Non-invasive markers of inflammation in alcohol-associated liver disease: A scoping review.

Clinical manifestations of liver inflammation in alcohol-associated liver disease (ALD) can range from asymptomatic to severe alcoholic hepatitis. While biopsy is the gold standard for identifying liver inflammation, it is an invasive procedure with risks of bleeding, visceral damage, and infection. We aim to establish the state of the current literature on non-invasive markers of inflammation in ALD. We searched Ovid MEDLINE, Embase, and the Cochrane Library for original studies on the association between one or more non-invasive biomarker(s) and histological inflammation or hepatitis in ALD patients. Exclusion criteria were lack of histological data, abstract only, non-English-language articles, and animal studies. Two independent reviewers screened abstracts, reviewed full texts, and extracted data from included papers. Our search identified 8051 unique studies. Title and abstract screening resulted in 563 studies, and full-text screening resulted in 31 studies for final inclusion. The majority were single-center observational cohorts with an average sample size of 124. Review of these studies identified 44 unique biomarkers and 8 calculated scores associated with histological inflammation and/or hepatitis, in addition to a metabolomic panel of 468 metabolites. Six studies examined diagnostic accuracy for histological inflammation and/or hepatitis. The highest area under the receiver operating characteristic curve was 0.932 using a model based on four metabolites. This review highlights the available literature on non-invasive markers of inflammation in ALD. There is a dearth of studies that evaluate the diagnostic accuracy of these biomarkers, and larger studies are needed to confirm findings identified in small cohorts.

Work system barriers and facilitators of a team health information technology.

Designing health IT aimed at supporting team-based care and improving patient safety is difficult. This requires a work system (i.e., SEIPS) evaluation of the technology by care team members. This study aimed to identify work system barriers and facilitators to the use of a team health IT that supports care transitions for pediatric trauma patients. We conducted an analysis on 36 interviews - representing 12 roles - collected from a scenario-based evaluation of T3. We identified eight dimensions with both barriers and facilitators in all five work system elements: person (experience), task (task performance, workload/efficiency), technology (usability, specific features of T3), environment (space, location), and organization (communication/coordination). Designing technology that meets every role's needs is challenging; in particular, when trade-offs need to be managed, e.g., additional workload for one role or divergent perspectives regarding specific features. Our results confirm the usefulness of a continuous work system approach to technology design and implementation.

Disseminating child abuse clinical decision support among commercial electronic health records: Effects on clinical practice.

Objectives: The use of electronic health record (EHR)-embedded child abuse clinical decision support (CA-CDS) may help decrease morbidity from child maltreatment. We previously reported on the development of CA-CDS in Epic and Allscripts. The objective of this study was to implement CA-CDS into Epic and Allscripts and determine its effects on identification, evaluation, and reporting of suspected child maltreatment. Materials and Methods: After a preimplementation period, CA-CDS was implemented at University of Wisconsin (Epic) and Northwell Health (Allscripts). Providers were surveyed before the go-live and 4 months later. Outcomes included the proportion of children who triggered the CA-CDS system, had a positive Child Abuse Screen (CAS) and/or were reported to Child Protective Services (CPS). Results: At University of Wisconsin (UW), 3.5% of children in the implementation period triggered the system. The CAS was positive in 1.8% of children. The proportion of children reported to CPS increased from 0.6% to 0.9%. There was rapid uptake of the abuse order set.At Northwell Health (NW), 1.9% of children in the implementation period triggered the system. The CAS was positive in 1% of children. The child abuse order set was rarely used. Preimplementation, providers at both sites were similar in desire to have CA-CDS system and perception of CDS in general. After implementation, UW providers had a positive perception of the CA-CDS system, while NW providers had a negative perception. Discussion: CA-CDS was able to be implemented in 2 different EHRs with differing effects on clinical care and provider feedback. At UW, the site with higher uptake of the CA-CDS system, the proportion of children who triggered the system and the rate of positive CAS was similar to previous studies and there was an increase in the proportion of cases of suspected abuse identified as measured by reports to CPS. Our data demonstrate how local environment, end-users' opinions, and limitations in the EHR platform can impact the success of implementation. Conclusions: When disseminating CA-CDS into different hospital systems and different EHRs, it is critical to recognize how limitations in the functionality of the EHR can impact the success of implementation. The importance of collecting, interpreting, and responding to provider feedback is of critical importance particularly with CDS related to child maltreatment.

Boosting neuregulin 1 type-III expression hastens SMA motor axon maturation.

