The Maryland (USA) Critical Care Coordination Center (C4): From Pandemic to Permanence.

INTRODUCTION: The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland's (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care. METHODS: The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation. RESULTS: Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide. CONCLUSION: The C4 has played an integral role in the State of Maryland's pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.

Clinicians' and Users' Views and Experiences of a Tele-Mental Health Service Implemented Alongside the Public Mental Health System during the COVID-19 Pandemic.

A tele-mental health model called Head to Health was implemented in the state of Victoria, Australia to address the crisis caused by the COVID-19 pandemic. It was a free centralized intake service that adopted a targeted approach with several novel elements, such as stepped care and telehealth. This study examines the views and experiences of clinicians and service users of the tele-mental health service in the Gippsland region of Victoria during the COVID-19 pandemic. Data from clinicians were obtained via an online 10-item open-ended survey instrument and from service users through semi-structured interviews. Data were obtained from 66 participants, including 47 clinician surveys and 19 service user interviews. Six categories emerged from the data. They were: 'Conditions where use of tele-mental health is appropriate', 'Conditions where tele-mental health may not be useful', 'Advantages of tele-mental health', 'Challenges in using tele-mental health', 'Client outcomes with tele-mental health', and 'Recommendations for future use'. This is one of a few studies where clinicians' and service users' views and experiences have been explored together to provide a nuanced understanding of perspectives on the efficacy of tele-mental health when it was implemented alongside public mental health services.

A Systemwide Postpartum Inpatient Maternal Mental Health Education and Screening Program.

OBJECTIVE: To expand a hospital system's maternal mental health program to standardize screening for perinatal mood and anxiety disorders. DESIGN: Quality improvement initiative using a continuous Plan-Do-Study-Act (PDSA) cycle. SETTING/LOCAL PROBLEM: In a hospital system consisting of 66 maternity care centers across the United States, there was significant variation in maternal mental health screening, referral, and education practices. The COVID-19 pandemic and increasing rates of severe maternal morbidity further elevated system-level concern about the quality of maternal mental health care being provided. PARTICIPANTS: Perinatal nurses. METHODS: An "all-or-none" bundle methodology was used to measure adherence to a system standard for maternal mental health screening, referral, and education. INTERVENTIONS: A toolkit was designed internally to support streamlined implementation and ensure standardization for screening, referral, and education. This comprehensive toolkit includes screening forms, a referral algorithm, staff education, patient education literature, and a community resource list template. Training on how to use the toolkit was provided to nurses, chaplains, and social workers. RESULTS: The initial system bundle adherence rate was 76% (2017) in the first year of the program. The following year, the bundle adherence rate increased to 97% (2018). Despite the disruption caused by the COVID-19 pandemic, this mental health initiative has maintained an overall adherence rate of 92% (2020-2022). CONCLUSION: This nurse-led quality improvement initiative has been successfully implemented across a geographically and demographically diverse hospital system. The initial and sustained high rates of adherence with the system standard for screening, referral, and education illustrate perinatal nurses' commitment to the delivery of high-quality maternal mental health care in the acute care setting.

Factors Associated with Avoiding Referrals by Dental Teleconsulting Sessions in Brazil.

This cross-sectional analytical study assessed the frequency of avoided referrals of primary care to other care levels by dental teleconsulting and its association with individual and contextual variables using a multilevel approach. It appraised asynchronous dental teleconsulting sessions from the secondary database of the Monitoring and Evaluation System of the Telehealth Results during 2020, during the COVID-19 pandemic. The outcome was "whether referral to secondary care was avoided". Individual variables were related to teleconsulting and professionals that requested it: sex, dental specialty, and dentistry field. Contextual variables were related to each municipality that requested responses: Municipal Human Development Index, oral health teams (OHTs) in primary health care coverage, dental specialty centers coverage, illiteracy rate, Gini index, longevity, and per capita income. A descriptive analysis was made using the Statistical Package for the Social Sciences. Hierarchical Linear and Nonlinear Modeling software was used to perform multilevel analyses to assess the association of individual and contextual variables with avoiding patient referral to other care levels. Most teleconsulting sessions avoided patient referral to other care levels (65.1%). Contextual variables explained 44.23% of the variance in the outcome. Female dentists were more likely to avoid patient referrals than male dentists (OR = 1.74; CI = 0.99-3.44; p = 0.055). In addition, an increase of one percentage point in OHT/PHC coverage of municipalities increased the likelihood of avoiding patient referral by 1% (OR = 1.01; CI = 1.00-1.02; p = 0.02). Teleconsulting sessions efficiently avoided patient referral to other care levels. Both contextual and individual factors were associated with avoided referrals by teleconsulting sessions.

