Anaesthetic pre-assessment of obese patients in obstetrics: challenges in COVID recovery

Introduction: One in five pregnant women in the UKis obese. Obesity is associated with increased risk of both maternal and foetal adverse outcomes. RCOG guidelines [1] recommend that all women with a booking BMI over 40 kg/m2 should be reviewed antenatally by a senior obstetric anaesthetist to guide risk assessment, medical optimisation and shared decision-making. The 2021 MBRRACE report [2] recommends that all women should be reweighed in the third trimester for accurate VTE risk scoring and prophylactic LMWH dosing. In our institution, reconfiguration of hospital areas as part of the COVID-19 response led to loss of designated clinic space for our obstetric anaesthetic clinic. As a result, our practice since has been to initially offer a telephone consultation followed by a face-to-face review if needed. Finding space for the latter has often been a significant logistical challenge. Our project sought to assess whether our practice continued to meet national standards in the wake of these changes. Method(s): Following audit approval, we retrospectively reviewed all women with a BMI >40 kg/m2 undergoing caesarean section (CS) over a six-month period (1/4/22 to 31/9/22). Result(s): 20 women met inclusion criteria (Category 1-3 CS - 12 women;Category 4 CS - 8 women). 100% of patients had booking height, weight and BMI recorded. 20% (4/20) of patients were reweighed in the 3rd trimester. Only 55% (11/20) of patients had been referred to and reviewed in the antenatal obstetric anaesthetic clinic (Figure). Of the 11 patients referred, 6 were referred later than 30 weeks. Of the 9 patients not referred, 8 had a BMI between 40 and 45 kg/m2. By contrast, 87% (6/7) of patients with BMI over 45 kg/m2 were referred and seen. Discussion(s): Our audit showed that we are not meeting national standards. Possible reasons identified were lack of awareness of the RCOG standards and referral criteria (especially for women with a BMI of 40 to 45 kg/m2) and logistical issues in undertaking face-to-face reviews without designated clinic space. Presentation of our results at the joint anaesthetic, obstetric and midwifery governance meeting has helped identify space in the antenatal clinic for face-to-face reviews, to start from March 2023 and to raise awareness of the national standards to ensure referral of all women with a BMI over 40 kg/m2. A reaudit is planned in 6 months. [Figure presented]Copyright © 2023 Elsevier Ltd

Use of technology to facilitate recovery in young adults with first-episode psychosis

Aims: Accessibility and engagement to high quality non pharmacological interventions for First-Episode Psychosis individuals (FEP) is hindered by different factors such as patients motivation, clinical time, lack of adaptation to patient needs. Taking into account patients' preference in the design in an individualized treatment plan as well as challenges faced by this particular patient, and his specific context/ environment can possibly enhance patient satisfaction and engagement. Technology can help to both standardized and individualize intervention to maximize the proposed services impacts. Method(s): This symposium explore how different technological tools can assist both clinicians and patients in enhancing patient experience of care First, the technokinpep, an innovative telekinesiology project offered by a peer support worker in multiple early psychosis services simultaneously, maximized accessibility of physical activity during the COVID-19 pandemic, social distanciation requirements. Second, Ocean empire, a mobile app aimed at improving physical activity motivation and affect in early psychosis. With this study, this presentation will shed light on the development and implementation of this mobile app. Third, exercise your wau used a mobile app to tailor the physical activity intervention program to the patients preferences and needs. Finally, the Freedom app gives the duo patient-clinicians a tool to facilitate shared decision making to enhance the therapeutic relation. Result(s): These different technologies can enhance patient and clinicians experience of collaborative and tailored adapted treatment. Conclusion(s): The development of new technology can help improving care by adapting it to better individual's needs.

Updated Guidance Regarding The Risk ofAllergic Reactions to COVID-19 Vaccines and Recommended Evaluation and Management: A GRADE Assessment, and International Consensus Approach.

