What individuals think, say, and do produces workplace culture. In health care, the COVID-19 pandemic has reshaped every aspect of this framework. Today, people think and talk through screens and do so in isolation. When clinical care delivery, operational processes, and work environments have all transformed so rapidly, the demands and stresses on our clinician workforce are bound to mount. So how do leaders facilitate optimal communication among frontline teams? Culture refers to the set of shared and widely accepted beliefs, values, and social practices of a group [1]. Eff ective communication that integrates complete transparency on the dynamic nature of operations, particularly during times of crisis, forms the foundation for building a culture of wellness for clinicians. With the onset of the COVID-19 pandemic, however, clinical care delivery, operational processes, and work environments have all transformed rapidly to adapt to the remote world. Such changes have markedly amplifi ed the demands and stresses on clinicians [2]. Though large-scale deployment of telehealth has facilitated access to convenient medical care, the virtual medium may diminish the perception of humanism within the patient encounter. Mass home-confi nement directives such as quarantines and social distancing have amplifi ed social isolation. Remote work environments reducing interaction among colleagues have placed camaraderie and peer support at risk. Worklife balance has shifted: with children attending school remotely in the home environment, clinician parents are struggling with the concurrent tasks of working and child-rearing. While entire medical systems have rallied to support clinicians during a time in which clinicians have demonstrated increased altruism, the longterm risk of burnout has risen substantially [3]. To nurture trust, achieve values alignment, and strengthen workplace culture—all core elements of a strategy to prevent burnout [4]—communication of a shared mission in a time of crisis must be clear, consistent, and sincere. So how do leaders facilitate optimal communication among frontline teams, generating the inclusion, intentionality, and interactivity that achieves such trust and sustains engagement [4]? This article discusses the role of optimizing transparency and communication within the framework of medical teams as an essential component of a strategy to address clinician burnout, particularly during COVID-19. Using interventions in the department of psychiatry at Brigham and Women’s Hospital as a representative case study, the authors of this paper discuss strategies implemented for frontline clinical teams consisting of physicians, nurses, medical assistants, and social workers. This article aims to address the following:

Gibbons, Laura E. MD; Gitlin, David F. MD; Erkkinen, Michael G. MD; Kolodziej, Meghan S. MD; Pomahac, Bohdan MD; McComiskey, Kevin RN, BSN; Shah, Sejal B. MDAuthor Information

BACKGROUND:Negative stress significantly impacts major depressive disorder (MDD), given the shared brain circuitry between the stress response and mood. Thus, interventions that target this circuitry will have an important impact on MDD. The aim of this study was to evaluate the acute effects of a novel respiratory-gated auricular vagal afferent nerve stimulation (RAVANS) technique in the modulation of brain activity and connectivity in women with MDD in response to negative stressful stimuli.METHODS:Twenty premenopausal women with recurrent MDD in an active episode were included in a cross-over experimental study that included two functional MRI visits within one week, randomized to receive exhalatory- (e-RAVANS) or inhalatory-gated (i-RAVANS) at each visit. Subjects were exposed to a visual stress challenge that preceded and followed RAVANS. A Factorial analysis was used to evaluate the effects of RAVANS on brain activity and connectivity and changes in depressive and anxiety symptomatology post-stress.RESULTS:Compared with i-RAVANS, e-RAVANS was significantly associated with increased activation of subgenual anterior cingulate, orbitofrontal and ventromedial prefrontal cortices and increased connectivity between hypothalamus and dorsolateral prefrontal cortex, and from nucleus tractus solitarii to locus coeruleus and ventromedial prefrontal cortex. Changes in brain activity and connectivity after e-RAVANS were significantly associated with a reduction in depressive and anxiety symptoms.CONCLUSIONS:Our study suggests exhalatory-gated RAVANS effectively modulates brain circuitries regulating response to negative stress and is associated with significant acute reduction of depressive and anxiety symptomatology in women with recurrent MDD. Findings suggest a potential non-pharmacologic intervention for acute relief of depressive symptomatology in MDD.

