ABSTRACT
Allogeneic hematopoietic cell transplantation (alloHCT) is a potentially curative treatment for patients diagnosed with blood cancers (such as acute myeloid leukemia) and blood disorders (such as sickle cell disease). It is a resource-intensive treatment that generally requires a long hospital stay and recovery period. If continuous caregiver support is not available, alloHCT likely will not be a treatment option. To learn more about caregiver requirements and perspectives on those requirements, we conducted web-based focus groups with alloHCT social workers who worked with adult patients at United States (US) transplant centers (TCs) from May-July 2022. Web-based interviews with adult alloHCT recipients,caregivers of adult alloHCT recipients, and physicians/advanced practice professionals will also be conducted. Twenty-two social workers from TCs across the US (Midwest [n=8];West [n=5];Northeast: [n=5];South, [n=4]) and with varying volumes (median: 97 alloHCTs performed/year) participated. All noted their TC required a caregiver to proceed to alloHCT. However, there was variation across TCs in the length of time a recipient was required to have a caregiver, the distance/time needed to stay near the TC post-alloHCT, and COVID-19 vaccination requirements. The majority of participants also noted variance among the transplant team in allowing exceptions for caregiver requirements. All participants noted it would be helpful to have a 'gold standard' of requirements across TCs, though there was discussion about what such a standard would include, as well as the need for flexibility to account for different patient and TC needs. Social workers were also asked to identify patient barriers to meeting the caregiver requirement;common barriers included patients feeling they did not have anyone to ask to be a caregiver, the need to relocate closer to the TC, and financial barriers. The impact of the COVID-19 pandemic was also noted (e.g., vaccination requirements, and increased telework allowing more flexibility for caregivers). In analysis of the first of four populations interviewed in this study, social workers reported variation in caregiver requirements across TCs. Finding a caregiver is one of many barriers patients face in accessing alloHCT. Though this variation may allow for some flexibility, it may also contribute to access barriers. This study focused on those who received an alloHCT, but further research is needed to learn about barriers faced by those unable to access alloHCT. Results from this and other cohorts will describe current practices related to caregiver requirements and help inform the development of new programs to reduce caregiver-related barriers to alloHCT.Copyright © 2023 American Society for Transplantation and Cellular Therapy
ABSTRACT
Introduction: Survival after hematopoietic cell transplantation (HCT) has improved tremendously over the last few decades. HCT survivors are at increased risk of long-term complications and secondary cancers. This poses unique challenges to the HCT-related healthcare system given the growing need for survivorship care. Developing a HCT survivorship program with a dedicated clinic to survivors ensures equitable access to care and ongoing patient education. Herein, we describe our program survivorship model and our initial experience. Method(s): The Moffitt Cancer Center (MCC) survivorship clinic (SC) planning committee was initiated in September 2019. The SC was launched in January 2021 with the mission to provide high-quality, comprehensive, and personalized survivorship care and to empower patients and community health care providers with education and a roadmap for screening for late effects. The SC initially focused on allogeneic (allo) HCT patients and later opened to autologous (auto) HCT recipients in February 2022. HCT patients are referred by primary HCT team after HCT with an emphasis on preferred timeframe of initial SC visit no earlier than 3 months but less than 12 months from HCT. SC is located at 2 physical locations: main campus and satellite, with virtual visit options to account for the distance from MCC and COVID considerations. SC applies a consultative model. SC is staffed by dedicated advanced practice professional (APP), supervised by SC faculty. The scope of SC care includes but is not limited to prevention of infections (education, vaccinations), surveillance of late effects (endocrine, pulmonary function, cardiac, bone health), and general cancer screenings (breast, colon, skin cancer). Patients' clinical data from SC inception to August 2022 were reviewed. Result(s): From January 2021 to August 2022, a total of 138 patients were seen in SC. The majority were seen in person (62% in clinic, 38% by virtual visit). Median age was 58 years (range, 19-82). Median time to first SC visit was 21 months (range, 3-1464) after HCT. Allo HCT was the most common type of HCT seen in clinic (87%, n=120). Most common diagnoses were acute myeloid leukemia (43%, n=59), myelodysplastic syndrome (17%, n=23), and acute lymphoblastic leukemia (10%, n=14). Only 17 patients (12%) were seen in 2021 but the volume increased significantly in 2022. Currently there are more than 10 patients seen in SC per month. Conclusion(s): We report successful experience in launching a contemporary HCT SC despite the challenges of an ongoing COVID pandemic. As a stand-alone cancer center, we serve a wide geographical location with subspecialty and primary care providers dispersed throughout the community. Our consultative model and experience could provide a useful guide for other programs. In 2023, we plan to expand our SC to a broader population of patients receiving other cellular immunotherapies.Copyright © 2023 American Society for Transplantation and Cellular Therapy
ABSTRACT
