Moving towards trauma informed care. A model of research and practice.

Context: Cork Simon Community offers care, accommodation and support for almost 1200 people annually. The current unprecedented housing crisis is pushing people into homelessness and preventing people from leaving homelessness. With increasing demands on resources those who are often the most vulnerable struggle to navigate systems and services and thus consideration of service design and delivery is required in order to maximise a service user’s ability to engage effectively. There is a growing body of research that argues that trauma informed care (TIC) improves outputs for both staff and the people they serve. Aims & Method: The aim of this project is threefold; (a) establish the prevalence of trauma within Cork Simon Community (b) assess Cork Simon Community’s capacity for Trauma Informed Care (c) ascertain the implications of the findings for clinical and non-clinical interventions within homeless settings. This aim was addressed by completing three research studies. Trauma awareness training was also delivered to 120+ staff and data regarding capacity for TIC was collected at 6 training dates. 1. Establish service users’ levels of early childhood trauma (ACE’s) 2. Establish staff/volunteers levels of vicarious trauma (ProQOL) 3. Complete agency trauma informed assessment The model (Fig. 1.0) offered an integrated exploration of the experiences of service users, and staff in parallel with the organisation they operating within. The information gained from these micro and macro perspectives informed the content of the trauma training as a means of amplifying existing strengths while shoring up skills and service deficits. Fig 1.0 Model of TIC Implementation vi Findings & Conclusions: The results of the ACE study revealed that there are significant levels of childhood trauma in the Service Users who participated in the research and that SU’s were experiencing a range of negative health related behaviours as a result of substance misuse, homelessness and associated behaviours. The results of the staff audit for secondary trauma revealed that there is considerable satisfaction with the work among staff but that there is a trauma contagion effect and that one quarter of the staff surveyed reported signs of secondary traumatic stress with 12% reporting indicators of burn out. The implementation of TIC and a re-evaluation of staff supervision and self-care processes can mitigate this. An agency self- assessment for capacity for TIC revealed that in the main many of the organisations existing policies and procedures are operating from a place that provides for working with deeply traumatised people. There were some areas for improvement and these were mostly constrained by resource issues. There were a number of issues identified that are beyond the organisations control as they are dictated by national policies such as intake paperwork that is not strengths based and a policy of ‘centre of interest’1 that disregards a persons’ choices which may well be dictated by an avoidance of memories of trauma situations. Organisations that work with people experiencing homelessness should advocate for greater resources and changes to national policies that conflict with strengths based trauma informed approaches. A number of recommendations have been provided

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

Background: Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. Methods: The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). Findings: Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29–146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0– 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25–1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39–1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65–1·60]; p=0·92). Interpretation: These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

Background: Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. Methods: The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). Findings: Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29–146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0– 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25–1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39–1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65–1·60]; p=0·92). Interpretation: These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

BACKGROUND: Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. METHODS: The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). FINDINGS: Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29-146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0- 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25-1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39-1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65-1·60]; p=0·92). INTERPRETATION: These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention. FUNDING: British Heart Foundation

Corporate governance in the public sector: Reflections on experience in Ireland

The article proceeds from the context for corporate governance in the public sector in Ireland. It examines the adoption and evolution of corporate governance guidance, standards and codes, and focuses on the Code of Practice for the Governance of State Bodies. In reflecting on the scope and depth of the provisions of the state body code, the article points to various implementation challenges using examples in the areas of culture, risk appetite and assurance arrangements. The article concludes by pointing to future challenges and suggestions for a research agenda for corporate governance in the public sector in Ireland

An evaluation of practitioner's experience of service users seeking community detoxification from benzodiazepines.

A recent report in Ireland identified that two-thirds of poisoning deaths involved poly drug use with an average of four different drugs involved. Of these, benzodiazepines were the most common drug group involved. Concern has been expressed regarding high levels of benzodiazepine prescriptions globally. Community-based detoxification programs are required, but detoxification is complex with associated high risks, such as overdose. This study utilized a survey to gather the experiences of a range of drug workers in addiction settings in the southern region of Ireland who are tasked with the management of supporting service users who wish to detoxify from benzodiazepines. The purpose of this study is to identify the issues highlighted in the data and consequently inform policy development, service delivery, future training, and pathways to support service users (SUs). Findings indicate that, while practitioners had high levels of confidence in managing community-based detoxes, levels of knowledge of schedules, contraindications, access to support, and appropriate referral pathways were limited. Barriers to supporting detoxes emerged, emphasizing the importance of multidisciplinary and interagency care planning. Changing trends in drug use led participants to indicate a need for pharmacology training and development of specific local protocols

Moving towards trauma informed care. A model of research and practice.

Context: Cork Simon Community offers care, accommodation and support for almost 1200 people annually. The current unprecedented housing crisis is pushing people into homelessness and preventing people from leaving homelessness. With increasing demands on resources those who are often the most vulnerable struggle to navigate systems and services and thus consideration of service design and delivery is required in order to maximise a service user’s ability to engage effectively. There is a growing body of research that argues that trauma informed care (TIC) improves outputs for both staff and the people they serve. Aims & Method: The aim of this project is threefold; (a) establish the prevalence of trauma within Cork Simon Community (b) assess Cork Simon Community’s capacity for Trauma Informed Care (c) ascertain the implications of the findings for clinical and non-clinical interventions within homeless settings. This aim was addressed by completing three research studies. Trauma awareness training was also delivered to 120+ staff and data regarding capacity for TIC was collected at 6 training dates. 1. Establish service users’ levels of early childhood trauma (ACE’s) 2. Establish staff/volunteers levels of vicarious trauma (ProQOL) 3. Complete agency trauma informed assessment The model (Fig. 1.0) offered an integrated exploration of the experiences of service users, and staff in parallel with the organisation they operating within. The information gained from these micro and macro perspectives informed the content of the trauma training as a means of amplifying existing strengths while shoring up skills and service deficits. Fig 1.0 Model of TIC Implementation vi Findings & Conclusions: The results of the ACE study revealed that there are significant levels of childhood trauma in the Service Users who participated in the research and that SU’s were experiencing a range of negative health related behaviours as a result of substance misuse, homelessness and associated behaviours. The results of the staff audit for secondary trauma revealed that there is considerable satisfaction with the work among staff but that there is a trauma contagion effect and that one quarter of the staff surveyed reported signs of secondary traumatic stress with 12% reporting indicators of burn out. The implementation of TIC and a re-evaluation of staff supervision and self-care processes can mitigate this. An agency self- assessment for capacity for TIC revealed that in the main many of the organisations existing policies and procedures are operating from a place that provides for working with deeply traumatised people. There were some areas for improvement and these were mostly constrained by resource issues. There were a number of issues identified that are beyond the organisations control as they are dictated by national policies such as intake paperwork that is not strengths based and a policy of ‘centre of interest’1 that disregards a persons’ choices which may well be dictated by an avoidance of memories of trauma situations. Organisations that work with people experiencing homelessness should advocate for greater resources and changes to national policies that conflict with strengths based trauma informed approaches. A number of recommendations have been provided