Improving Clinical Decisions Via Remote Blood Sampling

3 An important component for the provision of patient-centric healthcare is the ability to collect blood samples remotely in a manner that delivers samples of a quality comparable to that of current standard phlebotomy collection, enabling routine clinical testing, monitoring disease progression and testing drug concentrations.2-4-г, This blood sampling could be performed at the patient's home, at a nearby pharmacy, or at a local clinic, rather than a centralized facility. Examples of commercially available devices include the Neoteryx Mitra,13 Tasso-M20, SST and Tasso+,14 SeventhSense TAP and TAP II,15 Trajan hemaPEN,16 Labcorp Pixel,17 Capitainer qDBS,1" HemaXis DB10 and DX,19 and Drawbridge OneDraw.20 These devices are capable of collecting from as little as 20 microliters (approximately half a drop) to several hundred microliters of blood and have been widely used to determine clinical parameters,21 drug concentrations,5'22 therapeutic drug monitoring,23 and, more recently, COVID antibody levels.24,25 Some of these devices enable the collection of a fixed volume of blood, collected as dried blood, which can then be shipped and handled at room temperatures-avoiding the need for freezers and dry ice for storing and shipping samples-enabling its adoption even in remote areas with limited infrastructure. Patient-centric blood sampling techniques have been gaining popularity for use in pharmaceutical drug development;however, to date they have not been broadly accessible to the general public.26 This can be partially attributed to the "cliniccentric" healthcare model, where reimbursement is dependent on in-person visits and sample collection. [...]the status quo remains and anyone who needs a blood test is required to go to the doctor's office or clinic. [...]studies have demonstrated that the overall cost to society will be lower, by improving health outcomes and allowing broader access and patient convenience.27 The availability and adoption of patient-centric approaches can provide access and treatment options to clinical trial participants not geographically co-located with the investigative sites and improving access in rural or lesser developed communities, globally, potentially improving the health of the general population.

Decentralized Clinical Trials: A Flexible and Efficient Adjunct to Accelerate Pregnancy Complication Research

INTRODUCTION: This study sought to determine whether a decentralized, mobile-friendly, virtual model could achieve appropriate enrollment for a pregnancy health study after COVID-19 closed most clinical research. Preterm birth continues to be a significant and growing issue with 2021 rates exceeding 10%. There is urgent need for new research and technology to improve the ability to predict, prevent, and personalize treatment for complications such as preterm birth, preeclampsia, and gestational diabetes. METHODS: This was a prospective, observational study of a cell-free RNA platform utilizing direct-to-participant recruitment via targeted social media from July 2020 to December 2021. The IRB-approved study was open to patients aged 18–45 with a singleton pregnancy in the United States. Participants signed informed consent, provided record release forms, completed a short questionnaire, and scheduled mobile phlebotomy via a web-based platform. RESULTS: One thousand eight hundred ninety-four participants submitted samples in less than 18 months. Because of delays in shipping, insufficient volume, temperature stability, and hemolysis, 63 samples (3.3%) were not useable. Medical records were received for over 85% of participants. The cohort is geographically and ethnically diverse representing 1,220 zip codes across 30 states. CONCLUSION: This work demonstrates a decentralized, mobile-friendly, virtual study is feasible, efficient, scalable, and flexible, enabling clinical research during a global pandemic. The rate of medical records receipt is likely affected by the large quantity of unique providers and hospitals. This is a rapid, patient-accepted way to conduct clinical research as a supplement to traditional enrollment models. [ FROM AUTHOR] Copyright of Obstetrics & Gynecology is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

An Audit Showing the Successful Operation of a Nurse-Led Gout Clinic during the Covid-19 Pandemic

Background/Aims Research has shown nurse-led gout clinics provide better outcomes compared to usual care. This District General Hospital set up a pilot nurse-led gout clinic in autumn 2019. This aimed to improve patients' understanding of their condition, achieve better control of serum uric acid levels (SUA), reduce flares and prevent Emergency Department attendances. Methods A modified clinic protocol, closely modelled on BSR guidance was agreed within the department. With consultant supervision, one nurse specialist provided a mix of in-person and telephone appointments. Targets were set aiming for SUA <360mumol/L for most patients and <300mumol/L for those with erosive change or tophi. All patients were offered prophylaxis. Patients required a rheumatologist's diagnosis of gout or crystal confirmation for enrolment. Exclusion criteria were significant renal or hepatic derangement. Within 3 months of the service starting SARS-CoV-2 impacted the operation of healthcare worldwide and led to the closure of routine outpatient clinics in Northern Ireland. A decision was made to switch the gout clinic to run entirely by telephone. Blood testing was facilitated through primary care and phlebotomy hubs. Results Over a 19-month period, 78 patients were treated and audited through this clinic: 69 men and 9 women. Average age was 57, mean SUA 509 mumol/L at referral and 322 mumol/L on discharge. 69 patients received allopurinol and 9 received febuxostat. No patients required uricosuric drugs. All patients were offered and agreed to take prophylaxis with a majority (85.8%) remaining on it for 3-6 months. Patients required a mean of 3.38 appointments prior to discharge from the clinic. The mean dose of urate lowering therapy on discharge was 315.9mg allopurinol and 93.3mg febuxostat. 95% experienced >=2 flares during their enrolment in the clinic with no patients requiring Emergency Department attendance due to gout flare. Conclusion The nurse-led gout clinic was well received by patients and was effective as a telephone service during the pandemic when so many services were stood down. The clinic was able to continue to provide education, deliver effective reductions in uric acid as well as reduce incidence of flares and Emergency Department attendances. Lower doses of urate lowering therapy than expected were needed to achieve target. A small number of patients were discharged prior to enrolment for initial non-engagement which may have been exacerbated by the lack of face-to-face appointments. Our COVID-19 model did struggle with those patients needing an interpreter. In-person initial appointments have since been restarted;however, a greater proportion of reviews will continue to be offered by telephone given the unexpected success of the model. This audit showed that a nurse-led gout clinic can run successfully, even during a pandemic with a significant reliance on telephone consultations.