Introduction: Efficient and comprehensive trial oversight and data management ensures valid, robust outcomes necessary to inform health policy and improve patient outcomes. This is particularly challenging in the context of multicenter trials. The format of this session will include four introductory presentations (15 min each), followed by 30-min panel discussion/Q&A focusing on recent experiences and innovative approaches utilized within the Wake Forest NCI Community Oncology Research Program Research Base (WF NCORP RB). Since 2017, WF has managed 15 studies with approximately 3000 patient and 1000 provider/stakeholder accruals across 1000 potential participating community oncology practices within the United States and Puerto Rico. These practices often operate differently from academic medical centers, with varying patient capacity, provider number and level of engagement, use of advanced practice providers, and services offered. In addition, practices within this network have heterogeneous utility of electronic health records (EHRs) and display a wide range of clinical research staffing models. The COVID-19 pandemic has highlighted the need for streamlining research visits and maximizing telehealth technologies when applicable, particularly for intervention non-therapeutic clinical trials. As such, research expectations must be standardized to ensure quality trial conduct and data collection across diverse practices. Recently, the WF NCORP RB has taken many steps to improve efficiency and data quality across our studies. This session will discuss a comprehensive approach to data quality and management across the lifespan of a trial. This starts with consent/ recruitment strategies and general oversight/ monitoring of our portfolio of trials. WF RB now utilizes REDCap for all data capture, as this allows direct data entry for site personnel and participant entered patient-reported outcomes using surveys. In addition, REDCap facilitates data monitoring, query, and auditing strategies. We will also introduce a team-based approach to adjudicate complex outcomes. Talk 1 (15 min): Specifically, Karen Craver, our RB administrator, will discuss approaches to obtain robust data as a result of strong screening and recruitment. She will provide an overview on how we survey practice research staff within the Landscape assessment and brief, pre-trial interest surveys to identify optimal target populations during the planning stage. We utilize our internal EHR to create custom screening reports to identify potential participants and generalize these for other practices to customize and use as a screening tool within their clinic. The RB has integrated remote consenting in part due to the pandemic, but we realize the need to continue offering flexibility in consent modality moving forward. Talk 2 (15 min): Emily Dressler, lead Biostatistician, will discuss oversight of the RB portfolio using dynamic reports within Tableau. These reports update daily and provide a comprehensive assessment of all ongoing and completed studies. RB personnel can filter reports to create custom results subset by timeframe, practice or set of practices, trial type, and/or other demographic characteristics. This has greatly reduced the request for study-specific accrual reports and has standardized our reporting across studies. She will also discuss the rationale for transitioning to REDCap, including strengths and weaknesses for integrating in multicenter studies. Talk 3 (15 min): Bill Stanfield, lead data manager, will demonstrate our utilization of the REDCap Data Resolution Workflow and Data Quality modules to efficiently manage data collection, data quality, and audits. He will show how REDCap can be used to seamlessly communicate with research staff to obtain missing or late data, verify out of range values, and then validate and lock responses for analysis. Talk 4 (15 min): Glenn Lesser, WF NCORP multiple principal investigator (mPI), will discuss a team approach to adjudicating cancer treatment information that often consists of combination of surgery, radiation, chemotherapy, or immunotherapy/targeted agents. This remains a particularly challenging problem in large trials enrolling patients with multiple types of cancer who may be treated with a wide spectrum of standard therapeutic regimens. This diversity limits both the effectiveness of automated reviews of remote data entries and the study-specific training of data management staff at sites. Data are pulled in real time from multiple forms within REDCap and collated into participant-level summaries of treatment, starting with the time of baseline assessment and sorted sequentially for each drug administration or event. A multidisciplinary team of data managers, biostatisticians, and clinicians meet to adjudicate each participant as data collection completes. Particularly for trials with multiple cancer types or treatment regimens, our experience with this approach has shown it identifies significant data gaps in treatment, with at least 75% of entries requiring clarification from research staff prior to finalizing and locking data. This process highlighted the challenge of real-time adjudication of treatment data in patients receiving multiple anti-cancer agents, given at varying doses and schedules, and in multiple combinations and/or phases over an individual patient's course of therapy. Panel (30 min): We will conclude with a panel discussion and Q&A. The panel will contribute additional perspective on implications of these strategies in the conduct of multilevel cancer care delivery research studies. We will also incorporate perspectives from NCORP community sites implementing these strategies. Panelists will discuss the broad applicability of these strategies for diverse trials, with attention to size/ complexity, database vendor, and patient population.
ABSTRACT
Background: A survivorship care plan (SCP) is a detailed cancer care summary and future care plan that is generally given to a patient upon completion of adjuvant treatment for a cancer diagnosis. The initial goals of SCPs were to educate patients and other health care professionals about the treatments received, make them aware about potential long-term effects of therapy, and emphasize recommendations for future cancer screening and care (1). Due to numerous barriers-scheduling, staffing, and lack of awareness-SCPs are not delivered to all eligible patients. To address this unmet need our multidisciplinary breast clinic (MDBC) established an Advanced Practice Professional (APP) Survivorship Clinic. With the acute impact of the COVID-19 pandemic, survivorship referrals decreased. We, therefore, developed and implemented system solutions to address SCP access. Method(s): System solutions include partnering with the Cancer Registry to provide the list of patients potentially in need of survivorship visits, partnering with pharmacy to confirm patient eligibility, creating specifically designated telemedicine survivorship visits in our electronic scheduling system, prospectively scheduling persons identified, engagement of APPs across the MDBC, and establishing a single coordinating point. Numbers of SCPs delivered are tracked monthly and patient satisfaction is assessed through data collected Press Ganey surveys. Result(s): This presentation will share our process interventions and outcomes as they mature. Our early data demonstrate the efficacy of the workflow and appear promising. Conclusion(s): We anticipate that system-based solutions will provide more patients with SCPs and demonstrate patient satisfaction. Blaes AH, Adamson PC, Foxhall L, Bhatia S. Survivorship Care Plans and the Commission on Cancer Standards: The Increasing Need for Better Strategies to Improve the Outcome for Survivors of Cancer.