Characterizing Patients Referred For Ambulatory Rehabilitation Post COVID-19...American Congress of Rehabilitation Medicine (ACRM) Annual Conference, November 8-11, 2022, Chicago, Illinois

to describe baseline characteristics of patients referred for outpatient rehabilitation therapies during the first 7 months of Bryn Mawr Rehabilitation Hospital's Post-COVID Recovery Program. Retrospective cohort. Outpatient rehabilitation clinic. All patients referred to the BMRH Post-COVID Recovery Program from May – December 2021, excluding those with neurodegenerative conditions and those already receiving physical, occupational, and/or speech therapy for a pre-existing condition at the time of their COVID-19 diagnosis. Not applicable. This study focuses on describing baseline characteristics of a relatively new clinical population, ergo there is no main outcome measure. Of 116 patients referred to the program, 94 (81.0%) were assessed by at least one therapy discipline. Of patients assessed, 72.3% were assessed by more than one discipline, and 37.2% were evaluated by all three: PT, OT, and Speech. The mean duration from COVID-19 diagnosis to referral was 203.2 days (SD=160.11). The majority of patients, 66.7%, were not hospitalized for COVID-19. Among patients' chief complaints, the top five were cognitive issues (76.6%), decreased endurance (75.5%), decreased strength (62.8%), pain (56.4%), and balance deficits (50.0%). The most common premorbid conditions were anxiety/depression (37.0%), hypertension (35.3%), lipid disorders (33.6%), current/former smoker (31.0%), and migraines (21.6%). Average body mass index at time of COVID-19 diagnosis was 31.33 (SD=8.89), with 29.15 and 25.88 at the median and first quartile, respectively, indicating that the majority of patients fell within CDC ranges for overweight or obesity. Cognitive complaints were correlated with female assigned sex, lower levels of care received for COVID illness, and preserved strength. Decreased endurance was correlated with higher BMI, lipid disorder, higher level of care, and other physical complaints. Balance deficits were correlated with hypertension and longer duration. These results shed light on a relatively new patient population and their rehabilitation needs. As SARS-CoV-2 continues to spread, more and more patients will seek rehabilitation services as part of their recovery. Understanding the characteristics of these patients is key to developing and refining effective treatment protocols. Nothing to disclose.

Charity programme supports practices' mental health services

The article reports that the charity Mind Cymru has urged practice nurses in Wales to refer patients with mild to moderate mental health problems for Great Britain National Health Service (NHS) counseling to a free, guided self-help service. It mentions that the Active Monitoring programme can support practices' mental health service delivery.

Cancer treatment backlog: what's gone wrong and what we need to do to fix it: Nurses in rapid diagnostic centres, one-stop clinics and other services are striving to clear treatment backlogs, but urgent and coordinated action is needed

This time last year it looked like cancer services were back on the road to recovery. The number of people starting treatment was on the rise and had even nudged above pre-pandemic levels.

MONitoring Knockbacks in EmergencY (MONKEY) - An Audit of Disposition Outcomes in Emergency Patients with Rejected Admission Requests.

Background: Emergency Department (ED) clinicians commonly experience difficulties in referring patients to inpatient teams for hospital admission. There is limited literature reporting on patient outcomes following these complicated referrals, where ED requests for inpatient admission are rejected - which study investigators termed a "knockback". Purpose: To identify disposition outcomes and referral accuracy in ED patients whose admission referral was initially rejected. Secondary objectives were to identify additional patient, clinician and systemic factors associated with knockbacks. Selection and Methodology: Emergency clinicians prospectively nominated a convenience sample of patients identified as having knockbacks over two time periods (Jan-Feb 2020 and Aug 2020 to Jan 2021) at a tertiary Australian ED. Data were analyzed with a mixed-methods approach and subsequent descriptive and thematic analyses were performed. Results: A total of 109 patients were identified as knockbacks. The referrals were warranted, with 89.0% of cases (n = 97) ultimately requiring a hospital admission. In 60.6% (n = 66) of the admissions, patients were admitted under the inpatient team initially referred to by the ED, suggesting referrals were generally accurate. The number of in-hospital units involved in the admission process and ED length of stay were positively correlated (0.409, p < 0.001). Patient factors associated with knockbacks include pre-existing chronic medical conditions and presenting acutely unwell. Analysis of clinicians' perspectives yielded recurring themes of disagreements over admission destination and diagnostic uncertainty. Conclusion: In this patient sample, emergency referrals for admission were mostly warranted and accurate. Knockbacks increase ED length of stay and may adversely affect patient care. Further focused discussion and clearer referral guidelines between ED clinicians and their inpatient colleagues are required.

