The Living Room, a Community Crisis Respite Program: Offering People in Crisis an Alternative to Emergency Departments

Objective: To describe The Living Room, a community crisis respite center that offers individuals in crisis an alternative to obtaining services in an emergency department (ED).Methods: This article describes the problems individuals in a mental health crisis may encounter in traditional EDs and explains how The Living Room addresses these problems.  The Living Room’s development, setting, staffing and procedures are described in order to promote increased use of this type of program. Results: In its first year of operation, The Living Room hosted 228 visits by 87 distinct individuals (termed “guests”).  Guests were deflected from EDs on 213 of those visits – a 93% deflection rate.  These deflections represent a savings of approximately $550,000 to the State of Illinois since guests of The Living Room are overwhelmingly individuals with Medicaid or no insurance of any kind.  On 84% (n=192) of the occurrences in which guests were deflected from EDs, they alleviated their crises sufficiently to decide to leave The Living Room and return to the community.  These guests reported an average decrease of 2.13 points on the Subjective Units of Distress Scale. Conclusions: Community crisis respite centers such as The Living Room represent an important alternative to EDs by remedying many criticisms of traditional EDs made by individuals in crisis. Outcomes from The Living Room’s first year of operation suggest that community crisis respite centers are cost-effective, effective in helping many individuals alleviate crises, and have the potential to decrease the use of EDs for mental health crisis

The Living Room, a Community Crisis Respite Program: Offering People in Crisis an Alternative to Emergency Departments

Objective: To describe The Living Room, a community crisis respite center that offers individuals in crisis an alternative to obtaining services in an emergency department (ED).Methods: This article describes the problems individuals in a mental health crisis may encounter in traditional EDs and explains how The Living Room addresses these problems.  The Living Room’s development, setting, staffing and procedures are described in order to promote increased use of this type of program. Results: In its first year of operation, The Living Room hosted 228 visits by 87 distinct individuals (termed “guests”).  Guests were deflected from EDs on 213 of those visits – a 93% deflection rate.  These deflections represent a savings of approximately $550,000 to the State of Illinois since guests of The Living Room are overwhelmingly individuals with Medicaid or no insurance of any kind.  On 84% (n=192) of the occurrences in which guests were deflected from EDs, they alleviated their crises sufficiently to decide to leave The Living Room and return to the community.  These guests reported an average decrease of 2.13 points on the Subjective Units of Distress Scale. Conclusions: Community crisis respite centers such as The Living Room represent an important alternative to EDs by remedying many criticisms of traditional EDs made by individuals in crisis. Outcomes from The Living Room’s first year of operation suggest that community crisis respite centers are cost-effective, effective in helping many individuals alleviate crises, and have the potential to decrease the use of EDs for mental health crisis

Wash Your Hands... And Brush Your Teeth!

COVID-19 has become a novel pandemic increasing rapidly all over the world. Periodontal disease and COVID-19 share many of the same risk factors such as age, gender, and systemic diseases like diabetes and hypertension. Although not many studies exist on periodontal disease (PD) and COVID-19 due to it being a new and emerging topic, many studies suggest key links between the two. Maintaining superior oral health is especially important during the COVID-19 pandemic to prevent PD. Further research is needed to have concrete evidence between PD and COVID-19 due to COVID-19 being a new and emerging illness, while PD is more frequently studied and understood.https://dune.une.edu/dh_studpost/1009/thumbnail.jp

Exploring patient-reported barriers to advance care planning in family practice

Abstract Background Although patient-centred care has become increasingly important across all medical specialties, when it comes to end of life care, research has shown that treatments ordered are not often concordant with people’s expressed preferences. Patient and family engagement in Advance Care Planning (ACP) in the primary care setting could improve the concordance between patients’ wishes and the healthcare received when patients cannot speak for themselves. The aim of this study was to better understand the barriers faced by older patients regarding talking to their family members and family physicians about ACP. Methods In this multi-site cross-sectional study, three free text questions regarding reasons patients found it difficult to discuss ACP with their families or their family physicians were part of a self-administered questionnaire about patients’ knowledge of and engagement in ACP. The questionnaire, which included closed ended questions followed by three probing open ended questions, was distributed in 20 family practices across 3 provinces in Canada. The free text responses were analyzed using thematic analysis and form the basis of this paper. Results One hundred two participants provided an analyzable response to the survey when asked why they haven’t talked to someone about ACP. Two hundred fifty-four answered the question about talking to their physician and 340 answered the question about talking to family members. Eight distinct themes emerged from the free text response analysis: 1. They were too young for ACP; 2. The topic is too emotional; 3. The Medical Doctor (MD) should be responsible for bringing up ACP 4. A fear of negatively impacting the patient-physician relationship; 5. Not enough time in appointments; 6. Concern about family dynamics; 7. It’s not a priority; and 8. A lack of knowledge about ACP. Conclusions Patients in our sample described many barriers to ACP discussions, including concerns about the effect these discussions may have on relationships with both family members and family physicians, and issues relating to patients’ knowledge and interpretation of the importance, responsibility for, or relevance of ACP itself. Family physicians may be uniquely placed to leverage the longitudinal, person- centred relationship they have with patients to mitigate some of these barriers

