Acute Medical Setting Research Articles

Thoracic Society of Australia and New Zealand Position Statement on Acute Oxygen Use in Adults: 'Swimming between the flags'.

Oxygen is a life‐saving therapy but, when given inappropriately, may also be hazardous. Therefore, in the acute medical setting, oxygen should only be given as treatment for hypoxaemia and requires appropriate prescription, monitoring and review. This update to the Thoracic Society of Australia and New Zealand (TSANZ) guidance on acute oxygen therapy is a brief and practical resource for all healthcare workers involved with administering oxygen therapy to adults in the acute medical setting. It does not apply to intubated or paediatric patients. Recommendations are made in the following six clinical areas: assessment of hypoxaemia (including use of arterial blood gases); prescription of oxygen; peripheral oxygen saturation targets; delivery, including non‐invasive ventilation and humidified high‐flow nasal cannulae; the significance of high oxygen requirements; and acute hypercapnic respiratory failure. There are three sections which provide (1) a brief summary, (2) recommendations in detail with practice points and (3) a detailed explanation of the reasoning and evidence behind the recommendations. It is anticipated that these recommendations will be disseminated widely in structured programmes across Australia and New Zealand.

Strategies utilized to prevent and control SARS-CoV-2 transmission in two congregate, psychiatric healthcare settings during the pandemic

BackgroundThe COVID-19 pandemic has had a substantial effect on the delivery of psychiatric health care. Inpatient psychiatric health care facilities have experienced outbreaks of COVID-19, making these areas particularly vulnerable. MethodsOur facility used a multidisciplinary approach to implement enhanced infection prevention and control (IPC) interventions in our psychiatric health care areas. ResultsIn a 16-month period during the COVID-19 pandemic, our 2 facilities provided >29,000 patient days of care to 1,807 patients and identified only 47 COVID-19 positive psychiatric health inpatients (47/1,807, or 2.6%). We identified the majority of these cases by testing all patients at admission, preventing subsequent outbreaks. Twenty-one psychiatric health care personnel were identified as COVID+ during the same period, with 90% linked to an exposure other than a known positive case at work. DiscussionThe IPC interventions we implemented provided multiple layers of safety for our patients and our staff. Ultimately, this resulted in low SARS-CoV-2 infection rates within our facilities. ConclusionsPsychiatric health care facilities are uniquely vulnerable to COVID-19 outbreaks because they are congregate units that promote therapeutic interactions in shared spaces. IPC interventions used in acute medical care settings can also work effectively in psychiatric health care, but often require modifications to ensure staff and patient safety.

Using Trauma-Informed Care in Practice: Evaluation of Internal Medicine Resident Training and Factors Affecting Clinical Use.

Trauma-informed care (TIC) acknowledges that childhood traumas can profoundly affect health outcomes and aims to creates a safe, nurturing medical environment. TIC curricula in graduate medical education are limited and lacking in assessment of the application of TIC in practice. This mixed-methods study followed implementation of a 4-hour required training session for 91 internal medicine residents at George Washington University Hospital. Pre- and posttests were administered to determine change in knowledge, attitude, and confidence. Six weeks after the training, individual participant interviews were conducted to ascertain how TIC is practiced in the clinical setting. For the 47 participants with matched pre- and posttest data available, there was a statistically significant score improvement after the session on 13 of 16 items (excluding only 3 attitude items). Six themes emerged: 1) patient characteristics trigger recognition to utilize TIC; 2) time plays a critical role; 3) the acute medical setting is a barrier; 4) the patient-doctor relationship impacts TIC application; 5) concern about next steps influences TIC use; and 6) incorporating TIC requires repetition, practice, and supervisor support. This study demonstrated that a 4-hour TIC session can promote growth in resident knowledge and confidence related to TIC. The findings highlight that TIC education needs to account for contextual factors that can impact its clinical application. A focus on work environment factors such as time, resources, and supervisory support can help to maximize TIC learning, retention, and application in practice.

