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1.
Int J Occup Saf Ergon ; : 1-21, 2022 Oct 27.
Article in English | MEDLINE | ID: covidwho-2087553

ABSTRACT

OBJECTIVES: This study analyzes the differences between goods companies with Standard No. ISO 9001:2015 Quality Management System (QMS) and those without it, in terms of implementation of biosecurity measures during the COVID-19 pandemic. The study shows whether having a QMS helped companies to implement the biosecurity measures required to continue operating during a pandemic. METHODS: The sample was composed of 145 Peruvian goods companies. The empirical data were collected through a questionnaire sent to company presidents, general managers, and department heads. The questionnaire focused on four biosecurity dimensions in the workplace: Protocols, Preventive Actions, Biosecurity Processes, and Risk Management. RESULTS: The study found that companies with a QMS (Standard No. ISO 9001:2015) significantly differed from companies without it in the implementation of three of the four biosecurity dimensions. CONCLUSIONS: This study is useful for academia and companies because it identifies the main differences between certified and non-certified companies, in terms of adoption of biosecurity measures. This study highlights the importance of a QMS to respond to hazardous situations like a global health crisis, but also provides useful information for the strategic decision-making process of companies.

2.
Pharmaceutical Journal ; 309(7964), 2022.
Article in English | EMBASE | ID: covidwho-2065050
3.
International Journal of Stroke ; 17(1):8, 2022.
Article in English | EMBASE | ID: covidwho-2064669

ABSTRACT

Introduction: Quality improvement activities have traditionally been face-to-face, a model limited in reach and regional and remote inequities. The coronavirus pandemic (COVID-19) necessitated adaptation to an interactive digital format which led to the development of the National Webinar Series. Aims: To improve stroke patient outcomes and reduce inequities in the provision care through a national digital quality improvement program. Methods: Collaborating with state and territory hospitals, specialists stroke experts and other expert organisations, we piloted a national digital interactive quality improvement program. The program utilised data and evidence from the National Stroke Audit and Clinical Guidelines for Stroke Management to support clinicians to identify barriers and gaps and provide effective improvements in quality of care. A secure webinar environment facilitated collaboration between sites and states, and a peer-topeer model allows opportunities for exemplary hospitals to share strategies for improvement Results: From July- December 2021, 940 health professionals, from 235 sites, attended our webinars. The online format has successfully enabled nationally equitable access for professional development, regardless of location, and continuity of education throughout disruptive lockdowns/ border closures. Topics include discharge planning and 'My Stroke Journey', audit, living guidelines, stroke prevention, sexuality, delirium, and best practice smoking cessation. Participants surveys showed that 93% agreed the program would help improve national consistency in stroke care, 100% recognised the training value for staff new to stroke, 91% would recommend the webinars to others and 100% were interested in future webinars. Conclusion/Discussion: We have learned from health professionals participating in our National Webinars that the webinars educational model could be an effective tool for patient support post-discharge from hospital. COVID-19 has placed a strain on hospitals and staffing. As a result, stroke patients are being discharged early and aren't receiving all the information they need to transition from hospital to home and support their recovery.

4.
Archives of Disease in Childhood ; 107(Supplement 2):A439, 2022.
Article in English | EMBASE | ID: covidwho-2064060

ABSTRACT

Aims The National Institute of Excellence (NICE) in 2016 guideline recommendations as per requirements of Care Act 2014, states to follow best practice for Transition from children to adults' services for young people who are using health or social care services. During this transition period the young people can be comprehensively prepared with adequate provision of information, services geared towards young people, person-centered planning, which is delivered by adequately trained professionals both in children's and adults' services, including support for parents and care providers. Our transition clinics are attended by Paediatrician, Rehabilitation medicine consultant, other relevant clinicians, and therapists. The aim of the study is to determine the quality of Transition Clinic Multidisciplinary Team proforma completed by Community Paediatrics team. Methods Retrospective data about Transition clinic, was retrieved from electronic health record database called systemone. The data collected from 4 clinics held over one year period between February 2020 to 2021. The clinic details are recorded on purpose-designed proforma for discussion in multidisciplinary meeting in transition clinic. The proforma captures these young people complex needs and comorbidities including learning disability, motor impairment, skeletal deformity, and feeding difficulties. The data was analysed and compared using Microsoft excel 2010. Results A total of 11 patients with age ranges from 15 to 19, were reviewed in Transition clinic from February 2020 to 2021. Among these cases, 6 patients had virtual consultation due to pandemic. There were higher proportion of girls about 63% compared to boys, who were about 36%, reviewed in these clinics. Among them 82% had Cerebral palsy and the rest 18% had complex congenital abnormality. There was 100% accuracy in the clinical data entry with regards to diagnosis, medication, and general health enquiry, except clinical examination which is close to 36%. This could be due to virtual clinics held during pandemic. Other professional and therapist involvement had been documented in a separate section. Also, there was 100% documentation on detailed plans, however only 30% had information about the relevant contact details for other services. The statistical calculation is not possible due to small sample size. Conclusion The study demonstrates that majority of these transition clinic entries followed MDT proforma. The clinical documentation does reflect the multidisciplinary discussion with focus on the young person's complex and multiple needs during transition period and to support before transition into adult care service. The professionals tried their best to deliver the care during the COVID pandemic, without any cancellation, also parental and carers concerns about pain and growth were taken into consideration during these virtual clinics. All children's and adults' services should give young people and their families or carers information about what to expect from services and what support is available to them. Therefore, we have introduced a standardised proforma incorporating the key areas specified by NICE, which include relevant details and contact information about the available adult services. The revised transition clinic format has been created as quality improvement project to improve clinical documentation.