Factors affecting blood culture contamination rates and effective reduction measures

Blood culture collection is a crucial procedure used universally in hospital settings to identify bloodstream infections. A false positive culture arises when contamination occurs during culture collection or when handling the culture in the laboratory. These contaminated cultures cause inaccurate diagnoses resulting in longer hospital stays, increased cost, and unnecessary antimicrobial treatments. It is therefore vital to limit the rate of blood culture contamination. Here we discuss various factors that play roles in blood culture contamination rates. The roles of phlebotomy teams, the coronavirus disease 2019 pandemic, blood draw location, and hospital department on blood culture contamination rates will be discussed. Potential methods that can be deployed to decrease blood culture contamination rates will be compared. Copyright (C) 2022 Wolters Kluwer Health, Inc. All rights reserved.

Applying principles of patient blood management during COVID-19 pandemic: a literature review

As of 15 December 2021, coronavirus disease 2019 (COVID-19) affected approximately 271 million and killed 5.3 million people globally. COVID-19 pandemic had a tremendous impact on world healthcare systems and blood supply. While principles of patient blood management (PBM) may have been previously implemented in many jurisdictions, their widespread adoption has become imperative during the pandemic. This review will discuss the impact of the COVID-19 pandemic on the Canadian blood supply and how the principles of PBM could be applied during a pandemic or other disruptions to healthcare delivery or blood supply. We described the local blood system and how it adapted during the pandemic. We also included a discussion of pandemic-associated local PBM challenges and solutions. We conducted a brief review of English language literature with a specific focus on the application of PBM to reduce unnecessary red blood cell (RBC) transfusions in elective major surgery, hematological malignancies, elective major gynecological surgery and obstetrics between January 2020 and April 2022. The common themes included anemia diagnosis and management, restrictive RBC transfusion strategies and reduction in blood loss. Anemia is common, is frequently caused by iron deficiency and can be treated with oral or intravenous iron. Erythropoiesis stimulating agents are effective in raising hemoglobin and may be indicated in certain perioperative settings. Evidence supports the use of restrictive RBC transfusion thresholds and single unit transfusions in most patient populations. Hemostatic therapy, such as tranexamic acid, is generally safe and effective in reducing bleeding. Diagnostic phlebotomy contributes to anemia and should be restricted to tests that are necessary and likely to change management. In conclusion, PBM interventions are generally effective and safe. Prioritization of PBM during the pandemic or a blood shortage may help sustain the blood supply and lead to improved patient outcomes.Copyright © Annals of Blood. All rights reserved.

REDESIGNING THE AMBULATORY ONCOLOGY SUPPORT TEAM

Oncology Nursing Practice The current supportive care team shortages have led to immeasurable negative impacts on the healthcare workforce, compounded by the existing workforce instability generated by the COVID-19 pandemic. To address increasing volume and complexity of patients coming to the ambulatory setting for oncology care amidst the current workforce challenges, it became imperative to re-design the roles and workflows for the ambulatory oncology support team. The Cancer Service Line (CSL) operations leadership team worked with Hospital, Ambulatory, and Laboratory leadership addressing workforce challenges to improve patient flow and satisfaction. The goals of this project were to improve integration, clinical oversight, and care coordination through a phased two-part initiative: 1) Transition Phlebotomists" working in the Cancer Center to align under CSL leadership, and 2) Increase resources and efficiency within Clinic and Lab by cross-training CSL Clinic CSAs and Lab Phlebotomy staff, creating a "one-stop shop" concept, where patients have pre-visit labs and vital signs captured in one location by one staff member. This project aims to improve both patient and provider experience through reduced delays, improved patient flow, and enhanced efficiency. CSL clinical support team expanded to include more role diversity to address the growing numbers of oncology patients amidst the current workforce shortages. Nurse Leaders assembled teams of Registered Nurses, Certified Medical Assistants, Certified Nursing Assistants, Phlebotomists, Licensed Practical Nurses, and Clinical Coordinators. All members of the clinical support team underwent extensive training to cross functional skillsets within the appropriate scope of practice. The cross-functional team received comprehensive didactic training, hands-on training, and competency validation. A new Cancer Center Intake workflow was created to improve patient flow and clinic efficiency. Patients now have their vital signs, intake questionnaires, and phlebotomy services in one location by one staff member, creating a "one-stop shop" for our patient's pre-visit intake needs. The care team redesign and new Intake workflow are being evaluated through the following metrics: patient satisfaction, improved patient flow, provider satisfaction with intake efficiency, increased "economies of scale" through better staffing coverage models, and staff satisfaction and retention through advancement and utilization of new skills. Early results indicate that the care team re-design and Intake workflow has consolidated pre-visit patient stops, streamlined patient flow, and increased efficiency. This low cost, high reward initiative may offer value in supporting oncology care team members through current and future workforce challenges.