Substance Use and Mental Health Disorders: Psychologists' Role in Bridging the Gap

Nearly 30% of people with a mental health disorder will also have a substance use disorder at some point in their lives. Despite widespread evidence of the complex interactions between mental health and substance use and the value of integrated treatment, the majority of people with concurrent disorders do not receive treatment that addresses both conditions. Psychologists are ideally suited to bridge this gap in care, but this will not be without challenges. Psychologists possess extensive skills in identifying, diagnosing, and treating mental health disorders, which are transferrable to substance use disorders. Psychologists also have formal training in supervision and consultation and thus can supervise or act as consultants for other professionals in treating concurrent disorders. They have expertise in program development, evaluation, and research and can lead projects to integrate mental health and substance use services. Barriers to psychologists bridging this gap center on siloes in our healthcare system, the lack of training for psychologists to develop competency and confidence in substance use disorder diagnosis and treatment, misperceptions about how individuals with substance use disorders respond to psychological treatment, as well as system barriers. Overcoming these barriers comes with clear benefits and will require changes to professional training, clinical practice, and research on evidence-based treatments for concurrent disorders. Agencies across Canada are calling for action to ensure individuals with concurrent disorders receive the integrated services they require. Being at the leading edge of this change offers an important opportunity for psychologists. Près de 30 % des personnes présentant un trouble de santé mentale auront aussi un trouble lié à la consommation d'une substance au cours de leur vie. Malgré les preuves répandues au sujet des interactions complexes entre la santé mentale et la consommation d'une substance et de la valeur d'un traitement intégré, la majorité des gens ayant des troubles concomitants ne reçoivent pas de traitement simultané pour les deux conditions. Les psychologues sont les mieux placés pour combler cette lacune, mais cela ne se fera pas sans difficulté. Ils possèdent de vastes compétences pour cerner, diagnostiquer et traiter les troubles de santé mentale, qui sont transférables aux troubles liés à la consommation de substances. Ils ont reçu une formation en supervision et en consultation, ce qui leur permet de superviser ou de conseiller d'autres professionnels au sujet du traitement de troubles concomitants. Les psychologues possèdent une expertise en matière de développement de programmes, d'évaluation et de recherche, et ils peuvent diriger des projets visant à intégrer des services en santé mentale et des services concernant la consommation de substances. Les obstacles au règlement des lacunes par les psychologues sont attribuables au travail en vase clos au sein de notre système de santé, au manque de formation qui permettrait aux psychologues d'acquérir les compétences et la confiance requises pour diagnostiquer et traiter les troubles liés à la consommation de substances, à la méconnaissance de la réponse des personnes ayant de tels troubles aux traitements psychologiques, ainsi qu'à divers obstacles du système. Surmonter ces obstacles apportera des avantages nets et nécessitera des changements à la formation professionnelle, à la pratique clinique et à la recherche sur les traitements fondés sur des preuves pour les troubles concomitants. Des organismes partout au Canada demandent que des mesures soient prises pour veiller à ce que les personnes présentant des troubles concomitants reçoivent les services intégrés dont elles ont besoin. Se positionner à la tête de ce changement constitue une occasion importante pour les psychologues.

Interventions, Participative Role, Barriers, and Facilitators for Involvement in eHealth Communication for People Undergoing Hemodialysis: Protocol for a Scoping Review.

