The coronavirus disease 2019 pandemic placed an unprecedented demand on health systems to rapidly shift ambulatory in-person care to virtual care. Geriatric patients face more challenges with video visit access compared to younger patients due to discomfort with technology and less access to devices and internet. Medical students at the University of Michigan created an initiative to improve access to and comfort with video visits for geriatric patients. The program's goals were to (a) explore options for the delivery of personalized training to older adults, (b) create materials for volunteers to successfully navigate conversations with patients and caregivers, (c) provide patients one-to-one remote guidance while identifying and overcoming barriers—with practice sessions to increase comfort, (d) share with the larger health system, and (e) ensure program sustainability. Over a 10-week evaluation period, providers whose patients worked with our geriatric education on telehealth access volunteers had a video visit rate of 43% compared to 19.2% prior to participation in the program (adjusted odds ratio = 3.38, 95% confidence interval = 2.49, 4.59), ultimately providing a platform for geriatric patients to foster stronger connections with their providers, while increasing Michigan Medicine's overall proportion of video telehealth visits.
Purpose Data shows that there is an increasing number of young people in the UK needing access to mental health services, including crisis teams. This need has been exacerbated by the current global pandemic. There is mixed evidence for the effectiveness of crisis teams in improving adult functioning, and none, to the authors’ knowledge, that empirically examines the functioning of young people following intervention from child and adolescent mental health services (CAMHS) crisis teams in the UK. Therefore, the purpose of this paper is to use CAMHS Crisis Team data, from an NHS trust that supports 1.4 million people in the North East of England, to examine a young person's functioning following a crisis. Design/methodology/approach This service evaluation compared functioning, as measured by the Outcome Rating Scale (ORS), pre- and post-treatment for young people accessing the CAMHS Crisis Team between December 2018 and December 2019. Findings There were 109 participants included in the analysis. ORS scores were significantly higher at the end of treatment (t(108) = −4.2046, p < 0.001) with a small effect size (d = −0.36). Sixteen (15%) patients exhibited significant and reliable change (i.e. functioning improved). A further four (4%) patients exhibited no change (i.e. functioning did not deteriorate despite being in crisis). No patients significantly deteriorated in functioning after accessing the crisis service. Practical implications Despite a possibly overly conservative analysis, 15% of patients not only significantly improved functioning but were able to return to a “healthy” level of functioning after a mental health crisis following intervention from a CAMHS Crisis Team. Intervention(s) from a CAMHS Crisis Team are also stabilising as some young people’s functioning did not deteriorate following a mental health crisis. However, improvements also need to be made to increase the number of patients whose functioning did not significantly improve following intervention from a CAMHS Crisis Team. Originality/value This paper evaluates a young person’s functioning following a mental health crisis and intervention from a CAMHS Crisis Team in the North East of England.
We sought to investigate the experiences of researchers in existing active-control trials in acute ischemic stroke comparing investigational therapy to tissue plasminogen activator (tPA) in order to identify the approaches and challenges in obtaining informed consent. Out of 401 articles evaluated, 14 trials met inclusion criteria. Trial representatives were contacted to complete a survey concerning the consent process. None of the 14 trials published materials related to the informed consent process. Trials with 75% to 100% of patients directly consented had shorter door-totreatment (DTT) times than trials that directly consented less than 50% of patients. Trials that had translators available (for recruiting participants who were not native speakers in the local language) and translated consent documents had longer DTT times. The study findings suggest that differences in the standards of informed consent internationally may allow more patients with moderate strokes to provide direct consent without delaying DTT time. Future trials should emphasize transparency to the public and scientific community in the informed consent process. KEYWORDS human research ethics, human subjects research, acute ischemic stroke, informed consent, randomized controlled trials, literature review