AMBULATORY ONCOLOGY NURSE BILLING AND CHARGE CAPTURE: OPPORTUNITIES DEVELOPED DURING POST-COVID RECOVERY

Oncology Nursing Practice COVID-19 recovery presented nursing leadership with opportunities to document productivity measures for oncology nursing services rendered and potentially impact revenue. A nurse billing and charge capture committee composed of network nursing and revenue department team members was convened to establish billable and productivity related nursing tasks. The purpose was to identify ambulatory oncology nursing practice that would generate billable revenue, identify non-billable tasks that could generate statistical codes to measure productivity, and create an educational plan to implement changes in nursing practice to support billing. Committee leads identified key stakeholders from each of the health system network sites to participate. The committee assessed and categorized nursing practice into actions such as central line maintenance and phlebotomy to support nursing revenue (billable) versus distinct productivity measures that were documented by nursing time (non-billable). Both groups included the nursing professional development specialists who engaged nursing informatics and the IT department. Their collaboration led to standardized nursing documentation using EPIC smart phrases, charge capture codes, and stat codes for productivity. The revenue integrity team ensured charges and statistical codes were compliant with regulatory standards. EPIC analysts optimized nursing documentation by creating smart phrases to support billing and track nursing time. Departmental reports used the smart phrases to identify patients to support nursing documentation compliance. For non-billable items, the smart phrases and documented time interval were used to capture productivity. The reports were monitored for nursing documentation and charge capture compliance. In the first two fiscal quarters, 1,421 nurse billing items were documented as well as 1,648 non-billable items that totaled over 440 hours of nursing time. Results were discussed at leadership and staff meetings. The revenue group identified and prioritized a list of oncology nursing functions that were associated with chargeable specific Current Procedure Terminology (CPT) codes. Initially, two nursing tasks, central line maintenance and therapeutic phlebotomy, were implemented. Other chargeable tasks that followed included in person chemotherapy and pre-operative/post-operative teaching visits, port assessment, chemotherapy pump and peripheral line assessment follow up, dressing changes and skin assessment. The productivity group defined and prioritized a list of productivity measures which included telephone encounters, authorization and registration, form completion (FMLA, disability, prior authorization, and oral medications), chemotherapy and preoperative/postoperative teaching which occurred in tandem with provider visits or by video or telephone.

SARS-CoV-2 Antibody Response Following COVID-19 Infection or Vaccination in Children and Young People with Multiple Sclerosis on Disease Modifying Treatment

Background: Currently there are no published data regarding SARS-CoV-2 vaccine efficacy in paediatric-onset multiple sclerosis (MS) on disease-modifying treatments (DMTs). In adults, DMTs such as SIP-inhibitors (e.g., Fingolimod) and anti-CD20 therapies (e.g., Ocrelizumab) have been found to diminish SARS-CoV-2 vaccine efficacy. Objective(s): To ascertain whether young people with MS on DMTs generate a protective B-and/or T-cell response following SARS-CoV-2 vaccination or wild type (WT) infection. Method(s): Five millilitre additional blood was taken from MS patients during routine surveillance phlebotomy. Vaccination status and exposure to WT COVID was recorded. Serum samples measured SARS-CoV-2 antibodies using MSD quantitative assay. Multiplex T-cell stimulation assay was used to measure T-cell activity and T-cell response to SARS-CoV-2 Spike peptide was analysed. Result(s): Thirty-one MS patients (M:F 5:26;11-18 years) were included. DMTs included Ocrelizumab (n = 26);Fingolimod (n = 2);other DMT (n = 3). Vaccination status was confirmed in 12 children. 26/31 patients demonstrated protective B-cell responses, of which 10 were vaccinated +/- previous infection;six previously infected with unconfirmed vaccine status;and 10 had no infection/vaccine data available. Of the five patients with no B-cell response two were vaccinated. Six patients had impaired T-cell proliferation but 5/6 generated a B-cell response. T-cell proliferation upon exposure to Spike peptide was seen in 10 children'3/10 were vaccinated and 9/10 were being treated with Ocrelizumab. Patients on Fingolimod had impaired T-cell activity and no response to SARS-CoV-2 peptides, despite one being vaccinated and having a B-cell response. Conclusion(s): Fingolimod appeared to impair T-cell responses, however, only two patients were on this treatment. Those on Ocrelizumab have some protection following vaccination or WT exposure with 5/26 patients showing an impaired B-cell response but partial preservation of T-cell responses. While vaccination prior to starting DMT is ideal, some protection will be generated whilst on treatment.