5.
Archives of Disease in Childhood ; 107(Supplement 2):A346-A347, 2022.
Article in English | EMBASE | ID: covidwho-2064041

ABSTRACT

Aims Many paediatric emergency departments (PED) reported an unexpected increase in attendances during summer 2021;most of these children were stated to have minor illnesses and were discharged with reassurance. The primary objective of our questionnaire was to obtain parental perspective of how changes to local acute paediatric healthcare services in response to Covid-19 had impacted upon accessing care for their children. Additional objectives aimed to identify if parents were more worried about their child's health in view of the pandemic, understand parents' ideas of how children should be assessed when unwell, and explore how parents felt remote consultations could be improved. Methods A questionnaire comprised of Likert scale, multiple choice and free-text questions was developed to explore the study aiSeveral iterations of the questionnaire were test-run with parents prior to roll-out. The project was registered with the Trust's Quality Improvement team. A total of 88 families presenting to the paediatric emergency department and local urgent treatment centres completed the questionnaire between 26th October and 31st December 2021. Excluded were families for whom a translator was needed for their medical assessment. A thematic analysis was performed using NVivo, and quantitative analysis performed using PRISM statistical software. Results 68.2% of parents had sought medical advice outside of the PED prior to presentation, either in the community and/or online. 20.5% of respondents sought healthcare input from two or more sources prior to attending PED. Figure 1 outlines the responses to Likert-scale questions. Statistical analysis of the responses in relation to of age of child, number of children in the family and whether English was the family's first language was performed. Confidence of phone/video assessments and English/non-English as first language approached statistical significance (p=0.059). No other comparisons were statistically significant. Analysis of free-text responses identified key themes regarding the parental expectation of how children should be reviewed when unwell, and how parents thought remote consultations can be improved. An outline of the identified themes and a selection of responses are outlined in Figure 2. Conclusion The questionnaire identified that parents had still been able to access healthcare during the pandemic when they felt their child was unwell. Parents reported concerns of their children becoming sick with Covid-19, but still felt confident managing minor illnesses at home. The increasing volume of remote assessments in primary care was a necessary adjustment during the pandemic which is likely to be embraced as a more permanent model of service. Many parents recognised the benefit of remote consultations for non-urgent issues. However, a key theme from the questionnaire was the lack of parental confidence in remote (particularly phone) consultations;parents were more likely to still seek a face-to-face assessment in PED if they felt they couldn't communicate their child's signs and symptoms over the phone. As local networks embrace a more remote model of working to deliver some urgency and emergency care it is necessary to identify the cohorts of patients who may still attend PED, and plan how better to provide clinical reviews for them in the community.

6.
Archives of Disease in Childhood ; 107(Supplement 2):A150-A151, 2022.
Article in English | EMBASE | ID: covidwho-2064024

ABSTRACT

Aims Hospital Miri is a district hospital with NICU that caters neonatal care service in Northern Sarawak. Preterm birth rate in our centre makes up of 10% (n=487) in 2019 and 11% (n=491) in 2020 of the live births, with mortality rate of 3% for preterm infants less than 33 weeks. According to WHO and Cochrane review (2016), Kangaroo mother care helps to reduce mortality, nosocomial infection, hypothermia, and improved growth and exclusive breastfeeding. Methods This is a retrospective observational study. Kangaroo Mother Care (KMC) Project was introduced in 2020 in Hospital Miri NICU as part of quality improvement project. Stable preterm infants with postmenstrual age 30 weeks to 34 weeks 6 days were enrolled with mother's consent into the project. It was carried out in 3 phases, with phase 1 of stable infants under room air or HFNC, phase 2 of stable infants on NIV and phase 3 with intubated infants. As COVID-19 endemic encroached, the project was put on hold at phase 2. Infants' demographic data was analysed using frequency and percentage. Outcomes were measured in mean, frequency and percentage. Maternal mental health score, knowledge score were taken prior to implementation of KMC and upon discharge. The mental health score is described as median and knowledge score is compared by wincoxon signed-rank test. Overall experience score was taken as median and mean. Results A total of 41 infants with the gestation of 32 to 34 weeks 6 days participated, 22 (53.7%) with majority of 41.5% aged 34 to 34 weeks 6 days post menstrual age at the time of enrolment. Mean length of stay was 38.34 days (SD:24.4), time taken to achieve birth weight was 11.4 days (SD: 4.05). Time taken to initiate breastfeeding range from 8 to 14 days to >22 days of life, mean: 24.78. Eighteen infants (43.9%) achieved exclusive breastfeeding on discharge. Mother's mental health, knowledge and experience were measures using Likert scale with the total score of 15 for mental health and 18 for knowledge and experience. For mental health score, pre-KMC median score:14, post-KMC median score was 15. There was improvement in the mother's experience upon discharge (p-value: <0.001). For overall experience, median was 18 with the mean score of 16.88 (SD:1.56). Conclusion Our study was suspended prematurely as per local pandemic control guideline. Knowing about the benefit of KMC to both mother and infants, we suggest that it should be encouraged and continued with adaptation and modification of the procedure during COVID-19 pandemic.

7.
Chest ; 162(4):A2594, 2022.
Article in English | EMBASE | ID: covidwho-2060971

ABSTRACT

SESSION TITLE: Late Breaking Pulmonary Vascular Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Pulmonary embolism (PE) is a common form of thromboembolism which has a variable and non-specific presentation that can often be fatal. The Simplified Pulmonary Embolism Severity Index (sPESI) which includes hemodynamic parameters of perfusion has been shown to correlate with 30-day mortality in patients with acute PE. The purpose of this quality improvement project was to compare how lactate and sPESI perform in predicting clinical outcomes at our institution with the hopes of developing institutional guidelines for management of patients admitted with an acute PE. METHODS: We conducted a single center retrospective analysis on patients admitted to the intensive care unit with a new diagnosis of PE between the years 2016-2021. Patients were identified using ICD-9 CM codes. Exclusion criteria included current or prior positive testing for SARS-CoV-2 (COVID-19). We performed univariate, multivariate, and ROC (Receiver Operating Characteristic) analysis to assess correlations between all cause mortality, lactate, and sPESI. Both lactate and sPESI were included as continuous variables. Our covariates included age, sex, Body Mass Index, prior or current history emphysema/COPD, smoking, CKD, diabetes, cancer, atrial fibrillation, and CHF. All analysis was carried out using software R version 3.6.3. RESULTS: Of the 161 patients who were included in the study, the mean age was 60 years (SD 17 years) and 38% (61/161) were females. 31 patients (19.3%) were deceased. Mean BMI of study participants was 29.9 kg/m2. Comorbidities included 9.9% (16/161) with emphysema/COPD, 44% (71/161) with active or prior history of smoking, 6% (10/161) with CKD, 12% (20/161) with diabetes, 15% (24/161) with diagnosis of cancer, 15% (24/161) with atrial fibrillation, 15% (24/161) with history of CHF. We found that in univariate analysis, both sPESI (p=3.4*10