BACKGROUND: eHealth interventions have been shown to offer people living with chronic kidney disease the opportunity of embracing dialysis therapies with greater confidence, the potential to obtain better clinical outcomes and increased quality of life, and diverse and flexible designs and delivery options. eHealth interventions or solutions can offer one-way information without the possibility for dialogue, as with most mobile apps. eHealth interventions intending to enable two-way communication between patients undergoing hemodialysis and health professionals are the focus of this review. eHealth communication interventions that enable two-way communication between patients undergoing hemodialysis and health professionals is an emerging field, but issues relating to participation in eHealth communication for patients undergoing hemodialysis are scarcely described. The current conceptualization of this issue is too scattered to inform the development of future interventions. In this scoping review, we want to assemble and examine this scattered knowledge on participation in two-way eHealth communication for patients undergoing hemodialysis. OBJECTIVE: We want to understand the participative role of people living with chronic kidney disease undergoing hemodialysis in available communicative eHealth interventions and to understand which barriers and facilitators exist for patient involvement in eHealth communication with health professionals. METHODS: A scoping review methodology is guiding this study. Peer-reviewed primary studies, including quantitative, qualitative, and mixed methods study designs will be included. A systematic search for published studies, dissertations, and theses at the doctoral level in the English language will be conducted in five databases (MEDLINE, Embase, CINAHL, Scopus, and ProQuest Dissertations and Theses). The included literature will focus on adult (18 years or older) patients undergoing hemodialysis who are involved in eHealth communication with health professionals. Data on the type of eHealth communication interventions, the participative role, and barriers and facilitators for the involvement in eHealth communication for people undergoing hemodialysis will be extracted independently by two reviewers. The extracted data will be collected in a draft charting table prepared for the study. Any discrepancies between the reviewers will be solved through discussion or with a third reviewer. RESULTS: Results are anticipated by the spring of 2023 and will be presented in tabular format along with a narrative summary. The anticipated results will be presented in alignment with the objectives of the study, presenting findings on the participative role of patients undergoing hemodialysis in eHealth communication interventions. CONCLUSIONS: We anticipate that this study will inform on eHealth communication interventions and the level of patient participation in eHealth communication for patients undergoing hemodialysis. The systematized overview will possibly identify research gaps and motivate further development of eHealth communication to ensure patient participation. The findings will be of interest to key stakeholders in clinical care, research, development, policy, and patient advocacy. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/38615.

Impact Of Covid-19 Pandemi On Mortality Profile Of Pediatric Oncology Patient In Referral Hospital

Background cancer patients are at higher risk of COVID-19 infection and more likely to have higher morbidity and mortality than the general population, While cancer it self is still the main cause of death in children around the world, In countries with limited health facilities, that might cause delayed of seeking treatment, cancer death rate in children could reach 90%, this condition would become bigger in the pandemic condition expecially in hospital that appointed as a referral hospital for COVID-19 but also tertiary hospital for hematology and oncology cases. The aim of the study was to describe is there any differences mortality profile of pediatric oncology patient before and during COVID-19 pandemic. Method : we collected data pediatric oncology patient aged 1 to 18 years that admitted to Hasan Sadikin General Hospital from Hospital Information Systems, IP-CAR, and Waiting List of Oncology Ward Hospital Admission, data conducted to differentiate between Admission Rate, New case Diagnosis and abandonment rate before and during COVID-19 pandemic. Mortality data and what might caused it also collected after audited by experts from Hasan Sadikin General Hospital. Results There were 87 death cases from January to Desember 2021 when pandemi has already happened, Acute lymphoblastic leukemia still the main oncology diagnosis for those cases (33%), most of the death cases was caused by septic Shock ((24%), the second leading caused was covid 19 (8%). We also found in our research there was a significantly increased rate of treatment abandonment from 1.1% before to 17% during COVID-19 pandemic. This may pose risk for the patients involved, not only cause treatment failure, increased toxicity or complications. Conclusion Pandemic COVID-19 increased abandonment rate that could impact the general condition of oncology patient, that might indirectly related to mortality rate. While infection as the leading causes of death before and after pandemic remain the same but the distinction was the COVID-19 as a second most caused of death. Optimal efforts should be made to avoid abandonment and prevent the occurrence of infection

Using video consultation technology between care homes and health and social care professionals: a scoping review and interview study during COVID-19 pandemic

Background: The COVID-19 pandemic disproportionately affected care home residents' and staffs' access to health care and advice. Health and social care professionals adapted rapidly to using video consultation (videoconferencing) technology without guidance. We sought to identify enablers and barriers to their use in supporting care home residents and staff.

Non-medical prescribing considerations in emergency mental health services

The emergency mental health practitioner's job involves providing immediate care to patients who are suffering a mental health crisis. Independent nurse prescribing supports this service through timely access to pharmacological and non-pharmacological measures or cognitive behavioural strategies. This case study involves a service user diagnosed with bipolar type II disorder who presents with suicidal ideation, and outlines the prescribing options available for short-term crises and long-term risk management. There is a complex balance of appraising physical and mental health including capacity, assessment of risk of self-harm and harm to others, and working in consultation to optimise adherence and concordance. The authors highlight the importance of using a person-centred approach, which includes family, carers and their wider support network, to develop a therapeutic relationship which promotes positive outcomes. This is further supported by utilising the most recent and up-to-date policy, guidelines and legislation, including local and national policies.

