Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation

Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.

Initial Medication Adherence by Psychiatric Outpatients in a General Hospital and Relevant Factors

Background: The International Society for Pharmacoeconomics and Outcomes Research proposed two types of medication adherence: initial and long-term. Initial adherence is a predictor of long-term adherence and thus is a crucial metric to explore and support. This study aimed to investigate initial medication adherence by psychiatric outpatients and relevant factors. Methods: The study surveyed psychiatric outpatients using a 30-day timely return visit rate (TRVR) after the first visit to indicate initial adherence. All participants agreed to engage in the self-designed survey and assessments of the Eysenck Personality Questionnaire (EPQ) and Symptoms Checklist-90 (SCL-90). Clients who missed timely return visits received telephone follow-up to determine the main reasons. Results: The overall TRVR was 59.4%, and 40.6% of clients missed return visits. Logistic regression analysis revealed risk factors for initial adherence were work, tense family atmosphere, negative attitudes towards medication, higher EPQ psychoticism score, and lower SCL-90 phobic anxiety score. The main reasons given for non-timely return visits were improvement suggesting lack of need for a return visit, various limitations, no improvement, and side effects. Conclusion: Psychiatric outpatients had poor initial medication adherence related to multiple dimensional factors, including job, family, personality characteristics, mental status, and thoughts about mental illness and treatments.

Impact of In Situ Education on Management of Cardiac Arrest after Cardiac Surgery

Background: Advanced life support interventions have been modified for patients who have recently undergone sternotomy for cardiac surgery and have new suture lines. We aimed to determine whether the use of in-situ simulation increased adherence to the cardiac surgery unit-advanced life support algorithm (CSU-ALS) for patients with cardiac arrest after cardiac surgery (CAACS). Methods: This was a retrospective chart review of cardiac arrest management of patients who sustained CAACS before and after implementation of in-situ simulation scenarios utilizing CSU-ACLS in place of traditional advanced cardiac life support. We utilized classroom education of CSU-ACLS followed by in-situ high-fidelity simulated scenarios of patients with CAACS.. Interprofessional learners (n = 210) participated in 18 in-situ simulations of CAACS. Two groups of patients with CAACS were retrospectively compared before and after in situ training (preimplementation, n=22 vs postimplementation, n=38). Outcomes included adherence to CSU-ALS for resuscitation, delay in initiation of chest compressions, use of defibrillation and pacing before external cardiac massage, and time to initial medication. Results: Chest compressions were used less often in the postimplementation vs the preimplementation period (11/22 [29%] vs 13/38 [59%], P = 0.02). Time to initial medication administration, use of defibrillation and pacing, return to the operating room, and survival were similar between periods. Conclusion: In this pilot, adherence to a key component of the CSU-ALS algorithm—delaying initiation of chest compressions—improved

Patterns of antipsychotic prescribing in first episode psychosis – differences between acute and early intervention services

