial which will compare the open use of buprenorphine with dihydrocodeine for illicit opiate detoxification, in the UK primary care setting. The LEEDS project will involve consenting adults and will be run in specialist general practice surgeries throughout Leeds. The primary outcome will be the results of a urine opiate screening at the end of the detoxification regimen. Adverse effects and limited data to three and six months will be acquired

The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) prisons project pilot study: protocol for a randomised controlled trial comparing dihydrocodeine and buprenorphine for opiate detoxification

Background In the United Kingdom (UK), there is an extensive market for the class 'A' drug heroin. Many heroin users spend time in prison. People addicted to heroin often require prescribed medication when attempting to cease their drug use. The most commonly used detoxification agents in UK prisons are buprenorphine, dihydrocodeine and methadone. However, national guidelines do not state a detoxification drug of choice. Indeed, there is a paucity of research evaluating the most effective treatment for opiate detoxification in prisons. This study seeks to address the paucity by evaluating routinely used interventions amongst drug using prisoners within UK prisons. Methods/Design The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) Prisons Pilot Study will use randomised controlled trial methodology to compare the open use of buprenorphine and dihydrocodeine for opiate detoxification, given in the context of routine care, within HMP Leeds. Prisoners who are eligible and give informed consent will be entered into the trial. The primary outcome measure will be abstinence status at five days post detoxification, as determined by a urine test. Secondary outcomes during the detoxification and then at one, three and six months post detoxification will be recorded

eConsent Forms on Ancillary Applications with Electronic Medical Record Integration – Reducing Consent Error

Purpose of Project: The purpose of this project is to utilize electronic consents (eConsents) with ancillary applications as an evidence-based intervention to reduce consent errors. Background: Studies show that paper-based handwritten forms have an error rate of up to 50%. Consent errors, especially in the preparation of surgery, are not merely documentation errors but patient safety pitfalls that allow for incorrect surgeries or financial loss due to aborted or delayed interventional cases. Internal organizational evidence indicates the implementation of an evidence-based opportunity as there was no use of electronic tools for consents utilized in the inpatient setting. Methods: Inpatient departments were provided tablets that contain a consent application connected with the electronic medical record (EMR). Only blood and surgical consents were transformed into eConsent format. The electronic form is automatically attached to patient’s EMR to prevent misplacement and ease of access for all treatment team members. System-wide education was provided to nursing staff on how to access eConsents when preparing the patient for surgery as well as associated policy implications. Collaboration with analysts, leadership, and clinicians was essential to ensuring successful inpatient operational use when launched in May 2021. Metrics were tracked over an additional five months post-intervention. Results: The primary outcome of reducing the eConsent error rate per patient day indicated an overall decrease of 42% from January 2021 to October 2021. However, this decrease comparing 5 months pre-intervention versus 5 months post-intervention and the associated result of the two-tailed independent samples t-test was not significant based on an alpha value of .05, t(8) = -0.42, p = .686. Secondary outcomes showed a steadily increase in eConsent usage between May 2021 to October 2021. Evaluation: eConsents have proven worthy for surgical consents and in the reduction of consent error and continued use. Considerations should be made to expand eConsents to other types of consent forms not only for the consolidation of patient documentation and enhanced workflow but to further pursue safe patient practices and prevent documentation error. Nursing informatics is essential to coordinating evidence-based interventions on electronic healthcare platforms that also marry well with bedside operations and workflows

Improving Patient Satisfaction with the Virtual Handoff Process through the Utilization of Educational Pamphlets in the Emergency Department

Boarding patients in the emergency room while waiting to transfer the patient to the proper unit can be harmful to clinical care and have significant financial opportunity costs. At one local hospital it was found that on average patients were being boarded in the emergency room (ED) for approximately 85 minutes waiting to be transferred. Several barriers that caused this delay were found including, delay in room cleaning, nurse staff shortage, and inability to give report to the nurse receiving the patient. In an attempt to combat this delay which may be caused by a difficulty in giving patient report, this organization is rolling out a virtual bedside handoff process. While virtual technology is not a new concept, there are many patients that may not be comfortable with the technology. The purpose of the evidence-based project was to provide a written educational pamphlet that details the how’s and why’s of the virtual handoff process to the patient to be given upon admission. The goal of the educational pamphlet was to increase the patients’ satisfaction with the process. A pre-survey was given to a group of patients after they experienced the virtual handoff process to assess their comfort level. These results were compared to the post-survey results of patients that received the educational pamphlet prior to experiencing the virtual handoff process. Ten pre-surveys and seven post-surveys were analyzed utilizing SPSS and descriptive statistics. The analysis concluded that the participants who received the educational pamphlet felt more prepared for the virtual handoff process

