Judicious use of the Critical Care Outreach Team: A QIP to reduce the inappropriate use of Early Warning Scores through targeted communication

Introduction: Early Warning Scores (EWS) use physiological parameters to create an aggregate score alerting medical teams to patient deterioration. Although vital tools for triggering referrals to critical care services in appropriate patients, the score does not take account of patients with persistently altered physiology or patients who are not deemed suitable for escalation to critical care. In these instances, EWS can result in the over-monitoring of patients and inappropriate contact of already strained critical care outreach services.1-2 Guidelines state that in such circumstances routine recording of EWS may be stopped.1 The COVID-19 pandemic has placed unprecedented demands on already overstretched resources in the critical care services,3 in particular on the Critical Care Outreach Team (CCOT). This makes their judicious use, and this QIP, ever more pertinent. Objective(s): In our trust, it was found that despite documented decisions not to escalate patients to critical care, these patients were still being monitored according to EWS, resulting in the inappropriate call out of the CCOT. We introduced measures to improve the proportion of inpatients with treatment limitations in place that had these limitations documented on their EWS charts, with the overall aim of reducing the number of inappropriate call-out of the CCOT. Method(s): We performed two snapshot audits on acute medical (control) and general medical wards (intervention) in a large district general hospital between the years 2018-2019. We obtained the percentage of patients with treatment limitations in place who had this documented on their EWS charts before and after improvement measures. Firstly, a paper prompt on the EWS chart was used in both control and intervention wards. Secondly, targeted communication interventions to general medical wards only. Targeted communication was not repeated after the second audit. A third snapshot audit was completed a year after improvement measures (2020) to identify whether improvements were sustained. Result(s): There was no significant difference in EWS amendment in the acute medical ward, where only a paper prompt was used. However, where targeted communication was used (general medical ward), there was a statistically significant improvement in review and amendment of EWS scores between the first and second audit in the intervention ward (37.2% vs 59.1%, p=0.017). However, this improvement was not sustained when the audit was repeated a year later. Conclusion(s): The proportion of inpatients with treatment escalation limitation decisions in place that have EWS amended can be improved by targeted communication, but paper prompts alone are not sufficient. However, these improvements are not sustained without repeated communication. The importance of appropriate amendment of EWS has two key benefits. Firstly, it reduces inappropriate and futile monitoring of end-of-life patients, allowing them to have a more dignified death. Secondly, instead of performing repeated observations (nursing staff) or patient reviews (CCOT) that will not alter management, nursing staff can better utilise their time in providing palliative support where appropriate (particularly considering current visiting restrictions), and the ever- stretched CCOT can be used more judiciously.

Pediatric Cardiac Screening Data Warehouse: A National Public Health Resource

Background: Cardiac screening of youth for prevention of sudden cardiac death in the young (SCDY) has been debated due to the absence of large population-specific screening data with outcomes. Despite years of screening by US public screening groups (PSG), there is minimal coordination of effort and no standardized methods for real-world data collection. Objective(s): To understand the methods, quality, outcomes, and best practices of youth screening, the Cardiac Safety Research Consortium Pediatric Cardiology Working Group, in collaboration with FDA and PSGs, developed and enabled a scalable system to collect a uniform pediatric cardiac screening dataset including digital ECGs and post-screening electronic follow-up data. Method(s): Front end data collection (figure) was developed to include use of a universal unique ID system to align paper/digital collection of health and ECG data. PSGs use secure data transfer portals for digital ECG data upload for conversion to device-agnostic standardized FDA format to store in the national pediatric cardiac screening data warehouse. Follow-up data are obtained at designated post-screening intervals (one week, one and 3 months for pilot study) using initial text message contact followed by electronic consent (REDCap) and answering online health surveys. Result(s): Fourteen PSGs in ten states participated in the pilot study. PSG warehouse data include 33840 retrospective ECG datasets collected from 2010 to 2021 containing limited screened history/symptoms but demographics similar to US census as follows: Age 13-30y, Male/Female 57/43%, Asian 6%, Black 19%, Native American <1%, Pacific Islander <1%, White 68%, Other 4%;Hispanic/Non-Hispanic 27%/79%. Individual PSG site demographics reflected local populations. Prospective data collection since 2021 include >4000 uniform screening datasets (age, sex, race, ethnicity, ht, wt, screening H&P, COVID history, medications, digital ECG with results, screening outcome, and, if applicable, ECHO results). Follow up participation allowing initial cellular contact was high (avg 73%, range 51-91%/screening). Conclusion(s): Establishment of a national pediatric cardiac data warehouse enables large-scale aggregation of pediatric cardiac screening information to address deficits in the understanding and prevention of SCDY. This large real-world dataset will help establish normative data for pediatric ECGs which can facilitate development of new diagnostic tools such as machine learning and support pediatric drug and device development. [Formula presented]Copyright © 2023

N-of-1 trials versus usual care in children with hypertension: a pilot randomized clinical trial.