Objective: To determine whether continuous virtual monitoring, an intervention that facilitates patient observation through video technology, can be used to monitor suicide risk in the general hospital and emergency department (ED). Method: This was a retrospective analysis of a protocol in which select patients on suicide precautions in the general hospital and ED received virtual monitoring between June 2017 and March 2018. The primary outcome was the number of adverse events among patients who received virtual monitoring for suicide risk. Secondary outcomes were the percentage of patients for whom virtual monitoring was discontinued for behavioral reasons and the preference for observation type among nurses. Results: 39 patients on suicide precautions received virtual monitoring. There were 0 adverse events (95% confidence interval (CI) = 0.000-0.090). Virtual monitoring was discontinued for behavioral reasons in 4/38 cases for which the reason for terminating was recorded (0.105, 95%CI = 0.029-0.248). We were unable to draw conclusions regarding preference for observation type among nurses due to a low response rate to our survey. Conclusions: Suicide risk can feasibly be monitored virtually in the general hospital or ED when their providers carefully select patients for low impulsivity risk.

Suicidal ideation is a common psychiatric emergency seen across a broad range of patients. Although admission to a dedicated psychiatric unit is preferable, patients with suicidal ideation are often admitted to internal medicine or family medicine services, either for management of comorbid medical conditions or because of a lack of available psychiatry beds. Primary care physicians and emergency physicians are particularly likely to encounter suicidal patients, given their high clinical volume and the relatively high prevalence of suicidality in their community of patients. In addition, many patients who present with nonpsychiatric complaints will also have concurrent suicidal ideation. This review discusses the approach to the patient, and definitive treatment, disposition, and outcomes. Figures show suicide in 2010 was the 10th leading cause of death in the United States, accounting for 38,364 deaths, men are more likely to use firearms and hanging, while women are more likely to attempt suicide by poisoning, and suicide is more common in whites and Native Americans compared to Hispanics or Asians. This review contains 3 figures, 6 tables, and 45 references. Keywords: Suicide, suicidal ideation, depression, overdose, suicidal management, mental health

Objective: The authors sought to determine whether a walk-in psychiatry model with longitudinal follow-up capability could improve access for patients who traditionally miss appointments. Methods: An urgent care clinic that offers treatment exclusively on a walk-in basis was opened within an adult psychiatry practice to accommodate patients who missed prior scheduled appointments. Electronic health records for patients who received an initial psychiatry evaluation at the practice during a 6-month period (N=355) were reviewed retrospectively to track the clinic's productivity and patient demographic characteristics. Results: Eighty patients (23%) accessed their initial psychiatry encounters through the walk-in clinic. Medicaid recipients odds ratio [OR] =1.89, 95% confidence interval [CI] =1.10-3.24) and individuals without a college degree (OR=1.86, 95% CI=1.04-3.32) were more likely than patients with other insurance carriers and those with a college degree, respectively, to access care through a walk-in encounter versus a scheduled appointment. Conclusions: Longitudinal walk-in psychiatry services can feasibly be offered through the longitudinal urgent care psychiatry model. This model may serve as a unique access point for patients from historically underserved groups.

Objectives Although the reporting of adverse events (AEs) is widely thought to be a key first step to improving patient safety in hospital systems, underreporting remains a common problem, particularly among physicians. We aimed to increase the number of safety reports filed by psychiatrists in our hospital system. Methods We piloted an online survey for psychiatry-specific AE reporting, the Psychiatry Morbidity and Mortality Incident Reporting Tool (PMIRT) for a 1-year period. An e-mail prompt containing a link to the survey was sent on a weekly basis to all psychiatry department clinical staff. The primary outcome was the total number of events reported by psychiatrists through PMIRT; secondary outcomes were the total number of AEs and the number of serious harm events filed by psychiatrists in our hospital's formal event reporting system before and after implementation of the new protocol. Results Psychiatrists filed 65 reports in PMIRT during the study period. The average number of AEs reported by psychiatrists in the hospital's formal event reporting system significantly increased after the intervention ( P = 0.0251), and the average number of serious harm events reported by psychiatrists increased nonsignificantly ( P = 0.1394). Conclusions The combination of an increase in awareness of event reporting with a psychiatry-specific AE reporting tool resulted in a significant improvement in the number of reports by psychiatrists.