8.
Chest ; 162(4):A1506-A1507, 2022.
Article in English | EMBASE | ID: covidwho-2060835

ABSTRACT

SESSION TITLE: Respiratory Care: Oxygen, Rehabilitation, and Inhalers SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Background More than 1.5 million Americans live with supplemental oxygen that improves quality of life in adults living with chronic lung disease. After hospitalization for serious illness such as pneumonia (especially COVID), heart failure, COPD exacerbation or other lung disease, patients are discharged on supplemental oxygen. Hypoxemia often resolves after recovery from the illness and supplemental oxygen is no longer needed. As a part of “Choosing Wisely” campaign from ABIM, ATS/ACCP recommends “For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, don’t renew the prescription without assessing the patient for ongoing hypoxemia within 90 days after discharge. Objectives The primary objective of the study is to improve home oxygen reassessment after discharge from the hospital. METHODS: Study Design Subjects will be identified by electronic medical records (EMR) report and will include data from the 1st of January 2021 to 30th June 2021 (period of 6 months) Inclusion Criteria Subjects 18 years and older who were discharged from the RPH on supplemental oxygen Exclusion: Subjects 18 years and older on oxygen for palliation and hospice Study Outcomes The primary outcome measure will be assessed as percent of patients in whom oxygen requirement reassessed and percent in whom oxygen requirement was not reassessed. The secondary outcome measure will be assessed as percent of patients who had PCP follow up and percent of patients on continuous oxygen without reassessment Quality improvement PDSA: Phase I: pre-intervention data Phase II: Intervention-> education session to the providers and new epic order inclusion (BPA for reassessment and discontinuation) Phase III: post-intervention survey RESULTS: Based on chart review, 155 patients qualified for the study criteria. Among 155 patients, regarding the primary outcome-> 63 patients (40.6%) 90 days oxygen reassessment was done, 64 patients (41.2%) oxygen reassessment was not done, 10 patients (6%) died within the 90 days reassessment period and 19 patients were 90 days reassessment was not applicable (12%- 19 patients-on long term oxygen). Regarding the secondary outcomes, 113 patients (72.9%) were followed up with PCP, 16 patients (10.3%) did not have follow up, 19 patients (12.2%- no information available) had outside PCP follow up, 7 patients (4.5%- 2 died on same admission, 5 opted for hospice). Regarding patient who continued to use oxygen, 74 patients (47.7%) were continued on oxygen, 47 patients (30.3%) were discontinued of oxygen and 34 patients (22%) did not have any information available regarding oxygen use. CONCLUSIONS: From the above data, There is room for improvement regarding oxygen reassessment by educating primary care providers. Post intervention survey will be done in 6 months. CLINICAL IMPLICATIONS: Improve oxygen reassessment in patients after discharge with oxygen DISCLOSURES: No relevant relationships by Anam Aqeel No relevant relationships by Mansur Assaad No relevant relationships by Apurwa Karki No relevant relationships by Shobha Mandal No relevant relationships by Rajamurugan Meenakshisundaram

9.
Chest ; 162(4):A1465, 2022.
Article in English | EMBASE | ID: covidwho-2060821

ABSTRACT

SESSION TITLE: Actionable Improvements in Safety and Quality SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Ventilator alarms are an audible and visual safeguard within a system which alerts clinicians to potentially critical changes within the patient or ventilator unit. They are a crucial aspect of patient care;however, not every alarm that is generated by the ventilator will provide actionable information. Unfortunately, this can contribute significantly to the overall alarm burden in the intensive care unit. This has been especially true with the marked increase in ventilator use during the COVID-19 pandemic. The individual impact of each alarm can easily become dampened due to the sheer quantity of alarms, ventilator-related and others. Excessive alarming may lead to cognitive overload and alarm fatigue for providers, and eventually, adversely impact patient outcomes. This potentially can lead to missed life-sustaining interventions and medical errors. METHODS: As part of a quality improvement initiative, we evaluated ventilator alarms through the month of October 2021 in the medical intensive care unit within Bellevue Hospital Center in New York City. Respiratory therapists recorded ventilator parameters and extracted alarm data daily from every ventilator within the medical intensive care unit. Ventilator logs were exported from each individual Servo-U ventilator unit in use onto a USB flash drive and the captured data was uploaded to a secure network for review. For each ventilator, data regarding specific alarm type and priority as defined by the manufacturer, as well as time, frequency, and duration was obtained for review. RESULTS: From October 4, 2021, to October 31, 2021, a total of 30,230 ventilator alarms were initiated over 672 hours in the MICU. This provided an approximate mean of 45 alarms per ventilator hour. Data was collected daily from all MICU ventilators in use which averaged about 12 ventilators per day (between 6-16). The top four alarms as defined by the ventilator were “airway pressure high,” “respiratory rate high,” “PEEP [positive end expiratory pressure] low,” and “expiratory minute volume low.” 18,451 alarms over the month were “airway pressure high.” 3,982 alarms were defined as “respiratory rate high.” 2,220 alarms were “PEEP low” and 2,041 alarms were “expiratory minute volume low.” CONCLUSIONS: Ventilator alarms, both nuisance and actionable alarms, contribute significantly to the alarm burden in the medical intensive care unit. Dedicated research is necessary to ensure safer alarm practices. CLINICAL IMPLICATIONS: Evaluating baseline alarm data allows for assessments as well as analyses of trends and patterns that are contributing to the excessive noise within the intensive care units. This gives hospitals an opportunity to provide targeted multidisciplinary educational initiatives and create standardized protocols to enhance the quality and safety surrounding ventilator alarms within intensive care units. DISCLOSURES: No relevant relationships by Kerry Hena No relevant relationships by Charmel Rogers no disclosure on file for Amit Uppal;No relevant relationships by Tatiana Weinstein