ABSTRACT
INTRODUCTION: The COVID-19 pandemic created major barriers to communication with patient families, impacting patient care and staff satisfaction. We surveyed an interprofessional group of medical intensive care unit (MICU) stakeholders to identify their concerns surrounding family communication and solicited recommendations for performance improvement. METHOD(S): An anonymous survey was distributed electronically to 260 MICU physicians, advanced practice providers (APPs), nurses, and physical, occupational, and respiratory therapists, with a 1 week reminder. The results were analyzed using thematic analysis. RESULT(S): Thirty-nine participants (response rate 15%) completed the survey, providing 95 unique comments. Major themes included challenges created by visitor policy restrictions (providers unable to connect well with families by phone;families not understanding how to work video platforms;frequent misunderstandings);medical system distrust (antivaccine and overall hostility, unrealistic expectations, challenging treatment decisions);trainee communication concerns (lack of communication training, not seeing the "big picture", nurse not knowing whether families were contacted/what was discussed), and A2F bundle failures (F component not organized, family updates too infrequent, distorted messages). This feedback prompted a quality improvement initiative to strengthen our family communication process. The responsible resident or APP is now encouraged to use a "Get to Know Me Board" to structure the collection of relevant social history with patient and family on admission, establishing an initial relationship and line of communication. Our rounding template was modified to discuss the family communication plan each day using a tiered structure (brief summary/introduction on admission;update;serious update/acute event;goals of care;transition to comfort) and clarify which team members will be present for the conversation. Afternoon rounds were also modified to routinely confirm successful family contact and address any concerns. CONCLUSION(S): We describe the results of our interprofessional survey to define the barriers to family communication during the COVID-19 pandemic, and process improvements in our MICU to make daily family involvement and contact feasible and efficient within our daily workflow.
ABSTRACT
INTRODUCTION: Ivermectin has been widely requested or prescribed as treatment for COVID-19 despite NIH and WHO recommendations against its use. Even so, clinicians commonly receive requests for unproven COVID-19 therapies (UCTs) and face substantial disruption to the therapeutic alliance when clinicians deny these requests from patients. METHOD(S): This study was conducted from 2021-2022 in Moultrie, Georgia. Physicians or advanced practice clinicians who treated a COVID-19-positive patient in the health system were eligible. Purposive, convenience sampling was used to recruit clinicians to participate in a 30-minute qualitative interview exploring experiences and thoughts related to UCT requests, patient trust in the healthcare system, and personal impact of distrust and UCT requests. Thematic analysis was applied to transcripts. RESULT(S): Participants were 8 clinicians (7 physicians, 1 advanced practice nurse) from several fields (outpatient setting=2, inpatient or mixed setting=6): pulmonary/critical care (n=3), internal medicine/hospitalists (n=2), nephrology (n=1), and family medicine (n=2). Five themes emerged: 1) Clinicians do not understand why people trust social media and not their clinical expertise;such distrust is hurtful and frustrating;2) Clinicians feel ambivalence about discussions about UCTs and are generally accepting of community beliefs;3) Clinicians perceived that distrust in healthcare originates outside of the healthcare system yet patients exhibit trust within the local healthcare system;4) Clinicians are torn about whether to use UCTs to build trust and rapport;5) Counseling strategies are variable yet clinicians spend significant time focusing on education. CONCLUSION(S): Clinicians experience distress related to perceived patient distrust in their recommendations about COVID-19 vaccination and UCT requests. Some clinicians perceive that acquiescing to UCT requests may help repair therapeutic relationships with minimal harm. Clinician perspectives are aligned with themes from a related study of patient trust and UCT request from the same healthcare system. Taken together, these studies provide insight for clinicians looking to craft savvy and ethical messages that are responsive to patient needs while upholding professional standards in prescribing medications.
ABSTRACT
INTRODUCTION: Burnout results from physical and mental exhaustion and affects the intentionality to leave the profession. Unfortunately, burnout scenarios have been quite common among Critical Care Advance Practice Providers (APPs). The calls to action to sustain the critical care workforce were in full force before COVID-19 attacked the world and rapidly turned into a pandemic. Already overburdened and depleted critical care workforce was further exacerbated by overwhelming work demands. Our research was aimed at understanding the influence of COVID-19 on the critical care APPs. METHOD(S): We utilized a cross-sectional REDCap survey to understand the self-perceived extent to which the burnout among critical APPs had changed. A single link to survey was emailed to 2775 SCCM physician assistant and nursing section members. There were 578 responses (response rate 20.8%). After excluding 60 non-APPs responses, our sample size was 518. Survey questions asked about the symptoms of emotional exhaustion, depersonalization, perception of reduced personal accomplishments and intention to leave. RESULT(S): We found an increase in burnout and related dimensions. Emotional exhaustion increased from 28.8%- 69.9%, depersonalization increased from 17.2%-37.6%%, and perception of reduced personal accomplishments increased from 18.1%-38% among our study population. We also asked about the intentions to leave critical care and a total of 513 participants engaged with this question. Twenty-two percent (n=114) of our sample expressed an intention to leave critical care. We also asked about the intention to leave the profession altogether and only 21.8% (n=113) participants responded. A total of 43.3% (n=49) respondents reported the intention to leave the profession altogether within the following 2-5 years. Of those who responded, 22.1% (n=25) intended to leave within 1 year and 25.7% (n=29) intended to leave between 5-10 years while 8.9% (n=10) stated that they intended to stay beyond 10 years. CONCLUSION(S): COVID-19 pandemic exacerbated the burnout and its dimensions among critical care APPs. It is crucial to attend to the trends in burnout and intention to leave and mitigation strategies must be employed to sustain the critical care workforce which is key to planning the future of critical care in the US and globally.
