We anticipate that this document, representing a synthesis of our discussions and supported by literature, will serve as a practical aid to clinicians evaluating patients with suspected encephalitis and will identify key areas and approaches to advance our knowledge of encephalitis.

Monitoring both urine toxicology and aberrant behavior in chronic-pain patients treated with opioids identified more problem patients than by monitoring either alone. The authors recommend routine urine testing on all patients prescribed opioids for noncancer pain and as a required element in all opioid analgesic studies.

Objective-To examine the adequacy of assessment and management ofdeliberate self harm (DSH) undertaken by accident and emergency (A&E) medical staff. Methods-The records for attendances to the Leicester Royal Infirmary A&E department with a diagnosis of "self inflicted" injury for the 12 month period April 1994 to March 1995 were scrutinised. If the episode was identified as DSH, then assessment and management were examined, using an instrument based on the Royal College of Psychiatrists' standards of service for the general hospital management of adult DSH. Results-There were 934 episodes of DSH involving 854 patients. The mean age was 32 (SD 14.2), with an even sex distribution. Overdose was by far the most common method of DSH (91.5%). Information concerning suicide intent was documented in 70% of cases, and psychiatric history in 67%. Less information was recorded for medical history (50%), mental state (51%), recent stress (55%), or previous DSH (47%), and only 23% had an assessment of risk of further DSH. Very little was recorded concerning alcohol or substance misuse. In 291 cases (31%), the patient was discharged directly home by A&E medical staff, and 50 of these were referred for psychiatric outpatient follow up; 210 (23%) were referred for specialist assessment in the department and 423 (45.5%) were admitted to medical/surgical wards. The frequency with which information was recorded varied significantly between outcome groups. At night A&E staff were far more likely to discharge a patient home themselves than refer for specialist assessment (P << 0.001). Conclusions-With over half the sample not admitted, the responsibility for the initial risk assessment lies with A&E medical staff. The study reveals a need for improved planning and delivery of services. The A&E department of the Leicester Royal Infirmary has a catchment area of 0.9 million persons, and a multidisciplinary specialist service for the assessment of those presenting with DSH. This service, comprising of psychiatric nurse specialists and a social worker, is however restricted to weekdays between the hours of 9 am and 5 pm, and is dependent on A&E or ward staff to perform the initial screen and instigate referral.Our principal objective was to examine the adequacy of the management of DSH in the A&E department by comparing with an "ideal" standard.4 In addition to examining the management of 934 consecutive attenders to the Leicester Royal Infirmary with a diagnosis of DSH, we also surveyed A&E staff concerning their knowledge, confidence, attitudes, and postgraduate training in the psychosocial assessment of this behaviour. MethodsAll attendances at the Leicester Royal Infirmary A&E department with a discharge diagnosis of "self inflicted injury" for the 12 month period April 1994 to March 1995 were retrospectively identified from the PAS (patient activity analysis) system. The year chosen for the project spanned three rotations of junior medical staff. A&E records were located for 1592 of 1702 episodes of "self inflicted injury...

Background Effective communication skills for clinical practice are essential for all advanced practice nurses. However, competence in these skills is not necessarily intuitive. Advanced communication skills should be taught in a way that is similar to the way other psychomotor skills in advanced nursing practice programs are taught. Objectives To develop a patient communication simulation laboratory for the acute care nurse practitioner program at a major university and to evaluate students’ perceived confidence and communication effectiveness before and immediately as well as 4 months after completion of the laboratory. Methods The communication simulation laboratory was developed in collaboration with faculty from the schools of nursing and medicine. Students participated in a didactic session and then completed a 2-hour communication simulation in the laboratory. Content and simulation concentrated on breaking “bad news,” empathetic communication, motivational interviewing, and the “angry” patient. Students’ self-reported confidence and perceived skill in communication were measured via a Likert scale before, immediately after, and 4 months after completion of the laboratory simulation. Students also evaluated the experience by responding to open-ended questions. Results Compared with baseline findings (before the lecture and simulation), students’ confidence in initiating difficult conversations increased significantly both immediately (P&lt;.001) and 4 months after (P=.001) the laboratory simulation. Students’ self-ratings of overall ability to communicate were also significantly greater immediately (P&lt;.001) and 4 months (P=.001) after the simulation. Overall, students rated the laboratory simulation experience highly beneficial. Conclusions The content and methods used for the simulation improved students’ confidence and perceived skill in communication in potentially difficult acute care situations.