10.
Chest ; 162(4):A840, 2022.
Article in English | EMBASE | ID: covidwho-2060703

ABSTRACT

SESSION TITLE: Sepsis: Beyond 30cc/kg and Antibiotics SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Sepsis is the leading cause of hospitalization and mortality in the United States. In addition, sepsis is, by volume, the leading cause of 30 day readmissions across all payer mix in the United States. The risk factors for 30 day readmissions are multifactorial and often portends poor outcomes and increase hospitalization costs. We trialed a pilot program of enhanced sepsis discharge education which consisted of direct patient education prior to discharge, providing a Sepsis Education brochure with tips on self management at home as well as a QR code to direct patients to institutional website in case they needed further assistance, and finally a disposable thermometer to maintain an accurate temperature log to aid in monitoring for signs and symptoms of sepsis. Our primary goal was educate patients about their diagnosis and reduce sepsis readmissions in all non-medicare patients being discharged home. METHODS: The pilot was implemented at on one med/surg unit in our 550-bed tertiary, academic medical center starting in March 2021 and progressively expanded hospital wide over the next six months. The sepsis administrative coordinator screens new in-patient admissions for sepsis (non-Medicare) patients daily and informs medical/surgical unit coordinators of potential candidates. Med/surg coordinators will confirm if patients meet criteria for follow-up (non-Medicare, being discharged to home), provide discharge education and enter the patient in a log for continued surveillance. Subsequently, the administrative coordinator then follows up with a phone call 7-10 days after discharge during which, they assess the patient for worrisome symptoms, confirms follow up appointments, medication compliance and review of temperature log. If the patient needs clinical assistance, they will refer to the patient to the hospital sepsis clinical coordinator or patient’s outpatient physicians. RESULTS: We compared sepsis discharges and 30day readmissions (all excluding COVID-19 cases) from March 1, 2019 – Dec 31, 2019 to March 1, 2021 – Dec 31, 2021. Readmissions amongst Medicare patients discharged home was 15.9 % (110 / 962) in 2019 vs 11.9% (83 / 696) in 2021. For non-medicare patients, the rate was 13.2% (41/311) in 2019 vs 13.1% (51/390) in 2021. In our pilot program, the readmission rate in medicare patients was 17.2% (28/163) versus 5.6% (5/90) in non-medicare patients. CONCLUSIONS: This program captures a patient population which may have been lost to follow-up. Implementation of the enhanced Sepsis Discharge Education led to at least a 30 patient reduction in readmissions yielding an approximate cost savings of $594,000. CLINICAL IMPLICATIONS: Providing educational support, instructions, and follow up calls upon discharge improves medication adherence, compliance, and maintains patient follow up thus reducing readmissions and improving hospital resource utilization and overall cost. DISCLOSURES: No relevant relationships by Laura Freire No relevant relationships by Nirav Mistry No relevant relationships by Caitlin Tauro

11.
Journal of Pediatric Gastroenterology and Nutrition ; 75(Supplement 1):S258-S259, 2022.
Article in English | EMBASE | ID: covidwho-2058386

ABSTRACT

Background: NASPGHAN guidelines for fellowship training in pediatric gastroenterology (GI) highlight the importance of multidisciplinary treatment across GI conditions. Specific required medical knowledge for pediatric GI fellows includes (1) understanding of the biopsychosocial model and brain-gut axis involvement in functional GI disorders (FGIDs) and (2) familiarity with the role of psychological evaluation and interventions within the multidisciplinary management of FGIDs. Pediatric psychologists are well-suited to provide this training as education of interdisciplinary professionals is a defining competency in pediatric psychology. While pediatric GI psychologists may be informally involved in the training of GI fellows through shared multidisciplinary patient care, we sought to develop a didactic series to formalize a GI Psychology curriculum consistent with clinical training guidelines and the expressed interests of fellows at our institution. Method(s): GI psychologists and GI chief fellows at Children's Hospital of Philadelphia (CHOP) developed an 8-lecture didactic series to be incorporated into an existing weekly didactic meeting for all GI fellows. GI psychologists presented a topic quarterly over the course of 2 training years (FY20-FY21). Topics for the inaugural 2-year series were: Introduction to GI Psychology, Giving the Positive Functional Diagnosis, Cognitive Behavioral Therapy for Functional Abdominal Pain Disorders, Behavioral Interventions for Constipation and Encopresis, Psychosocial Adjustment in Inflammatory Bowel Disease, Behavioral Treatment of Rumination Syndrome, Somatic Symptom Disorders, and Treatment Adherence. In summer 2020, GI psychologists also presented an unplanned didactic session related to coping with secondary traumatic stress during the COVID-19 pandemic. For the next iteration of the 2-year series (FY22-FY23), GI psychologists selected a new topic of Feeding and Eating Difficulties: Role of GI Psychology to replace Introduction to GI Psychology. Introduction to GI Psychology was moved to a fellow orientation session. Fellows participated in the first three years of the program which spanned the inaugural 2-year series and 1 year of a second series (n = 12, 11, 11). Attendance at specific didactic sessions was not recorded. At the end of each training year, fellows completed an anonymous program evaluation survey via REDCap for ongoing quality improvement. Fellows rated 5 items assessing the impact of the didactics on their knowledge of the biopsychosocial approach, delivery of clinical impressions and recommendations, confidence with description of psychological goals and strategies, and recommendations for continuation of the GI Psychology didactics. Items were scored on a 5-point Likert scale ranging from Strongly Agree to Strongly Disagree. During the inaugural 2-year series, the survey also included items rating the value of each didactic topic. Each year the survey allowed for open-ended suggestions for additional topics. Result(s): The GI Psychology didactic series for GI fellows has been implemented successfully at CHOP for an inaugural 2-year series (FY20-FY21) with a second series currently in progress (FY22-FY23). Although survey response rate was low (33% FY20;9% FY21;45% FY22), 100% of the fellows completing the survey Agree/Strongly Agree the didactic series increased their knowledge of the biopsychosocial approach to managing GI conditions, informed how they deliver clinical impressions and treatment recommendations for patients/families, recommended continued GI Psychology involvement in GI fellow didactics and recommended other institutions consider Psychology involvement in GI fellow didactic education. Additionally, 80% of the fellows Agree/Strongly Agree the didactic series increased their confidence to describe common goals and strategies within psychological treatment for patients with GI conditions. Conclusion(s): We describe development of a novel GI Psychology curriculum for GI fellows at CHOP focused on core topics to enhance competency in the biopsychosocial approach across GI conditions, which was favorably evaluated by GI fellows. Fellowship training programs in pediatric GI may wish to consider a similar approach to incorporating didactic training from pediatric psychologists. Doing so may increase relevant medical knowledge and facilitate experience with and use of a multidisciplinary approach to evaluation and management across GI conditions, consistent with NASPGHAN clinical training guidelines and calls for best practice to incorporate integrated psychological care across GI conditions.