BACKGROUND: Blood pressure (BP) is often inadequately controlled in children treated for hypertension, and personalized (n-of-1) trials show promise for tailoring treatment choices. We assessed whether patients whose treatment choices are informed by an n-of-1 trial have improved BP control compared to usual care. METHODS: A randomized clinical trial was conducted in a pediatric hypertension clinic in Houston from April 2018 to September 2020. Hypertensive adolescents and young adults 10-22 years old were randomized 1:1 to a strategy of n-of-1 trial using ambulatory BP monitoring to inform treatment choice or usual care, with treatment selected by physician preference. The primary outcome was the proportion of patients with ambulatory BP control at 6 months in a Bayesian analysis. RESULTS: Among 49 participants (23 randomized to n-of-1 trials and 26 to usual care), mean age was 15.6 years. Using skeptical priors, we found a 69% probability that n-of-1 trials increased BP control at 6 months (Bayesian odds ratio (OR) 1.24 (95% credible interval (CrI) 0.51, 2.97), and 74% probability using neutral informed priors (OR 1.45 (95% CrI 0.48, 4.53). Systolic BP was reduced in both groups, with a 93% probability of greater reduction in the n-of-1 trial group (mean difference between groups = -3.6 mmHg (95%CrI -8.3, 1.28). There was no significant difference in side effect experience or caregiver satisfaction. CONCLUSIONS: Among hypertensive adolescents and young adults, n-of-1 trials with ambulatory BP monitoring likely increased the probability of BP control. A large trial is needed to assess their use in clinical practice.

Creative and visual communication of health research: development of a graphic novel to share children's neighbourhood perspectives of COVID-19 lockdowns in Aotearoa New Zealand

Research dissemination to target stakeholders including communities, policymakers and practitioners is a fundamental element of successful research projects. For many of these stakeholders, however, barriers to access and uptake exist, including time taken to publish, academic jargon, language barriers, paywalled articles and time taken to consume and understand academic outputs. Ultimately these barriers could prevent research from reaching target audiences or could severely delay the uptake of key research messages. Creative and visual dissemination approaches as a complement to traditional academic outputs offer numerous advantages and may improve real-world uptake in a timely manner. In this practitioner piece, the authors present detailed methods for the development of a graphic novel using research findings from an online survey that asked children what they liked about their neighbourhood during COVID-19 lockdowns in Aotearoa New Zealand. Here, they share critical reflections from the process of developing and disseminating this creative communication, with the aim of informing and supporting future creative and visual dissemination of research findings. © The Author(s) 2023.

SETTLE DOWN: Preliminary investigations and development of an online toolkit to support student self-regulation in higher education

The impact of stressors on student wellbeing and academic performance is widely documented within the Higher Education (HE) sector, with student drop-out rates linked to poor wellbeing. Identified connections between attrition rates and the levels of support offered to students has led to concerted efforts to better support student wellbeing-particularly for those in the first year of study. The COVID-19 pandemic and the rapid and abrupt shift toward online learning has complicated how students manage stress by reducing students' access to the very resources that might otherwise buffer them (e.g., social connection) exposing them to risk factors (e.g., isolation and greater uncertainty). Accordingly, empowering students to better self-regulate during stressful times is, more than ever, essential to supporting the transition to the adult learning environment. The development of students' self-awareness and self-knowledge of the influences of being stressed on their engagement in study is an important adjunct to self-regulated learning. This nexus between psychology and education is a point for an interventive program that meets a gap in current support efforts, and that recognises the need for such endeavours that situate within the digital landscape of HE. In this paper we describe the groundwork of a single cohort case study that outlines a novel approach to student wellbeing. We discuss the design and development process of the SETTLE DOWN program;an evidence-based and clinically informed series of self-regulation workshops for undergraduate students, which aimed to foster student self-awareness about personal stress responses, facilitate a guided self-discovery of self-regulation techniques, and embed self-knowledge through reflection and practice. Preliminary pilot data is presented with respect to the intended purpose of assessing the suitability of the program material to achieve desired outcomes. The translation of these workshops into an online format to maximise accessibility for students and teachers is extrapolated in discussion of future-directions and next steps for the SETTLE DOWN program. The case study offers an example of the development of an evidence-based approach to ultimately support students with online availability of the necessary knowledge and skills to foster self-awareness and self-knowledge in the context of engaging in study under stress.

Creating a collaborative cross-institutional culture to support STEM women of color and women with family responsibilities at four midwestern research institutions

NSF ADVANCE has been instrumental in supporting institutional practices leading to the increased representation of women in STEM. However, research suggests institutional culture and practices evolve slowly, and much progress remains to create a collaborative and supportive work environment where women scientists, mathematicians, and engineers can thrive, particularly those with intersectional identities, including women of color and women with caregiving responsibilities. A partnership of four midwestern research universities joined together in late 2019 to adapt, design, implement, and assess the impact of a coordinated suite of programs intended to enhance the career success of women and underrepresented STEM faculty. The programs promote mentoring, male advocacy, and informed and intentional leadership as integral to campus culture, and foster community and cross-institutional data-based collaboration. This paper summarizes the programs designed and implemented to improve retention and job satisfaction of women in STEM fields with a focus on the intersectionalities of women of color and women with family responsibilities, including navigating the challenges presented by the COVID-19 pandemic, by creating support networks for these faculty. © American Society for Engineering Education, 2022.

TRANS-NASAL OESOPHAGOGASTRODUODENOSCOPY (OGD): CHALLENGING THE STATUS QUO - A DISTRICT GENERAL HOSPITAL CASE SERIES

Introduction Oesophagogastroduodenoscopy (OGD) is commonly performed and trans-oral OGD is a very safe procedure. However, it requires nursing support, patient sedation, a dedicated endoscopy suite, and is disliked by patients. The national census by the Joint Advisory Group on Gastrointestinal Endoscopy reported 860,000 OGDs were performed across the UK in a calendar year. of these, only 26,685 were trans-nasal despite having a similarly low risk profile and being preferred by patients. We compared comfort score, sedation, and safety to show trans-nasal OGD is a feasible alternative to trans-oral OGD reducing nursing burden, avoiding endoscopy suites, and reducing procedure length. Methods A single centre retrospective analysis was performed comparing all OGDs performed by a single endoscopist at Whipps Cross and Mile End Hospitals between 01/06/2021 and 24/11/2021. Demographic data, route of entry, indication, comfort score (scale of 0-3), sedation agent and dose, and any complications were recorded for each procedure. The data sets were compared using paired t-test for statistical significance. Results There was 110 OGDs performed (table 1);73 transoral (66%) and 37 trans-nasal (34%). of those trans-nasal OGD 18 (49%) were completed seated. The trans-nasal route had mean comfort score of 0.29 compared with 0.85 for trans-oral route (p = 0.001). There was no statistical difference in xylocaine application with either route. The mean dose of both fentanyl and midazolam was statistically higher in the trans-oral route compared with trans-nasal (p = 0.0001). There were only two complications reported in the cases reviewed. Conclusions Trans-nasal OGD caused significantly less discomfort than trans-oral OGD and required significantly less sedation, and almost half of patients undergoing trans-nasal OGD were able to tolerate the procedure in a seated position. This has advantages for patient safety, as the risk of aspiration is greatly reduced, but is also much less resource intensive. Given the current pressure on endoscopy services nationwide, amplified by COVID-19, trans-nasal endoscopy is safe, less resource intensive, and can be performed outside of a dedicated endoscopy suite. This may be a useful tool in alleviating waiting list pressure and should be discussed with patients and service leads.

SEVERE ACUTE VULVAL ULCERATION ASSOCIATED WITH COVID-19 INFECTION IN A SEXUALLY ACTIVE DUAL COVID-VACCINATED YOUNG PERSON: A CASE REPORT

Case A 20-year old was seen at the height of the Omicron wave of the COVID-19 pandemic with a two day history of a first episode of painful genital ulceration. Her last sexual contact was one week previously. She had no other symptoms and no medical or drug history. There was bilateral inguinal lymphadenopathy and a unilateral 1cm slightly indurated shallow vulval ulcer with slough. She was treated empirically for secondarily infected primary herpes. Three days later she presented with increased pain and negative HSV PCR and STI/ BBV tests. She had large bilateral genital ulcers (figure 1) and was admitted. Repeat swabs for HSV, VZV and syphilis were negative. She had a neutrophilia, raised CRP and negative EBV and CMV IgM. A routine nasopharyngeal swab identified SARS-CoV-2 and a full respiratory virus PCR panel was otherwise negative. She disclosed a sore throat and fevers the week before the onset of her vulval symptoms but was reassured by negative home antigen tests. She had received the second dose of an mRNA COVID-19 vaccine four months previously but no booster. She was discharged after five days and treated with a reducing course of oral steroids. At four weeks her ulcers were healing well. Discussion There are few published cases of Lipschütz ulcers associated with COVID-19 and this case adds to the burgeoning evidence of the possible dermatological manifestations of the disease and crucially it illustrates the value of prompt access to sexual health services during the pandemic. (Figure Presented).

Trends in teledermatology utilization in the United States

Background: Teledermatology is an effective healthcare delivery model that has seen tremendous expansion over the last decade, which has been particularly pronounced during the Coronavirus Disease 2019 (COVID-19) pandemic. Objective: To better understand teledermatology utilization and patient demographic trends throughout the COVID-19 pandemic. Methods: National-level data were curated for all practices enrolled in the American Academy of Dermatology’s DataDerm registry from April 1, 2020, through June 30, 2021. Encounter utilization rates were collected for visit type (i.e., teledermatology versus in-person), sex, race, age, insurance provider, and location. Results: Data from up to 13,964,816 encounters across the United States were analyzed. Sex, race, age, insurance provider, and location were each found to have a significant association with telemedicine utilization (adjusted p<0.001). The proportion of women who utilized services via teledermatology (n=65,023, 66.0%) was greater than those who utilized in-person services (n=2,940,122, 58.3%). Non-white patients made up a higher percentage of teledermatology utilizers (n=8,920, 14.3%) when compared to in-person utilizers (n=394,680, 11.2%). Younger patients (age<40) contributed more to teledermatology service utilization (n=62,695, 83.2%) when compared to in-person services (n=1,329,218, 40.3%). Medicare and Private were larger payor contributors for in-person services (n=1,089,777, 25.2%;n=2712594, 62.6%) than for teledermatology services (n=8232, 5.4%;n=73940, 48.2%). Utilization by out-of-state patients was proportionally higher for teledermatology services (n=19,422, 14.6%) compared to in-person services (n=580,358, 4.2%). Conclusions: Teledermatology services may reach and benefit certain populations (females, younger patients, non-White races, out-of-state patients) more so than others.

Day Centres for Homeless People in South London: Early Learning Points from Operating During the First COVID-19 Lockdown in England

Context: Many day centres for homeless people remained open during the first national lockdown in England following the COVID-19 pandemic. Lacking any official guidance on how to adapt, day centres for homeless people had to navigate risks of infection and changes in the situation of homeless people during this time. Objective: This small study aimed to discover how some day centres for homeless people approached and experienced the implications of lockdown. The objective was to draw early learning points to inform further research on the future trajectory of day centre provision for homeless people during the pandemic and beyond. Methods: This rapid qualitative study included semi-structured phone interviews with day centre managers (n = 5) and a systematic search of public facing websites of day centres (n = 10) across four South London boroughs. Data were analysed inductively, using the framework method. Findings: Findings indicate three learning points 1: the importance of strong networks between day centres with local authorities and other organisations for homeless people to enable services to provide humanitarian assistance, 2: the significance of day centres in their role as humanitarian assistants as a first point of contact for newly homeless people 3: the value of a central information hub. Limitations: The regional focus on South London and the sample size, which reflects ethical imperatives involved in avoiding undue pressure on day centre staff during the COVID-19 pandemic, limit this study. The findings are to be considered as a springboard for in-depth research into day centres’ support for homeless people during and after the COVID-19 pandemic. Implications: Findings are valuable as a snapshot of this largely under-researched group of services and service users during the first lockdown. Further research based on the findings could lead to good practice examples to inform the future trajectory of social care provision for homeless people. © 2021 The Author(s).

Human Rights as ethical foundation for health professions - a sketch of the disciplines and their spheres of activities

Based on the definitional foundations of the disciplines human rights and ethics, the article links the normative and legal significance of human rights, as exemplified by the right to health, with state and individual action in healthcare. Applying human rights as an ethical foundation in healthcare also means repeatedly weighing up rights and obligations for the individual and the collective, as exemplified by current controversies surrounding the corona pandemic.

