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Patient mental state deterioration presents significant challenges in acute hospital settings, affecting outcomes, increasing reliance on restrictive interventions, and placing additional strain on healthcare staff. Despite its prevalence, consensus on best practice remains limited. The De-escalation, Intervention, Early Response Team (DIvERT) is a pilot rapid response system introduced to improve early identification, enable timely interventions, reduce crisis incidents, and support ward staff in caring for patients with mental state deterioration.
A realist evaluation approach was used to test, validate, and refine program theories explaining DIvERT's mechanisms. Data collection included a cross-sectional survey, semi-structured interviews, field observations, a medical record audit, and incident report analysis. Analysis was guided by the Context-Mechanism-Outcome framework to explain DIvERT's effective functioning in responding to patient deterioration.
DIvERT facilitated early intervention through multidisciplinary collaboration, though organisational factors such as staffing constraints, workload pressures, and inconsistent assessment practices influenced effectiveness. Key mechanisms included structured escalation pathways, clinical skills, staff training, and interprofessional collaboration. Challenges included limited after-hours availability, reflecting the constraints of a pilot initiative, underreporting of incidents, and hierarchical decision-making. While causation cannot be directly established, trends indicate DIvERT was associated with fewer Code Grey responses, particularly during initial episodes of mental state deterioration.
This realist evaluation highlights the value of structured escalation pathways, multidisciplinary collaboration, organisational support, and tailored training in managing mental state deterioration. Preliminary trends suggest DIvERT may enable more proactive and timely early intervention, whereas traditional reactive hospital emergency response for aggression (Code Grey) was more often linked to repeat incidents. Workforce constraints and inconsistent assessment limited effective functioning, underscoring the need for strengthened training, integration into workflows, and improved after-hours coverage to support scalability and long-term success.
This study demonstrates that a proactive rapid response model (DIvERT) can strengthen the recognition and management of mental state deterioration in acute hospital settings. By formalising escalation pathways, improving interdisciplinary collaboration, and tailoring training to staff needs, the model supports safer and more timely responses to patient deterioration. Embedding such approaches into organisational workflows has implications for patient safety, staff confidence, and system efficiency.
The study addressed the challenge of inconsistent and reactive responses to patient mental state deterioration, which are often reliant on crisis interventions such as Code Grey. DIvERT facilitated early intervention through structured escalation processes, improved interdisciplinary collaboration, and enhanced staff skills. However, organisational barriers such as workforce constraints, after-hours gaps, and inconsistent use of mental state deterioration assessment tools limited its effective functioning. Findings are directly relevant to clinicians in acute hospital settings (particularly nursing and allied health staff), hospital administrators responsible for patient safety and workforce planning, and policymakers overseeing standards for recognising and responding to acute deterioration. The results highlight where investment in training, structured escalation systems, and organisational support can reduce reliance on restrictive interventions and improve both patient and staff safety.
This evaluation adhered to the Realist And Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) II reporting standards for realist evaluations, as outlined in the EQUATOR Network guidelines.
This study did not include patient or public involvement in its design, conduct, or reporting.
Exploring the concept of patient agitation in the intensive care unit.
Patient agitation in the intensive care unit is of widespread concern and linked to negative outcomes for patients, staff, and family members. There is currently no consensus on what constitutes agitation in the intensive care context, hindering effective and tailored prevention and management.
Concept Analysis.
Walker and Avant's eight-step concept analysis approach.
A comprehensive search was carried out in the databases MEDLINE, PsychINFO and CINAHL. A total of 32 papers published between 1992 and 2023 were included, reviewed, and analysed to explore definitions, attributes, antecedents and consequences of patient agitation.
Patient agitation in the intensive care unit is characterised by excessive motor activity, emotional tension, cognitive impairment, and disruption of care, often accompanied by aggression and changes in vital signs. Antecedents encompass critical illness, pharmacological agents and other drugs, physical and emotional discomfort, patient-specific characteristics and uncaring staff behaviours. Consequences of agitation range from treatment interruptions and poor patient outcomes to the psychological impact on patients, families, and staff.
Agitation in the intensive care unit is a complex issue which significantly impacts patient treatment and clinical outcomes. For healthcare professionals, patient agitation can contribute to high workloads and job dissatisfaction. Due to the complex nature of agitation, clinicians must consider multifaceted strategies and not rely on medication alone. Further research is needed to fully understand patient agitation in the ICU. Such understanding will support the development of improved strategies for preventing and managing the behaviours.
A clearer understanding of patient agitation supports the development of tailored interventions that improve patient care, guide ICU training, and inform future research.
This concept analysis was developed with input from a patient representative.
Managing patients' mental state deterioration in acute hospital settings is a critical challenge, requiring prompt specialised intervention to mitigate adverse outcomes. Current responses vary widely across health systems. Integrating rapid response systems that incorporate mental health expertise offers a promising approach to reduce risks and adverse outcomes.