The role of health kiosks: a scoping review

Background: Health kiosks are publicly accessible computing devices that provide access to services including health information provision, clinical measurement collection, patient self-check-in, telemonitoring and teleconsultation. While the increase in internet access and ownership of smart personal devices could make kiosks redundant, recent reports have predicted that the market will continue to grow. Objectives: We sought to clarify the current and future roles of health kiosks by investigating: (a) the setting, role, and clinical domains in which kiosks are used; (b) whether usability evaluations of health kiosks are being reported and if so, what methods are being utilized; and (c) what the barriers and facilitators are for the deployment of kiosks. Methods: We conducted a scoping review by a bibliographic search of the Google Scholar, PubMed and Web of Science databases for studies and other publications between January 2009 and June 2020. Eligible papers describe the implementation, either as primary studies, systematic reviews, or news and feature articles. Additional reports were obtained by manual searching and through querying key informants. For each article we abstracted settings, purposes, health domains, whether the kiosk was opportunistic or integrated with a clinical pathway, and inclusion of usability testing. We then summarized the data in frequency tables. Results: A total of 141 articles were included, 134 primary studies and seven reviews. 47% of the primary studies described kiosks in secondary care settings, other settings included community (23.9%), primary care (17.9%), and pharmacies (6.0%). The most common roles of health kiosks were providing health information (35.1%), taking clinical measurements (20.9%), screening (12.7%), telehealth (8.2%), and patient registration (6.0%). The five most frequent health domains were multiple conditions (24.6%), Human Immunodeficiency Virus (HIV) (7.5%), hypertension (7.5%), pediatric injuries (5.2%), health and wellbeing (4.5%) and drug monitoring (4.5%). Kiosks were integrated in the clinical pathway in 70.1%, opportunistic kiosks accounted for 23.9% and 6.0% were being used in both. Usability evaluations of the kiosk were reported in 20.1% of the papers. Barriers (use of expensive proprietary software) and enablers (handling on-demand consultations) to deploying health kiosks were identified. Conclusions: Health kiosks still play a vital role in the healthcare system, including collecting clinical measurements and providing access to online health services and information to those with little or no digital literacy skills, and others without personal internet access. We identified research gaps, such as training needs for teleconsultations, and scant reporting on usability evaluation methods

Organizational level responses to the COVID-19 outbreak : challenges, strategies and framework for academic institutions

The outbreak of the novel coronavirus, severe acute respiratory syndrome (SARS)–CoV-2, has gained unprecedented global attention. SARS-CoV-2, which causes the newly described coronavirus disease 2019 (COVID-19), has affected millions of people and led to over 1.9 million deaths worldwide by the beginning of January 2021. Several governments have opted for lockdown as one of the measures to combat the rapidly increasing number of COVID-19 cases. Academic institutions (i.e., universities, colleges, research centers and national laboratories), which are home to thousands of students, researchers, technicians, and administrative staff, have strictly followed government regulations. Due to the lockdown, the majority of academics have been facing various challenges, especially in transitioning from classroom to remote teaching and conducting research activities from a home office. This article from an early-career researchers’ perspective addresses the common challenges that academic institutions have encountered and possible strategies they have adopted to mitigate those challenges at the individual organizational level. Furthermore, we propose a framework to facilitate the handling of such crisis in any near future at the organizational level. We hope academics, policymakers and (non) government organizations across the globe will find this perspective a call to better improve the overall infrastructure of academic institutions