This guidance updates 2021 GRADE recomendations regarding immediate allergic reactions following COVID-19 vaccines and addresses re-vaccinating individuals with 1st dose allergic reactions and allergy testing to determine re-vaccination outcomes. Recent meta-analyses assessed the incidence of severe allergic reactions to initial COVID-19 vaccination, risk of mRNA-COVID-19 re-vaccination after an initial reaction, and diagnostic accuracy of COVID-19 vaccine and vaccine excipient testing in predicting reactions. GRADE methods informed rating the certainty of evidence and strength of recommenations. A modified Delphi panel consisting of experts in allergy, anaphylaxis, vaccinology, infectious diseases, emergency medicine, and primary care from Australia, Canada, Europe, Japan, South Africa, the UK, and the US formed the recommendations. We recommend vaccination for persons without COVID-19 vaccine excipient allergy, and re-vaccination after a prior immediate allergic reaction. We suggest against >15-minute post-vaccination observation. We recommend against mRNA vaccine or excipient skin testing to predict outcomes. We suggest re-vaccination of persons with an immediate allergic reaction to the mRNA vaccine or excipients be performed by a person with vaccine allergy expertise, in a properly equipped setting. We suggest against pre-medication, split-dosing, or special precautions because of a comorbid allergic history.

Developing Multidisciplinary Models of Care in Rheumatology at University College London Hospital: 18 Months of Learning from Conception to Delivery and Beyond

Background/Aims The COVID-19 pandemic has placed unprecedented pressures on NHS departments, with demand rapidly outstripping capacity. The British Society for Rheumatology 'Rheumatology Workforce: a crisis in numbers (2021)' highlighted the need to provide innovative ways of delivering rheumatology specialist care. At University College London Hospitals (UCLH) we created a rheumatology multidisciplinary team (MDT) clinic to meet rising demands on our service. The aims of the Rheumatology MDT clinic were to: reduce new appointment/follow-up waiting times, increase clinic capacity, incorporate musculoskeletal (MSK) point of care ultrasound, reduce number of hospital visits and add value to each clinic encounter. Methods We ran a 6-month pilot, supported by our outpatient transformation team, incorporating a Rheumatology Advanced Practice Physiotherapist (APP), Clinical Nurse Specialist (CNS) and MSK ultrasound within a Consultant clinic. The success of the pilot helped secure funding for a further 12 months. Over 18 months we have implemented: APP/Consultant enhanced triage - up to 40% of referrals were appropriate for APP assessment, including regional MSK problems and back pain. This increased capacity for consultant-led appointments. Standardisation of time-lapse between CNS and consultant follow-up appointments to ensure appropriate spacing between patient encounters. Facilitated overbooking of urgent cases afforded by additional capacity provided by the APP. MSK ultrasound embedded in the clinic template. 'Zoom' patient education webinars facilitated by MDT members and wider disciplines e.g. dietetics, to empower self-management and reduce the administrative burden of patient emails/phone calls occurring outside the clinic. Patient participation sessions and feedback to help shape the service. Results During the 6-month pilot we reduced our waiting time for follow-up appointments from 9 months to 2. We now have capacity to book 1-2 urgent cases each week. Pre-MDT the average wait from consultant referral to physiotherapist appointment was 55 days. The MDT allows for same day assessment (reducing 2-3 patient journeys a clinic) and where suitable, facilitates discharge or onwards referral to the appropriate service. A dedicated MDT CNS has shortened treatment times, reduced email traffic between CNS and consultant and allows for same day, joint decision-making resulting in fewer appointments. Zoom webinar feedback has been positive. Patients value the broad expertise of allied health professionals which supports self-management. Embedding ultrasound allows for same day diagnostics, decreased referrals to radiology and reduced hospital visits. Conclusion Our MDT model has reduced waiting lists, decreased treatment delays and cut hospital attendances. Point of care ultrasound allows for same day decision making and abolishes the cost and diagnostic delay associated with referrals to radiology or outsourced providers. Shared decision-making adds value to outpatient attendances, which is reflected in patients' positive feedback. The MDT model maximises the existing workforce skill set by enhancing the APP and CNS role, allowing patients immediate access to their expertise.