Polycythemia in a Pediatric Patient with Chronic Kidney Disease: Overuse of Erythropoetin During COVID-19 Isolation

We describe a case of a patient with Chronic Kidney Disease who developed polycythemia due to Erythropoiesis Stimulating Agents overuse during COVID-19 isolation. A 12-year-old male had not been able to attend routine controls since had been in isolation for 4 months after the COVID-19 outbreak. He had continued to take Erythropoiesis-Stimulating Agents during that period at the starting dose of 150 U/kg/week. He had been on peritoneal dialysis in the last year because of end-stage renal failure. Laboratory investigation revealed a hemoglobin (Hb) level of 20.8 g/dl, hematocrit level of 66%, creatinine level of 6.5 mgr/dl. He underwent daily phlebotomy sessions (10cc/kg/session). During this period aspirin was also started (5mg/kg). After 5 sessions his Hb level decreased to 14 gr/dl and hematocrit to 40%. Pediatric nephrologist should be aware that there is a potential risk of polycythemia with Erythropoiesis Stimulating Agents when Hb level is not appropriately followed on a routine basis. Copyright © 2021 Ankara Pediatric Hematology Oncology Training and Research Hospital. All rights reserved.

Effect of automated feedback laboratory comments promoting good phlebotomy practice on the frequency of ethylenediaminetetraacetic acid (EDTA) contamination of serum samples.

BACKGROUND: Ethylenediaminetetraacetic acid (EDTA) contamination of serum samples is common but under-recognized unless EDTA is measured. Incorrect order of draw with closed phlebotomy (vacutainer) does not cause EDTA contamination. EDTA contamination occurs largely or solely during open phlebotomy due to syringe tip or needle-tip contamination when delivering blood into EDTA sample tubes before other sample tubes or direct transfer of blood from EDTA containing tubes to other tubes. Therefore, preference for closed phlebotomy or following the order of tube fill when open phlebotomy is used may reduce EDTA contamination. METHODS: The laboratory's comments for EDTA-contaminated serum samples were amended to encourage closed phlebotomy and with open phlebotomy filling of serum tubes before EDTA and fluoride-EDTA tubes. The weekly frequency of EDTA sample contamination, normalized for weekly urea and electrolyte (U&E) requests, was studied 52 weeks before and 43 weeks after amending the comments. RESULTS: Median (IQR) frequency of EDTA-contaminated samples per week per 10,000 U&Es decreased by 58% [5.6 (3.1-9.2) versus 2.3 (1.1-4.4); P < 0.001] after the introduction of the new comment. CONCLUSION: Explicit automated laboratory feedback comments promoting closed phlebotomy and order of tube fill with open phlebotomy were associated with a 58% reduction in EDTA-contaminated samples and thus may play a role in improving phlebotomy practise.

A Potassium-Based Quality-of-Service Metric Reduces Phlebotomy Errors, Resulting in Improved Patient Safety and Decreased Cost.

OBJECTIVES: Poor phlebotomy technique can introduce pseudohyperkalemia without hemolysis, requiring additional workup and placing a significant burden on patients, clinical teams, and laboratories. Such preanalytical biases can be detected through systematic evaluation of potassium concentrations on a per-phlebotomist basis. We report our long-term experience with a potassium-based quality-of-service phlebotomy metric and its effects on resource utilization. METHODS: Potassium monitoring and retraining of 26 full-time phlebotomists were piloted as a quality-of-service intervention. Changes in potassium concentrations and impact on resource utilization were assessed. An algorithm for data monitoring and phlebotomist feedback was developed, followed by institution-wide implementation. RESULTS: Systematic intervention and retraining normalized K+ concentrations and lowered the percentage of venipunctures with K+ above 5.2 mmol/L, leading to a marked increase in phlebotomist compliance. This change resulted in resources savings of 13% to 100% for individual phlebotomists, reducing the total extra laboratory time required for repeat phlebotomies to determine hyperkalemia, mostly in the high-volume phlebotomist group. CONCLUSIONS: A quality-of-service algorithm that involved monitoring potassium concentrations on a per-phlebotomist basis with feedback and retraining contributed to a concrete, data-based quality improvement plan. The institution-wide implementation of this metric allowed for significant cost savings and a reduction in critical value alerts, directly affecting the quality of patient care.