ABSTRACT
BACKGROUND: The rising prevalence of autism spectrum disorder (ASD) diagnoses has caused an increased number of community practitioners to care for this population. However, community practitioners report a lack of knowledge and confidence in treating these patients, resulting in unmet healthcare needs. The Extension of Community Healthcare Outcomes (ECHO) Autism model aims to address this through case-based and didactic learning to help guide community practitioners in providing comprehensive, best-practice care for ASD screening, diagnosis, and management of co-occurring conditions. Each ECHO session involves a case presentation followed by a list of recommendations generated by community participants and an interdisciplinary 'hub' team. While ECHO Autism has been shown to improve physicians' abilities to care for children with ASD in their practices, recommendations stemming from ECHO cases have yet to be characterized and may help guide future care. OBJECTIVE(S): To quantify and characterize the common categories within ECHO Autism Ontario case recommendations. DESIGN/METHODS: A content analysis of 422 recommendations from 61 ECHO cases was conducted to identify categories of recommendations and their frequencies. Three researchers independently coded recommendations from five ECHO cases, from which an original coding guide was developed. The researchers then independently coded the remaining cases and met regularly with the ECHO lead to modify and consolidate the codes and coding guide. From there, categories and sub-categories from the various codes were identified. Finally, the frequencies of each code and category were calculated. RESULT(S): Fifty-seven codes were included in the final coding guide and grouped into eight broad categories. Categories included: 1) diagnosis;2) concurrent mental and physical health conditions;3) referrals to allied health providers and other specialists;4) accessing community resources, such as parent and sibling support groups;5) providing education and guidance to physicians, patients, and families;6) management strategies such as nutrition, physical activity, and social skills;and 7) patient and family-centered care. A COVID-19 category was added, as many of the later recommendations were adapted to online service delivery. An analysis of the frequency of codes found that 1,384 total in-text codes were distributed amongst the various categories. The three highest frequencies of categories were providing general guidance and education (22%), accessing resources (16%), and referrals (15%). CONCLUSION(S): This is the first time recommendations from ECHO Autism have been characterized and quantified. Our results, particularly the most common category of providing general guidance and education about ASD, show there is still important work to be done with educating clinicians and families about aspects of ASD. Furthermore, findings from this study should inform Pediatrics residency programs about real-world knowledge gaps in ASD care, and may help create more tailored ASD training programs and educational materials.
ABSTRACT
Background. Vaccine attitudes of healthcare providers (HCPs) influence patient vaccine acceptance. We sought to characterize vaccine knowledge, attitudes, and practices (KAP) among HCPs in NYS. Methods. An electronic survey was developed to assess vaccine KAP among HCPs. The questionnaires were sent to members of various national medical organizations via local chapter administrators. Results. 864 surveys were returned from 672 (78%) physicians and 192 (22%) mid-level practitioners (MLPs). 624/724 (86%) of HCPs report always recommending routine vaccines to eligible patients, yet only 76% recommend influenza vaccine (IV) and 77% strongly recommend HPV vaccine at 11-12 yrs. MLPs had a higher mean agreement level that recommending vaccines (4.6 vs 4.2 p < 0.01) or promoting HPV vaccine (4.2 vs. 3.9 p < 0.05) is within their scope of practice. Physicians had a higher mean agreement level that: vaccine benefits outweigh risks (4.9 vs 4.6 p < 0.01), HPV vaccine prevents cancer (4.7 vs 4.5 p < 0.01), and COVID-19 vaccine is safe (4.8 vs 4.5 p < 0.01) and effective (4.8 vs 4.7 p < 0.01). 82% (680/825) of HCPs knew that vaccines should not be deferred for mild illness. 14/836 (2%) believed that HPV vaccine could increase sexual activity, while 273/705 (39%) knew that the most common HPV associated malignancy is oropharyngeal cancer. HCPs who correctly answered >= 5/7 questions (462/507 91%) were more likely to recommend all vaccines to eligible patients than HCPs with lower scores (22/40 50% p < 0.05). Routine IV recommendation was more likely among HCPs who: strongly disagree that influenza is not serious enough for vaccination (292/397 (74%) vs 137/249 (55%) p < 0.01), strongly agree that it prevents severe disease (267/352 (76%) vs 162/294 (55%) p < 0.01), and receive annual IV (423/629 (67%) vs 6/17 (35%)) p < 0.01). HPV vaccine recommendation at 11-12 years was more likely among HCPs who strongly agree that the vaccine prevents cancer (273/326 (84%) vs 48/86, 56% p < 0.01) and those who stated that vaccination does not increase risk of unprotected sex (316/392 (79%) vs 3/12 (25%) p < 0.01). Conclusion. Vaccine recommendation practices are influenced by HCP vaccine misperceptions and hesitancy. Interventions to reduce misperceptions and improve vaccine confidence are needed.