Appropriateness and Completion of Multitarget Stool DNA Testing in Primary and Subspecialty Care

Introduction: Colorectal cancer (CRC) is the third most prevalent cancer in the United States, with a 4% lifetime incidence. While more clinicians have begun ordering multitarget stool DNA (mt-sDNA) testing due to the COVID-19 pandemic, adherence to guidelines on mt-sDNA and rates of subsequent follow-up testing has not been well studied. We assessed the appropriateness of mt-sDNA orders and rate of high-quality colonoscopy completion following a positive result in a large academic medical center. Method(s): We identified patients ordered for mt-sDNA in primary care and gastroenterology clinics at our institution between April 2020 and July 2021. For each case, we reviewed the appropriateness of mtsDNA testing, documentation of shared decision making, result of testing, and subsequent follow-up. Appropriateness was defined in accordance to the most recent American College of Gastroenterology guidelines on mt-sDNA use for CRC screening. Result(s): Of the 797 patients in our study, 685 (86%) met all appropriateness criteria for mt-sDNA testing (Table). Shared decision making was documented in 488 (62%) cases, and the most common reason for ordering mt-SDNA was hesitancy for colonoscopy. 483 patients (61%) completed mt-sDNA testing, of which 74 cases (15%) were positive. Rates of positivity were higher in cases of inappropriate (28%) rather than appropriate (13.7%) orders (p = 0.01). Colonoscopy was ordered in 73 cases (99%) and completed by 59 patients (80%). Of the 56 patients who underwent colonoscopy at our institution, most had documentation of a high-quality colonoscopy, defined as adequate prep (84%), cecal intubation (93%), visualization of the appendiceal orifice and ileocecal valve (94%), and right colon retroflexion (83%). Sixteen patients (29%) were found with advanced adenomas and 19 (34%) had other adenomas or sessile polyps. Among the 409 patients with negative tests, a 3-year follow-up recommendation was documented for 369 patients (90%). Conclusion(s): Most clinicians at our institution identified appropriate patients for mt-sDNA testing and provided appropriate follow-up< and the majority of patients who underwent colonoscopy had documentation of a high-quality colonoscopy. In contrast, there were suboptimal rates of mt-sDNA completion and documentation of shared decision making. Further studies are needed to identify barriers to documentation of shared-decision making and to completion of high-quality colonoscopies in patients being screened with mt-sDNA.

Integrating Bioethics and Neonatal Palliative Care in a Pandemic: The Scope of Advocacy and Online Collaboration for Exceptional Life-Sustaining Medical and Surgical Interventions in a Regional Neonatal Intensive Care Unit

Purpose of Study: The regional NICU is an essential healthcare resource for families of newborns with serious life-threatening illnesses. Mechanical ventilation, cardiovascular therapies, therapeutic hypothermia, and neonatal surgeries are common life-sustaining interventions. Our NICU serves an underprivileged population in a resource poor environment and several ethical questions frequently emerge when facing extremes of innovative therapies. The pandemic and rapidly changing institutional protocols accentuated challenges faced by frontline NICU teams caring for newborns at risk for devastating illnesses and death. Concurrently, evolving paradigms in neonatal ethics required urgent and high quality palliative care in a background of racial and socioeconomic inequities, restrictive visitation policies, and limited healthcare resources. The purpose of this study was to ensure that neonates and their families receive ethically sound care, timely referrals for innovative therapies, and specialized palliative care in the strained and uncertain environment of the COVID-19 pandemic. Methods Used: The key steps consisted of structured and impromptu discussion forums for specialized palliative care and medical ethics, perinatal case conferences and pediatrics grand rounds on virtual platforms, educational webinars for interdisciplinary teams, and improved electronic communication. Online collaboration and innovative combinations of in-person and virtual meetings were utilized for urgently Incorporating clinical updates. Summary of Results: 1. A neonate with severe HIE and postnatally diagnosed congenital diaphragmatic hernia required emergent ECMO center referral. NICU providers utilized a structured bioethics and palliative care framework for providing family support and discussing the prognostication challenges of acute illnesses. 2. Many important bioethical questions emerged while caring for infants with life-threatening chromosomal abnormalities. Ethical tension was addressed by teaching tools, quality of life and pediatrics ethics conversations, mitigation of moral distress, contemporary clinical and surgical experience, community engagement, and family perspectives. 3. Ethical conflicts are central in the decision to resuscitate neonates born between 22 and 23 weeks of gestation. To provide urgent prenatal consultations and attend high risk deliveries, we collaborated across geographically distant healthcare systems, unified management strategies and analyzed outcomes data. 4. NEC in several extremely preterm babies had devastating outcomes and the team respected each family's voice with compassionate, shared decision-making for both curative care surgeries and palliative care. Conclusion(s): The new workflows, telephone and video conferences, and redirection to telehealth based family meetings did not change important outcomes during the pandemic. Advocacy and education for integrating bioethics and palliative care were vital facets of neonatal critical care in a resource poor and ever-changing pandemic environment.