A Novel Dry-Stabilized Whole Blood Microsampling and Protein Extraction Method for Testing of SARS-CoV-2 Antibody Titers.

The COVID-19 pandemic has revealed a crucial need for rapid, straightforward collection and testing of biological samples. Serological antibody assays can analyze patient blood samples to confirm immune response following mRNA vaccine administration or to verify past exposure to the SARS-CoV-2 virus. While blood tests provide vital information for clinical analysis and epidemiology, sample collection is not trivial; this process requires a visit to the doctor's office, a professionally trained phlebotomist to draw several milliliters of blood, processing to yield plasma or serum, and necessitates appropriate cold chain storage to preserve the specimen. A novel whole blood collection kit (truCOLLECT) allows for a lancet-based, decentralized capillary blood collection of metered low volumes and eliminates the need for refrigerated transport and storage through the process of active desiccation. Anti-SARS-CoV-2 spike (total and neutralizing) and nucleocapsid protein antibody titers in plasma samples obtained via venipuncture were compared to antibodies extracted from desiccated whole blood using Adaptive Focused Acoustics (AFA). Paired plasma versus desiccated blood extracts yields Pearson correlation coefficients of 0.98; 95% CI [0.96, 0.99] for anti-SARS-CoV-2 spike protein antibodies, 0.97; 95% CI [0.95, 0.99] for neutralizing antibodies, and 0.97; 95% CI [0.94, 0.99] for anti-SARS-CoV-2 nucleocapsid protein antibodies. These data suggest that serology testing using desiccated and stabilized whole blood samples can be a convenient and cost-effective alternative to phlebotomy.

Antecedents of Patient Satisfaction in Private Clinical Laboratories toward Patient Loyalty with Switching Cost and Location as Moderating Factors (An Empirical Study from Indonesia)

BACKGROUND: Clinical laboratory (CL) services are at the forefront to support health-care services, particularly during the pandemic of COVID-19. The increasing number of private clinical laboratories at present days indicates the increase in patient needs, causing the health-care service provider to face challenges as people have more options. Therefore, fostering patient loyalty (PL) is a crucial success factor for the business growth of clinical laboratories as health-care providers. AIM: The purpose of this study is to analyze antecedents of patient satisfaction (PS) in clinical laboratories towards PL with the switching cost and location as moderating factors. METHODS: This study was done as a quantitative survey, and data were obtained by a cross-sectional approach with partial least squares structural equation modeling for the data analysis method. There are 266 respondents eligible as samples, who undergo the phlebotomy process (PP) in a private laboratory located within a specific area. RESULTS: This study demonstrated that all the nine hypotheses supported with α: 0.05 and p < 0.05, include six independent variables named administrative process, information availability (IA), the environment in the phlebotomy room, PP, waiting time, and result notification that influence PS. PS has been shown to have a direct effect on PL and also mediate the antecedents. Furthermore, SC and LO have demonstrated a significant effect to moderate this relationship. CONCLUSIONS: PS has been confirmed as the main construct to predict PL whereas the AP is the most important independent variable followed by IA. CL management should pay more attention to these antecedents to ensure PS and retain the clinic’s patients. The cost from the patient’s perspective should be taken into account since this helps the CL keep the patient loyal.

Improving Experiences for Children with Complex Medical Needs in Hospital

Aims Attendance to hospital for children and young people with complex medical needs and autism can be frightening and stressful, due the unfamiliar setting and unknown people, communication difficulties and sensory overload. Currently at our Trust, there are no specific resources for this patient group, and we have received informal and formal feedback that the needs of these young people and their families are not being met. We aim to improve the experiences of children and young people with complex medical needs and autism at our Trust by creating a new patient pathway, involving children and families early to drive change. Methods We designed a focus group for parents of children with complex medical needs and autism. We identified families from the neurology clinic, and wrote to them to explain the project and our aims and to invite them to take part in the focus group. We followed this up with a phone call to discuss the project further and to answer their questions. The focus group took place in September 2021. Results Five parents and one grandparent attended the focus group. Between them, they had experience of emergency hospital attendances, inpatient admissions, outpatient appointments, paediatric intensive care, multiple investigations and care across multiple sites in the UK and abroad. Their children attended both mainstream and special schools. There was a wide range of complexity of need, and input from health, school, therapies and social care. The range of experience made for a highly insightful and interesting discussion. Positive feedback was received for the neurology consultant, epilepsy clinical nurse specialist, play specialists and hospital school team, with a particular focus on parents knowing who to contact when they needed advice and support. Key areas for change identified included more privacy for adolescents, a leaflet detailing what to expect during an admission, sensory toys, a patient passport and iPads for the emergency department. Families also commented that specific changes could be made to improve their children's experiences of outpatient clinics, including minimising the wait to be seen, considering whether the child needs to be brought to a face-to-face appointment, the presence of a sensory room and improvements to the phlebotomy room, including the presence of play specialists. They also identified opportunities to join up care between secondary and tertiary services, for example arranging for pre-admission COVID-19 swabs at the local hospital, rather than at the tertiary hospital where the admission was planned. The next phase will be to apply for funding to achieve these aims. We are devising a Makaton passport and a system to help children to communicate using symbols. We will involve the children, young people and families at every stage of our project. Conclusion Patients and families have a much greater insight into the challenges faced than professionals, and their input is the most valuable tool to drive change. Relationships between patients and professionals have a huge impact on experience of care. We will continue to work with families in order to bring about meaningful and impactful change.