To evaluate how a response system manages patient mental state deterioration in acute hospital settings, focusing on the mechanisms driving system effectiveness, for whom it works and under what circumstances, using a realist-informed theory-testing approach with field observation.
We conducted non-participant field observations in one trauma and one surgical unit over 4 months to examine the contexts, mechanisms and outcomes shaping a mental state deterioration response system. Observations captured multidisciplinary interactions, escalation processes and decision-making. Structured field notes were thematically coded using a realist framework to refine program theories and identify key factors influencing timely intervention.
Twenty responses were observed, most in the trauma unit. The system worked best when bedside nurses escalated early signs of deterioration, prompting timely intervention. Multidisciplinary collaboration involving nurse unit managers, liaison psychiatry, doctors and allied health professionals activated mechanisms of integrated assessment and coordinated care, enabling both medical and mental health needs to be addressed. Competing medical acuity demands at times reduced system availability. Teleconferencing supported specialist input when in-person attendance was not possible, ensuring person-centred care.
System functioning depended on early risk communication by bedside nurses and proactive multidisciplinary collaboration. Organisational support and staff training are essential to address operational challenges. Findings provide evidence for strengthening response systems to deliver timely, comprehensive interventions that improve physical and mental health outcomes.
DIvERT (De-escalation, Intervention, Early, Response, Team) is a proactive rapid response model of care piloted to improve the management and outcomes of patients experiencing mental state deterioration in acute hospital settings. The model achieves this through structured escalation pathways, proactive interventions and coordinated multidisciplinary collaboration to integrate medical and mental health care. Strengthening organisational support and staff training further reduces reliance on restrictive practices and promotes safer, person-centred care.
What problem did the study address? Acute hospitals face persistent challenges in responding to patient mental state deterioration alongside medical acuity, with existing rapid response systems often insufficiently integrated with mental health expertise. What were the main findings? Field observations of the DIvERT model demonstrated that proactive integration of mental health expertise, supported by organisational investment in training, clear escalation protocols and multidisciplinary collaboration, enabled earlier intervention and more coordinated responses. Where and on whom will the research have an impact? These findings have implications for acute hospital services, informing system-level improvements to rapid response models that support patient safety, reduce adverse events and improve staff wellbeing.
This study adhered to the relevant EQUATOR guidelines. Specifically, reporting followed the RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards II) reporting standards, which provide criteria for transparent and rigorous reporting of realist evaluation methodology.
No patient or public contribution.
Post-intensive care syndrome affects up to 70% of adult intensive care unit (ICU) survivors, with ICU-acquired weakness contributing substantially to long-term disability. Despite evidence supporting early and structured rehabilitation to enhance physical recovery, targeted upper-limb rehabilitation approaches in the ICU remain comparatively underexplored. This scoping review will map and summarise existing evidence on upper-limb weakness and rehabilitation strategies delivered by healthcare professionals for critically ill adults.
This scoping review protocol has been developed in accordance with the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews, ensuring transparent and comprehensive reporting. Searches will be conducted in MEDLINE (Ovid), CINAHL (EBSCO), Embase, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL). The search will include studies published between March 2009 and August 2025, aligning with National Institute of Clinical Excellence (NICE) Guideline CG83 (2009), which marked a major policy shift in ICU rehabilitation practice. Quantitative data will be summarised descriptively (eg, frequencies and proportions), while qualitative data will undergo thematic synthesis to identify patterns in experiences, perceptions and implementation of upper-limb rehabilitation. Grey literature (eg, OpenGrey and relevant conference proceedings) will also be screened to reduce publication bias. Rayyan AI software will be used to manage citation screening and reviewer collaboration; no artificial intelligence-assisted decision tools will be used to determine study inclusion.
As this review will synthesise previously published data, ethical approval is not required. Results will be disseminated through peer-reviewed publication, conference presentations and open-access platforms. Findings from this review will inform the development of evidence-based ICU rehabilitation guidelines and highlight priorities for future research to improve upper-limb recovery in critically ill adults.
Open Science Framework (osf.io/j86nf).
This study aims to analyse the crowding-out and crowding-in effects of non-communicable diseases (NCDs) related out-of-pocket (OOP) health expenditures on household consumption in Bangladesh.
This study used data from the nationally representative Bangladesh household income and expenditure survey (HIES) 2022.
Eight divisions of Bangladesh.
14 395 households.
We examined how household consumption patterns across 20 expenditure categories were impacted by OOP health spending for NCD management, with a focus on income-level disparities.
