Suicide risk assessment in the emergency department:an investigation of current practice in Scotland

Background: Suicide is a global public health issue. Approximately one third of individuals who complete suicide have attended an emergency department in the year preceding their death. The aim of this study was to investigate current suicide risk assessment practices across emergency department clinicians in Scotland.Methods: A mixed‐methods design was employed. A total of 112 surveys for emergency department clinicians were posted to 23 emergency departments in Scotland between March and September 2016. Follow‐up semi‐structured interviews were also conducted exploring clinician's experiences of suicide risk assessment. Interviews were analysed using thematic analysis.Results: Fifty‐one emergency department clinicians across 17 emergency departments completed the survey. Thirty‐five (68.6%) participants were currently using a suicide risk assessment tool; with most using locally developed tools and proformas (n = 20, 62.5%) or the SAD PERSONS scale (n = 13, 40.6%). Remaining participants (n = 16, 31.4%) did not use suicide risk assessment tools during assessment. Variation in practice was found both across and within emergency departments. Six clinicians participated in follow‐up interviews, which identified four major themes: Clinician Experiences of Suicide Risk Assessment; Components of Suicide Risk Assessment; Clinical Decision‐Making; and Supporting Clinicians.Conclusions: There is substantial variation in current practice, with around two‐thirds of clinicians using a variety of empirically and locally developed tools, and a third using their judgement alone. Clinicians find suicide risk assessment a challenging part of their role and discuss the need for increased training, and appropriate and helpful guidelines to improve practice

Study to determine the likely accuracy of pH testing to confirm nasogastric tube placement

Objective To establish the likely accuracy of pH testing to identify gastric aspirates at different pH cut-offs to confirm nasogastric tube placement.Methods This prospective observational study included a convenience sample of adult patients who had two (one fresh and one frozen) gastric and oesophageal samples taken during gastroscopy or two bronchial and saliva samples taken during bronchoscopy. The degree of observer agreement for the pH of fresh and frozen samples was indicted by kappa (k) statistics. The sensitivities and specificities at pH ≤5.5 and the area under the receiver operating characteristics (ROC) curve at different pH cut-offs were calculated to identify gastric and non-gastric aspirates.Results Ninety-seven patients had a gastroscopy, 106 a bronchoscopy. There was complete agreement between observers in 57/92 (62%) of the paired fresh and frozen gastric samples (k=0.496, 95% CI 0.364 to 0.627). The sensitivity of a pH ≤5.5 to correctly identify gastric samples was 68% (95% CI 57 to 77) and the specificity was 79% (95% CI 74 to 84). The overall accuracy to correctly classify samples was between 76% and 77%, regardless of whether patients were taking antacids or not. The area under the ROC curve at different pH cut-offs was 0.74.Conclusion The diagnostic accuracy of pH ≤5.5 to differentiate gastric from non-gastric samples was low, regardless of whether patients were taking antacids or not. Due to the limited accuracy of the pH sticks and the operators’ ability to differentiate colorimetric results, there is an urgent need to identify more accurate and safer methods to confirm correct placement of nasogastric tubes

Risk Factors for Suicide and Suicidal Behavior Relevant to Emergency Health Care Settings: A Systematic Review of Post-2007 Reviews

Suicide is a global public health problem and with recent economic and societal changes, there may be emerging risk factors unrecognised by healthcare professionals. The aim of this systematic review is to update existing suicide risk factor literature applicable to emergency healthcare settings. A total of 35 articles identified from PsycINFO, CINAHL and Medline met the inclusion criteria. Results supported the significance of existing suicide risk factors and identified emerging risk factors. The review provides a high-quality update of risk factor literature that could be applied to emergency healthcare settings, however further research is needed to confirm emerging risk factors

Diagnostic accuracy of a pH stick, modified to detect gastric lipase, to confirm the correct placement of nasogastric tubes

Objective The correct placement of a nasogastric feeding tube is usually confirmed by establishing that an aspirate is acidic using a pH stick. However, antacid medication and achlorhydria can cause false negative pH tests that may delay feeding and increase resource use. The purpose of this study was to evaluate a modified pH stick designed to detect gastric lipase and therefore reduce false negativetests.Methods In this prospective observational study, a convenience sample of adult patients who had either gastric and oesophageal samples taken during routine diagnostic gastroscopy (n=97) or bronchial and saliva samples taken during a bronchoscopy (n=106). The samples were tested by blinded observers using the modified and standard pH sticks. The sensitivities and specificities of the two pH sticks in identifying gastric and non-gastric aspirates were compared using the pH cut-off ≤5.5.Results The sensitivities of a pH≤5.5 to correctly identify gastric samples were 66% (95% CI 56 to 75) and 68% (95% CI 57 to 77) for the modified and the standard pH, respectively. The specificities were 81% (95% CI 76 to 85) and 79% (95% CI 74 to 84). There were no significant differences in the distribution of the discordant resultsbetween the paired gastric and non-gastric samples for both the modified and standard pH sticks at pH≤5.5 (both McNemar’s tests, p≥0.05).Conclusions There were no significant differences between the paired modified and standard pH tests for the gastric samples. Due to the limited accuracy of pH sticks, further research is required to identify accurate and cost-effective bedside methods to confirm the correct placement of nasogastric tubes

Implementing Supported Self-Management in Community-Based Stroke Care: A Secondary Analysis of Nurses’ Perspectives

The provision of supported self‐management (SSM) is recommended in contemporary guidelines to address the longer‐term needs and outcomes of stroke survivors and their families, yet its implementation across stroke pathways has been inconsistent. This paper presents a secondary analysis of qualitative data, which aims to identify and offer insight into the challenges of implementing SSM from the perspectives of community stroke nurses (n = 14). The findings revealed that the implementation of SSM in stroke is influenced by factors operating at multiple levels of the healthcare system. Contextual challenges arise because of different understandings and interpretations of what SSM is, what it comprises and professionals’ perceptions of their roles in its implementation in practice. A professionally controlled, one‐size‐fits‐all model of SSM continues to be reinforced within organizations, offering few opportunities for nurses to deliver contextually tailored and person‐centred SSM. In conclusion, there are many professional concerns and organizational tensions that need to be addressed across multiple layers of the healthcare system to achieve the consistent implementation of contextually tailored and person‐centred SSM following a stroke. Attempts to address these challenges will help to narrow the gap between policy and practice of implementing SSM, ensuring that stroke survivors and families benefit from SSM in the longerterm

Development and evaluation of a nurse-led, tailored stroke self-management intervention.