Impact of the Covid-19 Pandemic on Longitudinal Molecular Surveillance in the KOAR Registry

Purpose: The SARS-CoV2 pandemic increased the complexity of delivering routine clinical care and laboratory services for immunosuppressed kidney transplant (KTx) recipients. We evaluated how the pandemic impacted adherence with scheduled laboratory draws among patients enrolled in the Kidney allograft Outcomes AlloSure Registry (KOAR, NCT03326076). Method(s): 1663 kidney transplant (KTx) recipients undergoing post-transplant surveillance using donor-derived cell-free DNA (dd-cfDNA, AlloSure, CareDx Inc.) were enrolled in KOAR between 2017 and 2021. Participating centers were free to individualize their surveillance strategies. We estimated adherence by using the pre-pandemic distribution of surveillance dd-cfDNA draws across participating sites to establish a baseline regimen, and then compared adherence before the pandemic (P1;through 1/2020) with two subsequent periods in 2020: P2 (2/2020 - 6/2020), coinciding with the first wave of infections, and P3 (7/2020 - 12/2020), which captures the bulk of the second and third waves in the US. Result(s): The distribution of surveillance dd-cfDNA draws at participating sites before COVID (P1) identified 7 peaks corresponding to draw points at or around months 1, 2, 3, 4, 6, 9, and 12 [Figure 1a]. Estimated adherence during P1 based on this regimen was 60.5%. Over the subsequent 5 months (P2), reflecting the early months of the pandemic, adherence declined to 50.5% (p < 0.01). After the expanded availability of mobile phlebotomy services in 7/2020 and despite rising SARS-CoV2 case counts and hospitalizations, adherence during P3 improved to 57.6% (p < 0.01 compared to P2, p = 0.1 compared to P1) [Figure 1b]. Conclusion(s): Our findings demonstrate that adherence to laboratory surveillance among transplant recipients enrolled in the KOAR registry declined in the early period of the SARS-CoV2 pandemic, however, a variety of adaptations in the latter half of 2020, including the widespread availability of remote phlebotomy for these patients, appears to have led to substantial improvements, with adherence approaching pre-pandemic levels.

Lister hospital children day services quality improvement project

Aims• Initially to review the use of the Children’s Day Services at the Lister Hospital1. Reviewing the first of a three-part quality improvement project to review and improve the booking system for Children’s Day Services• To compare the expected demands of the day services unit with daily realities in services provided.• To assess how this interplays with staffing levels and safe, appropriate usage.• Eventually, to provide an overview of what services are required for the local population and to assess what changes might be required to deliver this safely.• Finally, to review changes implemented to improve day services especially the use of the booking system.Methods• Quantitative data:1. 90 days of appointment data was reviewed retrospectively between April-June 2021. A total of 842 appointments were reviewed. This was categorised into type of day service appointment e.g. blood test, jaundice clinic, allergy etc.2. Using the data from a patient and staff survey and previous phlebotomy audit, completed by the Children’s day services team.• Qualitative data: 2 weeks’ worth of qualitative data was collected. This included a written account of all informal or verbal requests including additional ‘walk-in’ patients. The qualitative data also included written accounts of staff that reflected on patient safety.ResultsOver the data collection period, blood tests accounted for 41.6% of workload, despite only 12.5% of appointments being for phlebotomy. This was reached largely through the use of designated ‘ward attender’ slots for blood tests. 20.2% of day service appointments were used to provide a prolonged jaundice clinic, which is a foundation doctor led clinic. An average of 9.3% of day services consisted of allergy clinic, while registrar reviews were 9.3% of encounters.Quantitative results overall showed a disproportionate and inappropriate number of appointments booked as blood tests, and more jaundice clinic slots than required.The qualitative data displayed a broad range of scenarios varying in complexity. Some showed foundation doctors being required to oversee difficult procedures alongside running clinic. Other scenarios included poor referrals with missing or inadequate information with demands on day services that were inappropriate and potentially unsafe.ConclusionThe day service has changed over the COVID pandemic and, with that, the demands on its staff have also changed. One key finding is that there is a high phlebotomy service demand which is currently disproportionate to expectations. The demand on prolonged jaundice clinic is lower than expected, and there is huge variety between the complexity of tasks that are indistinguishable in the current booking system. There may be opportunities to outsource phlebotomy to better use resources, while staffing should better match real demands. Patient booking must find a balance between flexibility and rigidity to ensure an efficient and safe system. Lastly, the day services unit is a bridge between the hospital service and community paediatrics and could be utilised better with the knowledge this review has shown. The next stage will be to review the changes made to the service to complete the cycle of the quality improvement project.