ABSTRACT
Background: The COVID-19 pandemic has impacted our community in many ways, with negative downstream effects on the mental health system. Greater limitations on community resources have resulted in increased emergency room visits for acute mental health treatment. The increase in patients, along with limited resources, has led to patients boarding for hours to days in emergency rooms and medical floors. Method(s): Given the need for acute psychiatric treatment in the ED and medical floor, a rapid psychiatric stabilization (RPS) team was created. This team consists of 2 complex case BH managers, ED BH case managers, advanced practice clinicians, and psychiatrists;they meet virtually each morning to deploy resources where needed. The goal is to start active psychiatric treatment at time of presentation. Result(s): Examples of cases treated by the RPS team: Example #1: J.R. is a 10 yr. old who presented to the ED for increasing aggressive behaviors. Initial recommendation was for inpatient psychiatric admission;however, no bed was able to be secured. A psychiatrist met with J.R. daily and started medication for his aggression. After 4 days in the ED, J.R was stable for discharge, with an aftercare plan arranged by the complex BH case manager. Additionally, the team collaborated with his pediatrician to obtain prior authorization for psychotropic medication until an outpatient psychiatric appointment was secured. Example #2: H.B. is a 28 yr. old who presented to the ED with SI, however, was medically admitted due to being COVID positive. She was treated psychiatrically on the medical floor. As a result, she was discharged prior to her 10-day quarantine was completed, due to her positive response to treatment, and with psychiatric follow up arranged by the complex BH case manager. Prior to establishing the RPS team, discharges from the medical floor would have been difficult due to the inability to set up aftercare. Discussion(s): The American Academy of Child and Adolescent Psychiatry and Children's Hospital Association have declared a national emergency in children's mental health (1). Data from Mental Health America showed that any mental illness has increased 5% nationally, with a 7.6% increase in Pennsylvania (2). Additionally, adults with serious thoughts of suicide have increased 6% nationally and 16% in Pennsylvania. At LVHN-Lehigh Valley, psychiatric emergency room presentations have increased 1,401 (20%) compared to last year and are projected at 8,398. Clearly, demand for psychiatric treatment has grown, creating strain on the limited recourses available. Conclusion(s): The increased need for psychiatric treatment, coupled with the reduction of community resources, will cause psychiatric providers to rethink and redesign care in the post-pandemic world. The deployment of a RPS team to actively treat patients in non-traditional psychiatric settings is just one attempt at dealing with the psychiatric crises. Copyright © 2022
ABSTRACT
Study Objectives: The diagnosis of septic arthritis cannot be ruled out without performing an arthrocentesis. Delay in diagnosis leads to potentially irreversible joint damage and patient mortality. It is essential for emergency physicians (EPs) and advanced practice providers (APPs) to perform this procedure. Ultrasound guidance during arthrocentesis has been shown to reduce procedural pain scores and improve first-pass success rates compared to a landmark-guided approach. However, many providers trained when ultrasound was not readily available and feel uncomfortable recognizing a joint effusion on ultrasound. The study objective was to assess the impact of a hands-on cadaver lab arthrocentesis training on emergency medicine provider confidence in performing knee and ankle ultrasound-guided arthrocentesis and subsequent utilization in clinical practice. Method(s): EPs and APPs from a large academic, quaternary-care hospital prospectively enrolled in a 2-hour cadaver lab ultrasound-guided arthrocentesis training intervention. Didactic video content was created and distributed prior to cadaver lab training. The cadaver knee and ankle joint capsules were pre-injected with saline to create realistic effusions. Participant confidence performing and interpreting US-guided arthrocentesis was assessed pre- and post-cadaver lab via electronic survey based on a 0-10 scale (0=not confident at all, 10=extremely confident). Ultrasound-guided knee and ankle arthrocentesis utilization in clinical practice was compared before and after the cadaver lab which was held on October 4, 2021. The pre- intervention comparison time frame was January 1, 2019-December 31, 2019 to avoid changes in ED visits and practice associated with the COVID-19 pandemic. The post-intervention comparison time frame was October 5, 2021 through April 4, 2022. Median confidence scores with interquartile ranges (IQR) and monthly rates of ultrasound-guided arthrocentesis were calculated and presented with 95% confidence intervals. Result(s): A total of 28 emergency providers participated in the ultrasound-guided arthrocentesis cadaver lab (17 EPs, 10 APPs, 1 unknown) and 28 (100%) completed both pre- and post-intervention surveys. Sixty-one percent (17/28) of participants had greater than 5 years of post-training clinical practice. The median (IQR) confidence rating was 7.5 (IQR 5.0-9.0) pre-intervention and 8.0 (IQR 6.0-9.8) post-intervention (p=.153) for performance of ultrasound-guided knee arthrocentesis and was 2.5 (IQR 1.0-4.3) pre-intervention and 7.0 (IQR 6.0-8.8) post-intervention (p<.001) for performance of ultrasound-guided ankle arthrocentesis. Ultrasound-guided knee arthrocentesis utilization increased from a monthly average of 2.3 (95% CI 1.5-3.3) pre-intervention to 6.3 (95% CI 4.5-8.6) post-intervention, rate ratio 2.74 (95% CI 1.64 - 4.63), p<.001. Ultrasound-guided ankle arthrocentesis utilization increased from a monthly average of 0.8 (95% CI 0.4-1.5) pre-intervention to 2.5 (95% CI 1.4-4.1) post-intervention, rate ratio 3.02 (95% CI 1.27 - 7.53), p=.009. Conclusion(s): Our data demonstrate that a cadaver-based educational intervention increased EP and APP confidence in performing ultrasound-guided ankle arthrocentesis and increased ultrasound-guided ankle and knee arthrocentesis utilization in clinical practice. Further studies are needed to determine if this resulted in a meaningful reduction in time to diagnosis and ED length of stay. No, authors do not have interests to disclose Copyright © 2022
ABSTRACT