12.
Journal of Pediatric Gastroenterology and Nutrition ; 75(Supplement 1):S147-S148, 2022.
Article in English | EMBASE | ID: covidwho-2058251

ABSTRACT

Background: Clinical documentation is a means to document care and supports several important areas including inter-provider and patient communication, reimbursement, patient safety, and overall patient care. However, a significant knowledge gap exists with respect to the evaluation and potential improvement of the quality of outpatient clinical documentation. This may be related in part to a lack of standardized tools or metrics to assess clinical documentation. Aim(s): 1) To develop a reliable outpatient assessment & plan clinical documentation scoring tool;and 2) To assess its impact on improving clinical outpatient documentation quality amongst pediatric gastroenterologists. Method(s): Development of a clinical documentation scoring tool: A tool was developed to score the assessment & plan sections of outpatient clinical notes for both clarity and soundness (Table). It was implemented in 2020, and after two rounds of division-wide scoring, a formal IRB-approved investigation of scale reliability was undertaken. An additional round of scoring took place in 2021. The implementation of telemedicine in response to the COVID-19 pandemic permitted subanalyses of telemedicine vs in-person clinical documentation. QI Project: Assessment & plan documentation of new outpatient visits within a single center were extracted between 2020 and 2021 (18 months). Ten notes were compiled from each clinician, and the chief complaint was used as a guide to increase variability. All identifiers were removed. Using the tool, division clinicians then scored 10 clinic notes from other members of the division. Following each cycle, peer scores were provided back to each clinician. In addition, anonymized scores were shared amongst the division's clinical providers. Scales Reliability Assessment: After the first two rounds of the QI project, IRB approval was secured for a separate study. Division clinicians used the developed tool to rate the clarity and soundness of assessment and plan documentation from a set of 10 examples (Set 1). The same providers were asked to complete a second set of 10 examples (Set 2) several months later. Both sets were comprised of 5 overlapping cases to calculate the inter-rater and intra-rater intra-class correlation coefficient (ICC) for both scales. Result(s): Scale Reliability Analyses: The above protocol created 3 different scoring sets for calculating the inter-rater ICC of the clarity and soundness scales: Set 1, Set 2, and Combined Set 1 & 2. The Clarity Scale inter-rater ICC for these sets were 0.71 (N=9), 0.51 (N=11), and 0.51 (N=8), respectively. The Soundness Scale inter-rater ICC for these scoring sets were 0.51 (N=9), 0.31 (N=10), and 0.32 (N=8), respectively. The Clarity Scale intra-rater ICC was 0.77 and 0.55 for the Soundness Scale (N=8 for both analyses). Quality Improvement: We found a trend toward increasing clarity and soundness scores with each subsequent round of scoring (Figure). The number of evaluations which scored less than a 3 on the clarity scale decreased from (52/407) 12.8% to (34/394) 8.6% and finally (36/433) 8.3%. Of note, scoring of clarity and soundness in notes derived from telemedicine vs in-person visits were similar. Conclusion(s): There is great interest in QI in Pediatric Gastroenterology, although it is difficult to find universally applicable targets. The assessment & plan sections of the outpatient note is of central importance and has the potential to be a useful area for QI. Scoring the clarity of notes is relatively reproducible, and this program has the potential to yield substantial improvement amongst a clinical team. Soundness of the assessment & plan documentation is more subjective and will require additional revision in order to achieve favorable reliability.