Strongyloides Hyperinfection Syndrome Following Corticosteroid Therapy in a Patient with COVID-19 infection: A Case Report

Strongyloides stercoralis (S. stercoralis) is a helminth, which infects humans widely in tropical and subtropical countries. This parasitic infestation usually does not produce symptoms in humans;however, severe and life-threatening forms of this infection can occur in immunocompromised individuals. Patients with Coronavirus disease 2019 (COVID-19) with concurrent immunosuppressive therapy are at risk of developing Strongyloides hyperinfection syndrome (SHS). We present a 70-yearold male with a history of high-dose dexamethasone therapy due to severe COVID-19 who was referred to our hospital with chest discomfort, nausea, and anorexia. Histological assessment of the gastric and duodenal mucosae revealed numerous eggs and filariform larvae of S. stercoralis indicative of SHS. Ivermectin and albendazole were administered to the patient. Following the treatment, the patient's symptoms improved. Clinicians must be aware of the risk of SHS, especially in S. stercoralis endemic countries before and during corticosteroid therapy for COVID-19 because early diagnosis and appropriate treatment can significantly reduce mortality in these patients.

Impact of COVID-19 pandemic on head-neck cancer referral and treatment pathway in North East London.

INTRODUCTION: The COVID-19 pandemic has led to wide-ranging disruption of head-neck cancer (HNC) service provision in the UK. Early reports suggest delays in referral, diagnosis and initiation of treatment for new cancer cases compared with before the pandemic. METHODS: The HNC service was studied retrospectively for the time-periods between 1 January 2020 to 31 October 2020 (hereafter 'post-COVID') and 1 January 2019 to 31 October 2019 (hereafter 'pre-COVID'). We analysed: (1) the number of cases treated at our centre, (2) stage of disease at presentation and (3) treatment delivery times. RESULTS: In the post-COVID period, the total number of HNC cases treated decreased (48 vs 56 pre-COVID). There was increase in advanced stage at presentation (58% vs 42% pre-COVID) and a significant increase in the need for airway stabilisation (13 vs 5 pre-COVID; p=0.03). Average time from referral to treatment was significantly prolonged (72.5 days vs 49.23 days pre-COVID; p=0.03). Two-week wait referrals were seen in HNC clinics at median time of 11.9 days, compared with 7.1 days during the pre-COVID period (p=0.07). However, there was no delay in the initiation of first treatment after the decision to treat (29.2 days vs 24.7 days pre-COVID; p=0.58). CONCLUSION: The results of this study call for early referral at the primary care level and rapid radiopathological confirmation at the tertiary level to prevent delays in diagnosis of new HNC cases.

Few consultations by video

The article reports that very few consultations in general practice occur by video;and mentions that patient focus groups, there was agreement that practices should offers consultation options without making assumptions about which patients or conditions would be suitable for each approach.

Barriers to Community Pharmacists Referring Patients With Suspected COVID-19 Symptoms.

BACKGROUND: With the necessary skills available to community pharmacists, they are well equipped to relieve pressure on hospitals and general practices by providing referral services for symptomatic patients for COVID-19 testing. OBJECTIVE: The assessment of potential barriers that limit the successful implementation of a community pharmacy referral service for patients with suspected COVID-19 symptoms. METHODS: A questionnaire comprising of 100 questions was administered to one pharmacist by interview in 1023 working community pharmacies in 4 regions of Egypt between May 17 and May 30th 2020. RESULTS: Forty-five barriers were identified. Respondents (79%, n = 803) had difficulty obtaining an accurate patient history. Patient data confidentiality was a significant issue for pharmacists who had not received referral training, with these respondents being significantly (P = .010) less able to differentiate between COVID-19 and similar conditions. Respondents (68.8%, n = 698) were not confident in determining whether COVID-19 was the cause of the patient's presenting symptoms. A large majority (73.7%, n = 747) of respondents were worried about referring misdiagnosed patients and were concerned about the negative implications of proceeding with such a referral, including legal consequences. Of Respondents (71.7%, n = 727) reported that online referral was not easy, and 71.6% (n = 722) were unable to locate paper referral forms. Only a small number of pharmacists (11%, n = 112) preferred to report a referral in their own name. CONCLUSIONS: This study has demonstrated the potential of the community pharmacist's role as a point of referral for COVID-19 testing, and identified some major barriers to implementation of this. The lack of pharmacists' education, legal support, availability of referral forms, clarity of responsibility and unsupportive management teams are key obstacles that must be overcome for the successful implementation of a COVID-19 referral service.