In Bangladesh, OOP health expenditures for NCDs crowded out household expenditures on essential items like food and rent. Across all households, OOP health expenditures for NCDs by 10 US$ crowded out –3.8 US$ of expenditure on food (95% CI –5.1 to –2.5), and more specifically on protein-rich foods (–2.0 US$, 95% CI –2.8 to –1.2), spices (–0.2 US$, 95% CI –0.3 to –0.1), and restaurant and café meals (–0.9 US$, 95% CI –1.4 to –0.5). Crowding-out was also seen for tobacco, rent, durable goods and miscellaneous. In lower-income households, expenditures on food (–4.1 US$, 95% CI –7.2 to –1.1), restaurant and café meals (–2.0 US$, 95% CI –3.1 to –0.8), spices (–0.4 US$, 95% CI –0.7 to –0.09), and rent (–3.1 US$, 95% CI –4.5 to –1.6) were significantly crowded out.
This research demonstrates that NCD-related spending in Bangladesh reduces budgets for both food and non-food expenditures, with a stronger crowding-out effect on food items and rent, particularly in lower-income households. Effective financial and social protection mechanisms against NCDs are warranted to safeguard the consumption of the NCD-affected households in Bangladesh.
Effective haemorrhage control is crucial in cases of limb trauma involving arterial injury, such as shark attacks, to prevent potentially fatal outcomes. International first aid consensus recommends the use of arterial tourniquets (proprietary or makeshift) as a primary treatment for life-threatening external bleeding. Manual pressure applied directly over a major artery proximal to the injury, such as inguinal fist compression (IFC), is more accessible in a first-aid situation, but is currently not recommended due to limited evidence. The purpose of this study is to determine whether the application of IFC is superior to commercial windlass tourniquets (CWTs) in reducing blood flow in the femoral artery when performed by untrained bystanders.
Stopping Haemorrhage by Application of Randomised Compression or Tourniquet (SHARC-2) is a superiority, assessor-blinded, cross-over, randomised controlled trial conducted with healthy untrained adult volunteers in non-clinical settings. Participants will be rotated as providers and recipients of both IFC and CWT, with providers randomised to the order that they perform the techniques. Providers will be exposed to an educational infographic before applying that technique to a recipient behind a drop sheet. A sonographer, blinded to the technique, will measure the peak systolic velocity of blood flow in the superficial femoral artery using Doppler ultrasound at baseline and then during application of each technique for 5 min. The mean percentage reduction in peak systolic velocity will be compared between IFC and CWT groups.
Ethics approval for this study was granted by the Bond University Human Research Ethics Committee (BUHREC JF01036) on 23 January 2023. All participants will be provided with written informed consent prior to enrolment and the trial will involve healthy adult volunteers. To minimise risk, preintervention screening, sonographic assessment and postintervention follow-up will be implemented with adverse events monitored and reported in accordance with HREC guidelines. Results will be disseminated through peer-reviewed journals, academic conferences, local resuscitation forums and public health education initiatives. A lay summary will also be shared with relevant community groups and via social media platforms to enhance public accessibility.
ACTRN12624001054505.
Head and neck cancer (HNC) affects the mouth, throat, salivary glands, voice box, nose or sinuses. Every year, over 12 000 people in the UK are diagnosed with HNC. Neck dissection is a key, surgical component of patient care. However, many people experience postoperative restriction in shoulder and neck movements, pain, fatigue and low mood, with only half ever returning to work.
Getting Recovery Right After Neck Dissection (GRRAND) is a two-arm, multicentre, pragmatic randomised controlled trial. The trial aims to compare clinical and cost-effectiveness of a personalised physiotherapy programme (GRRAND programme) versus usual practice, National Health Service (NHS), postdischarge care.
The planned sample size is 390 participants. Participants will be recruited from across UK sites and followed up for 12 months. The primary outcome is the shoulder pain and disability index at 12 months. Economic evaluation will be conducted from a healthcare system and personal social services perspective. Secondary outcome data, including pain, function, health-related quality of life, mental well-being, health resource use and adverse events, will be collected at 6 weeks, 3, 6 and 12 months, with exercise adherence at 6 weeks. A process evaluation will determine how GRRAND is implemented, delivered and received across clinical settings, exploring what works, for whom and under what conditions. Analysis will be on an intention-to-treat basis and reported inline with the Consolidated Standards of Reporting Trials statement.
The trial was approved by the London-Brent Research Ethics Committee (ref: 24/LO/0722) on 15 October 2024. Trial results will be disseminated via peer-reviewed publications, presentations at national and international conferences, in lay summaries and social media. This protocol adheres to the recommended Standard Protocol Items: Recommendations for Interventional Trials checklist.
Background
Chronic pain occurs in 30% of older adults. This prevalence rate is expected to increase, given the growth in the older adult population and the associated growth of chronic conditions contributing to pain. No population-based studies have provided detailed, longitudinal information on the experience of chronic pain in older adults; the pharmacological and nonpharmacological strategies that older adults use to manage their chronic pain; and the effect of chronic pain on patient-reported outcomes.