The Application of Time Series Analysis to Injury Epidemiology Data

Introduction: Injury fatality rates in the United States (US) decreased throughout the majority of the 20th century, mostly due to declining rates of occupational and motor vehicle injuries. However, near the beginning of the 21st century, fatal injury rates in the US began to increase. This is principally due to the nation’s opioid epidemic, which has been characterized by different epidemic “waves”, each driven by overdoses associated with specific substances. Given the temporally dynamic nature of US injury trends, this study aimed to explore the application of time series analysis to injury data in the US. First, rates of non-fatal occupational injuries treated in US emergency departments were assessed to determine if non-fatal occupational injury rates mirror the historic decline of fatal occupational injuries in the 20th and 21st centuries. Next, we explored the temporal shift from prescription to illicit opioid overdose deaths in West Virginia (WV) to elucidate the transition between the opioid epidemic’s first and second waves in the state with the highest fatality rates in the nation. Finally, we compared the forecasting performance of three time series models when applied to national US opioid overdose data to explore what time series approaches best predict future rates of overdose. Methods: Study one assessed temporal trends in non-fatal occupational injuries treated in US emergency departments (EDs) using data the National Electronic Injury Surveillance System – Occupational Supplement (NEISS-Work) dataset. Descriptive statistics were used to assess annual injury rate estimates and monthly seasonality. Autoregressive integrated moving average (ARIMA) modeling was used to quantify trends in ED-treated occupational injury rate estimates while controlling for serial data correlation. Analyses were conducted both overall and stratified by injury event type. Study two used data from the Drug Enforcement Agency’s (DEA) Automation of Reports and Consolidated Orders System (ARCOS) database (accessed via The Washington Post) to determine when shipments of oxycodone and hydrocodone tablets to WV began decreasing; tablet shipments were measured both as dosage units and morphine milligram equivalents (MMEs). To identify the exact point when tablet shipments began decreasing, we used locally estimated scatterplot smoothing (LOESS). The point when total tablet shipments began decreasing was used as an intervention point in an interrupted time series analysis (ITSA) of prescription and illicit opioid overdose death rates calculated using data from the WV Forensic Drug Database (FDD), which collects drug death data from the WV Office of the Chief Medical Examiner. Prescription opioid deaths were defined as those involving oxycodone or hydrocodone, while illicit opioid overdoses were defined as those involving heroin or synthetic opioids other than methadone. The ITSA impact of the LOESS-identified points was compared via Akaike Information Criteria (AIC) to that of the 2010 release of an abuse deterrent formulation (ADF) of OxyContin, which is widely cited as a driving factor initiating the transition between the opioid epidemic’s first and second waves. Study three examined the forecasting performance of ARIMA; Error, Trend, and Seasonality (ETS); and Facebook Prophet models when applied to national US opioid overdose death data, both overall and stratified by the type of opioid involved in overdoses. Overdose death counts were extracted from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database. Overdose death rates were calculated using monthly all-cause ii mortality as a denominator. Forecasts were validated used time series cross validation (TSCV), while forecast bias and predictive coverage probability were measured using mean average percent error (MAPE) and Winkler Scores, respectively. Results: Study one found that US ED-treated non-fatal occupational injury rate estimates were highest in 2012 and lowest in 2019. Apart from falls, slips, and trips, all injuries occurred at the highest rate in a summer month. ARIMA modeling found that there was a significant decrease in monthly rate estimates for 2012-2019. Study two found that the point at which opioid tablet shipments (measured via dosage units) to WV began decreasing had a greater impact on changing rates of prescription and illicit opioid overdose rates than the 2010 ADF OxyContin release. Study three found that ETS models accurately forecasted monthly rates US opioid- involved overdoses while maintaining a high degree of precision relative to ARIMA or Facebook Prophet, particularly during the opioid epidemic’s fentanyl-dominated third wave. Discussion: The findings presented here indicate that although occupational injury rates have likely continued their decades-long decline in the US, the nation’s opioid epidemic has contributed significantly to recent US injury rate increases and is temporally dynamic. Future research should explore trends in other injury data by expanding the methodology used here to other epidemiological contexts

The Role of Targeted HIV Screening in the Emergency Department:A Scoping Review

BACKGROUND: Human immunodeficiency virus (HIV) infection continues to expand worldwide and a significant proportion of infection is still undiagnosed. Recent studies have addressed the impact and feasibility of 'opt-out' HIV screening in Emergency Departments (EDs) in urban settings at high HIV prevalence, whereas little is known about the yield of implementing 'targeted' HIV testing especially in low-prevalence areas.OBJECTIVE: The present study undertakes a scoping review of research carried out on the implementation of targeted HIV screening in adult EDs to determine the impact, feasibility and acceptability of HIV testing in different HIV prevalence settings.DESIGN: Online databases (EMBASE, MEDLINE) were used to identify papers published between 2000 to 2020. A threeconcept search was employed with HIV (HIV, Human immunodeficiency virus infection, HIV infections), targeted testing (Target, screening or testing) and emergency medicine (Emergency Service, emergency ward, A&E, accident and emergency or Emergency Department) (28th February 2020). Only full-text articles written in English, French, Spanish or Italian and using impact and/or feasibility and/or acceptability of the program as primary or secondary outcomes were analysed.RESULTS: The search returned 416 articles. Of these, 12 met inclusion criteria and were included in the final review. Most of the included studies were carried out in the United States (n=8; 67%) and in areas of high HIV prevalence (n=11; 92%). Three (20%) were randomized control studies. While the rate of newly diagnosed HIV cases varied widely (0.03-2.2%), likely due to methodological heterogeneity between studies, the linkage of new HIV diagnosis was often high (80-100%) and median CD4+ cell count was always greater than 200 cells per microliter. Targeted HIV screening was found to be cost-effective (out of 2 studies) and well accepted by participants (out 2 studies).CONCLUSIONS: Targeted HIV screening at the ED can be impactful, feasible and well accepted, but often requires extra funding and staff. Most previous work has focused on areas of high disease prevalence

Feasibility study to inform the design of a UK multi-centre randomised controlled trial of prophylactic antibiotics for the prevention of recurrent cellulitis of the leg

Background: This paper describes the results of a feasibility study for a randomised controlled trial (RCT). Methods: Twenty-nine members of the UK Dermatology Clinical Trials Network (UK DCTN) expressed an interest in recruiting for this study. Of these, 17 obtained full ethics and Research & Development (R&D) approval, and 15 successfully recruited patients into the study. A total of 70 participants with a diagnosis of cellulitis of the leg were enrolled over a 5-month period. These participants were largely recruited from medical admissions wards, although some were identified from dermatology, orthopaedic, geriatric and general surgery wards. Data were collected on patient demographics, clinical features and willingness to take part in a future RCT. Results: Despite being a relatively common condition, cellulitis patients were difficult to locate through our network of UK DCTN clinicians. This was largely because patients were rarely seen by dermatologists, and admissions were not co-ordinated centrally. In addition, the impact of the proposed exclusion criteria was high; only 26 (37%) of those enrolled in the study fulfilled all of the inclusion criteria for the subsequent RCT, and were willing to be randomised to treatment. Of the 70 participants identified during the study as having cellulitis of the leg (as confirmed by a dermatologist), only 59 (84%) had all 3 of the defining features of: i) erythema, ii) oedema, and iii) warmth with acute pain/tenderness upon examination. Twenty-two (32%) patients experienced a previous episode of cellulitis within the last 3 years. The median time to recurrence (estimated as the time since the most recent previous attack) was 205 days (95% CI 102 to 308). Service users were generally supportive of the trial, although several expressed concerns about taking antibiotics for lengthy periods, and felt that multiple morbidity/old age would limit entry into a 3-year study. Conclusion: This pilot study has been crucial in highlighting some key issues for the conduct of a future RCT. As a result of these findings, changes have been made to i) the planned recruitment strategy, ii) the proposed inclusion criteria and ii) the definition of cellulitis for use in the future trial

Assessment of Veteran Satisfaction With Telehealth Services During the COVID-19 Pandemic

Abstract With the advent of the COVID-19 public health emergency in the United States, many U.S. veterans were unable to maintain their usual office visits due to safe access concerns. Patients were strongly encouraged to maintain their healthcare needs at home by utilizing online technology resources like telehealth services with their healthcare providers. Providing excellent healthcare services for veterans during COVID-19 became a challenge for primary care providers at many veteran healthcare organizations. Since little was known about the satisfaction of veteran clients with healthcare management using virtual care during the pandemic, this formative program evaluation was designed to survey and assess veteran clients’ satisfaction using a veteran telehealth survey tool. This study found that approximately 88% of participating veterans agreed that telehealth made positive changes in their life, 89% agreed telehealth led to positive health changes, and 90% would recommend telehealth to others. Of these participants, nearly 70% were 60 years and older, with 40% of all participants being 70–79-year-olds, primarily representing an older veteran population. Some 99% of veteran participants perceived improved health management as validating the importance of providing continued telehealth care services. This formative evaluation on telehealth care will serve to provide healthcare leaders with information on improving healthcare using telehealth services, reinforce data of the positively perceived healthcare outcomes, and support a trend of the evolving need for continued healthcare access to the veteran during challenging conditions. Keywords: veteran, telehealth, COVID-19, primary care provider