Adaptation and Preliminary Validation of the Advance Care Planning Engagement Survey for Surrogate Decision Makers

CONTEXT:Although measures that assess patient engagement in the advance care planning (ACP) process exist, there are no validated tools to assess surrogate decision makers' (SDMs') role in ACP. OBJECTIVES:The objective of this study was to adapt and begin to validate a patient-oriented questionnaire for use with SDMs of patients with chronic illness. METHODS:Questions from the 55-item patient-oriented ACP engagement survey were adapted for SDMs and assessed for face validity. The resultant 47-item questionnaire was administered to 65 SDMs of patients with chronic illness. Responses were assessed and items were flagged for removal based on item redundancy, nonresponses, and ceiling effects. A preliminary exploratory factor analysis was performed, internal consistency was assessed, and domains were constructed based on findings. RESULTS:The 47-item questionnaire was administered to 65 participants (mean age 51.8; 81% female; 96% Caucasian). Seventeen items were removed owing to redundancy (r > 0.80), and 13 items lacking face validity were removed. In a preliminary exploratory factor analysis of the resultant 17-item questionnaire, a three-factor solution was deemed most statistically and conceptually sound. Items were organized into domains: 1) serving as an SDM (seven items); 2) contemplation (four items); 3) readiness (six items). Internal consistency for each domain was high (Cronbach alpha 0.90-0.91). CONCLUSION:The 17-item ACP engagement survey for SDMs (ACP-17-SDM) is a conceptually sound and reliable questionnaire adaptation of the original ACP engagement survey. This questionnaire may be used by researchers in parallel with the patient-oriented ACP engagement survey to more fully understand the impact of ACP interventions on SDMs. Larger studies are needed to more closely examine construct validity

Impact of enteral feeding on vasoactive support in septic shock: A retrospective observational study

Background: Introducing enteral nutrition (EN) during hemodynamic instability may induce the splanchnic steal phenomenon, which may worsen systemic oxygen delivery and increase vasopressor dose. We aimed to determine the change in vasopressor dose in septic shock patients who received concomitant EN. We hypothesize that EN delivery is not associated with worsening hemodynamic instability, as defined by an increase in vasopressor dose ≥50% at 24 hours.Methods: This is a retrospective observational cohort study of adult patients with septic shock who were admitted to the intensive care unit from January 2015 to June 2015 and received EN. Vasopressor and EN parameters were collected at 6-hour intervals for the first 24 hours.Results: Data were available for 28 consecutive patients. The mean age was 60 years (SD = 18), and 54% were females. Norepinephrine (NE) was used in 100%. EN and vasopressor overlap totaled 36 hours (interquartile range [IQR], 27-69). Median NE dose when starting EN was 5.9 μg/min (IQR, 3.88). Median change in dose from 0 to 6 hours was 0.85 μg/min (95% CI, 0.681.06; P = 0.136), corresponding to a median increase of 14.5%. Total NE duration was 60.5 hours (IQR, 47.5-75.5). No serious complications occurred.Conclusion: The median vasopressor dose did not increase by ≥50% during the first 24 hours of EN. This suggests early EN delivered during septic shock is not associated with worsening hemodynamic instability. Limitations include a small sample size and residual confounding. Prospective data are needed

Data Dictionary - Canadian ACP engagement sample BMJ Open

This file describes the variables that were included in the dataset, and their allowable values

Data from: Measuring engagement in advance care planning: a cross-sectional multicentre feasibility study.