Ethical Lessons Learned from the COVID-19 Pandemic in Perinatal Medicine

The COVID-19 pandemic is unprecedented in our lifetime, especially in perinatology. The gold standard is to strongly recommend COVID-19 vaccinations to those trying to get pregnant, to those who are pregnant, and to those who are postpartum. When the benefits of vaccines far outweigh the risks, it is unethical to disseminate wrong information and discourage patients from becoming vaccinated. COVID-19 vaccinations and boosters prevent severe diseases and adverse pregnancy and neonatal outcomes. A pregnant patient's vaccination also protects the newborn infant because maternal antibodies protect the fetus and newborn. COVID-19 vaccinations and boosters in pregnancy are safe for the pregnant patient and her fetus. The three root causes of physician hesitancy-misapplication of therapeutic nihilism, misapplication of shared decision-making, and misapplication of respect for autonomy should not be ignored and need to be addressed. It is important that we heed Brent 's insightful recommendations. Doing nothing with respect to vaccination is not an option, whether it applies to COVID-19 vaccines or to future pandemics. Physician hesitation is not an option. When there is sufficient evidence of vaccine safety and effectiveness without documented risks, vaccine recommendations before, during, and after pregnancy should be explicitly made to prevent maternal, fetal, and neonatal morbidity and mortality.Copyright © The Author(s). 2023.

Novel Corona Virus Pandemic- 2019 and Patient Experience Comparing Telemedicine with Conventional Clinic Visit in Patients with Juvenile Idioapthic Arthritis and Childhood Systemic Lupus Erythematosus

Purpose of Study The COVID-19 pandemic changed the physician- patient interaction. Telemedicine has emerged as the universal method of communication with patients. We compared conventional clinic visit (CCV) with telemedicine (TM) in clinic administered through video conferencing. Physician patient communication is key in determining treatment outcome and patient satisfaction in complex auto immune disease process including Systemic Lupus Erythematosus (cSLE) and Juvenile Idiopathic Arthritis (JIA). Methods Used We performed a quality improvement project using a telephone questionnaire survey in rheumatology clinic at Valley Children's Healthcare. We surveyed 25 patients total. The respondents in the survey experienced both CCV before and during pandemic and TM during pandemic. Summary of Results Among the 25 patients surveyed 15 had JIA and 10 had cSLE. Among JIA patients 95% felt doctor was paying attention, able to make shared decision regarding the medications and treatment options. All the JIA and cSLE patients in the group felt that doctor listened and asked appropriate questions. Patients in both groups felt they were able to discuss all their problems and had a strong positive impact on the quality of care during the TM visit as compared with CCV. In cSLE group 70% felt shared decision making and ability to discuss their medical problem via TM was not as good as CCV. Conclusions This survey divulged patient perspective regarding clinic visit during pandemic. Telemedicine is preferred by 95% and 75% of the respondents over the conventional clinic visit during the pandemic among JIA and CSLE groups. The main concerns were breakdown of the physician-patient relationship and issues regarding the technologies with connectivity along with organizational challenges. Patients in both groups strongly agreed that TM met the need for their care compared to conventional clinic visit. Patients in the JIA group were satisfied with TM visit in handling complex medical problems and shared decision making. Patients in cSLE group preferred CCV especially in addressing complex medical issues and shared decision making.

The Relationship between Prostate Cancer and Colorectal Cancer Screening: How Important Is Shared Decision-Making?

