Every Minute Counts: Using Process Improvement and Performance Feedback to Improve Patient Flow in an Emergency Department

Prolonged emergency department (ED) visits are associated with a number of adverse outcomes for patients as well as lower patient satisfaction scores and increased costs. Several factors that influence the length of ED visits are out of the control of hospital employees, but some opportunities exist to improve performance. For this study, the ED department of a 150-bed hospital in the southeastern United States wanted to improve door-to-discharge time. To do so, a subprocess of door-to-discharge time was targeted, door-to-order. After analyzing the process, the team created standard orders for the 10 most common presenting conditions in the ER with preapproval, allowing nurses to submit the orders without the provider first visiting the patient. Following the process change, daily feedback was added to increase utilization of the preapproved orders. Reductions in door-to-order times and door-to-discharge were observed and patient satisfaction remained stable. Implications for future research in this area are discussed.     

Cross Validation of the Gambling Problem Severity Subscale of the Canadian Adolescent Gambling Index (CAGI/GPSS) on a Sample of Ontario High School Students

This paper reports on the cross validation of the Gambling Problem Severity Subscale of the Canadian Adolescent Gambling Index (CAGI/GPSS). The CAGI/GPSS was included in a large school based drug use and health survey conducted in 2015. Data from students in grades 9–12 (ages 13–20 years) derived from the (N = 3369 students). The CAGI/GPSS produced an alpha of 0.789. A principle component analysis revealed two eigenvalues greater than one. An oblique rotation revealed these components to represent consequences and over involvement. The CAGI/GPSS indicated that 1% of the students fell into the “red” category indicating a severe problem and an additional 3.3% scored in the “yellow” category indicating low to moderate problems. The CAGI/GPSS was shown to be significantly correlated with gambling frequency (r = 0.36), largest expenditure (r = 0.37), sex (more likely to be male) (r = ?0.19), lower school marks (r = ?0.07), hazardous drinking, (r = 0.16), problem video game play (r = 0.16), as well as substance abuse. The CAGI/GPSS was cross validated using a shorted version of the short SOGS, r = 0.48. In addition the CAGI/GPSS and short SOGS produced very similar patterns of correlations results. The results support the validity and reliability of the CAGI/GPSS as a measure of gambling problems among adolescents.     

Psychological Vulnerability and Problem Gambling: The Mediational Role of Cognitive Distortions

Despite numerous studies demonstrating the influence of cognitive distortions on gambling problem severity, empirical data regarding the role of psychological vulnerability on the latter is limited. Hence, this study assesses the mediating effect of cognitive distortions between psychological vulnerability (personality and mood), and gambling problem severity. It also verifies whether the relationships between these variables differs according to the preferred gambling activity. The sample is composed of 272 male gamblers [191 poker players; 81 video lottery terminal (VLT) players] aged between 18 and 82 years (M = 35.2). Bootstrap analysis results revealed that cognitive distortions mediate the effect of narcissism on gambling problem severity for both groups. The level of depression for VLT players significantly predicted gambling problem severity, both directly and indirectly via the mediating effect of cognitive distortions. Mediation analyses also indicated that narcissism had an indirect impact on problem gambling through cognitive distortions for both groups. These findings suggest that certain vulnerabilities related to personality and mood may influence cognitive distortion intensity and gambling problem severity. In addition, psychological vulnerabilities could differ based on preferred gambling activity. These results may be useful for prevention policies, identifying high risk gamblers and planning psychological interventions.     

Problem Gambling and Delinquent Behaviours Among Adolescents: A Scoping Review

Despite many studies indicating an association between problem gambling and delinquent behaviours among adolescents, there has been no effort to systematically analyze the state of the literature on this relationship. To fill this gap, we conducted a scoping review of the literature published between 2000 and 2016 on problem gambling and delinquent behaviours among adolescents. We searched twelve databases and reviewed reference lists to identify eligible studies. Search terms included a combination of medical subject headings and keywords for gambling, youth, and delinquency, which were combined with the Boolean operator “AND”. 1795 studies were identified through the literature search. Nine studies were eligible for inclusion. All of the studies were conducted in North America, with primarily male participants, and most of the data were cross-sectional. No qualitative studies met the inclusion criteria. Screening tools used to measure problem gambling were inconsistent, making comparisons across studies difficult. We found a consistent moderate to strong association between problem gambling and delinquent behaviour. Only one study presented associations by socio-economic status and none considered gender, sex or ethnic differences. Studies in the review showed that problem gambling is associated with both violent and non-violent behaviours among adolescents. These associations may suggest that problem gambling and delinquent behaviours have common risk factors and reflect a syndrome of risky behaviours best targeted through prevention and treatment that is holistic and considers the context in which the youth is situated. Further research is warranted to better understand the relationship between problem gambling and delinquent behaviours.     

In Search of Executive Impairment in Pathological Gambling: A Neuropsychological Study on Non-treatment Seeking Gamblers

Pathological gambling is characterized by a persisting maladaptive and recurrent behavior with severe social and psychological consequences. There is evidence of strong comorbidity with psychiatric manifestations as well as cognitive mainly involving executive functions. This study aimed to investigate impairment in executive functions and working memory, and personality traits in a sample of Greek gamblers. Twenty-four men involved in various gambling activities were recruited from ecological settings as probable pathological gamblers. They were assessed with a comprehensive neuropsychological battery involving several executive tasks, the Zuckerman–Kuhlman Personality Questionnaire, the Hospital Anxiety Depression Scale, and the Difficulties in Emotion Regulation Scale. An age- and education-level matched group of 21 men without history of habitual gambling served as controls. As a group, gamblers displayed significantly lower scores on indices of inhibition, decision making and self-reported emotional awareness, and scored higher on impulsivity/sensation seeking personality traits. Notably, gamblers scored similarly or significantly higher on measures of verbal and visuospatial working memory, cognitive flexibility, processing speed, verbal fluency, and sustained attention. Overall, we argue that gamblers do present with specific cognitive deficits, but there is no evidence for a generalized executive impairment, and further stress the importance of investigating cognitive, personality, and psychiatric aspects of gambling on the basis of an ecologically valid sampling.     