246 IMPROVING LUMBAR PUNCTURE TECHNIQUE AMONG INTERN TRAINEES TO ENHANCE QUALITY OF CARE FOR PATIENTS

Abstract Background Lumbar puncture (LP) is a common procedure performed on older adults in acute medical settings. A higher peri-procedural risk has been shown in older patients. Non-consultant doctors (NCHDs) often lack confidence and competence in performing LP. Simulation based training using task trainers has been shown to improve confidence, preplanning skills and technique. Methods A simulation based teaching session was developed in a university teaching hospital (training structure was adapted from the LP training guide published in MedEdPortal). Small group teaching (with 6–8 learners) was delivered to 25 NCHDs with no prior exposure or experience with lumbar puncture completion. Trainees completed one LP simulation without practice to mastery level. On-demand and post-performance feedback was delivered to learners. An assessment checklist was completed by the supervisor. Learners completed an anonymised quantitative and qualitative questionnaire using Qualtrics XM software at a later date to evaluate self-perceived teaching outcomes. Results 16 doctors completed the questionnaire (64% response rate). 55% rated the LP workshop as a ‘strongly positive’ impact on their learning, while 18% indicated a ‘positive’ impact on a 5-point Likert scale. 19% of trainees reported they were ‘very comfortable’ at performing the procedure post training, with 56.5% ‘comfortable’ to perform an LP in their clinical practice. Qualitative learner feedback included ‘more hands on practice’ on the mannequin, ‘smaller groups for the workshops’ and ‘more practice tips’ during the simulation workshop. Conclusion This pilot study demonstrated interest and positive feedback for the LP simulation training from novice doctors with improved self-assessed confidence. Formal development of an LP simulation training curriculum is underway. The impact of this training on patient care should be assessed in practice.

Implementing PODS (Patient Oriented Discharge Summary) in an acute medical urban health setting in Vancouver, Canada

The transition from hospital to home or community is a vulnerable time for patients and families, who face risks associated with misunderstanding instructions about medications, self-monitoring and when to seek emergency care. The quality of the discharge process can have a significant impact on patient confidence, overall patient experience, ability to manage health at home, and hospital readmission rates. Patient Oriented Discharge Summary (PODS) is a standardized form and set of process changes, utilized to overcome communication barriers faced at discharge. We implemented PODS in two Acute Medicine units of a tertiary care hospital in western Canada and used a mixed-methods approach to evaluate the four process changes (PODS form, use of teach-back, engagement of caregivers in discharge teaching, follow-up phone calls). Evaluation showed that 60% of patients received PODS and 87% found the form helpful. There was a large increase in the percentage of patients who felt adequately prepared at the time of discharge, and a 10% increase in the number of patients who rated their overall hospital experience positively. Healthcare providers reported that using PODS they were more confident that patients were adequately prepared to return home. The update of PODS on the implementation units has been sustained at 60% for 18 months. Implementation of the PODS form and process can be accomplished with an interdisciplinary team, leadership support and by working closely with Patient Family Partners. PODS can improve the discharge process even in the complex urban acute medical environment in ways that offer wide-reaching benefits.

Acute hypercapnic respiratory failure and its management on the acute medical take.

Acute hypercapnic respiratory failure accounts for 50 000 hospital admissions each year in the UK. This article discusses the pathophysiology and common causes of acute hypercapnic respiratory failure, and provides practical considerations for patient management in acute medical settings. Non-invasive ventilation for persistent acute hypercapnic respiratory failure is widely recognised to improve patient outcomes and reduce mortality. National audits highlight a need to improve patients' overall care and outcomes through appropriate patient selection and treatment initiation. Multidisciplinary involvement is essential, as this underpins inpatient care and follow up after hospital discharge. New non-invasive ventilation modalities may offer better patient comfort and compensate better for sleep-related changes in respiratory mechanics. Emerging therapies, such as nasal high flow, may offer an alternative treatment approach in those who cannot tolerate non-invasive ventilation, but more research is required to completely understand its effectiveness in treating acute hypercapnic respiratory failure.

67.2 ADDRESSING PROBLEMS OF DISTRIBUTIVE JUSTICE IN THE CARE OF CHILDREN WITH INTELLECTUAL DEVELOPMENTAL DISORDERS (IDDS) WHO HAVE SUFFERED TRAUMA