Intercellular communication between axons and Schwann cells is critical for attaining the complex morphological steps necessary for axon maturation. In the early onset motor neuron disease spinal muscular atrophy (SMA), many motor axons are not ensheathed by Schwann cells nor grow sufficiently in radial diameter to become myelinated. These developmentally arrested motor axons are dysfunctional and vulnerable to rapid degeneration, limiting efficacy of current SMA therapeutics. We hypothesized that accelerating SMA motor axon maturation would improve their function and reduce disease features. A principle regulator of peripheral axon development is neuregulin 1 type III (NRG1-III). Expressed on axon surfaces, it interacts with Schwann cell receptors to mediate axon ensheathment and myelination. We examined NRG1 mRNA and protein expression levels in human and mouse SMA tissues and observed reduced expression in SMA spinal cord and in ventral, but not dorsal root axons. To determine the impact of neuronal NRG1-III overexpression on SMA motor axon development, we bred NRG1-III overexpressing mice to SMA∆7 mice. Neonatally, elevated NRG1-III expression increased SMA ventral root size as well as axon segregation, diameter, and myelination resulting in improved motor axon conduction velocities. NRG1-III was not able to prevent distal axonal degeneration nor improve axon electrophysiology, motor behavior, or survival of older mice. Together these findings demonstrate that early SMA motor axon developmental impairments can be ameliorated by a molecular strategy independent of SMN replacement providing hope for future SMA combinatorial therapeutic approaches.

Piloting a novel medical student virtual discharge counseling process in the time of the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, we identified a gap in adequate discharge counseling for COVID-19 patients in the Emergency Department. This was due to high patient volumes and lack of patient education regarding a novel disease. Medical students were also restricted from clinical areas due to safety concerns, compromising their clinical experience. We piloted a novel program in which medical students served as virtual discharge counselors for COVID-19 patients via teleconference. We aimed to demonstrate an impact on patient care by examining the patient bounce back rate as well as assessing medical student education and experience. METHODS: This program was piloted in a tertiary care Emergency Department. Medical student volunteers served as virtual discharge counselors. Students were trained in discharge counseling with a standardized protocol and a discharge script. Eligible patients for virtual discharge counseling were 18 years old or greater with a diagnosis of confirmed or suspected COVID-19 and no impediment precluding them from participating in a telemedicine encounter. Counseling was provided via secure teleconference in the patient's preferred language. Counseling included diagnosis, supportive care with medication dosing, quarantine instructions, return precautions, follow up, and time to ask questions. Duration of counseling was recorded and medical students were anonymously surveyed regarding their experience. RESULTS: Over an 18-week period, 45 patients were counseled for a median of 20 min. The 72-hr ED revisit rate was 0%, versus 4.2% in similarly-matched, not counseled COVID-19 patients. 90% of medical students believed this project increased their confidence when speaking with patients while 80% indicated this was their first telemedicine experience. CONCLUSION: Our pilot discharge program provided patients with an extensive discharge counseling experience that would not otherwise be possible in an urban ED setting and demonstrated benefit to patient care. Medical students received a safe clinical experience that improved their communication skills.

Managing multiple perspectives in the collaborative design process of a team health information technology.

We need to design technologies that support the work of health care teams; designing such solutions should integrate different clinical roles. However, we know little about the actual collaboration that occurs in the design process for a team-based care solution. This study examines how multiple perspectives were managed in the design of a team health IT solution aimed at supporting clinician information needs during pediatric trauma care transitions. We focused our analysis on four co-design sessions that involved multiple clinicians caring for pediatric trauma patients. We analyzed design session transcripts using content analysis and process coding guided by Détienne's (2006) co-design framework. We expanded upon Détienne (2006) three collaborative activities to identify specific themes and processes of collaboration between care team members engaged in the design process. The themes and processes describe how team members collaborated in a team health IT design process that resulted in a highly usable technology.

Leveraging a natural murine meiotic drive to suppress invasive populations.

Invasive rodents are a major cause of environmental damage and biodiversity loss, particularly on islands. Unlike insects, genetic biocontrol strategies including population-suppressing gene drives with biased inheritance have not been developed in mice. Here, we demonstrate a gene drive strategy (tCRISPR) that leverages super-Mendelian transmission of the t haplotype to spread inactivating mutations in a haplosufficient female fertility gene (Prl). Using spatially explicit individual-based in silico modeling, we show that tCRISPR can eradicate island populations under a range of realistic field-based parameter values. We also engineer transgenic tCRISPR mice that, crucially, exhibit biased transmission of the modified t haplotype and Prl mutations at levels our modeling predicts would be sufficient for eradication. This is an example of a feasible gene drive system for invasive alien rodent population control.

Team Cognition in Handoffs: Relating System Factors, