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Background: Consensus guidelines and recommendations play an important role in fostering quality, safety, and best practices, as they represent an expert interpretation of the biomedical literature and its application to practice. However, it is unclear whether the recent collective experience of implementing telemedicine and the concurrent growth in the evidence base for teledermatology have resulted in more robust guidance. Objective: The objective of this review was to describe the extent and nature of currently available guidance, defined as consensus guidelines and recommendations available for telemedicine in dermatology, with guidance defined as consensus or evidence-based guidelines, protocols, or recommendations. Methods: We conducted a single-reviewer scoping review of the literature to assess the extent and nature of available guidance, consensus guidelines, or recommendations related to teledermatology. We limited the review to published material in English since 2013, reflecting approximately the past 10 years. We conducted the review in November and December of the year 2022. Results: We identified 839 potentially eligible publications, with 9 additional records identified through organizational websites. A total of 15 publications met the inclusion and exclusion criteria. The guidelines focused on varied topics and populations about dermatology and skin diseases. However, the most frequent focus was general dermatology (8/15, 53%). Approximately half of the telemedicine guidance described in the publications was specific to dermatology practice in the context of the COVID-19 pandemic. The publications were largely published in or after the year 2020 (13/15, 87%). Geographical origin spanned several different nations, including Australia, the United States, European countries, and India. Conclusions: We found an increase in COVID-19-specific teledermatology guidance during 2020, in addition to general teledermatology guidance during the period of the study. Primary sources of general teledermatology guidance reported in the biomedical literature are the University of Queensland's Centre for Online Health and Australasian College of Dermatologists E-Health Committee, and the American Telemedicine Association. There is strong evidence of international engagement and interest. Despite the recent increase in research reports related to telemedicine, there is a relative lack of new guidance based on COVID-19 lessons and innovations. There is a need to review recent evidence and update existing recommendations. Additionally, there is a need for guidance that addresses emerging technologies. © Mollie R Cummins, Triton Ong, Julia Ivanova, Janelle F Barrera, Hattie Wilczewski, Hiral Soni, Brandon M Welch, Brian E Bunnell.
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Penang is often known as a multilingual and multiethnic city in Malaysia. Its diversity of growing population based on its pre-colonial history and evidence of different ethnic groups living together has resulted in an emergence of a variety of languages today. Henceforth, this chapter embarks on an examination of languages that appear on public health signs in Penang. Conceptualising the study within the framework of language planning and policy, it dissects the languages observed on COVID-19 related signs that were designed by the multiple layers of agency in Penang. The findings are hierarchically organised as follows: (a) state government, (b) district government, (c) large enterprise, and (d) small enterprise. Although a trend of dynamism is reflected in the findings, they still mark social inequality for people's access to public advice related to the COVID-19 outbreak in Penang. The chapter concludes that the linguistic landscape of Penang is a mosaic closely connected to the social and political processes and urges for an increased use of community languages to safeguard vulnerable groups in Penang and across the globe. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.
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When the COVID-19 virus began spreading aggressively after its first detection, government of most countries impose mandated lockdowns to combat the virus. Subsequently, leaders communicate to their citizens through live telecast, which are usually presented in one language alongside sign language. This may have hindered communication within small ethnic and indigenous communities and thus risking lives. To seek an understanding of the sociolinguistic reality of the interplay and language practices in multilingual countries, this study examines 26 speeches presented by the Prime Minister of Malaysia. The analysis reveals that the main language used is Bahasa Melayu but the Prime Minister switches to English when emphasising important terms. Although the speeches were not translated into community languages, the analysis shows that the top five highest frequency words in both Bahasa Melayu and English transcripts were similar. This result indicates that although effective communication within small ethnic and indigenous communities may not be successful, the Malaysian government still cares about its citizens during the pandemic. The findings provide a snapshot of the language vitality in Malaysia, which acts as a wakeup call for nations that are keen about protecting their citizens while maintaining a multilingual identity. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.