Children with intellectual development disorder (IDD) present with unique challenges when in crisis. Medical and nursing staff in emergency rooms/mental health crisis response are often less effective in understanding the needs of these children when they present relative to children of the same age without IDD. Ineffective communication can be misunderstood as defiance. The trauma response can be construed as agitation, and hence, they receive less equitable attention and care. Takahiro Soda, MD, PhD, will present a case of a patient with IDD that presented to the emergency room medically decompensated and will discuss the numerous challenges and ethical dilemmas that often arise when patients with IDD present in crisis. The practical/systematic barriers that exist in some communities that make providing optimal care for patients with IDD presenting with trauma difficult will be discussed, and the ethical duties of the child and adolescent psychiatrist in these difficult circumstances will be addressed. Practices to reduce further traumatization while in the acute medical care setting will be presented. Through this presentation, participants will gain an understanding of how to help the child with IDD and their families optimally navigate through an acute traumatic event leading to crisis and reduce further traumatization. Closely considering traumatic events as a possible cause of behavioral dysregulation will also assist in providing individuals with IDD much-needed care during crisis or after acute traumatic experiences. The psychiatrists will also be able to advocate for more equitable care. Incorporating trauma into the differential for patients with IDD with an acute medical presentation can improve the care of the child with IDD by helping providers reframe the patient’s behaviors, increase therapeutic alliance, and help us advocate for better care.

The role of sepsis screening, SIRS and qSOFA in head and neck infections: An audit of 104 patients

Sepsis is associated with high morbidity and mortality and is a known complication of infections of the head and neck. Screening for sepsis should be conducted on admission in order to identify patients at risk and provide early intervention. Compliance with sepsis screening was poor on an ENT ward in a district general hospital, however this can be improved further by education and visual reminders such as poster or a clerking proforma. The most common head and neck infections admitted to a district general hospital were tonsillitis, peritonsillar cellulitis and peritonsillar abscesses. The incidence of sepsis as a complication of head and neck infections is very rare if using the qSOFA criteria. Using SIRS criteria may result in overidentification of sepsis and may lead to excessive and inappropriate clinical management in patients who could otherwise be managed less aggressively.

Communicating diagnostic uncertainty in the acute and emergency medical setting: A systematic review and ethical analysis of the empirical literature.

Background: diagnostic uncertainty is ubiquitous. Its communication to patients requires further investigation. Aims: To determine: 1) What is known about how and why diagnostic uncertainty is communicated in acute care; 2) evidence of the effects of (not) communicating diagnostic uncertainty in the acute setting; 3) associated ethical issues. Methods: systematic review of Medline, Web of Science and SCOPUS for (acute or emergency care) AND (diagnostic uncertainty) AND (ethics OR behaviours). Critical interpretive synthesis and ethical analysis were conducted. Results and conclusion: Nine studies (primarily surveys and interviews) were identified. Doctors are not trained in communicating diagnostic uncertainty and perceive it to have negative effects on patients; however not communicating diagnostic uncertainty can disempower patients, resulting in delayed/missed diagnoses or inappropriate use of resource.

Sociometric wearable devices for studying human behavior in corporate and healthcare workplaces.

Wearable sensor technology enables objective data collection of direct human interactions. The authors review sociometric wearable devices (SWD) and their application in healthcare. Human interactions captured by wearable sensors have been shown to correlate with social constructs such as teamworkand productivityin the office. Application of SWD in the field of healthcare requires special considerations: validation studies have shown technological disadvantagesin acute medical settings. Application of SWD in healthcare should be considered based on the strengths and weaknesses of the methodology. SWDcan also play an important roleininvestigation of human interaction and epidemic spread. Whenstudy designs and methodologies arecarefully considered, incorporation of SWD in healthcare researchhas promising potential for new insights.

Examining the average scores of nursing teamwork subscales in an acute private medical ward

BackgroundHealthcare is delivered by multidisciplinary healthcare teams who rely on communication and effective teamwork to ensure safe patient care. Teamwork builds on employee cohesion and reduces medical and nursing errors, resulting in greater patient satisfaction and improved healthcare. Effective teamwork not only improves efficiency and patient safety but leads to a healthier and happier workplace, reducing burnout among healthcare professionals. The purpose of this paper is to describe the findings of a pilot project on an acute medical ward in Western Australia. The aim was to understand the participants perceived level of teamwork to support future work practices and ultimately patient care.MethodsThis study used a descriptive survey research method to measure nursing teamwork in a clinical environment. The Nursing Teamwork Survey (NTS) measures the levels of nursing teamwork in acute healthcare facilities. Items for the NTS were generated on theoretical grounds, based on teamwork behaviours, offering a practical explanation of teamwork dynamics.ResultsThe survey incorporated five subscales. The response rate to the survey was 90 % (n = 45) with an overall average result on the survey being (m = 2.97) on a 0–4 Likert scale. The validated NTS has provided participants the opportunity to consider nursing teamwork with regards to their position and perceived responsibilities towards patients and team members.ConclusionThe findings highlight areas for consolidation and improvement in teamwork. Introducing teambuilding strategies and acting on results of this survey may support enhanced communication and teamwork influencing nursing care and patient outcomes. Findings recommend that activities to improve teamwork and ensuring teambuilding strategies are implemented to improve effective communication in an acute medical care setting would have significant impacts on staff satisfaction.