INTRODUCTION AND OBJECTIVE: While guidelines require shared decision-making (SDM) prior to PSA screening, there are more categorical recommendations for colorectal cancer (CRC) screening in persons aged 50-75.Historically, though, patients have been more likely to pursue PSA vs CRC, despite more equivocal recommendations for the former and stronger evidence for the latter.Recently, COVID-19 altered access to and patients' perceptions of healthcare services. This study investigates the relationship between PSA screening, CRC screening, and SDM, with the hypothesis that SDM is associated with higher rates of both screening practices. METHOD(S): The 2020 Behavioral Risk Factor Surveillance System (BRFSS) annual survey report was assessed for male patients between the ages of 50 and 75. The identified patients were further eliminated based on response availability: history of PSA and CRC screening must have been provided. Univariate logistic regression was used for predictor selection and multivariate logistic regression models were generated to assess associations between socioeconomic factors that influenced SDM for PSA screening as well as screening practices themselves. RESULT(S): 38,617 men between the ages of 50 and 75 met the inclusion criteria. 44% of respondents had PSA screening, 72.2% CRC screening, 38.83% had both, and 22.67% had neither. 45.2% had discussions about PSA advantages and 22.1% had discussions about PSA disadvantages. Odds of CRC screening increased if the patients had PSA screening (OR 2.52, CI 2.43 - 2.6), and if they had discussion on the advantages (OR 1.23, CI 1.09 - 1.38) and the disadvantages (OR 1.23, CI 1.13 - 1.34). Odds of PSA screening increased if the patient had CRC screening (OR 1.48, CI 1.37 - 1.58), had a discussion of the advantages of PSA testing (OR 2.06, CI 1.91 - 2.21), and when the PSA test was recommended (OR 3.95, CI 3.84 - 4.06). Odds of PSA screening decreased when the disadvantages of PSA were discussed (OR 0.84, CI 0.74-0.95). The Northeast had higher odds of PSA screening (OR 1.29, 1.16-1.41) but lower odds of CRC screening (0.68, CI 0.58-0.77) compared to the West. There were no significant associations with being from the Midwest or South and history of PSA or CRC screening. CONCLUSION(S): There are higher rates of CRC vs PSA screening in a contemporary cohort of patients in men aged 50-75. PSA screening has decreased amid fluctuating guidelines in an era of SDM, and in the post-COVID environment. SDM is associated with both screening practices, and may serve as a metric for quality of care across cancer types.

Development of a national cystic fibrosis patient and caregiver experience of care survey

Background: Since 2015, the Cystic Fibrosis Foundation (CFF) has collected and reported experience-of-care (XoC) data. Data collection was discontinued with the onset of the COVID-19 pandemic in 2020. In 2021, CFF convened a steering committee of a person with cystic fibrosis (CF), caregivers, and clinicians to develop a XoC survey to help understand and improve the XoC at CFF accredited programs. Method(s): Using prior CFF patient and family XoC surveys (2015-2020 pediatric and adult versions) [1,2] and a telehealth survey created in 2020 [3], draft pediatric and adult versions of the survey were developed. The steering committee and CFF leaders conducted three rounds of reviewand revision. After the surveys were professionally translated into Spanish, and the CFF Spanish Speakers Committee reviewed them, the surveys were programmed into Qualtrics for data collection. The data collection process was piloted with selected programs before a national launch. Result(s): Pediatric and adult surveys were developed in English and Spanish. The surveys cover in-person and telehealth (phone/video) visits and visits that are a mix of in-person and telehealth. The topics include interactions with care team members, relationship-centered care, care planning, shared decision-making, overall quality of care, race and ethnicity, gender identity, infection, prevention and control, quality of the virtual connection, and experience with remote monitoring. People with CF (PwCF) and their families are invited to complete a survey once every 6 months by text or email. PwCF and family contact data (email and mobile phone number) are stored in CFF's CFSmartReports Patient and Family Tool. After a clinic visit, contact data are electronically transferred to the Qualtrics platform to trigger a survey invitation. Responses are anonymous and reported back to programs via an electronic dashboard in near-real time. The data collection process was tested with three pediatric and three adult care programs for 3 weeks before the national launch on October 25, 2021. More than 2,000 PwCF and their families have completed a survey. Conclusion(s): The new XoC surveys offer PwCF and their families an opportunity to share feedback about their in-person and virtual care experiences. Efforts are underway to create a national report for dissemination and to engage programs with the data reported in their dashboards to celebrate what PwCF and their families appreciate about their care and to work together with them to improve gaps.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

Evaluation of an Advanced Care Planning Training Program Incorporating Online Skills in Shared Decision Making: A Preintervention and Postintervention Comparative Study.