Preliminary Findings of mRNA COVID-19 Vaccine Safety in Pregnant Persons

The first coronavirus disease (COVID-19) vaccines in the United States were the messenger RNA (mRNA) vaccines BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna). Pregnant persons were excluded from the original Emergency Use Authorization (EUA) issued by the Federal Drug Administration (FDA) in December 2020. Pregnant persons with COVID-19 are at increased risk for adverse pregnancy outcomes compared with pregnant persons without COVID-19. This study presents preliminary findings of mRNA COVID-19 vaccine safety in pregnant persons from the United States. To conduct this study, the researchers extracted data from 3 different US vaccine safety monitoring systems: the "v-safe after vaccination health checker" surveillance system, the v-safe pregnancy registry, and the Vaccine Adverse Event Reporting System (VAERS). V-safe asks participants to report local and systemic signs and symptoms as mild, moderate, or severe during daily surveys. Women were eligible if they received their mRNA vaccination during pregnancy or during the preconception period, defined as 30 days before the last menstrual period through 14 days after, and were 18 years of age or older. Participant-reported pregnancy outcomes were spontaneous pregnancy loss (defined as spontaneous abortion and stillbirth) and neonatal outcomes (such as preterm birth, congenital anomalies, small size for gestational age, and neonatal death). Data were obtained through December 14, 2020, to February 28, 2021. In all, 35,691 v-safe participants ages 16 to 54 years identified themselves as pregnant. The majority of enrolled participants were between the ages of 25 and 44 years (98.8%), non-Hispanic White (79.0%), and did not report a COVID-19 diagnosis during pregnancy (97.6%). Overall, 92 (2.3%) of participants received their first vaccination dose during the preconception period, 1132 (28.6%) in the first trimester, 1714 (43.3%) in the second trimester, and 1019 (25.7%) in the third trimester. In terms of adverse effects, injection site pain was described more among pregnant persons compared with nonpregnant women. Headache, myalgia, chills, and fever were reported less often among pregnant persons compared with nonpregnant people. Of the 3958 participants enrolled in the v-safe pregnancy registry, 827 had a completed pregnancy. Of these, 827 completed pregnancies, 115 (13.9%) resulted in a pregnancy loss, and 712 (86.1%) resulted in a live birth (mainly among participants with vaccination in the third trimester). Adverse neonatal outcomes included preterm birth (in 9.4%) and small size for gestational age (in 3.2%);no neonatal deaths were reported. There were 221 pregnancy-related adverse events reported to VAERS, of which the most frequently reported event was spontaneous abortion (46 cases). No congenital anomalies were reported. Of note, the proportions of adverse pregnancy and neonatal outcomes in the v-safe pregnancy database were similar to those published before the COVID-19 pandemic. The findings from this study did not show obvious safety concerns among pregnant persons who received mRNA COVID-19 vaccines. More longitudinal follow-up and studies including larger numbers of women vaccinated earlier in pregnancy are needed to better inform outcomes. Further, new evidence has shown transplacental transfer of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies after maternal COVID-19 vaccination during the third trimester. This evidence suggests that maternal vaccination might provide some protection to the neonate. However, more data are needed to make evaluations on the level of protection.

Outcomes of a pilot study of community-based, collaborative glaucoma care in a tertiary referral public glaucoma clinic

Purpose: To evaluate the outcomes of the Glaucoma Community Collaborative Care Program (G3CP) from the Royal Victorian Eye and Ear Hospital (RVEEH), Melbourne. Method: The program enrolled community optometrists in a shared care model with the RVEEH Glaucoma Unit. Patients classified as low risk and/or stable glaucoma patients were recruited according to RANZCO Collaborative Care Guidelines. The program's aims were to increase access and provide timely glaucoma care, contribute to the continuing education of optometrists and to be scalable to accommodate increased future demand. Results: The pilot program enrolled 104 patients between March 2019 and April 2020. The uptake rate by patients offered the G3CP was 73%. Clinical outcomes showed 93% of patients had stable glaucoma over the period and all had timely reviews. There was 95% agreement between the enrolled optometrists and a RVEEH Glaucoma Specialist. Surveys of patient and optometrist satisfaction demonstrated high acceptability. The challenges identified were frequent changes in the optometry network (up to 50% of originally enrolled), low recruitment (35% of predicted) and low quality of information shared (40% of optical coherence tomography tests reviewed were too degraded for adequate review). Conclusion: The G3CP pilot provided timely care to the patients enrolled and created additional capacity in outpatients, which has become even more important with the increased demand caused by the COVID-19 pandemic. With acceptability and feasibility of the project demonstrated, it is intended that this model of collaborative care will continue;however, to enable scalability, several challenges will need to be addressed. Genetics.