AimsThis study aimed to evaluate the patterns of antipsychotic prescribing in patients with first episode psychosis (FEP) at the time of their initial treatment and over the first year with the Early Intervention Service (EIS). It was hypothesised that different care teams would have a preference for certain antipsychotic medications and that initial medication choice would be continued through the first year.BackgroundResearch indicates that with the exception of clozapine, all antipsychotics are equally as effective. However, anecdotally it has been observed that inpatient and crisis teams and EIS have differing initial medication choices.MethodAn analysis of the North West Sussex EIS caseload (n = 67) was conducted. The first antipsychotic prescribed and initiating team was recorded. Prescribed medication for those that had completed 12 months (n = 43) with EIS after initial prescription was recorded. An analysis was performed of prescribing choice by initial care team (acute vs EIS vs other community services) with the frequency with which medication was changed during treatment.Result97% (n = 65) of patients were started on an antipsychotic. Initial medication choice was olanzapine (44.8%, n = 30), aripiprazole (22.4%, n = 15), risperidone (20.9%, n = 14), quetiapine (6%, n = 4) and zuclopenthixol were least common (1.5%, n = 2). At the 12 month point 51.2% (n = 22 of 43) had switched and 16.3% (n = 7 of 43) had discontinued.The most common medication started by acute services was olanzapine (56.0%, n = 28 of 50), though of those who completed 12 months this had been switched in 53% of cases (n = 9 of 17). EIS most commonly initiated aripiprazole or risperidone (37.5% each n = 4). At 6 and 12 month follow-up by EIS, the most commonly prescribed antipsychotic was aripiprazole (24 patients 40.7%, and 14 patients 32.6% respectively).ConclusionThere was a clear preference for olanzapine as initial treatment of First Episode of Psychosis in the region. On breakdown it was apparent that there was a split in prescribing choices between more sedating medication in acute services and less sedating medication in EIS. Given that most patients changed to less sedating and less metabolic active medications over their first year it is not clear why alternative options are not used at the start of treatment. Future research will focus on clinician's rationale for initial prescribing choice. This will look for any underlying bias toward specific medications.

Guidance for post-discharge care following acute kidney injury: an appropriateness ratings evaluation

BackgroundAcute kidney injury (AKI) is associated with poor health outcomes, including increased mortality and rehospitalisation. National policy and patient safety drivers have targeted AKI as an example to ensure safer transitions of care.AimTo establish guidance to promote high-quality transitions of care for adults following episodes of illness complicated by AKI.Design & settingAn appropriateness ratings evaluation was undertaken using the RAND/UCLA Appropriateness Method (RAM). The Royal College of General Practitioners (RCGP) AKI working group developed a range of clinical scenarios to help identify the necessary steps to be taken following discharge of a patient from secondary care into primary care in the UK.MethodA 10-person expert panel was convened to rate 819 clinical scenarios, testing the most appropriate time and action following hospital discharge. Specifically, the scenarios focused on determining the appropriateness and urgency for planning: an initial medication review; monitoring of kidney function; and assessment for albuminuria.ResultsTaking no action (that is, no medication review; no kidney monitoring; or no albuminuria testing) was rated inappropriate in all cases. In most scenarios, there was consensus that both the initial medication review and kidney function monitoring should take place within 1–2 weeks or 1 month, depending on clinical context. However, patients with heart failure and poor kidney recovery were rated to require expedited review. There was consensus that assessment for albuminuria should take place at 3 months after discharge following AKI.ConclusionSystems to support tailored and timely post-AKI discharge care are required, especially in high-risk populations, such as people with heart failure.

Initial Glaucoma Medication in the Hypertensive Phase Following Ahmed Valve Implantation: A Comparison of Results Achieved Using Aqueous Suppressants and Prostaglandin Analogs

Background: To compare the effects of aqueous suppressants (AS) and prostaglandin (PG) analogs during the hypertensive phase on intraocular pressure (IOP) and surgical outcomes. Methods: In this retrospective, observational study, 66 eyes (66 patients) with Ahmed glaucoma valve (AGV) implantation were included. As evaluation items, IOP changes, number of postoperative medications, the surgical success rate, and postoperative complications were examined. Complete success was defined as IOP between 6 and 21 mmHg without medications, while qualified success was with a maximum of four medications. Results: The short-term IOP reduction following initial medication was 9.3 mmHg for AS and 4.4 mmHg for PG analogs (p = 0.016). More postoperative medications were used in PG than in AS from postoperative 3 months to 3 years (all p < 0.05). The qualified success rate with the initial medication was higher in AS than in PG (67.5% vs. 42.3% at 1 year, 80.6% vs. 37.5% at 2 years, 80.0% vs. 35.0% at 3 years, all p < 0.05). Conclusions: Association between AS used as the first medications during the hypertensive phase and better IOP control and a higher success rate was observed. The type of the initial glaucoma medication after AGV implantation could affect short- and long-term surgical outcomes.