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Background: The Cystic Fibrosis Learning Network (CFLN) is a group of 34 programs that work and learn together with shared measures and processes to improve patient outcomes. Interventions are organized into change packages (collected, actionable concepts to share tested, refined ideas across multiple care centers). Since 2016, these change packages have helped advance team level co-production and improve timely data entry (TDE) and quality and use of Cystic Fibrosis Foundation Patient Registry (CFFPR) data. In the context of the COVID-19 pandemic, in-person meetings were curtailed, and team membership changed often. New learning structures to promote peer-to-peer learning were needed to spread and sustain these interventions. The objective was to describe the shared multicenter learning method used to spread practices in two series: co-production (recruitment and onboarding of patient and family partners (PFPs)) and TDE entry into the CFFPR. Method(s): In the design phase of the learning structure, we developed objectives specific to each series. Community content experts refined the curriculum from the established change package concepts. Teams were recruited through an open invitation to all CFLN sites. and met virtually biweekly for 30-minute sessions for 10 to 12 weeks. CFLN content experts used the change packages to coach teams and share their experiences during learning structure huddles. These sessionswere followed by 2-week action periods to review and test change package ideas. Teams shared progress at each meeting in round-robin format. Progress toward smart aims, team experience, and participation were assessed using descriptive surveys before, during, at the end of the series, and 6 months after it closed. Result(s): In initial surveys, teams self-reported awide range of experiences with co-production and TDE into the CFFPR. Participating teamswere from pediatric and adult programs that varied in number of patients and geographic location. Four teams participated in the co-production series to recruit and onboard PFPs within 6 months of completion. In the 6-month follow-up survey, two of the four teams met their goal of recruiting and onboarding a new PFP. The remaining teams reported barriers related to institutional policies that limited training for volunteers. In the TDE series, five teams joined and aimed to improve TDE into the CFFPR within 8 months. All five teams are on target to meet this goal. For both series, action-period surveys revealed completion of tasks assigned (e.g., reviewof change package concepts, testing tools, process maps, barriers, facilitators). Feedback surveys collected during the final sessions of each series indicated that the learning structure helped teams meet expectations, learn something new, and increase confidence in the interventions. Conclusion(s): This learning structure for spreading standard interventions helped teams meet series' aims. The small-group structure allowed teams to learn and adapt coproduction and timely data change package ideas and sustain practices for at least 6 months. In future iterations, this learning structure could be used as a model to spread standard interventions to other programs in the CFLN and the larger care center network.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved
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Since the 2008 global financial crisis, many innovations have emerged in the financial sector as investors started to look for alternative methods to eliminate irrational decision-making in wealth management, and Robo-advisors is among those. Nine years after the first launching of Robo-advisors in the U.S. in 2008, the Securities Commission Malaysia has been issuing licenses to seven Robo-advisor platforms. The current COVID-19 outbreak has made this industry more in demand, increasing 763% in registration in 2020. However, much skepticism about Robo advisors' ability and reliability in providing a similar quality or better advisory service compared to human-financial advisors. Therefore, this study examines the factors influencing the acceptance of Robo-advisors in wealth management in Malaysia. Adopting some factors from various established technology acceptance models, an online survey with 122 respondents was conducted using convenience sampling. Findings show that Relative Advantage, Effort Expectancy, and Social Influence significantly positive influence the Malaysian Behavioral Intention to Accept Robo-Advisors. On the contrary, there is no significant relationship between Perceived Risk and Malaysian Behavioral Intention to Accept Robo-Advisors. The study provides a positive insight into factors influencing the acceptance of Robo-Advisors in Malaysia. © 2023 The Author(s). This open access article is distributed under a Creative Commons Attribution (CC-BY) 4.0 license.
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Phobias and related anxiety are common and costly mental health disorders. Experts anticipate the prevalence of phobias will increase due to the COVID-19 pandemic. Exposure therapies have been established as effective and reliable treatments for anxiety, including recent innovations in virtual reality-based exposure therapy (VRET). With the recent advent of telemental health (TMH), VRET is poised to become mainstream. The combination of VRET and TMH has the potential to extend provider treatment options and improve patient care experiences. In this narrative review, we describe how recent events have accelerated VRET + TMH, identify barriers to VRET + TMH implementation, and discuss strategies to navigate those barriers. Copyright © 2022 Ong, Wilczewski, Soni, Nisbet, Paige, Barrera, Welch and Bunnell.