Objectives: To assess feasibility, acceptability, and clinical sensibility of a novel survey, the Advance Care Planning (ACP) Engagement Survey in various health care settings. Setting: A target sample of 50 patients from each of primary care, hospital, cancer care, and dialysis care settings. Participants: A convenience sample of patients without cognitive impairment who could speak and read English was recruited. Patients 50 years and older were eligible in primary care; patients 80 and older or 55 years and older with clinical markers of advanced chronic disease were recruited in hospital; patients aged 19 and older were recruited in cancer and renal dialysis centres. Outcomes: We assessed feasibility, acceptability and clinical sensibility of the ACP Engagement Survey using a 6-point scale. The ACP Engagement Survey measures ACP processes (knowledge, contemplation, self-efficacy, readiness) on 5-point Likert scales and actions (yes/no). Results: 196 patients (38 to 96 years old, 50.5% women) participated. Mean (±standard deviation) time to administer was 48.8 ±19.6 minutes. Mean acceptability scores ranged from 3.2±1.3 in hospital to 4.7±0.9 in primary care and mean relevance ranged from 3.5±1.0 in hospital to 4.9±0.9 in dialysis centres (p values <0.001 for both). The mean process score was 3.1±0.6 and the mean action score was 11.2±5.6 (of a possible 25). Conclusions: The ACP Engagement Survey demonstrated feasibility and acceptability in out-patient settings, but was less feasible and acceptable among hospitalized patients due to length. A shorter version may improve feasibility. Engagement in ACP was low to moderate

Recognizing difficult trade-offs: values and treatment preferences for end-of-life care in a multi-site survey of adult patients in family practices

Background: Decisions about care options and the use of life-sustaining treatments should be informed by a person’s values and treatment preferences. The objective of this study was to examine the consistency of ratings of the importance of the values statements and the association between values statement ratings and the patient’s expressed treatment preference. Methods: We conducted a multi-site survey in 20 family practices. Patients aged 50 and older self-completed a questionnaire assessing the importance of eight values (rated 1 to 10), and indicated their preference for use of life-sustaining treatment (5 options). We compared correlations among values to a priori hypotheses based on whether the value related to prolonging or shortening life, and examined expected relationships between importance of values and the preference option for life-sustaining treatment. Results: Eight hundred ten patients participated (92% response rate). Of 24 a priori predicted correlations among values statements, 14 were statistically significant but nearly all were negligible in their magnitude and some were in the opposite direction than expected. For example, the correlation between importance of being comfortable and suffering as little as possible and the importance of living as long as possible should have been inversely correlated but was positively correlated (r = 0.08, p = 0.03). Correlations between importance of values items and preference were negligible, ranging from 0.03 to 0.13. Conclusions: Patients may not recognize that trade-offs in what is most important may be needed when considering the use of treatments. In the context of preparation for decision-making during serious illness, decision aids that highlight these trade-offs and connect values to preferences more directly may be more helpful than those that do not.Medicine, Faculty ofOther UBCNon UBCCritical Care Medicine, Division ofMedicine, Department ofPopulation and Public Health (SPPH), School ofReviewedFacult

Recognizing difficult trade-offs: values and treatment preferences for end-of-life care in a multi-site survey of adult patients in family practices

Abstract Background Decisions about care options and the use of life-sustaining treatments should be informed by a person’s values and treatment preferences. The objective of this study was to examine the consistency of ratings of the importance of the values statements and the association between values statement ratings and the patient’s expressed treatment preference. Methods We conducted a multi-site survey in 20 family practices. Patients aged 50 and older self-completed a questionnaire assessing the importance of eight values (rated 1 to 10), and indicated their preference for use of life-sustaining treatment (5 options). We compared correlations among values to a priori hypotheses based on whether the value related to prolonging or shortening life, and examined expected relationships between importance of values and the preference option for life-sustaining treatment. Results Eight hundred ten patients participated (92% response rate). Of 24 a priori predicted correlations among values statements, 14 were statistically significant but nearly all were negligible in their magnitude and some were in the opposite direction than expected. For example, the correlation between importance of being comfortable and suffering as little as possible and the importance of living as long as possible should have been inversely correlated but was positively correlated (r = 0.08, p = 0.03). Correlations between importance of values items and preference were negligible, ranging from 0.03 to 0.13. Conclusions Patients may not recognize that trade-offs in what is most important may be needed when considering the use of treatments. In the context of preparation for decision-making during serious illness, decision aids that highlight these trade-offs and connect values to preferences more directly may be more helpful than those that do not