Self-Directed Gambling Changes: Trajectory of Problem Gambling Severity in Absence of Treatment

Most problem gamblers do not seek formal treatment, recovering on their own through cognitive re-appraisal or self-help strategies. Although barriers to treatment have been extensively studied, there is a paucity of research on self-directed changes in problem gambling and very few studies have examined these changes prospectively. The aim of this study was to examine the trajectory of gambling severity and behavior change over an 18-month period, among a sample of non-treatment seeking/attending problem gamblers recruited from the community (N?=?204) interested in quitting or reducing gambling. Separate mixed effects models revealed that in absence of formal treatment, significant reductions in gambling severity, frequency, and amount gambled could be observed over the course of a 6 to 9-month period and that changes experienced within the first 12 months were maintained for an extended 6 months. Problem gambling severity at baseline was significantly associated with changes in severity over time, such that participants with more severe gambling problems demonstrated greater reductions in their gambling severity over time. A total of 11.1% of participants gambled within a low-risk threshold at 18 months, although 28.7% of the sample reported consecutive gambling severity scores below problem levels for the duration of 1 year or longer. The findings suggest that among problem gamblers motivated to quit or reduce their gambling, significant self-directed changes in gambling severity can occur over a relatively short time. Additional prospective studies are needed to document the role of specific self-help tools or thought processes in exacting gambling changes.     

Unclaimed Prize Information Biases Perceptions of Winning in Scratch Card Gambling

Unclaimed prize information (i.e., the number of prizes still available to be won) is information commonly provided to scratch card gamblers. However, unless the number of tickets remaining to be purchased is also provided, this information is uninformative. Despite its lack of utility in assisting gamblers in choosing the most favourable type of scratch card to play, we hypothesized that unclaimed prize information would bias participants’ judgments within a scratch card gambling context. In Experiment 1 (N?=?201), we showed that participants are influenced by this information such that they felt more likely to win, were more excited to play, and preferred to hypothetically purchase more of the scratch card with the greatest number of unclaimed prizes. In Experiment 2 (N?=?201), we attempted to ameliorate this bias by providing participants with the number of tickets remaining to be purchased and equating the payback percentages of all three games. The bias, although attenuated, still persisted in these conditions. Finally, in Experiment 3 (N?=?200), we manipulated the hypothetical scratch cards such that games with the highest number of unclaimed prizes were the least favourable, and vice versa. As in Experiment 2, participants still favoured cards with greater numbers of unclaimed prizes. Possible mechanisms underlying this bias are discussed. In conclusion, across three experiments, we demonstrate that salient unclaimed prize information is capable of exerting a strong effect over judgments related to scratch card games.     

The Impact of Speed of Play in Gambling on Psychological and Behavioural Factors: A Critical Review

Conceptually, there is a common association between gambling games with fast speeds of play and problem gambling. This relationship however, is largely correlational in nature, which comes at the expense of carefully controlled empirical investigation. Research that does exist aimed towards investigating the impact of gambling speeds on psychological and behavioural factors, is in its relative infancy, and the research possesses disparate methodologies and variables of interest. The aims of the current review is therefore to evaluate and summarise the existing body of evidence relating to speed of play in gambling, as well as discuss how this evidence can be used to inform harm minimisation approaches aimed at facilitating self-control during gambling. Eleven studies were selected for review based on the inclusion criteria, comprising nine experimental and two qualitative studies (one self-report focus group study and one observational study). There was a consistent finding across studies that games with faster speeds of play were preferred and rated as more exciting for all gamblers, ranging from non-problem to problem gamblers. Of concern, was the repeated finding that fast games are particularly appealing to those suffering with a gambling problem. Behavioural results were more inconsistent across studies, though the general trend supports the notion that games with faster speeds of play encourage more wagers, longer game play, and caused players, particularly problem gamblers, to experience difficulty in ceasing gambling. The implications of these findings for gambling policy, harm minimisation approaches, and future research are discussed.     

Implicit Valuation of the Near-Miss is Dependent on Outcome Context

Gambling studies have described a “near-miss effect” wherein the experience of almost winning increases gambling persistence. The near-miss has been proposed to inflate the value of preceding actions through its perceptual similarity to wins. We demonstrate here, however, that it acts as a conditioned stimulus to positively or negatively influence valuation, dependent on reward expectation and cognitive engagement. When subjects are asked to choose between two simulated slot machines, near-misses increase valuation of machines with a low payout rate, whereas they decrease valuation of high payout machines. This contextual effect impairs decisions and persists regardless of manipulations to outcome feedback or financial incentive provided for good performance. It is consistent with proposals that near-misses cause frustration when wins are expected, and we propose that it increases choice stochasticity and overrides avoidance of low-valued options. Intriguingly, the near-miss effect disappears when subjects are required to explicitly value machines by placing bets, rather than choosing between them. We propose that this task increases cognitive engagement and recruits participation of brain regions involved in cognitive processing, causing inhibition of otherwise dominant systems of decision-making. Our results reveal that only implicit, rather than explicit strategies of decision-making are affected by near-misses, and that the brain can fluidly shift between these strategies according to task demands.