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Introduction Hand grip strength is a useful measure of muscle function. Many hand dynamometers that are less costly than the gold standard Jamar dynamometer are available but their use in clinical outpatient setting has yet to be validated. This study aimed to determine the inter-instrument reliability between Camry electronic and Jamar hydraulic dynamometers. Method A cross-sectional study was conducted on patients aged ≥65 years during their post COVID-19 follow up clinic visit. Hand grip strength was assessed using both Jamar and Camry dynamometers following standard protocol while information on participants’ demographics, health and COVID-19 hospitalizations were collected from hospital electronic medical records. Reliability between both devices was determined using intraclass correlation coefficient (ICC) and devices were compared based on subcategories of participants’ demographics and clinical characteristics. Results Ninety-three participants (mean age: 73 ± 6 years, 52.7% males) were recruited in this study. Average grip strength recorded with Jamar dynamometer (18.1 ± 7.4 kg) was higher than Camry dynamometer (19.5 ± 6.6 kg). Sub categorical comparison depicted no significant discrepancy between the devices discovered among male participants (p = 0.262), Malay participants (p = 0.243) and participants aged >70 years (p = 0.090). According to the diagnostic cut-off recommended by Asian Working Group for Sarcopenia (AWGS) 2019, similar number of participants had low grip strength using Jamar (n = 69, 74.2%) and Camry (n = 68, 73.2%) dynamometers. The odds of Camry detecting low grip strength was 0.946 times (95% CI: 0.493–1.817) as compared to Jamar dynamometer. Readings measured using both dynamometers were highly correlated to each other (r = 0.88) with ICC of 0.92, indicating an excellent inter-instrument reliability. Conclusion Comparable measures between Jamar and Camry hand dynamometers support the interchangeable use of the devices among older population. Hence, the alternative use of Camry dynamometer is appropriate for the outpatient setting.
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Introduction Muscle strength is one crucial determinant of functional activity among older adults. While COVID-19 infection is often described as an acute respiratory disease with potential multiorgan involvement, its severe inflammatory nature may lead to changes to structure and function of skeletal muscles. This present study aimed to evaluate grip strength among post COVID-19 elderly with exploration of factors influencing the change in grip strength. Method Patients with history of COVID-19 infection aged ≥65 years were recruited in the COVID-19 follow up clinic. Grip strength was assessed using Jamar dynamometer following standard protocol while baseline clinical information was collected from hospital electronic medical record. Data collected were analysed to evaluate grip strength in relation to participants’ demographics, comorbidity, length of hospital stay and steroids medication use. Total steroids equivalent doses were calculated and dichotomy of 400 mg was selected based on its median. Results Ninety-three participants (mean [SD] age: 73 [6], 52.7% males) were recruited at an average (SD) of 55 (37) days after hospital discharge, with 79.6% participants hospitalized with COVID-19 of clinical category 4. Majority (74.2%) of the participants recorded measurements lower than diagnostic cut-off for low grip strength recommended by Asian Working Group for Sarcopenia (AWGS) 2019. Results showed that increasing age was associated with a decrease in grip strength (r = −0.30, p = 0.003). Besides, increase in hospital stay (r = −0.22, p = 0.035) and Charlson Comorbidity Index (CCI) score (r = −0.42, p = 0.000) were associated with decreasing grip strength measurements. No significant discrepancy in grip strength was observed between subgroups of patients receiving total steroids equivalent doses of <400 mg and ≥ 400 mg (p = 0.881). Conclusion Low grip strength readings were recorded among post COVID-19 elderly particularly patients of older age, with longer hospital stay and higher CCI. This suggests the need for close monitoring and provision of rehabilitation intervention to older adults affected by COVID-19 infection.