Background: Previous studies have demonstrated that proactive psychiatric consultation reduces hospital length of stay (LOS) in the general medical setting; however this model has not been studied in the intensive care unit (ICU). Objective: To compare outcomes between a conventional consultation model and a proactive psychiatric consultation model. Methods: Two medical ICUs ( MICUs) were randomized to proactive psychiatric consultation vs conventional consultation psychiatric models. Proactive consultation included embedding a psychiatrist into daily MICU team rounds on all patients. In the conventional consultation MICU, psychiatric consultations were activated when deemed necessary. Primary outcomes were hospital LOS and MICU LOS. Secondary outcomes included delirium-coma-free hours and ventilator-free hours. Results: A total of 429 patients were admitted to the proactive consultation MICU; 393 patients were admitted to the conventional consultation MICU. The consultation rate for the intervention group was 24.2% vs 6.1% in the control group (p < 0.001). Time to psychiatric consultation was shorter in the intervention group. Median hospital LOS was 6.92 days, interquartile range 3.70-14.31 in the intervention group vs 7.69 days, interquartile range 3.95-16.21 in the control group (p = 0.113). MICU LOS, delirium-coma-free hours, and ventilator free hours were not significantly different between the 2 groups. Among the respiratory failure subgroup, hospital LOS was shorter in the intervention vs control group (median 9.46 days, interquartile range 4.95-17.56 vs 12.29 days, interquartile range 6.58-21.10, p = 0.011). Conclusions: Proactive psychiatric consultation in a MICU was associated with decreased time to consultation among all patients and shorter hospital LOS among patients with respiratory failure.

BACKGROUND:In November of 2017, The Academy of the Psychosomatic Medicine voted to change its name to the Academy of Consultation-Liaison Psychiatry. It followed a similar change in which the American Board of Medical Specialties voted to change the name of the field to Consultation-Liaison Psychiatry.OBJECTIVE:The authors, all instrumental in bringing about this change, discuss the history and rationale for this name change.

Background: Face transplantation is a novel option for patients with severe facial disfigurement. Quality of life (QoL) outcomes of face transplantation remain poorly understood. Objectives: We sought to evaluate psychosocial functioning among 6 patients undergoing facial transplantation. Methods: We prospectively assessed depressive symptoms, health status, mental and physical QoL, and self-esteem at 3-month intervals for 2 years. Social desirability was assessed pretransplant. Results: On average, before transplantation, patients generally reported minimal to subthreshold depressive symptoms, normal to high health status, normal mental-health QoL, slightly below normal physical-health QoL, and normal to high self-esteem. Most endorsed high social desirability. As patients recovered from surgery, hospitalization, and immunosuppression induction, physical-health QoL generally deteriorated 3 months posttransplantation. Posttransplant trajectories show that perceived health state improved; health status and mental and physical health-related QoL slightly improved; self-esteem remained stable and high; and overall depressive symptoms remained stable but 3 patients experienced a depressive episode. Conclusions: Pretransplant ceiling effects may render improvements difficult to quantify. Future research should use mixed methods including population-specific measures with demonstrated sensitivity to change.

