Implementing Universal Suicidality Screening in a Critical-Access Emergency Department

Background: Implementation of a universal suicidality screening is considered best practice as it is associated with improved the detection of occult, or latent, suicide risk and can reduce subsequent risk. This quality improvement (QI) project evaluates the implementation of the Columbia-Suicide Severity Rating Scale (C-SSRS) to screen patients over the age of twelve at a regional healthcare system. Methods: The QI project was conducted at Littleton Regional Healthcare (LRH) emergency department, a critical-access hospital in Littleton, New Hampshire that serves about 206 patients per week. Implementation of suicidality screening was of interest to LRH to promote mental health in the communities they support. The QI project utilized three plan-do-study-act (PDSA) cycles. PDSA cycle one involved monitoring the current use of suicidality screening from January 2023 – February 2023. PDSA cycle two was the implementation of the screening protocol from February 2023 – March 2023. PDSA cycle three was providing staff education from March 2023 – March 2023. Results: In PDSA cycle one, 11% of patients (n=66) were screened out of 585 total. In cycle two, 17% of patients (n=111) patients were screened out of 656 total patients. In cycle three, 28% (n=170) patients were screened out of 613 total patients. Conclusion: The PDSA cycles resulted in an increase in universal suicidality screening from 11% to 28% (t=4.143, p\u3c.001). This demonstrates an increase in the rate of screening; however, further work needs to be done to determine further barriers to implementing universal screening in the emergency department at a higher rate of success. Short-term impacts include early risk identification and early intervention for patients who might not have been identified as an at-risk person and long-term impacts can include improved detection of occult suicide risk, reduced subsequent risk, streamlined interventions, and decreased cost to the hospital

Opioid initiation and injection transition in rural northern New England: A mixed-methods approach

BACKGROUND: In rural northern New England, located in the northeastern United States, the overdose epidemic has accelerated with the introduction of fentanyl. Opioid initiation and transition to opioid injection have been studied in urban settings. Little is known about opioid initiation and transition to injection drug use in rural northern New England. METHODS: This mixed-methods study characterized opioid use and drug injection in 11 rural counties in Massachusetts, Vermont, and New Hampshire between 2018 and 2019. People who use drugs completed audio computer-assisted self-interview surveys on substance use and risk behaviors (n = 589) and shared personal narratives through in-depth interviews (n = 22). The objective of the current study is to describe initiation of opioid use and drug injection in rural northern New England. RESULTS: Median age of first injection was 22 years (interquartile range 18-28 years). Key themes from in-depth interviews that led to initiating drug injection included normalization of drug use in families and communities, experiencing trauma, and abrupt discontinuation of an opioid prescription. Other factors that led to a transition to injecting included lower cost, increased effect/ rush, greater availability of heroin/ fentanyl, and faster relief of withdrawal symptoms with injection. CONCLUSIONS: Trauma, normalization of drug use, over-prescribing of opioids, and abrupt discontinuation challenge people who use drugs in rural northern New England communities. Inadequate opioid tapering may increase transition to non-prescribed drug use. The extent and severity of traumatic experiences described highlights the importance of enhancing trauma-informed care in rural areas

The opioid epidemic in rural northern New England: An approach to epidemiologic, policy, and legal surveillance

The opioid crisis presents substantial challenges to public health in New England\u27s rural states, where access to pharmacotherapy for opioid use disorder (OUD), harm reduction, HIV and hepatitis C virus (HCV) services vary widely. We present an approach to characterizing the epidemiology, policy and resource environment for OUD and its consequences, with a focus on eleven rural counties in Massachusetts, New Hampshire and Vermont between 2014 and 2018. We developed health policy summaries and logic models to facilitate comparison of opioid epidemic-related polices across the three states that could influence the risk environment and access to services. We assessed sociodemographic factors, rates of overdose and infectious complications tied to OUD, and drive-time access to prevention and treatment resources. We developed GIS maps and conducted spatial analyses to assess the opioid crisis landscape. Through collaborative research, we assessed the potential impact of available resources to address the opioid crisis in rural New England. Vermont\u27s comprehensive set of policies and practices for drug treatment and harm reduction appeared to be associated with the lowest fatal overdose rates. Franklin County, Massachusetts had good access to naloxone, drug treatment and SSPs, but relatively high overdose and HIV rates. New Hampshire had high proportions of uninsured community members, the highest overdose rates, no HCV surveillance data, and no local access to SSPs. This combination of factors appeared to place PWID in rural New Hampshire at elevated risk. Study results facilitated the development of vulnerability indicators, identification of locales for subsequent data collection, and public health interventions

Pediatric Emergency Department Nurse’s Knowledge and Attitudes of Pediatric Fluid Resuscitation

Background: Rapid fluid resuscitation is essential to the management of pediatric shock, but there are many barriers to published guideline adherence. Limited evidence describing emergency department (ED) nurse’s knowledge and attitudes of fluid resuscitation exists. This study described pediatric ED nurse’s knowledge and attitudes of fluid resuscitation. Methods: This single-site descriptive study used survey methodology. A 23-question survey was distributed to nurses in the ED at Boston Children’s Hospital. The survey measured nurse’s knowledge, attitudes, and perceived barriers to fluid resuscitation. Results: Findings suggested gaps found between actual and perceived knowledge consistent with prior evidence. There was a 50.9% response rate to the survey, with the majority of the participants holding a bachelor’s degree and a nursing certification. One of the top concerns nurses considered with each method of fluid resuscitation was the IV gauge. Thematic analysis identified the need for further education, environmental modifications, staffing consistent with patient acuity, and piloting of new devices. Conclusion: Pediatric nurses\u27 knowledge and attitudes varied, and improving knowledge will enhance the provision of safe and effective care. Educational interventions should incorporate a variety of modalities and reassess frequency needed to maintain competency. Education should encourage consideration of all fluid resuscitation options. Demographics provided insight into how perception, years of experience, education level, and certifications related to knowledge. Limitations included that this was a single-center descriptive study with a small convenience sample. Additionally, this study took place during the COVID pandemic and social unrest which may have impacted survey response

Facilitators and barriers to advance care planning implementation in Australian aged care settings : A systematic review and thematic analysis

Objectives There are many studies investigating implementation of advance care planning (ACP) in aged care around the world, but few studies have investigated Australian settings. The objective of this study was to determine facilitators and barriers to implementation of ACP in Australian residential and community aged care. Methods Evidence from Australian studies published between 2007 and September 2017 of ACP in residential and community aged care was sourced from electronic databases using predetermined search strategies. Data were extracted and synthesised using thematic analysis, and summarised according to themes. Results Nine studies described facilitators and barriers of ACP implementation. Six themes were identified: “Education and Knowledge,” “Skills and Training,” “Procedures and Resources,” “Perceptions and Culture,” “Legislation” and “Systems.” Conclusions A whole of systems approach is necessary to facilitate uptake of ACP in residential aged care settings. More research is needed to understand facilitators and barriers to ACP in community aged care