AIM: This study evaluated an advanced care planning (ACP) training program incorporating online skills in shared decision making (SDM). METHOD: The New World Kirkpatrick Model was employed to assess the efficacy of the training program at four levels: reaction, learning, behavior, and results. Reaction measured the participants' satisfaction and difficulty with the training program alongside the status of support received from workplaces engaging in ACP. Learning evaluated the changes in SDM skills. Behavior assessed the changes in the relationship between patients and healthcare professionals when the latter were involved in the SDM process. Results evaluated whether the participants were willing to participate in ACP educational programs as a facilitator and whether their motivation for continuous learning changed through throughout the training program. The relationships among patients, healthcare providers, and third-party roles were analyzed in SDM role-playing via structural equation modeling (SEM). RESULTS: Between September 2020 and June 2022, 145 multidisciplinary participants completed the entirety of the training program. The most common responses to the training were "satisfied", "slightly difficult", and "I received some support from my workplace". The SDM skills significantly improved from the first to the third workshop, evaluated using the Wilcoxon rank-sum test. In the first workshop, SDM was primarily performed by healthcare providers; however, in the third workshop, patient-centered SDM was adopted. Of the participants who completed the program, 63% intended to participate in future ACP educational programs as ACP education facilitators. CONCLUSION: This study ascertained the validity of this training.

Cladribine Tablets: A Review of the Practical Considerations in Multiple Sclerosis Nursing Practice

Nurses specializing in the care of patients with multiple sclerosis (MS) are uniquely positioned to provide personalized care. Patients prescribed cladribine tablets (taken for <=10 days per year for 2 years), indicated for adults with highly active relapsing MS in the EU and Australia, can benefit from an active partnership with their healthcare professionals, including MS nurses, who can promote an understanding of and the adherence to treatment. In clinical studies, patients treated with cladribine tablets had lower annual relapse rates, greater odds of being relapse free, a longer time to sustained progression of disability and a significant reduction in radiological disease activity compared with patients receiving placebo. Patients should be advised that, although everyone will have a different experience, the safety of cladribine tablets is supported by 16 years of clinical trial and post-approval data. Furthermore, there is no indication of a more serious disease course or more severe outcomes for patients with MS treated with cladribine tablets who acquire coronavirus disease 2019 compared with the general population or other patients with MS. This article presents practical considerations that may help achieve a greater understanding of the potential benefits and drawbacks of MS treatment, build the patient-nurse relationship, encourage shared decision-making and ultimately may improve careCopyright © Touch Medical Media 2022

Getting to knowledge-enhanced health and healthcare

In this chapter, we describe advances in technology capabilities and in the healthcare ecosystem that are driving breakthrough innovations in clinical decision support (CDS). New and enhanced capabilities include the rise of precision medicine, patient/user engagement, aggregation of data for population health, onset of an "app culture,” artificial intelligence, and interoperability and standards development and adoption. Advances in healthcare delivery include new demands, stimuli, and incentives for CDS brought about by the factors such as broad adoption of electronic health record (EHR) systems, national programs such as the US Meaningful Use EHR certification, value-driven healthcare delivery and financing models, quality monitoring and reporting, as well as remarkable sociotechnical shifts during the COVID-19 pandemic. This chapter discusses the impact of these changes on the CDS landscape along with unique possibilities for CDS moving forward. © 2023 Elsevier Inc. All rights reserved.

Shared decision-making and the caregiver experience in tuberous sclerosis complex: results from a UK survey.