BACKGROUND:Boarding of patients with suicide risk in emergency departments (EDs) negatively affects both patients and society. Factors other than clinical severity may frequently preclude safe outpatient dispositions among suicidal patients boarding for psychiatric admission in the ED.OBJECTIVE:To determine the extent to which nonclinical factors preclude safe outpatient discharge from the ED among patients boarding for psychiatric admission based on suicide risk.METHODS:A survey regarding the importance of 13 clinical and 19 nonclinical barriers to safe outpatient disposition was administered in the ED to 40 adults who were determined by psychiatrists to require inpatient level of psychiatric care due to suicide risk. A second survey regarding whether addressing the nonclinical factors would have enabled a safe outpatient disposition in each case was administered to the psychiatrists who evaluated each patient participant.RESULTS:Out of 40 patient participants, 39 cited at least one nonclinical factor that could have enabled a safe outpatient disposition had it been correctable in the ED. According to the psychiatrists who made the decision to hospitalize, 10 (25%) of the patient participants could have been discharged had social support become available.CONCLUSION:Both clinical and nonclinical factors affect disposition from the ED after an evaluation for suicide risk. Attention to nonclinical factors should be considered in programmatic efforts to reduce ED boarding of patients with suicide risk.

BACKGROUND:Facial self-inflicted gunshot wounds (SIGSWs) cause a devastating midfacial defect and pose a challenging problem to the reconstructive surgeon. Face transplantation (FT) has the potential for near-normal restoration in otherwise non-reconstructible defects. Two out of 7 FT recipients at Brigham and Women's Hospital (BWH) sustained SIGSWs. In this study, we illustrate the role of FT in the management of SIGSWs through an aesthetic, functional, and psychosocial examination of outcomes.METHODS:We performed a retrospective analysis of individuals with SIGSWs who were screened at BWH between 2008 and 2015. We then collected data of the injuries, modes of conventional reconstruction (CR), and deficits. For the FT recipients, we critically reviewed the psychosocial screening process and post-transplantation aesthetic, functional, and psychosocial outcomes.RESULTS:A total of six individuals post-SIGSWs were screened for FT. All of them had undergone CR, with five receiving loco-regional flaps and free tissue transfers, and one undergoing serial debridement and primary soft-tissue repair. Following CR, all suffered from residual functional and aesthetic deficits. Two underwent partial FT and one is currently undergoing FT screening. We describe the pre-transplant psychosocial screening process and the aesthetic, functional, and psychosocial outcomes of the SIGSW FT recipients.CONCLUSIONS:We examined the facial SIGSW injury, outcomes of CR, and the mechanism of FT to offer a potential solution to the shortcomings of CR. More importantly, we highlight the critical nature of the psychosocial component of the multidisciplinary evaluation given the history of mental illness and suicidal behavior in this subset of patients.

Background: Previous research in the area of medical decision-making capacity has demonstrated relatively poor agreement between experienced evaluators in "gray area" cases. We performed a survey to determine the level of agreement about gray area decision-making capacity case scenarios within and between individuals of different professional backgrounds. Method: Participants received a survey consisting of 3 complicated decision-making capacity vignettes with an accompanying "yes/no" question regarding capacity and a certainty scale for each vignette. Participants were identified from mailing lists of professional organizations and local hospitals. We received responses from psychiatry trainees, consultation-liaison psychiatrists, forensic psychiatrists, and lawyers with experience in health care law. Results were analyzed using SPSS. Results: Across the 3 vignettes, the percentage agreeing that the individual described had capacity to refuse medical treatment ranged between 35% and 40% for trainees, 33% and 67% for consult psychiatrists, 41% and 76% for forensic psychiatrists, and 40% and 83% for health care lawyers. Only question 2 reached significance between-group differences (Pearson chi(2) = 11.473, p < 0.01). Across vignettes, trainees were less likely to consider patients to have capacity for decision-making than were forensic psychiatrists and lawyers. Conclusions: As found in previous research, agreement among experienced evaluators appears generally low in gray area capacity cases. It is noteworthy that individuals of different professional backgrounds at times offer divergent between-group opinions on capacity.