Study Objectives: Access to timely emergency medical care is essential to the US health care system but can be particularly challenging for individuals in rural communities and those with physical impediments, strained economic resources, and increased susceptibility to nosocomial COVID-19 infection. Emergency care access is further impacted by emergency department (ED) crowding and limited resources. Telemedicine presents an innovative solution towards improving this access. We aim to evaluate the final disposition of patients utilizing the Veterans Health Administration Desert Pacific Veterans Integrated Service Network's (VISN 22) novel Tele-Emergency Care program (TEC) to describe the efficacy of this innovative option in increasing Veterans' access to care and conserving ED resource utilization. Method(s): Veterans who called the VA Clinical Contact Center (CCC) Monday through Friday, 7a to 7p PST, were triaged via a Triage Expert Dual Purpose protocol. If patients were triaged to a recommended follow-up interval (RFI) of needing medical care in either a 0-2-hour or a 2-8-hour time window, consenting patients were routed to the VISN 22 TEC program. TEC clinicians consisted of emergency physicians and experienced advanced practice providers. After evaluation, TEC clinicians recorded their final dispositions as: (1) Resolved (completing the care encounter virtually);(2) Referred to ED;(3) Referred to Urgent Care (UC);or (4) e911 Activated by Tele-ED Clinician (activating emergency medical transport). Care resolution included ordering of outpatient laboratory and/or imaging studies, outpatient prescription medications, or scheduled outpatient referral to Primary or Specialty Care for further evaluation. Veterans initially triaged to a virtual evaluation but who later declined seeing a clinician were labeled as "Patient Self-Cancelled". Result(s): From March 2021 through April 2022, 7140 patients were referred to the 0-2-hour RFI and 9928 to the 2-8-hour RFI. Among those triaged to a 0-2-hour RFI, 3706 (51.9%) had their care resolved, 2697 (37.8%) were referred to an ED, 468 (6.6%) were referred to UC, 217 (3.0%) were cancelled by the patient, and 52 (0.7%) required e911 activation. Among those triaged to a 2-8-hour RFI, 6716 (67.6%) had their care resolved, 1949 (19.6%) were referred to an ED, 832 (8.4%) were referred to UC, 412 (4.1%) were cancelled by the patient, and 19 (0.2%) required e911 activation. Conclusion(s): Prior to VISN 22 Tele-Emergency Care implementation, Veterans who called the CCC and were triaged to a 0-2-hour or a 2-8-hour RFI would be referred to the nearest ED or UC. TEC provided eligible Veterans with a virtual expert consultation option to address their acute care needs. After implementation, more than half of Veterans triaged to either a 0-2-hour or a 2-8-hour RFI had their care resolved virtually, potentially reducing low-value and low-acuity ED visits and preserving resources for higher acuity and critical patients. Further research is needed to assess which presenting complaints were most amenable to telehealth evaluation, the economic impact to the VA health care system, and the rate of short-term unanticipated ED or UC visits despite TEC case resolution. No, authors do not have interests to disclose Copyright © 2022
ABSTRACT
Objective: Telehealth in the ED seems counterintuitive. However, COVID-19 surges have led to crowding and increases in patients leaving without being seen (LWBS). This study evaluated the impact of a novel virtual telehealth initiative (virtual telehealth rounding or VTR) in the ED on the prevalence of LWBS dispositions during the pandemic and its effect on mortality and patient safety. Method(s): We conducted a cross sectional study on adult patients presenting to a level 1 trauma and tertiary referral center who were triaged to the waiting room. The trial of VTR took place for 107 days in December 2021-April 2022 and was operational for 65 days (8-hours a day). The remaining 42 days without VTR served as a comparison group. During VTR patients were triaged per usual care on arrival to the ED. Those patients with triage acuity categories II to V who were triaged to the waiting room were then evaluated virtually by a remote clinician (advanced practice providers such as physician assistants, advanced nurse practitioners, and third year emergency medicine residents) after their initial screening examination using a secure virtual health platform in a private cubicle in the ED waiting room. Patients were then reevaluated at 1-2 hour intervals if necessary. ED paramedics were available onsite to take vital signs, transport patients, and communicate directly with the onsite nurses and ED physicians. Patients were evaluated virtually via an iPad by the virtual clinician and provided an initial assessment. They expedited care by ordering labs, radiography, changing the patient's triage category and determining early disposition according to usual clinical practice. Patients were then either left to wait in the waiting room, taken for radiography and/or blood work, or taken back to a room in the ED where they were seen by an onsite ED physician. The main outcome was the LWBS rate, including LWBS before and after triage, patients leaving against medical advice and elopements. Secondary patient outcomes included in-hospital mortality and improved patient safety via "great saves" defined as care that was urgently/emergently escalated by the virtual rounding provider. Result(s): There were 19,958 patients in the analysis, 6,953 (35%) were evaluated via VTR and 13,006 (65%) received standard of care. Mean patient age was 50 years (SD20), 48 (95% CI 48-49) in the VTR group and 50 (95% CI 50-51) in the standard group. Females were 49%, with 3,489 (50%) females in the VTR group and 6,204 (48%) in the standard care group. Overall acuity levels at triage were II 24%, III 54%, IV 22%, and V 1%. Mean triage levels were 2.95 (95% CI 2.94-2.97) in the VTR group and 3.07 (95% CI 3.06 - 3.09) in the standard group. The proportion of LWBS was 565 (8%) in the VTR group and 3,246 (25%) in the standard care group (p<0.001). Overall, 27 (0.1%) of patients did not survive to hospital discharge, 7 (0.1%) in the VTR group and 20 (0.2%) in the standard care group (p=0.421). VTR clinician documented "great saves" in 5% of their patient encounters. Conclusion(s): This novel approach to triage in the ED significantly reduced the proportion of patients with LWBS dispositions by 17%. Although in-hospital mortality was lower in the VTR group it was not statistically significant. Furthermore, VTR clinicians documented rapid escalations in care that may have otherwise been delayed or missed. This approach has the potential to improve patient care and provide relief from crowding. No, authors do not have interests to disclose Copyright © 2022
ABSTRACT