13.
Journal of Pediatric Gastroenterology and Nutrition ; 75(Supplement 1):S6-S7, 2022.
Article in English | EMBASE | ID: covidwho-2058077

ABSTRACT

Background: Enteral tubes, including nasogastric (NG) tubes, are an important tool in managing multiple medical conditions in which oral feeding cannot be successfully accomplished due to feeding ability or safety, and these devices are commonly employed at children's hospitals worldwide. While these devices are life-saving, they can develop are a significant burden on families and the healthcare system. There is relatively little published data on the practices of pediatric enteral tube outpatient management, including whether primary outpatient management is undertaken by pediatric gastroenterologists or other medical practitioners (e.g. primary care providers and other pediatric subspecialists), and if a primary management team would affect overall clinical outcomes. In the late fall of 2019, at the American Family Children's Hospital (AFCH), a tertiary care children's hospital, pediatric outpatient enteral tube management, with the exception of tubes in patients under the primary care of Pediatric Hematology/Oncology (PHO), was fully assumed by the Pediatric Gastroenterology (PGI) division, with previous management divided or shared among the PGI division, primary care providers, and other pediatric subspecialists. Due to the division having subspecialty nurses, nurse practitioners, and physicians who had expertise managing enteral tubes on an inpatient and outpatient basis, we hypothesized that primary outpatient management by Pediatric GI would reduce ED utilization for nasogastric tube evaluation. Method(s): We performed a retrospective chart review of all patients discharged from AFCH with a nasogastric tube in place from March 1 2018 to October 31 2019 and June 1 2020 to January 31 2022. The study was reviewed by the University of Wisconsin-Madison Minimal Risk Research Institutional Review Board and met criteria for exempt human subjects. We left a 7-month temporal gap to allow for complete implementation of the policy of pediatric GI management to be uniformly practiced within the hospital, and to account for the beginning of the COVID-19 pandemic, when outpatient clinics were closed and ED evaluation was required for all hands-on non-inpatient medical care at our institution. Patients were grouped and analyzed according to being pre-intervention or post-intervention, and they were followed until either their NG tube was permanently removed, or until their NG tube was replaced with a gastrostomy tube. Patients were excluded if they were primarily managed by PHO, lost to followup, still had NG tube in place at time of data analysis, died during the study period, or had their tube converted to a postpyloric tube. Our primary outcome was the incidence rate of ED visits for nasogastric tube evaluation per patient-weeks between the pre- and post-intervention groups. Patient demographics and diagnoses were also recorded and analyzed. Statistical analysis was conducted. Result(s): There were 130 patients identified after applying inclusion and exclusion criteria, with 56 in the pre-intervention group and 74 in the post-intervention group. The median chronological age of patients in the pre-intervention group was 5 months, and it was 6 months for the post-intervention group. The mean time from initial hospital discharge to either NG tube removal or conversion to gastrostomy tube was 6.2 weeks in the pre-intervention group and 8.8 weeks in the post-intervention group. In the pre-intervention group, the incidence rate of ED visits for NG tube evaluation was 15.6 visits per 100 patient-weeks (95% Confidence Intervals (CI): 11.7-20.3), and in the post-intervention group, the rate was 9.7 visits per 100 patient-weeks (95% CI: 7.4-12.4). Discussion(s): This study demonstrated that at our institution, there appeared to be a decrease in ED utilization for nasogastric tube evaluation after outpatient tube management was assumed by the PGI division, but this decrease was not quite enough to reach statistical significance. This study is limited by multiple factors including the retrospective nature of the study, modest sample size limiting statistical power, and, potentially, lingering effects of the COVID-19 pandemic affecting patient care decisions. Identifying balancing measures from this intervention, as well as identifying alternative changes that could further decrease ED evaluation rates, can be explored in future quality improvement initiatives.

14.
Journal of Pediatric Gastroenterology and Nutrition ; 75(Supplement 1):S155-S156, 2022.
Article in English | EMBASE | ID: covidwho-2057941

ABSTRACT

BACKGROUND: Electronic health record systems (EHRs) represent one of the most widely adopted digital healthcare technologies in the past decade. Among the potential benefits of EHRs has been the quantification of individual physician time spent performing key components of clinical workload. Epic EHR is a global system with the majority market share in North American acute care and ambulatory arenas and may offer a means to quantify the clinical workload of pediatric gastroenterology, as a subspecialty field of medicine. OBJECTIVE(S): To quantify clinical workload of pediatric gastroenterology across Epic EHR systems. METHOD(S): From January 2020 through April 2022, we evaluated Signal EHR data captured in Epic for all pediatric gastroenterologists (PGI), defined as physicians (MDs) with an Epic specified PGI profile. Signal data provides detailed data on clinician time spent daily (defined by days where a MD was clinically active or logged into the EHR) interfacing with the EHR, including clinical work process data in 4 key areas: In-Basket (including communications with patients and other healthcare providers), Orders, Notes and Letters, and Clinical Review. For our study purposes, clinical workload was characterized by 4 monthly metrics: days with appointments;appointments per scheduled day (data from April-July 2020 during COVID-19 lockdown were not included to accurately reflect current practice);pajama EHR time (5:30 PM to 7 AM);and EHR time outside templated clinic hours. Proportional time spent in different clinical arenas was reported for April 2022 only. Monthly process metrics captured in each of the 4 key areas focused on work volume and time spent. Outcome metrics were reported as average+/-standard deviation (SD) and median (interquartile range (IQR)). All metrics were evaluated for change over time using regression modeling. Statistical significance was set at p<0.05. RESULT(S): Signal data from 993 PGI at 213 institutions were analyzed. 95.8% (n=204) institutions were located in the US. Clinical workload Over the reporting period, PGI had clinical appointments an average of 43+/-3% [median (IQR) = 46% (35%, 57%)] days per month or about 3 days per week. PGI had 7.6+/-0.3 [7.0 (5.8, 8.9)] clinical appointments per scheduled day. On average, PGI spent an additional 23.7+/-1.6 [14.4 (4.6, 30.2)] pajama time minutes and 36.1+/-1.9 [30.3 (15.8, 43.3)] minutes outside scheduled hours interacting with the EHR each day. Clinical workload metrics remained stable over the study period. On average, PGI spent 60% time in the ambulatory arena, 9.7% in inpatient, 0.3% in the emergency department and 30% in other. In-Basket The average time spent in In-Basket by PGI was 23.0+/-1.3 [20.4 (13.2, 26.5)] minutes per day. Average time in In-Basket increased significantly over the study period (p<0.0001). Primary drivers for this change included increases in certain types of In-Basket messages, including results (p=0.01), patient medical advice (p<0.0001), hospital chart completion requests (p<0.0001), prescription authorization requests (p=0.003), and staff messages (p<0.0001). Orders On average, PGI prescribed 1 medication every other appointment, or 0.5+/-0.02 [0.4 (0.3, 0.6)] medications per visit. PGI ordered 2.2+/-0.3 [2 (1.4, 2.8)] tests/evaluations per appointment. Notes and Letters The average note length was 6392+/-193 [6072 (4344, 7696)] characters, equivalent to over 3.5 pages of text. Time spent in notes was 10.2+/-0.4 [9.7 (6.7, 13.1)] minutes per appointment and 46.9+/-2.4 [43.6 (29.9, 56.2)] minutes per day. Length of notes increased significantly over the study period (r=0.51, p=0.01) but time spent in notes did not. Clinical Review PGI spent an average of 17.7+/-1.5 [17 (12.7, 20.3)] minutes per scheduled day in chart review, equivalent to 4+/-0.2 [3.9 (2.7, 5.3)] minutes per appointment. CONCLUSION(S): Quantification of some key components of clinical workload inherent to PGI is possible using EHRs. PGIs routinely spend time outside of work hours performing EHR work. Over the past 2 years, In-Basket time has contributed substantially to PGI workload and has trended towards increasing messages from both external (patients and pharmacies) and internal sources (staff and hospital compliance). Considerable PGI time has also been spent constructing clinical notes of lengths that appear to have increased during the same 2-year period. Limitations to the study include non-standardized, opaque metric definitions and unclear fidelity of provider categorization. We would also note that our results document increasing EHR-related workload burdens on PGIs that can contribute to physician burnout. Through identification of best outcome metrics, quantification of PGI clinical workload using EPIC Signal data may allow quality improvement activities that reduce provider burden while enabling our subspecialty field to benefit from widespread implementation of EHRs.