A grounded theory study: Exploring health care professionals decision making when managing end stage heart failure care.

To explore how healthcare professionals in an acute medical setting make decisions when managing the care of patients diagnosed with end stage heart failure, and how these decisions impact directly on the patient's end of life experience. A constructivist grounded theory approach was adopted. A purposive sample was used to recruit participants that included 16 registered nurses, 15 doctors and 16 patients. Data were collected using semi-structured interviews and focus groups over a 12-month period of fieldwork concluding in 2017. The interviews were recorded and transcribed and the data were analysed using constant comparison and QSR NVivo. Four theoretical categories emerged from the data to explain how healthcare professionals and patients negotiated the process of decision making when considering end of life care. These were: signposting symptoms, organizing care, being informed and recognizing dying. The themes revolved around a core category 'a vicious cycle of heart failure care'. Healthcare professionals need to engage in informed decision making with patients to break this 'vicious cycle of care' by identifying key stages in the terminal phase of heart failure and correctly signposting the patient to the most suitable healthcare care professional for intervention. This study provides a theoretical framework to explain a 'vicious cycle of care' for patients diagnosed with end stage heart failure. This theory grounded in data demonstrates the need for both acute and primary care to design an integrative end of life care pathway for heart failure patients which addresses the need for early shared decision making between the healthcare professional, family and the patient when it comes to end of life conversations.

The impact of web-based and face-to-face simulation education programs on nurses' response to patient deterioration: A multi-site interrupted time series study

BackgroundNurses' response to patient deterioration in acute hospital wards is a priority issue. Simulation education programs improve nurses' knowledge and confidence, but the translation into better care is largely unknown for both web based (WB) and face to face (F2F) simulation programs. AimTo measure the impact of simulation education on nurses' response to patient deterioration in acute medical ward settings, and to compare the impact of WB and F2F versions. DesignAn interrupted time series, non-randomised trial across four medical wards in Victoria, Australia. Wards were allocated to either web-based or face-to-face versions of the same simulation program, FIRST2ACT. Interrupted time series measurement for six fortnights both before and after the intervention were used to measure and compare responses to deterioration. Responses to patient deterioration were extracted from medical records and grouped into outcomes for escalation (e.g. initiation of clinical review), assessment and observation (e.g. increased recording of vital signs, conscious state and pain scores) and clinical interventions (e.g. oxygen administration). Results126 nurses (89%) participated across the four wards. 946 patient records (506 in the F2F; 440 in the WB group) were included in analyses.There were significant and sustained improvements between pre and post samples in outcomes for escalation (13.0% to 28.8%; p = 0.000) and assessment and observation (conscious state recorded increased from 91.1% to 100%; p = 0.000, and pain score recorded increased from 97.8% to 99.8%; p = 0.000).There were no differences between the web-based and face-to-face groups except in appropriate oxygen application which increased by 7.7% in the F2F group and decreased by 11.8% in the WB group (p = 0.046). ConclusionsThere was a significant improvement in nurses' response to patient deterioration following both versions of simulation, indicating that both have a role to play in supporting nurses' response to patient deterioration.

An Innovative Model of Behavior Management to Address Behavioral Emergencies in the Acute Medical Inpatient Setting: Pilot Data.

Workplace violence in healthcare is a significant and costly problem. The majority of violent events that occur in the medical inpatient setting are perpetrated by patients against staff and occur during a behavioral emergency. The primary purpose of this study was to evaluate the impact of an innovative model of behavior management on occurrence of behavioral emergencies and staff comfort and competence in managing difficult patient behaviors. This model consists of primary, secondary, and tertiary interventions provided by a clinical psychologist which include proactive training for hospital staff and consultation-liaison services for behavior management. Forty-six staff at the University of Virginia Medical Center completed a 1-h training on preventing and managing difficult patient behavior. Self-report data on comfort and competence in managing challenging patient behaviors was collected at baseline, immediately following the intervention, and one and three months post-intervention. Behavioral emergencies were tracked for the intervention unit and a comparison unit. The occurrence of behavioral emergencies decreased by 50% in the three months following the intervention compared to a 142% increase on the comparison unit. Staff reported the greatest increase in confidence from baseline to three months post-intervention on caring for patients with psychiatric illnesses, managing verbal abuse, being supported by medical center leadership, having clear roles and responsibilities, and effectiveness of the skills and strategies used to manage difficult patient behavior. The results of this study provide preliminary support for the use of a comprehensive model for managing the behavioral needs of medical inpatients.