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Introduction: Preoperative carbohydrate loading in Enhanced Recovery After Surgery (ERAS) is an independent predictor of postoperative outcomes. By reducing the impact of surgical stress response, fasting-induced insulin resistance is modulated. As a clear fluid, consuming whey protein-infused carbohydrate is safe up to 2 hours preoperatively. Widely practiced in abdominal surgeries, its implementation in hip fracture surgeries is yet to be recognized. Methods: We aim to identify the feasibility of preoperative carbohydrate loading in hip fracture surgery and assess its clinical effects. A randomized controlled, open labelled trial in patients ≥ 65 years old without diabetes mellitus, has hip fracture was conducted in University Malaya Medical Centre between November 2020 and May 2021. Intervention: Carbohydrate loading (Resource-Nestle®) with 100g on the day before surgery and 50g up to 2 hours preoperatively versus standard preoperative fasting. Results: Thirty ASA 1-3 patients (carbohydrate loading and control, n = 15 each), mean age 79 years (SD±8.5), mean body mass index 23.8 (SD±3.5kg/m2) were recruited. Analysis for feasibility of carbohydrate loading (n = 15) demonstrated attrition rate of 20%, n = 3 (one participant completed the drinks but operation was postponed and two patients were not served the third drink by ward staff). Otherwise, patients were 100% compliant with no adverse events reported. 26 randomized participants were analyzed for secondary outcomes (intervention n = 12, control n = 14). There was no significant difference among groups in the postoperative nausea and vomiting, pain score, fatigue level and muscle strength assessed at 24-48 hours postoperatively. Conclusion: COVID-19 pandemic had interrupted recruitment resulting in a small number of participants. Nevertheless, this study demonstrated that implementation of preoperative carbohydrate loading is feasible for hip fracture surgeries without complications but requires careful coordination among surgical, anaesthetic and nursing teams. An adequately powered randomized controlled study is needed to examine the full benefits of preoperative carbohydrate loading in this group of patients.
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Introduction: COVID-19 has led to a change in the health-seeking behaviour and the delivery of healthcare. Globally, fragility fracture admissions have reduced by 0-54% depending on location. When Malaysia implemented the third movement control order on 3 May 2021 in response to increasing COVID-19 cases, the number of orthopaedic beds in the University Malaya Medical Centre was reduced from over a hundred to twenty-eight. To date, the impact of COVID-19 on fragility fracture admission in Malaysia is unknown. This study aims to investigate the relationship between COVID-19 cases and fragility fracture admissions to a tertiary hospital in Malaysia. Methods: This retrospective study was conducted from April to June 2021 in the University Malaya Medical Centre. The patients admitted to the University Malaya Medical Centre with fragility fractures between April and June 2021 were identified and compared to the corresponding periods in 2018. Patients <50 years old and those who had fractures due to cancer were excluded. The relationship between the total number of COVID-19 cases per week and weekly fragility fractures admissions were determined. Results: A total of 406,479 COVID-19 cases were reported over 3 months (April, n = 63,213;May, n = 163,644;June, n = 179,622). Fifty-five patients [mean age (78.9±8.6), female (44/55,80%), hip fractures (36/55,65.5%)] were admitted in April-June 2021, which was a 35.3% reduction when compared to the same period in 2018 [n = 85, mean age (75.1±9.9), female (62/85,72.9%), hip fractures (53/85,62.4%)], although no significant difference was found between the baseline characteristics. However, both fragility fracture and hip fracture admissions were found to be negatively correlated (r =-0.76 and r =-0.75) with the COVID-19 cases (P < 0.01). Twelve (12/51,23.5%) patients admitted in 2021 due to post-fall fragility fractures presented to the hospital more than a day after their injury. The proportion of patients with delayed presentation (>1 day post-fall) increased over the study period (April = 5/26, 19.2%;May = 3/13, 23.1%;June = 4/12, 33.3%). Conclusion: There was a reduction in fragility fracture admissions during the COVID outbreak in Malaysia. There might be a rebound in cases after the COVID crisis is over, reorganising medical services may be warranted to ensure effective fracture care delivery.