Objectives: The ED serves as a frequent interface for patients approaching end-of-life (EoL), with up to 75% of patients experiencing an emergency department (ED) visit in the last 6 months of life. Hospice care in the last 6 months is associated with improved patient experience, care satisfaction, and pain control. Earlier hospice enrollment also improves resource utilization by reducing hospital length of stay and readmissions. During the COVID-19 pandemic, our ED experienced an increased number of EoL patients receiving care in hallway beds while awaiting hospital admission or transfer to hospice care. Lack of patient privacy and limited prior training on caring for EoL patients contributed to the moral distress experienced by nurses, physicians, patients and families. To address this, we implemented and evaluated a hospice ED observation pathway (HEDOP) for EoL patients transitioning to comfort-focused care in the ED setting. Design/Methods: A HEDOP was developed to guide treatment for EoL patients transitioning to comfort-focused care during the ED course. The pathway identified the appropriate patient population with inclusion/exclusion criteria (Table 1). A 'comfort measures' order set provided quick access to medication orders for common EoL symptoms such as dyspnea and pain, spiritual care and social work consultation. The ED observation unit is staffed by ED registered nurses and Advanced Practice Providers, with emergency physician support. To provide EoL education, we offered didactic lectures, bedside teaching from a palliative medicine fellow, and the opportunity to shadow providers at a local hospice facility. Results/Findings: Over a 1-year period (January 2021-22), 38 patients were cared for using the HEDOP. Mean age was 77 years (range 43-102 years). Mean ED length of stay (including observation status) was 20 hours (range 3-49 hours). Patient disposition from the HEDOP was as follows: 29% home with hospice, 47% inpatient hospice facility, and 21% died during the observation stay. In addition to clinical EoL care and symptom management, 47% of patients received spiritual care and 97% had a social worker involved in their care. Conclusion(s): To our knowledge, this is the first use of an ED observation protocol for hospice initiation in the US. Implementation of a HEDOP offered patients and families earlier access to hospice care from the ED. Providers reported being better equipped to provide care and tailored support for EoL patients. All but one patient avoided hospital admission;the majority were discharged to home or inpatient hospice. A HEDOP provides opportunity to help patients access hospice care from the ED, facilitates disposition from the ED to home or inpatient hospice, and receive quality EoL care while in the ED. Future studies should assess patient and family satisfaction with care received under an ED HEDOP. [Formula presented] No, authors do not have interests to disclose Copyright © 2022
ABSTRACT
The objective of this study is to examine the incidence of reported stress due to mistreatment by patients toward clinicians and the role of mistreatment from patients along with organizational factors in clinician distress. A survey of clinicians was conducted at a large academic medical center, resulting in a final analytic sample of 1,682 physicians, nurses, advanced practice providers and clinical support staff. Nurses reported the greatest incidence of mistreatment by patients as a major stressor (18.69%), followed by Advanced Practice Providers (11.26%), Clinical Support Staff (10.36%), and Physicians (7.69%). Logistic regression analysis was conducted to determine the relationship of individual- and organization-level characteristics with the odds of reporting mistreatment from patients as a major stressor. Overall findings indicate that nurses and those who work in the ER and ambulatory or outpatient clinics were more likely to be stressed from mistreatment by patients than other clinicians. Stress due to mistreatment by patients was also associated with higher Well-Being Index (WBI) distress scores, rapid changes in workflows or policies, ongoing care of COVID-19 patients, under-staffing, and low perceived organizational support. Gender or sexual minorities (not identifying as male or female) and younger (18-34 years of age) healthcare workers were also more likely to experience stress from mistreatment by patients. Individual resilience was not statistically significantly associated with reported stress from mistreatment by patients. Organizations must examine expectations for patient and visitor behavior in tandem with service standards for clinicians toward patients. © The Author(s), 2022.
ABSTRACT
Background and/or Objectives: To investigate the efficacy and patient satisfaction with telehealth (TH) visits administered by non-surgical physicians, surgical physicians, and mid-level providers in a multidisciplinary spine practice. Design(s): Cross Sectional Study Setting: Multidisciplinary spine practice at large academic medical center Participants: 407 patients with TH appointment between June 1, 2021 and December 2, 2021 Interventions: Patients received an electronic survey developed to characterize patients' TH experiences. Main Outcome Measure(s): Respondents were surveyed on TH appointment type, type of medical provider, purpose of TH appointment, reason for TH utilization, length of time for visit, technical components to the visit, patient demographics, respondents level of satisfaction and likelihood to recommend. Result(s): 407 patients responded to survey. First time TH utilization was 48.6%. Gender utilization was higher with those who identified as female (65.6%). The largest age group utilizing TH was ages 65-74 years old (41%). Majority of respondents, 86.2%, identified as White, 8.1% identified as Black or African American and 6.6% identified as Hispanic or Latino. Medical care via TH was evenly distributed amongst all providers: 33.9% of respondents meet with a surgeon, 35.4% with non-surgical physicians, and 30.7% with a mid-level provider. A majority of visits were follow-up appointments (46.4%) new patient appointment made up 26.3% of visits 21.9% of appointments were post injection follow ups and 5.4% were for post-surgery follow up. Reasons listed for TH utilization: long distance to travel (35.9%) ease and convenience of virtual visit (23.3%) 4.4% to maintain social distancing during the COVID -19 Pandemic. 96.8% of respondents were very satisfied or satisfied with their TH visit, with 93.6% recommending TH visit to others. Conclusion(s): The study demonstrates that TH is a satisfactory and convenient option to care for patients in a multidisciplinary spine practice.