BACKGROUND: Tuberous sclerosis complex (TSC) is a rare genetic condition commonly accompanied by neurological and neuropsychological disorders, resulting in a high burden of illness for individuals and a substantial impact on their caregivers. Due to the diversity and complexity of clinical manifestations, patients with TSC need aligned multidisciplinary healthcare services starting in childhood through to adulthood. However, patients and caregivers are sometimes dissatisfied with the care provided, for which one of the most common reasons is a lack of involvement in clinical decision-making. Shared decision-making, whereby clinicians make clinical management decisions together with patients and their caregivers, is advocated for in the management of epilepsy, but evidence of its benefit in managing TSC is currently lacking. In this cross-sectional, UK-based analysis we used an online survey to capture the experiences of primary caregivers for individuals with TSC, including the impact on work productivity, clinical shared decision-making, satisfaction with care, and the impact of the coronavirus disease 2019 (COVID-19) pandemic. RESULTS: In total, 73 eligible caregivers provided consent (analysis set), with 14 completing the survey partially and 59 completing the full survey. Many caregivers (72%) reported receiving recommendations about new treatments from their doctor and discussing the treatment together, with a high proportion (89%) preferring that treatment was initiated at a low dose. Most caregivers (69%) were satisfied or extremely satisfied with pediatric TSC healthcare services, but only 25% were satisfied or extremely satisfied with the transition to adult TSC healthcare services. Several (n = 30) caregivers specified the impact of caring on their work productivity and career in optional open-ended survey responses. Finally, 80% of caregivers indicated that the COVID-19 pandemic had a "large" or "very large" impact on their caring activities, negatively affecting the emotional wellbeing and behavior of individuals with TSC, and caregivers' ability to work and arrange medical appointments. CONCLUSIONS: Caregivers largely feel involved in treatment decisions, and the majority were satisfied with healthcare services for children with TSC. However, many highlighted the need for an improved transition from pediatric to adult healthcare services. The survey also showed that COVID-19 has considerably affected caregivers and individuals with TSC.

Implementing patient-initiated follow-up in dermatology: a local departmental experience

As part of the National Health Service's response to the COVID-19 pandemic (https://www.england.nhs.uk/outpatienttransformation- programme/patient-initiated-follow-up-givingpatients- greater-control-over-their-hospital-follow-up-care/), and in line with the personalized care agenda (https://www.bad. org.uk/shared/get-file.ashx?itemtype=document&id=7237), 'patient-initiated follow-up' (PIFU) is being implemented across secondary care. This has been introduced by the National Outpatients Transformation Team and the aim of this initiative is to encourage self-management in patients and facilitate shared decision-making, together with supporting clinical waiting list reviews. The expected benefits include flexible personalized pathways and better access to specialist care when needed, thus benefiting general practitioners and the department. It replaces the old-style 'open appointment', which was rigid, without a clear pathway and not accurately recorded, impacting on demand and capacity planning. The British Association of Dermatologists has adapted this guidance and produced a document to support the roll out of this initiative throughout dermatology departments in England.4 It is important that clinicians appropriately assess which patients are suitable for PIFU. Criteria for selection include a low risk of urgent follow-up;confident to take responsibility of their care by understanding the condition, symptoms and when to seek advice;and understanding how to re-access care. Our experiences in setting up and using the PIFU pathway are shared. In our trust, it was first rolled out in dermatology and urology, two specialities with a high number of follow-ups. For dermatology, we included clinics in the main department and across all four community sites. In order to set up this service, engagement was sought with key stakeholders (service managers, administrative teams and clinicians). A Standard Operating Procedure was created to classify the pathway, agreed processes for the administrative and secretarial team, and written information for patients and general practitioners. Education sessions were given on how to use PIFU, assess patient suitability and measure outcomes. From September 2021 to November 2021, 548 patients have been added onto a PIFU and, as of December 2021, 11 have used it to re-access care. A staff survey has been done and has shown overall positive feedback, with 68% having a positive experience and only 8% having a negative experience. Seventy-six per cent of staff feel it is better for patients and doctors/administrators, and 95% would recommend it to other departments. The only negative issues have been an increase in workload for the secretaries who send out the written information. We aim to obtain patient feedback once more have re-accessed care, which we hope to present alongside our experiences on the benefits and challenges of implementing PIFU.

Lung Cancer Screening Program via Primary Care Clinics

Lung Cancer Screening (LCS) reduces lung cancer mortality by 20 to 24% however in the US only 5.7% of eligiblepatients participate. Increasing screening of individuals at risk for lung cancer is an unmet need. We started a LCSprogram using primary care physicians (PCP) visits where the intake nurse asked age appropriate patients abouttheir smoking status. If patients met criteria, the physician was alerted to perform shared decision making, offersmoking cessation and order a low dose screening CT scan (LDCT). The results were managed by a physician'sassistant dedicated to the LCS program. This quality improvement study analyzed all patients enrolled from June2019 to July 2021. The LCS program rolled out slowly beginning with 6 PCPs in June to November 2019, 26 PCPsfrom November 2019 to February 2020 and all 56 PCPs from February 2020 to July 2021. COVID-19 stopped LDCTsfrom March 2020 to August 2020. Use of a LCS program run through PCP clinics screened 1,247 (21.3%) eligibleveterans, a 3.7 fold increase over the national average. Of the 2,069 (35.3%) eligible patients initially identified by thecomputer based reminder, 1,824 (88.2%) accepted LCS, 1,383 (66.8%) completed the initial LDCT and 136 (9.8%)were ultimately found to be ineligible after completion of the LDCT. The 136 ineligible patients received 173 LDCTs ofwhich 91% were Lung-RADS 1 or 2 and 0.6% were Lung-RADS 4A. Within the appropriately screened patients, 12(1%) lung cancers and 1 papillary thyroid cancer were found and 26.5% of scans showed evidence of Chronic Obstructive Pulmonary Disease and 11.9% showed coronary artery disease. Use of PCP clinics increased enrollment 3.7 fold over national averages.