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Education worldwide has been conducted in the traditional face-to-face classroom teaching style for ages, and this includes the education in dentistry. Since the introduction of online education and distance learning, teaching institutions have gradually made e-learning an integral part of teaching and learning activities. With the emergence of COVID-19 pandemic and closure of teaching institutions worldwide, the faculty of dentistry is amongst the many that were forced to leap onto the online education field abruptly. There is a sudden need for educators to resort to online teaching and e-learning becomes an essential tool to be developed as an alternative to traditional education methods. This article serves as a review to explore and discuss the common concerns and institutional readiness in delivering e-learning and review the methods currently utilised during this time of crisis. © Penerbit Universiti Sains Malaysia. 2021
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Background Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and its pandemic disease have provided unprecedented challenges to medical treatment. To date there has been little definitive evidence of vertical transmission of SARSCoV-2 from mothers to foetuses/neonates during pregnancy and delivery. There is biological plausibility for in-utero infection of the foetus with SARS-CoV-2 virus as the virus has previously been demonstrated in placentae and amniotic fluid. Goh et al's meta-analysis reports the pooled incidence of vertical transmission as 16 per 1000 newborns. Objectives To describe cases of Covid-19 with a very high probability of vertical transmission in a large tertiary NICU in United Kingdom Methods Babies born to Covid positive mothers, who require NICU admission at St. Mary's Hospital, Manchester, receive their initial care in an isolation room within NICU, where all levels of neonatal care (intensive, high dependency or special care) can be provided. Following admission to the NICU isolation room, babies have a nasopharyngeal (NP) swab taken on day 1, 3 and 5 of life. The sample on day 5 is sent for rapid analysis (usually returning a result within 4 hours). If all NP swab results are all negative, the baby is moved from the isolation room on day 5 of life. Conversely, if any swabs are SARS-CoV2 positive, the baby remains in the isolation room for 14 days. We report the characteristics and clinical courses of the cases where any of baby's swabs samples tested positive for SARS-CoV-2. Results All three babies were admitted directly to the NICU isolation room immediately after birth without physical contact with their respective parents. All hospital staff caring for the babies used full personal protective equipment including a filtering facepiece (FFP) 3 mask, gloves and apron. Reverse transcriptase polymerase chain reaction (RT-PCR) testing of the nasopharyngeal swab detected the SARS-CoV-2 virus. Indeterminate results are presumed positive with sub reportable thresholds of viral loads. Table 1 summarises the characteristics of cases, their respective parental physical contact and first day of receiving expressed breast milk (EBM). Two out of three babies received EBM whilst under NICU isolation. Both of these babies had indeterminate SARS-CoV2 levels, prior to the administration of EBM, therefore we do not believe breast-milk to have been the route of transmission. Fortunately, all neonatal infections with COVID-19 in these cases were mild or clinically insignificant. None of these babies were symptomatic of Covid 19 respiratory infection, although some did required respiratory support but this was in keeping with their underlying condition. Conclusions From our single tertiary centre experience, we hypothesise that vertical transmission of COVID-19 is highly probable.
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Background: There is growing evidence to suggest that continuous monitoring and a proper use of patient-reported outcomes (PROs) in the clinical setting may improve patient care by facilitating doctor-patient communication, promoting individualized supportive care, and increasing patient satisfaction (Velikova, J Clin Oncol. 2004;22(4):714-24;Yang, Support Care Cancer. 2018 Jan;26(1):41-60). This may be of particular importance for patients with MM, a condition characterized by considerable heterogeneity in PROs at different timepoints within a patient's disease journey (TA King et al, Semin Oncol Nurs. 2017;33(3):299-315;R Abonour et al, Ann Hematol. 2018;97(12):2425-36). There is also a growing body of evidence to support that digital platforms in healthcare can have an impact on patients' lives and improve the patient care experience across diverse medical settings. Web-based platforms that provide education and allow patients to track data have demonstrated improvement across a range of PROs measuring empowerment, self-efficacy, and mastery when compared against standard of care in a variety of disease states (MR Fu et al, Internet Interv. 