Introduction The start of the Covid-19 pandemic placed an unprecedented demand on health systems to rapidly shift ambulatory in-person care to virtual care. Geriatric patients, at increased risk of morbidly and mortality from Covid-19 infection, face more challenges with video visit access compared to younger patients due to discomfort with technology and less access to necessary devices and broadband internet. Thus, it is a priority to enhance remote connections between geriatric patients and their providers. Methods The aim of this project was to facilitate the transition to video telemedicine for the geriatric population by creating a well-organized training program for volunteers to guide patients and caregivers to make the conversion from phone to video visits. A 28-page volunteer manual was created that included a structured process for how to call patients, including our three-call model, a walk-through of the video modalities, an algorithm for choosing which modality is best for each patient (Figure 1), and troubleshooting resources. Virtual training sessions oriented volunteers to the process and connected them with the faculty they would work with for the duration of the project. Volunteers provided patients with one-to-one remote guidance, identifying and overcoming barriers, with practice sessions to increase comfort with the technology. Initial volunteer work began in the Michigan Medicine Geriatric Psychiatry Clinic. With expansion of our team to 26 total individuals we also began servicing the Michigan Medicine Geriatric General Medicine Clinics. Quantitatively, we measured the proportion of video visits before and after intervention with the program. Qualitatively, we solicited feedback from providers, patients, and volunteers. Results The GET Access Program volunteers were successful in teaching and converting many visits to video that the schedulers were unable to do on a first pass. Of 95 contacted patients, 80 agreed to participate, and 71 switched from a phone visit to video visit, representing a conversion rate of 88.75% from phone to video visits. During a 10-week evaluation period of the two clinics GET Access serviced, 1942 patients had 2865 visits. Of 59 providers within the clinics studied, 12 providers with the lowest video visit rates received help from GET Access. Averaged over the evaluation period, visits after participation in the program were associated with video format 43% compared to 19.2% for visits prior to participation (adjusted OR 3.38 [95% CI 2.49, 4.59]) and visit by non-participating providers (32.1%, adjusted OR 1.65 [1.31, 2.08]) as shown in Figure 2. Conclusions A program dedicated to personalized virtual technological instruction and practice helped geriatric patients transition from phone to video visits, to provide a platform for stronger connection with their providers. Sustainability of the program beyond the immediate need of it due to Covid-19 was achieved...
Introduction: Obtaining informed consent from acute ischemic stroke patients poses many challenges, especially in the context of a research setting. Specifically, consenting for alternative acute ischemic stroke treatments to the standard of care, Tissue Plasminogen Activator (tPA), can cause delays leading to increased time to reperfusion and worse outcomes. Objectives: We sought to investigate the experiences of researchers in existing active-control trials in acute ischemic stroke comparing investigational therapy to tPA in order to identify the approaches and challenges in obtaining informed consent in this unique patient population. Methods: Out of 401 articles evaluated, 14 trials met inclusion criteria of patients receiving IV tPA vs alternative treatment within 4.5 hours of onset of symptoms for acute ischemic stroke. Trial representatives were emailed by the study team with a request for a copy of their patient consent form, other documents related to informed consent, and to complete a survey concerning aspects of the consent process. Results: Of the 6 trials conducted across 6 continents that completed the survey in its entirety, 2 were ongoing, 4 were published between 2009 and 2016, and the median NIHSS for each published trial was at least an 8. All published trials in the sample stated that informed consent was obtained, but only half reported involvement of a research ethics committee. Although 3 trials performed in Europe or Asia reported directly consenting 75-100% of enrolled patients, the median NIHSS for these trials represented a moderate stroke. Trials with 75-100% of patients directly consented had shorter door to treatment (DTT) times than trials that directly consented less than 50% of enrolled patients. 5 trials allowed consent by proxy, but only 2 of those trials also required patient assent. 4 trials had translators available and translated consent documents, and these trials had longer DTT times. All trials relied on experienced providers or dedicated research coordinators to obtain informed consent; however, only 2 of 6 trials mentioned specific training with regards to informed consent skills. Conclusions: The current informed consent process is not transparent and poses challenges to investigators in the USA directly comparing tPA to an alternative treatment. International differences in the standards of informed consent, such as deferred consent, may have allowed more patients with moderate strokes to provide direct consent after treatment administration without delaying DTT time. While targeted and innovative approaches for informed consent are needed to improve patient outcomes, we must balance protecting the autonomy of individuals whose willing involvement enables such pivotal discoveries. The stroke community must aim for efficiency, transparency, and inclusion of patients of diverse backgrounds in the informed consent process so that therapeutic advances are possible.
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