Validation of a hospital clinical pharmacy workforce calculator: A methodology for pharmacy?

The benefits of clinical pharmacy services are established within hospital practice but staff numbers required for service delivery are not well described and staffing levels vary. The need for a consistent, objective method of determining staffing levels was recognised at a UK University Hospital and a Clinical Pharmacy Workforce Calculator (CPWC) was developed. To develop the Activity Standard (AS) for pharmaceutical care and establish the reliability of the CPWC across acute hospital settings in UK. Acute hospital in-patient clinical pharmacy services on medical and surgical wards. Using the World Health Organisation's Workload Indicators of Staffing Need (WISN) methodology, a two-round Delphi study was undertaken. This developed the Activity Standard for pharmaceutical care and identified the staff-time unavailable for clinical work. Consenting panel members then tested the CPWC, calculating the staff required for three scenarios to determine whether it could be reliably used by different operators. Thirty-six participants consented to participate. Data were returned from 22 (61%) of whom 20 (56%) supplied analysable data. Consensus was achieved on the tasks required for pharmaceutical care delivery, the mean time each takes, how frequently they should be completed and the time unavailable for clinical work for each grade of staff. The CPWC calculates staffing requirements using these data. Eleven participants (55%) tested the CPWC and analysis of responses demonstrated that 30 of 33 (91%) calculations were accurately completed. This study defined the WISN Activity Standard for UK pharmaceutical care delivery to hospital inpatients and showed content validity for the CPWC in acute medical and surgical hospital settings. Different operators used the CPWC reliably and applied it to local sites. The CPWC offers hospital pharmacy managers a useful tool to negotiate adequate staffing to deliver pharmaceutical care. Its development methodology could be applied widely in pharmacy practice.

Patient experiences of alcohol specialist nurse interventions in a general hospital, and onwards care pathways.

To provide insight into patient experiences of a general hospital-based alcohol specialist nurse intervention during alcohol detoxification, experiences of alcohol specialist nurse hospital-based follow-up appointments (Pathway A) as well as the experiences of patients who did not have access to this additional help post detoxification (Pathway B). A longitudinal qualitative study. A thematic analysis of semi-structured interviews (2016-2017) with 24 patient participants (N=12 in each pathway; purposive selection) 1-4weeks post-detoxification and at 3 and 6months, to identify patient experiences of these interventions. Participants gave accounts of how 'empathic' and 'straight talking' interactions with alcohol specialist nurses during detoxification helped them to 'open up' and orient towards change. After detoxification follow-up, outpatient appointments in the hospital setting were seen as supporting change in early recovery and engagement with a wider range of services. Those with no access to nurse follow-up described experiencing a 'void' in available help. Participants in both groups described barriers to engagement with community alcohol services, peer groups and access to help for mild-moderate mental health problems. Patient accounts indicate alcohol specialist nurse interventions during and after unplanned detoxification in a hospital setting can help orient patients towards change and support early recovery. Providing alcohol specialist nurse interventions in general hospitals offers one route to initiating recovery in alcohol-dependent patients. This has potential to improve the lives of those affected and to reduce related demands on hospital services, but further research is needed.

COVID-19 and its effect on the provision of ophthalmic care in the United Kingdom.

The first quarter of 2020 gave light to a novel virus, Coronavirus 2019 (COVID‐19), causing a pandemic of unbridled proportions. The National Health Service in the United Kingdom issued guidance to ensure that capacity was increased in acute medical settings, to prepare for the surge of COVID‐19 cases. The Royal College of Ophthalmologists followed suit with guidance on the curtailment of all elective activity, aimed at protecting both patients and staff. Ophthalmology is one of the busiest outpatient specialities, and risk stratification of patients with appointments cancelled or on review lists was paramount to ensure there was no serious, permanent harm to sight. Our way of working, as we knew it, had to change in a short period of time. Local emergency eye care was changed from a walk in service, with the implementation of a strict triage protocol. Ophthalmologists, as well as Otorhinolaryngology colleagues, were identified as being at high risk of infection, due to the close proximity of clinical examination. The redesign of clinical areas to allow for social distancing, slit lamp barriers and personal protective equipment was all implemented. This time of relative pause has provided the opportunity to harness new ways of working, including the streamlining of services, reduction of backlog and the incorporation of telemedicine. Health preparedness is a new lexicon to Ophthalmology departments across the world, and it will now have to be stringently implemented in the ophthalmic setting.