2016;5:56-64;G Bouma et al, Support Care Cancer. 2017;25(7):2075-2083). This may be particularly relevant in light of the current coronavirus disease 2019 (COVID-19) global pandemic. Patient-reported outcome data (e.g., symptoms) that can be readily shared with healthcare professionals (HCPs) can support clinical decision making and impact patient outcomes (E Basch et al, JAMA. 2017 Jul 11;318(2):197-8). Data collected through wearables (such as emoji scales and activity) have been shown to be correlated with traditional, validated PRO measures in patients with cancer (CA Thompson et al, Blood. 2017;130(Suppl 1):2179). Digital medication tracking has led to better medication adherence, increased prescription refills, and better clinical outcomes. Centralized disease management digital platforms have shown potential to reduce patients’ risk of complications (S Kumar et al, Abstract for the 77th American Diabetes Association. 2017). Despite this body of evidence supporting the potential impact of the use of digital platforms, there is little evidence specifically in MM. The MyHOPE™ for MM Solution is a validated investigational digital technology platform designed to provide patients with a comprehensive set of tools and resources to support the patient throughout their overall experience with MM and to collect biometrics and self-reported data such as symptom tracking, medication adherence, and health-related quality of life (HRQoL) with the ability to share this data with the patient's care team. MyHOPE™ for MM is the first prospective study evaluating the impact of a digital intervention for patients with hematological malignancies. Study Design and Methods: This is a multi-center, randomized, pilot trial of the MyHOPE™ for MM Solution. Approximately 126 adult patients (≥ 18 years of age) with a diagnosis of MM and who reside in the USA will be recruited from approximately 30 study sites within the USA, reflecting both community and academic centers. Patients will be stratified according to disease status (newly-diagnosed multiple myeloma transplant-eligible or ineligible, newly-diagnosed multiple myeloma in patients undergoing their first autologous stem cell transplant, or relapsed and/or refractory) and will be randomized in a 2:1 manner to either the Patient App + HCP Portal (Cohort 1) or Patient App Alone (Cohort 2). Primary objectives include feasibility of the platform and patient empowerment and self-efficacy. Other objectives include user satisfaction with the platform, health-related quality of life, and clinical outcomes. Enrolled patients will receive MM-treament regimen according to their physician's care plan. The study is in start-up and recruitment is expected through 2021. Disclosures: Raje: Celgene: Consultancy. Nadeem: Amgen: Membership on an entity's Board of Directors or advisory committees;Adaptive: Membership on an entity's Board of Direct rs or advisory committees;Sanofi: Consultancy, Membership on an entity's Board of Directors or advisory committees;Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: TRAVEL, ACCOMMODATIONS, EXPENSES;Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: TRAVEL, ACCOMMODATIONS, EXPENSES;Janssen: Consultancy, Honoraria, Other: TRAVEL, ACCOMMODATIONS, EXPENSES. Mikhael: Amgen, Celgene, GSK, Janssen, Karyopharm, Sanofi, Takeda: Honoraria. Ludwig: Bristol Myers Squibb: Consultancy. Agarwal: Bristol-Myers Squibb Company: Current Employment, Current equity holder in publicly-traded company. Inumerable: Bristol Myers Squibb: Current Employment. Ong: Bristol Myers Squibb: Current Employment. Jagannath: BMS, Janssen, Karyopharm, Legend Biotech, Sanofi, Takeda: Consultancy.
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This study analyses and presents accounting academics’ experiences in six universities in Australia, Malaysia, and Indonesia to adapt to the swift change to the remote virtual classroom delivery model forced by the COVID-19 pandemic, while also gaining valuable lessons from this unique situation. In this study, autoethnography’s basic principles were used. The main results suggest that the universities’ combined current information and communication technologies, learning management systems, blended learning experiences, training, and supports, although not without hitches, were able to accommodate the shift to a remote virtual classroom model quite effectively. However, the move to fully online assessment has been conceded to likely increase the embedded risk of student cheating. The availability of reliable internet connection for students is also crucial in ensuring access equality and effective remote virtual classroom delivery. © 2021 Australasian Accounting Business and Finance Journal and Authors.