DRIVE-THROUGH PHLEBOTOMY-DOES IT WORK for CDMARDS MONITORING?

Background: Centralised phlebotomy services have been an integral part of providing blood monitoring facility for people with chronic diseases prescribed vital therapies. However the patient experience is not always optimal due to the issues of congestion, parking, long waiting times and have been accentuated during COVID-19 pandemic with the need for minimising physical contact. Expert panels have advocated for the creation of innovative approaches to provide safe patient care while maintaining precautions against COVID-19 spread. Several groups have published the concept and experience of using a drive-through clinic for anticoagulation monitoring and management. There is limited data on how this model of care can impact other clinical services such as rheumatology where patient groups are more vulnerable. Objectives: In response to the growing pressure on phlebotomy service at our institution enhanced by COVID-19 pandemic, our rheumatology service implemented a drive-through phlebotomy clinic to provide the option for patients and families to stay in their vehicles whilst having venepuncture. The objectives were to evaluate the feasibility and patient experience of the service. Methods: At our large university teaching hospital, we set up a drive-through phlebotomy service provided by a senior health care assistant supervised by the lead nurse. It was located near the hospital entrance where vehicles could park for a few minutes without disrupting traffic fow. Patients were identifed from the departmental database and were offered the facility via telephone. Eligibility was assessed using a standardised proforma focusing on logistics such as ability to drive and access to a mobile phone. Appointments were scheduled in advance with patients choosing this care option. On the day, patients were screened for COVID-19-related symptoms before their appointment and were encouraged to stay in their vehicles wearing a mask before being approached by the HCA. At the end of clinic, all samples were submitted to the central laboratory. All the data was prospectively collated with patients' consent and anonymised for analysis. In addition to demographics, diagnosis and drug record, duration of visit and patient feedback was collected. Results: 112 patients were offered the service during a 12-week pilot. Mean age of the participants was 49.5 yrs (19-91) with 73 (65%) women. 74 (65%) were of Caucasian and 28 (25%) of Asian origin. 94 (84%) had infammatory arthritides and all were prescribed DMARDs and/or bone active agents. 69 (61%) had blood samples taken using this service. Most common reason to decline was an already arranged appointment with standard phlebotomy (n=14, 12.5%). Six (5%) could not be bled due to difficult venepuncture. Mean duration of appointment was 12.5 mins (5-60). 68 (60%) provided feedback with 61 (90%) rating 5/5 and 60 (89%) rating it better than standard phlebotomy. All would like to have the option for future and 67 (98%) were highly likely or likely to recommend the service to family and relatives. Conclusion: To our knowledge, this is the frst study to demonstrate the utility of drive-through phlebotomy for people with rheumatic diseases prescribed DMARDs. Excellent feedback of the participants confrms the need and desire for such innovation in health care. Prior publications have shown the benefts of such clinics in anticoagulation services. Arguably, it's more prudent to have this facility for those where there is no alternative such as point-of-care or home INR monitoring. In post COVID-19 services reconfguration with telemedicine and innovative models of care, this allowed fexibility for our department to develop and establish an alternative process. The availability of drive-through appointments and the close physical proximity to the clinic made it an appealing option for a vulnerable group of patients evidenced by their outstanding experience and feedback. Overall, an HCA-delivered, nurse-supervised drive-through pathway is highly effective, safe and provides an innovative solution to stra ned phlebotomy services.

EFFECTS OF CESSATION OF VENESECTION IN OLDER PATIENTS WITH HAEMOCHROMATOSIS DURING COVID PANDEMIC

Introduction During the first wave of the COVID- 19 pandemic many elective procedures were postponed including venesection for the treatment of haemochromatosis. On resumption of venesection, limited capacity offered the opportunity to observe the effect of prolonged cessation of maintenance in non-cirrhotic patients over 70 years who guidelines suggest should undergo lifelong venesection. Methods 40 HFE haemochromatosis patients aged 70+ at Royal Derby Hospital (RDH) (25 C282Y homozygotes, 11 compound heterozygotes (CH) and 4 C282Y heterozygotes- 3 mutually exclusive groups) who had a SF< 150mg/L at the point of venesection cessation were identified. SF levels at venesection cessation and resumption were collected and the time interval used to express the change in SF over 12 months. Statistical analyses were conducted using STATA. Results The median projected increase in SF in 1 year in C282Y homozygotes was 40.8(-40.9-490.2)mg/L, in C282Y heterozygotes was 36.4(11.5-157.5) mg/L, and in compound heterozygotes was 74.1(-58.2-170.5) mg/L. There was no significant difference between the projected median increase in SF in 1 year between C282Y homozygotes compared to C282Y heterozygotes (p=0.95, p>0.05), between C282Y homozygotes compared to compound heterozygotes (p=0.72, p>0.05) or between all patients with a single C282Y mutation (compound heterozygotes and C282Y heterozygotes) compared to C282Y homozygotes (p=0.75,p>0.05). Considering all patients requiring venesection, the proportion of patients whose ferritin increased over 12 months by less than 50 was 50%, < 100 was 80% and 98% remain within normal range. Conclusions In non-cirrhotic HFE patients age 70+ the majority of patients can safely suspend venesection for at least 1 year and continued ferritin monitoring would likely reduce the burden on the service without clinically significant consequences as long as a threshold for resumption were agreed. Since evidence suggests that reduced iron absorption may be a physiological result of ageing, some patients may not require further venesection.