Community nurses are well placed to promote and support stroke survivors to engage in self-management. The aim of this study was to develop a stroke self-management intervention that could be tailored towards stroke survivors’ self-management needs, goals and levels of activation, in the first year post-stroke.MethodsMixed method study, designed in accordance with the British Medical Research Council’s (MRC) guidance for the development and evaluation of complex interventions. The intervention was developed and evaluated in two phases. The intervention was underpinned by the theoretical concept of patient activation and was developed based on a review of published research on stroke self-management interventions and qualitative interviews and focus groups (phase 1). It was evaluated using qualitative interviews and focus groups with stroke survivors and stroke nurses (phase 2). Participants comprised 26 stroke survivors, between 3 and 12 months post stroke and 16 stroke nurses, from across three NHS Boards in Scotland.ResultsThe intervention consisted of a tailored self-management action plan, incorporating an individualised assessment of stroke survivor’s readiness to self-manage (using the Patient Activation Measure), goal setting and motivational interviewing. Evaluation showed that many of the individual components of the intervention were perceived as feasible and acceptable to both stroke survivors and stroke nurses.ConclusionsTo our knowledge, this is the first UK study to explore the use of patient activation as a theoretical underpinning in stroke self-management research and to involve stroke survivors and stroke nurses in the design and development of a tailored, person-centred stroke self-management support intervention. The study findings provide the first step in understanding how to effectively develop and deliver stroke self-management support interventions to stroke survivors living at home in the first year following stroke. Further work is needed to develop and refine the intervention and identify how to effectively embed it into nurses’ routine clinical practice

The effect of concentration and duration of normobaric oxygen in reducing caspase-3 and -9 expression in a rat-model of focal cerebral ischaemia

The aim of this study was to determine the effect of different concentrations of normobaric oxygen (NBO) on neurological function and the expression of caspase-3 and -9 in a rat model of acute cerebral ischaemia. Sprague-Dawley rats (n=120) were randomly divided into four groups (n=30 per group), including 3 groups given NBO at concentrations of 33%, 45% or 61% and one control group given air (21% oxygen). After 2 h of ischaemic occlusion, each group was further subdivided into six subgroups (n=5) during reperfusion according to the duration (3, 6, 12, 24, 48 or 72 h) and concentration of NBO (33%, 45% or 61%) or air treatment. The Fluorescence Quantitative polymerase chain reaction (PCR) and immunohistochemistry were used to detect caspase-3 and -9 mRNA and protein relative expression respectively. The Neurologic Impairment Score (NIS) was significantly lower in rats given 61% NBO ≥3 h after reperfusion when compared to the control group (P<0.05, Mann–Whitney U). NBO significantly reduced caspase-3 and -9 mRNA and protein expression when compared to the control group at all NBO concentrations and time points (P<0.05, ANOVA). The expression of caspase-3 and -9 was lower in the group given 61% NBO compared any other group, and this difference was statistically significant when compared to the group given 33% NBO for ≥48 h and the control group (both P<0.05, ANOVA). These findings indicate that NBO may inhibit the apoptotic pathway by reducing caspase-3 and -9 expression, thereby promoting neurological functional recovery after stroke

Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people (Review)

BackgroundThere is evidence that water-loss dehydration is common in older people and associated with many causes of morbidity and mortality.However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well-being are compromised.ObjectivesTo determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screeningtests for detecting water-loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water-loss dehydration was defined primarily as including everyone with either impending or current water-loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated).Search methodsStructured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTAdatabases (The Cochrane Library), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studiesand identified relevant reviews were checked. Authors of included studies were contacted for details of further studies.Selection criteriaTitles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables.Data collection and analysis.Diagnostic accuracy of each test was assessed against the best available reference standard for water-loss dehydration (serum or plasma osmolality cut-off≥295mOsm/kg, serumosmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water-loss dehydration (including either impending or current water-loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water-loss dehydration, but restricted to current dehydration in the final review.We conducted bivariate random-effects meta-analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre-specified cut-off points investigated.Pre-set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre-specifying three cut-offs for each continuoustest may have led to missing a cut-off with useful sensitivity and specificity, we conducted post-hoc exploratory analyses to createreceiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut-off missed by the original three.These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability.Main resultsThere were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests tobe used as screening tests for detecting water-loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years.We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. Weassessed 67 tests (at three cut-offs for each continuous outcome) for diagnostic accuracy of water-loss dehydration (primary targetcondition) and of current dehydration (secondary target condition).Only three tests showed any ability to diagnose water-loss dehydration (including both impending and current water-loss dehydration) as stand-alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post-hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study.Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95%CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97).There was sufficient evidence to suggest that several stand-alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people.No tests were found consistently useful in diagnosing current water-loss dehydration.Authors’ conclusionsThere is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicatewater-loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a highproportion of people with dehydration, and wrongly label those who are adequately hydrated.Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy

Highlighting research priorities in stroke nursing

No abstract available