15.
Journal of Pediatric Gastroenterology and Nutrition ; 75(Supplement 1):S324, 2022.
Article in English | EMBASE | ID: covidwho-2057806

ABSTRACT

In 2020, telehealth (TH) in pediatric gastroenterology (GI) practice experienced unprecedented, meteoric growth, despite undefined best practices for the subspecialty. Use of synchronous video for TH first occurred in 1964, it was increasingly described in the literature from the 1970s to 1990s, and then catapulted to the forefront during the COVID-19 Public Health Emergency (PHE) beginning March 2020. Due to the sudden need for increased TH utilization by nearly all health care providers TH became essential to clinical practice. TH broadly encompasses most remote activities of clinical care, provider and patient education, and general health services. Prior to the COVID-19 PHE, surveys indicate that only 50% of North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) membership had any experience with telehealth. Although experience has grown dramatically, best practices for TH in pediatric GI, hepatology, and nutrition remain undefined and non-standardized. Key areas for review include: historical perspective, general and subspeciality usage, health care disparities, quality of the provider-patient interaction, modes of health care delivery, logistics and operations, licensure and liability, reimbursement and insurance coverage, research and quality improvement priorities, and future use of telehealth in pediatric GI with a call for advocacy. This present position paper from the Telehealth Special Interest Group of NASPGHAN provides recommendations for pediatric GI-focused telehealth best practices, reviews areas for research and quality improvement growth, and presents advocacy opportunities. Summary of Recommendations * The decision of when and how to use telehealth should be shared between patients-families and providers with the goals to achieve quality medical care and excellent patient experience * Telehealth is convenient for patients-families, affords a high degree of satisfaction and may improve access to high-value subspecialty care * Digital disparities exist for telehealth and providers need to be mindful of inequity in telehealth access and healthcare delivery * Individual providers carry the responsibility of licensed, secure, and HIPAA-compliant telehealth delivery in accordance with governmental regulations * Advocacy for permanent insurance coverage, reimbursement parity and universal licensure is urgently needed.

16.
BMJ Open Quality. Conference: Improvement Science Symposium. Gothenburg Sweden ; 11(Supplement 2), 2022.
Article in English | EMBASE | ID: covidwho-2057507

ABSTRACT

The proceedings contain 12 papers. The topics discussed include: health information-seeking among women diagnosed with breast cancer before commencing radiation therapy;essential together: a Pan-Canadian program for the safe re-integration of essential care partners;strengthening public health response to COVID-19 through policy learning and policy transfer;applying improvement to the co-creation of quality;multidisciplinary team's effects on quadruple aim in primary care, a study design;promoting a culturally adapted health-policy for the ultra-orthodox population during the COVID-19 crisis;embedding improvement science across an organization: our four-year journey;physician participation in quality improvement work interest and opportunity: a cross-sectional survey;and development and evaluation of the resilience analysis grid (RAG) in Dutch hospitals.

17.
Archives of Disease in Childhood. Conference: Royal College of Paediatrics and Child Health Conference, RCPCH ; 107(Supplement 2), 2022.
Article in English | EMBASE | ID: covidwho-2057500

ABSTRACT

The proceedings contain 839 papers. The topics discussed include: parental attitudes regarding safe handling of hand sanitizers and management of children with sanitizer poisoning amongst a cohort of children admitted to a tertiary care center in Sri Lanka;pediatric major incident triage and the use of machine learning techniques to develop an alternative triage tool with improved performance characteristics;unfair and unequal: comparing the experiences and outcomes of children with acute mental health and acute physical health presentations to the pediatric emergency department;tackling child inequality in a UK emergency department: a pilot early intervention service on the shop floor;introducing a new pediatric clerking proforma in a tertiary pediatric emergency department - a quality improvement project;changing patterns of bronchiolitis attendances to the emergency department in the COVID-19 pandemic;investigating prescribing errors in salbutamol nebulizers for acute asthma patients aged 5 and above in a district general hospital;assessment for testicular torsion in a DGH hospital- a service review;and changing spectrum of children presenting with asthma and viral induced wheeze in the COVID -19 pandemic.