Psychiatric Illness and Medical Decision-Making Capacity: A Retrospective Study in Medical Settings

Determination of medical decision-making capacity (DMC) is one of the common encounters in Consultation-Liaison Psychiatry (CLP) services. It is a common misbelief that patients with “psych history” lack capacity more often than patients without mental illness. The study aims to examine the relationship between mental illness and DMC in patients presented to acute medical settings. The study is a retrospective chart review, where data were collected from the patients admitted to the medical units and assessed for capacity by a psychiatrist. Clinical and demographic characteristics were compared between two groups (patients having capacity and lacking capacity) using t-tests or chi-square tests, as appropriate. The commonest reason for DMC evaluation requests was for the patients who wanted to leave the hospital against medical advice. Overall, 53% (52/98) of the patients evaluated for DMC were found to lack capacity. Group of patients lacking DMC had a significantly higher percentage of males (58% vs. 35%) but were significantly less employed (8% vs. 10%). No significant difference was observed in other demographic characteristics and primary psychiatric diagnoses (past and current) among the two groups. However, patients lacking capacity were found to have a significantly more occurrence of current (48% vs. 11%) and past (23% vs. 4%) history of neurocognitive disorder, and larger trend significance (31% vs. 15%) of active psychiatric symptoms. We conclude that patients with neurocognitive disorders and active psychiatric symptoms might have poor DMC but not all patients who have psychiatric diagnoses lack medical DMC. Larger studies especially in outpatient psychiatric settings are suggested to derive more conclusive results.

Mobility levels of acute medical patients: Is behavioural mapping comparable to accelerometry?

Objective: To (1) determine agreement between behavioural mapping and accelerometry for measuring mobility levels in an acute medical inpatient setting and to (2) explore and compare the required resources and costs for both methods. Design: Observational cross-sectional study Setting: Tertiary referral teaching hospital in Brisbane, Australia. Subjects: Adult patients admitted to two acute medical wards. Main measures: Mobility levels were recorded by behavioural mapping, and thigh and chest-worn accelerometers (ActivPAL). The level of agreement between the two methods was evaluated using the Intraclass Correlation Coefficients for each mobility level (i.e. lying, sitting, upright, standing and walking). Results: Nineteen patients (10 male (53%); mean(SD) age of 72(14) years) were included in the agreement analysis. The Intraclass Correlation Coefficients were high for ‘lying’ (ICC = 0.87), ‘sitting’ (ICC = 0.84) and ‘upright’ (ICC = 0.93), indicating good to excellent agreement between the two methods. For these mobility levels, mean differences between the two methods were small (<2%), with large standard deviations (up to 18%). Agreement was poor for ‘standing’ (ICC = 0.00) and ‘walking’ (ICC = 0.35). Both methods were labour-intensive, with labour costs of A$1,285/€798 (34 hours) for behavioural mapping and A$1,055/€655 (28 hours) for accelerometry. No further costs were involved in behavioural mapping, but clinical backfill was required. Accelerometry involved a financial investment for accelerometers (A$11,100/€6,894 for 22 ActivPAL devices). Conclusion: Agreement between behavioural mapping and accelerometry was good for measuring ‘lying’, ‘sitting’ and ‘upright’, but poor for ‘standing’ and ‘walking’ in an acute inpatient setting. Both behavioural mapping and accelerometry were labour-intensive, with high costs for the accelerometry equipment.

Managing Bipolar Disorder patients during COVID‐19 outbreak

On February 20, 2020 the first case of coronavirus disease (COVID-19) has been diagnosed in Italy. In a few weeks the Policlinico A. Gemelli Hospital in Rome has become a so called "COVID Hospital", so its structure has changed and consequently also the organization of the clinical activities of the Psychiatric Unit. In particular, outpatients' services (ambulatory and day hospital) have guaranteed the management of emergencies, the administration of oral and long acting drug therapies, the assistance of patients with severe mental illness by means of telephone checks.