UTILIZATION OF A MULTIDISCIPLINARY TELEHEALTH MODEL TO IMPROVE ACCESS TO CARE AND MAINTAIN AN ACADEMIC TEACHING PARADIGM FOR A UNIQUE PATIENT POPULATION DURING THE COVID-19 PANDEMIC

Background: The Familial Mediterranean Fever (FMF) Program at the University of California, Los Angeles is the only dedicated FMF diagnostic and treatment clinic in the United States, receiving global referrals. FMF is a rare autosomal recessive genetic disorder characterized by recurrent febrile polyserositis. Serious complications from untreated FMF are easily preventable with early diagnosis and treatment. The COVID-19 pandemic constrained educational and interdisciplinary in-person visits and prompted exploration of innovative telehealth solutions. Objective: This study aimed to explore the feasibility and clinical process outcomes associated with a multidisciplinary telemedicine model to deliver consultative and continuing care to FMF patients. Our secondary objectives included assessing provider, patient, and trainee satisfaction. Study design: We implemented a multidisciplinary telemedicine clinic with gastroenterologists, a medical geneticist, and trainees. All patients with suspected FMF referred to our clinic during the pandemic were included. Patients were sent a HIPAAcompliant Zoom link for their clinic appointment. We mirrored our in-person academic teaching model, first with the trainee interviewing the patient virtually and then later presenting to the team, along with family members, who joined for the case presentation and consensus on diagnostic impressions and management recommendations. Patient characteristics and clinical process outcomes were assessed during the visit and from the electronic medical record (EMR). Post-visit surveys of patients, physicians and trainees were then taken to assess effectiveness and desirability of the approach. Results: 86 patients were enrolled in the multidisciplinary telemedicine model from March 2020 to March 2021. In comparison, 87 pre-pandemic visits occurred between March 2019 to March 2020. No significant difference was found in patient volume seen with telehealth and surveys showed increased provider, patient, and trainee satisfaction. The telehealth model enabled health care delivery to a variety of locations that lacked expert experience with this rare disease. Patients could also avoid costly travel to UCLA and risk exposure to COVID-19. Surveys showed increased satisfaction with Zoom than the integrated video functionality in our in-house EMR by allowing for inclusion of multiple specialists and interested family members. Sample collection for indicated laboratory tests could still be ordered at a local phlebotomy center. Conclusion: A multidisciplinary telemedicine model for outpatient management of FMF patients resulted in rates of ambulatory management similar to those seen pre-pandemic and resulted in improved patient and physician satisfaction. FMF is especially amendable to this approach, as patients are asymptomatic between attacks, making hands-on physical exam less pertinent.

A PATIENT SURVEY TO UNDERSTAND THE IMPACTS OF COVID-19 ON DELIVERY OF HIV CARE FROM THE PATIENT'S PERSPECTIVE

Introduction Significant changes occurred in delivery of HIV care due to COVID-19. Our department recognised the benefits of some changes but understanding the impact on patients is essential in establishing a plan for recovery. Methods We conducted a survey using Microsoft forms, delivered via text message to approximately 3000 patients across two HIV departments. The patient experience, communications and information governance teams were involved in the design. Patients were given 4 weeks to respond. Results There were 325 responses. Demographics of respondents roughly matched the cohort, excepting a bias towards slightly older patients. Care was reported to be better than prior to the pandemic by 15%, with another 63% saying it was equally as good. A minority (19%) said their care was not as good. Almost half preferred telephone consultations, 48% said they were more convenient and another 33% said they were equally as convenient, 64% were happy to continue with telephone consultations. 37% said they would want to be seen in person at least every 6 months, 39% said every 12 months, and 13% 18 months. Off-site phlebotomy was popular with 42% saying this was more convenient and 71% happy to continue using it. Discussion This feedback is extremely valuable in shaping provision of future care. The department is proud to have maintained high quality care for the vast majority in the face of enormous pressures. However, a minority of patients have experienced negative impacts on their care;patient choice is clearly vital moving forwards. A patient survey to understand the impacts of COVID-19 on delivery of HIV care from the patient's perspective (Table Presented).