Developing novel referral pathways in emergency surgery

Introduction: In line with the principles of GIRFT and recognising the demand on the Emergency Department (ED) the Acute Surgical Unit (ASU) developed a direct admission pathway entitled 'ASU Direct' (ASUD). Nurse led ED triage with adherence to a referral proforma allows direct admission of suitable surgical patients eliminating medical ED review or discussion with the on-call Registrar. Aim: Investigate the usefulness of the ASUD pathway and adherence to admission criteria. Method: Two retrospective audits of ASUD referrals were completed and compared with concurrent traditional registrar referrals. Inter-departmental discussions occurred between audit cycles. Results: Audit 1: 13 days, 150 cases (8 excluded). 75 (53%) referred via ASUD, 67 (47%) via surgical registrar. Sixteen ASUD cases (22%) breached pathway protocols including 3 young women referred without pregnancy tests. Seventeen (25%) cases referred via the Registrar fulfilled ASUD criteria. Documentation complete in 56% of ASUD cases. Audit 2: (3 weeks after feedback)-10 days, 120 patients (25 excluded). Fifty one ASUD cases (54%) and 44 (46%) registrar referrals. 24% cases breached ASUD criteria, 7 registrar referrals (15%) appropriate for ASUD. ASUD documentation completed in 60% with 100% pregnancy status recorded. Conclusions: Proportion of ASUD / registrar referrals remained constant but there were fewer missed opportunities for ASUD. Inappropriate ASUD admissions remained similar. While ASUD worked well for visible pathology, less-so for protocol-driven abdominal pain. Senior 'front-door' triage in ED might improve protocol compliance, helping to develop such pathways, observing GIRFT and avoid unnecessary transfer of patients (especially during the COVID pandemic).

Association of use of remote patient monitoring (RPM) with reduced hospitalizations in cancer patients with COVID-19

Background: Patients with cancer and COVID-19 are at risk for poor clinical outcomes. An established multi-site remote patient monitoring (RPM) service was rapidly adapted to support a novel, interdisciplinary COVID-19 program for outpatient management of patients at high-risk for severe illness. The goal of this study was to assess the impact of the RPM program on clinical outcomes and acute care utilization in cancer patients diagnosed with COVID-19. Methods: This is a crosssectional analysis following a multi-site prospective observational study performed at Mayo Clinic Cancer Center (MCCC). All adult patients with active cancer - defined as currently receiving cancer-directed therapy or in recent remission on active surveillance - and PCR-confirmed SARS-CoV-2 infection between March 18 and July 31, 2020 were included. RPM was comprised of in-home technology to assess symptoms and physiologic data with centralized nurse and physician oversight. Results: During the study timeframe 224 cancer patients were diagnosed with COVID-19 at MCCC. Initial management included urgent hospitalization (within 48 hours of diagnosis) in 34 patients (15%). Of the remaining 190 patients (85%) initially managed in the outpatient setting, those who did not receive RPM were significantly more likely to experience hospitalization than those receiving RPM (OR 3.6, 95% CI 1.036 to 12.01, P = 0.044). Following balancing of patient characteristics by inverse propensity weighting, rates of hospital admission for RPM and non-RPM patients were 3.1% and 11% respectively, implying that RPM was associated with an 8% reduction in hospital admission rate (-0.077;95% CI: -0.315 to -0.019, P = 0.009). Use of RPM was also associated with lower rates of prolonged hospitalization, ICU admission, and mortality, though these trends did not reach statistical significance. Conclusions: In the midst of a global pandemic associated with inpatient bed, ventilator, and PPE shortages, the RPM program provided an effective strategy for outpatient clinical management and was associated with decreased rates of hospitalization, ICU admission, and mortality in cancer patients with COVID-19. This care model enabled simultaneous opportunity to mitigate the increased risks of exposure, transmission, and resource utilization associated with conventional care.