ABSTRACT
Background: Highly effective modulator therapy and the COVID-19 pandemic have transformed cystic fibrosis (CF) care. Increased use of telehealth has resulted in fewer in-person visits, although close monitoring continues to be crucial in preventing complications. Home spirometry is a useful, accessible tool that people with CF can use to monitor their lung function. In spring 2020, the University of North Carolina (UNC) Adult CF Clinic began to distribute home spirometers to their patients through the Cystic Fibrosis Foundation (CFF). At the time, we lacked a standardized home spirometry program and found it challenging to engage patients in regular use of the device. As a result, the UNC adult CF advanced practice provider (APP) and respiratory therapist (RT) collaborated to lead a quality improvement (QI) project aimed at improving home spirometry at their center. Method(s): Goals of the QI effort were to provide individual education for all patients with a home spirometer, incorporate home spirometry assessments into the RT workflow, and provide monthly interpretation of home spirometry results. The CF RT used Epic MyChart messages to engage patients who needed education and to remind patients to use their device before all visits (virtual or face-to-face). The RT and APP also provided inperson teaching and troubleshooting in clinic, and an educational handout was created. Lastly, one-on-one educationwas provided over the phone on nonclinic days. Between November 2021 and January 2022, people with CF who had received a device and adult CF clinicians were surveyed for anonymous feedback on the program. Survey questions used a 5-point Likert scale to indicate agreement with the survey statement and were adapted from a previous home spirometry survey in lung transplant patients [1]. Result(s): Two hundred sixty-five patients (of 327 total adults with CF at UNC) have received a home spirometer through the CFF or another source;250 of these (94%) have received one-on-one education. All six adult CF clinicians completed the feedback survey. The results indicated a high level of satisfaction and a sense that spirometer use was clinically useful (Figure 1). Seventy-eight patients completed the feedback survey. Regarding the program's utility, respondents agreed or strongly agreed with the following statements: spirometer is easy to use (81%), received adequate training (88%), spirometer is accurate (78%), team is interested in my results (96%), makes me feel secure in detecting problems with my lungs (60%), helpful to share results on the provider dashboard (68%), and am overall satisfied with the home spirometry program (78%). When patients were asked about barriers to use of their home spirometer, 48 (62%) selected "none." The most commonly identified barriers (number of responses)were anxiety (5), too difficult to use (4), too time consuming (3), forgetfulness (3), and accuracy (2).(Figure Presented) Figure 1. Adult cystic fibrosis clinician survey results on home spirometry Conclusion(s):Wewere able to leverage thewidespread availability of home spirometers to create a successful home spirometry program within the UNC adult CF clinic. Our survey results indicate that clinicians and patients felt that home spirometry was useful and were highly satisfied with the program Copyright © 2022, European Cystic Fibrosis Society. All rights reserved
ABSTRACT
Introduction: The objective of this study is to determine the likelihood of diagnosis and accuracy of treatment of various conditions via use of telemedicine services within an academic, multisubspecialty otolaryngology practice located in a COVID-19 hot spot. At the conclusion of this presentation, the participants should be able to understand the role that virtual care can play in otolaryngology, both in terms of diagnosis and management. Method(s): This retrospective cohort study included all telemedicine patient encounters with an otolaryngologist or advanced practice provider between March 17 and August 30, 2020. Pediatric and adult patients who completed a synchronous virtual visit (VV) were included. Patient demographics, new vs return patients, known and unknown visit diagnoses, treatment given and/or surgery scheduled, and recommended in-person follow-up were extracted. If in-person follow-up occurred, the diagnosis, whether scope was performed, and if in-person follow-up changed the diagnosis were extracted. A t test and chi2 analysis were utilized. Result(s): A total of 758 patients completed a VV;388 were new and 370 return patients. New patients were significantly younger than return patients (44.3 vs 48.2 years, P=.014). New patients with a known diagnosis were treated more often than return patients (80.6% vs 67.2%, P=.008). There was no significant difference between new and return patients in treatment given, recommendation for in-person follow-up, rate of in-person follow-up, rate of patients scoped, and if recommendations were made for surgery. Treatment was recommended in 71.1% of encounters, and surgery was recommended in 10.8% of encounters. The endocrine subgroup had the highest rate at 60.6% (CI, 42.1, 77.1) of recommending surgery. Conclusion(s): Telemedicine is an effective tool when used for diagnosis, as well as to recommend treatment and surgery when in-person visits are difficult or not possible.
ABSTRACT
Purpose: Although, much has been written about COVID risk and immunization efficacy in transplant recipients, there is little data on the impact of COVID on transplant professionalism. Method(s): A survey about the impact of COVID on professional development was sent to transplant providers. There were 138 responses (10% response rate) with equal representation from transplant nephrologists, pulmonologists, surgeons, cardiologists and advanced practice providers. Responses were evenly divided between gender and across regions of the US. Result(s): 75% of respondents reported that COVID has had a negative impact on their own education with the primary reasons given being 'virtual fatigue' and not taking time off to attend virtual meetings leading to lack of engagement. 40% of respondents reported that staffing shortages made it difficult to attend virtual meetings. When asked about any positive impact of COVID on their education 43% said the ability to view sessions on their own time without travel requirements was positive. The impact of COVID on fellows' education was seen with reduced disease specific education due to focus on COVID and reduced fellow time on the wards (55% & 48% respectively).74% of respondents reported a negative impact on their professional relationships within their own center. The primary reasons were physical and emotional fatigue (43%) and staffing shortages (37%). The inability to socialize outside the work setting also had a significant impact. Fortunately, few had family or colleagues ill with COVID, but 3 reported death of co-workers or family members. Though most reported no positive impact on their work relationships (62%), "bunker mentality" and increased patience with colleagues were reported by 35%. 64% of respondents reported fatigue and lack of opportunity to see colleagues outside their own institution as a negative impact on those relationships. 76% described no positive impact on those relationships. 60% of respondents related a negative impact on their own research as there was no time to focus on research and/or most non-COVID research stopped, leading to lack of connection with research colleagues. 81% of respondents reported 'burnout' and 18% reported Post Traumatic Stress Syndrome (PTSD). When asked what the most significant impact of COVD on professionalism the overwhelming responses were emotional and physical fatigue and isolation from colleagues. The emotional stress of family and colleagues ill and sometimes dying from COVID takes a toll. Conclusion(s): In summary, in addition to the stress and physical toll the pandemic created for health care providers, transplant professionals reported a loss of ability to advance the field of transplantation due to the inability to attend professional meetings, participate in transplant-related research, and network with colleagues on topics other than COVID related care.