Objectives
This article aims to describe the protocol for a population-based, longitudinal study focused on understanding the experience of chronic pain in older adults. The objectives are to determine the prevalence and characteristics of chronic pain; identify the pharmacological and nonpharmacological pain treatments used; evaluate for longitudinal differences in biopsychosocial factors; and examine how pain types and pain trajectories affect important patient-reported outcomes. Also included are the results of a pilot study.
Methods
A population-based sample of approximately 1,888 older adults will be recruited from the National Opinion Research Center at the University of Chicago’s AmeriSpeak Panel to complete surveys at three waves: enrollment (Wave 1), 6 months (Wave 2), and 12 months (Wave 3). To determine the feasibility, a pilot test of the enrollment survey was conducted among 123 older adults.
Results
In the pilot study, older adults with chronic pain reported a range of pain conditions, with osteoarthritis being the most common. Participants reported an array of pharmacological and nonpharmacological pain strategies. Compared to participants without chronic pain, those with chronic pain reported lower physical and cognitive function and poorer quality of life. Data collection for the primary, longitudinal study is ongoing.
Discussion
This project will be the first longitudinal population-based study to examine the experience and overall effect of chronic pain in older adults. Pilot study results provide evidence of the feasibility of study methods. Ultimately, this work will inform the development of tailored interventions for older patients targeted to decrease pain and improve function and quality of life. Background
Up to 45% of patients report cancer-related cognitive impairment (CRCI). A variety of characteristics are associated with the occurrence and/or severity of CRCI. However, an important gap in knowledge of risk factors for CRCI is the relative contribution of each factor. The multifactorial model of cancer-related cognitive impairment (MMCRCI) is a conceptual model of CRCI that can be used to evaluate the strength of relationships between various factors and CRCI.
Objectives
The purpose of this study was to use structural regression methods to evaluate the MMCRCI using data from a large sample of outpatients receiving chemotherapy (n = 1,343). Specifically, the relationships between self-reported CRCI and four MMCRCI concepts (i.e., social determinants of health, patient-specific factors, treatment factors, and co-occurring symptoms) were examined. The goals were to determine how well the four concepts predicted CRCI and determine the relative contribution of each concept to deficits in perceived cognitive function.
Methods
This study is part of a larger, longitudinal study that evaluated the symptom experience of oncology outpatients receiving chemotherapy. Adult patients were diagnosed with breast, gastrointestinal, gynecological, or lung cancer; had received chemotherapy within the preceding 4 weeks; were scheduled to receive at least two additional cycles of chemotherapy; were able to read, write, and understand English; and gave written informed consent. Self-reported CRCI was assessed using the attentional function index. Available study data were used to define the latent variables.
Results
On average, patients were 57 years of age, college educated, and with a mean Karnofsky Performance Status score of 80. Of the four concepts evaluated, whereas co-occurring symptoms explained the largest amount of variance in CRCI, treatment factors explained the smallest amount of variance. A simultaneous structural regression model that estimated the joint effect of the four exogenous latent variables on the CRCI latent variable was not significant.
Discussion
These findings suggest that testing individual components of the MMCRCI may provide useful information on the relationships among various risk factors, as well as refinements of the model. In terms of risk factors for CRCI, co-occurring symptoms may be more significant than treatment factors, patient-specific factors, and/or social determinants of health in patients receiving chemotherapy. Background
Morning and evening fatigue are distinct and distressing symptoms experienced during chemotherapy that demonstrate a large amount of interindividual variability.
Objectives
The objectives of this study were to identify subgroups of patients with distinct morning and evening fatigue co-occurrence profiles and evaluate for differences among these subgroups in demographic, clinical, and symptom characteristics and quality of life.
Methods
Oncology patients (n = 1,334) completed the Lee Fatigue Scale to self-report morning and evening fatigue, six times over two cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct morning and evening physical fatigue profiles.
Results
Four distinct morning and evening fatigue profiles were identified (i.e., Both Low, Low Morning + Moderate Evening, Both Moderate, and Both High). Compared to the Both Low profile, the Both High profile was significantly younger, less likely to be married or partnered, more likely to live alone, had a higher comorbidity burden, and lower functional status. The Both High profile had higher levels of anxiety, depressive symptoms, sleep disturbance, and pain and lower levels of quality of life.
Discussion
The variability in the morning and evening severity scores among the four profiles supports the hypothesis that morning and evening fatigue are distinct but related symptoms. Clinically meaningful levels of both morning and evening fatigue were reported by 50.4% of our sample, which suggests that the co-occurrence of these two symptoms is relatively common. Patients in Both Moderate and Both High profiles experienced an extremely high symptom burden that warrants ongoing assessments and aggressive symptom management interventions. 
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