18.
Pharmaceutical Journal ; 308(7957), 2022.
Article in English | EMBASE | ID: covidwho-2043164
19.
Journal of the Intensive Care Society ; 23(1):96-97, 2022.
Article in English | EMBASE | ID: covidwho-2043058

ABSTRACT

Introduction: 42% of patients in the intensive care unit (ICU) will suffer ocular damage during their stay.1 Multiple mechanisms that usually protect the eye are inhibited, whilst interventions such as positive airway pressure and muscle relaxants further expose the eye to harm.2 This became increasingly evident during the COVID-19 pandemic, where non-invasive ventilation and proning of patients exposed patients to risk of injury.3 Redeployment of Ophthalmologists to ICU during the first wave of the COVID-19 pandemic highlighted the need for a robust and sustainable intervention to reduce the frequency of eye complications in our unit. Objectives: Our objective was to reduce harm to eyes in all patients within the Royal Infirmary of Edinburgh (RIE) to zero ICU within nine months. Methods: Our QI project involved initial staff and patient data collection regarding current eye care practices. A fish-bone diagram facilitated group discussions with ICU clinical teams regarding prior eye care practices. A pareto chart identified categories to focus on, with a driver diagram identifying change ideas. Our primary intervention was the design and introduction of a bespoke eye care guideline. Specific outcomes, processes, and balancing measures were set out, and multiple PDSA cycles helped to prompt interventions to ensure consistent and standardised care was delivered. Run charts were regularly reviewed and a variety of interventions were introduced throughout the data collection period as tests of change. These included: 1. posters highlighting guideline enrolment 2. formal teaching at handovers and on the unit 3. educational emails to staff members 4. prompts on daily reviews to highlight eye care assessments. Between 28 Sept 2020 -28 June 21, twenty patients in RIE ICU were randomly selected by the data collection team weekly. Patient outcome -eyes were examined and noted if they had developed any ocular complications during their stay. Patients who had evidence of ocular damage on admission were excluded unless they developed further complications. A single episode was not counted twice. Process outcomes -Eye care guideline adherence was recorded, and non-compliance was rectified following data collection. The data was recorded on run charts, accessible via MS teams, allowing all project team members to review the data remotely. Results: During our data collection period, the introduction of our guideline and educational interventions reduced the median number of patients who suffered eye complications in ICU by 50% within nine months (Figure 1). Chemosis and evidence of dry eyes were the most common complications. Since initiation of the guideline, our educational interventions have maintained median guideline compliance at 80%. Conclusion: This is a comprehensive, patient-centred, QI project, utilizing a systematic methodology to introduce a new guideline within ICU. This project has resulted in a sustained improvement of eye care standards, and reduction of eye complications within RIE ICU. This project was ongoing during the second wave of the COVID-19 pandemic, where constant rotation of medical staff, unfamiliar with ICU, required education to ensure guideline compliance was achieved. Our eye care guideline is now part of a multicentre project to standardise care across NHS healthboards.

20.
Journal of the Intensive Care Society ; 23(1):190-191, 2022.
Article in English | EMBASE | ID: covidwho-2043044

ABSTRACT

Introduction: Intensive care patients often have complex swallowing and communication needs. These require coordinated input from the multi-disciplinary team. Increasing evidence highlights the role of speech and language therapy (SLT) within the critical care environment1 and this is represented well in national recommendations specific to patients with tracheostomies. Approximately 10-15% of ICU patients will have a tracheostomy nationally.2 SLT provide expertise in assessment and management of communication and swallowing difficulties, which can vastly improve psychosocial well-being and promote early safe enteral feeding for our patients.3 In 2014 On the right trache?4 found that 52% of patients with a tracheostomy suffered with dysphagia, however only 27% critical care patients had input from SLT. Objectives: To improve the assessment of swallowing and communication in patients undergoing tracheostomy ventilation at the Royal Infirmary of Edinburgh, to comply with Scottish Intensive Care Society Audit Group (SICSAG) quality indicator 2.3. This guidance stipulates all tracheostomy patients should have communication and swallowing needs assessed during ventilator wean.5 Methods: Four distinct areas of intervention were implemented. Pre-populated review text was added to NHS Lothian's clinical notation system (InterSystems TrakCare®), prompting nursing staff to consider swallowing, tracheostomy issues and SLT referral. These were refined between audit cycles. SLT were invited to join safety briefs to identify tracheostomy patients, as well as other patients with complex swallowing needs. This was an opportunity to raise awareness, educate, and prioritise workload. New guidelines for nurse-led swallowing observations were developed and disseminated amongst teams. Finally, staff were offered relevant educational sessions. Baseline data was collected in 2019;serial data collection was then during October - November 2020 and in June - July 2021 following the interventions. Results: All patients who received tracheostomy ventilation were audited (n=31). This showed that very few patients had swallowing and communication assessed adequately. Only 16.1% (n=5) patients had a regular nursing swallowing assessment on the majority of critical care days (>50%). Referral to SLT was often very late when patients were approaching de-cannulation and on many occasions by the time the SLT team were involved patients had already been de-cannulated. Following the intervention period, it became apparent that awareness of swallowing requirements had improved. By mid 2021, 58.9% more patients had swallowing assessed as part of daily care. Additionally, 81.2% of patients had SLT reviews on the unit demonstrating a sustained increase from late 2020. There was a notable increase in the quality of assessments after initial SLT review. Conclusion: Using quality improvement methodology our multidisciplinary team was able to substantially increase the quality of swallowing assessment within our ICU, despite the challenges of the COVID-19 pandemic. Our unit now complies with SICSAG quality indicator 2.3. This is in keeping with national recommendations for a multidisciplinary approach to care of tracheostomy patients. Patients with increased risk of dysphagia are being identified earlier and are more likely to progress and be established on enteral feeding early, which may subsequently reduce the burden of nasogastric feeding, total parenteral nutrition and even related invasive IV access.

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