Using participatory management to empower nurses to identify and prioritize the drivers of their burnout

Background: The coronavirus disease 2019 (COVID-19) pandemic contributed to intensified nurse burnout. Workplace factors influence burnout, requiring organizational-level action to mitigate this problem. Aim: To inform immediate and long-term organizational tactics, we created workforce-informed recommendations for addressing burnout by engaging our nursing workforce to identify and prioritize the factors driving their burnout. Methods: We creatively applied the participatory management LISTEN-SORT-EMPOWER model to gather nurse views on burnout, capturing data through focus group sessions and mobile app postings. We coded findings through thematic and sentiment analysis, and participants ranked these results to prioritize the factors of their burnout. Results: We collected 80 h of feedback and 603 app comments, resulting in 800,000+ words. Our analysis identified twelve drivers of burnout, including three themes: (1) Staffing shortages (660;43.8%);(2) Environment and culture (548;36.4%);(3) Total compensation (299;19.8%). Additionally, 1300+ nurses chose income, workload/stress injury, and work schedule as uppermost priorities for addressing their burnout. Conclusions: Through novel project methods, leaders embraced participatory management to actively partner with nurses in identifying the drivers of nurse burnout. Healthcare organizations can design relevant and effective interventions to lessen clinician burnout by directly engaging and partnering with those experiencing burnout. © 2023 Informa UK Limited, trading as Taylor & Francis Group.

Teledermatology triage models: redesigning the concept of outpatient referral

A total triage model for dermatology outpatient referrals has become increasingly important following the COVID-19 pandemic, both to ensure prioritization of outpatient appointments and to provide digital advice based on teledermatology images to support patients on long outpatient waiting lists. Digital specialist advice can support general practitioners (GPs) to commence appropriate treatment before or instead of a face-to-face review for selected patients. In England, the National Health Service (NHS) e-referral service (e-RS) offers two distinct triage channels: the referral assessment service (RAS) channel, and the advice and guidance (A&G) channel. In this study we compared the quantitative and qualitative impact of the RAS and A&G channels on non-2-week wait patient referrals in a large teaching hospital dermatology department between October and December 2021. Teledermatology images were encouraged with all referrals and all GPs had access to the Consultant Connect © secure clinical image app to allow use of personal mobile phones for image capture. In total, 984 patient 'referrals' were sent to the dermatology department through the RAS channel and 642 patient 'advice +/- referral' requests were sent through the A&G channel. Ninety-four per cent of patients referred through the RAS channel were added to an elective care waiting list with a waiting time of several months and no interim advice as RAS does not allow consultants to provide interim advice in e-RS. Only 6% of patient RAS referrals were returned with advice. In contrast 73% of patients sent through the A&G channel were managed with digital advice within 2 working days, and 27% of A&G requests were converted to referral with interim advice for the GP to help manage the patient while on the waiting list. The A&G channel of the NHS e-RS was converted into an advice, guidance and referral channel in February 2021 to support elective care recovery. By allowing two-way dialogue, A&G supports shared decision-making between GP and consultant, regardless of whether the patient is added to a waiting list or not. This new A&G functionality is helping to redesign the concept of 'outpatient referral', moving away from a refer/accept/reject model towards a model of 'specialist input and dialogue' and educational exchange. The A&G model is supported by the 'Getting It Right First Time' (GIRFT) Dermatology programme, and the Dermatology National Outpatient Transformation Programme, promoting equitable patient access to digital specialist advice using teledermatology.