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Background: The COVID-19 crisis provided an opportunity for shared learning across CF centers in the CF Learning Network (CFLN). The CFLN is a group of CF Foundation-accredited care programs led by people with CF (PwCF), their families, and clinicians. The teams learn from each interaction between clinicians and PwCF using quality improvement (QI) tools, data, and shared tests of change. QI work is focused on co-produced, interdisciplinary (IDC) care. At the onset of the pandemic, the CFLN network leadership team (NLT) and operations team shifted from prior QI work to develop a telehealth innovation lab (ilab) to maximize shared learning. We describe the innovation structure, team engagement, and shared learning across sites in the telehealth ilab. Aim: Increase percent of co-produced, IDC telehealth visits from 55 to 95% by May 31, 2020. Methods: The NLT designed the ilab structure in 3 weeks, compared to 3-6 months from prior ilab designs. An innovation model was used to determine the aim, measures, interventions and tests of change for the ilab. The initial key drivers and interventions prioritized were IDC and patient and family shared agenda setting at virtual visits. CFLN team participation was voluntary. Teams were allowed to choose one or both interventions with data submission expected for both interventions. Expectations included weekly huddle attendance, data collection, and orchestrated tests of change. Early tests included processes for IDC, agenda setting, and response to patient feedback. Teams shared learning in a collaborative platform. Teams able to execute reliable processes at 80% of visits presented their work during weekly huddles to benchmark learning. Results: Twenty-nine of 39 CFLN teams enrolled in the telehealth ilab. Over 4 weeks, teams submitted an average 1.2 tests of change per week. As of May 31, IDC team members joined 1265 of 1931 virtual visits across all teams (median 66%). This measure excluded the provider and nursing staff. Of those same virtual visits, 1136 visits (median 59%) included shared agenda-setting among the team, patients and families. Reliable processes shared were virtual team rooms, clinic flow facilitators, and surveys for patient feedback. Conclusions: The CFLN teams were highly engaged in sharing of rapid telehealth innovations. Although the aim to increase IDC and agenda setting in virtual visits did not reach goal, the ilab provided dynamic, data-driven learning to maintain team engagement and meet the needs of PwCF and their families. The lab structure will continue in order to meet the changing challenges of the pandemic and institutional barriers such as staff re-assignment, furloughs, and resumption of in-person care. The revised aim of the lab will continue interventions related to IDC and agenda setting while expanding the scope to include visits with both in-person and virtual visits with interdisciplinary team members.
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Background: Multidisciplinary clinics are the hallmark of cystic fibrosis (CF) care, but more experts often add time to the clinic visit. CF clinic appointment time at our institution extended to 170 minutes with approximately 6-8 disciplines per patent. To embed recent CF Foundation- supported scholars from Endocrinology (ENDO) and Gastroenterology (GI) into clinic, we sought to streamline visit time for patients and families without compromising multidisciplinary care. Objective: To maintain coordinated multidisciplinary clinic visit time at 120 minutes with the addition of ENDO and GI specialists after October 2019. Methods: A multidisciplinary quality improvement team including 2 parent partners met weekly to organize the initiative. We surveyed the CF clinic team to rank perceived barriers. We asked families perceived barriers to clinic through an added question on our clinic intake form and a survey to our Parent Advisory Council. Using pareto charts, we developed interventions to target most common barriers: 1) clinic road map to communicate across team which disciplines have priority patient assessments, 2) facilitator to decrease wait time between providers, 3) nurse-doctor (RN-MD) paired visits for shared communication and earlier RN sign-out of families. We tested interventions with plan-do-study-act (PDSA) cycles. We met hospital administrators monthly to accommodate PDSA cycles and adjust templates and rooms as needed. A subset of clinics were timed and displayed on a run chart monthly with interventions annotated. Visit time was compared before (5/2019-8/2019) and after (10/2019-3/2020) integration of ENDO and GI into clinic. Results: Survey of team members' perceived barriers to clinic had 24 responses. Most parent responses (14 of 19) reported concerns of wait time or visit length. PDSAs started in June 2019 before integration of ENDO and GI. Road map PDSAs adapted processes for improved use and integration of the tool. Clinic facilitator role was adopted with a medical assistant in the role. RN-MD pairs had positive feedback from both RNs and MDs. Prior to PDSAs, average clinic visit time was 127 minutes. Of 18 timed clinics, 7 had ENDO/GI provider present. Prior to ENDO and GI integration, clinic visit time was reduced to average clinic visit time of 121 minutes. Following integration, clinic visit time was maintained at 121 minutes. Proportion of clinic visit spent between waiting between team members was 26% (total time=31 minutes) which was also stable to slightly improved to 23% (28 minutes) after integration of ENDO and GI. Team members reported high satisfaction with all clinic visits finishing on time post-integration. Some families informally shared high satisfaction/noticeable change in duration of clinic visits. Conclusion: Interventions designed to address barriers in clinic flow demonstrated improvement in clinic visit time despite embedding 2 new subspecialists. COVID-19 limited further PDSAs for in-person clinic visits, however poises our team to address care coordination and communication for hybrid in-person and virtual models.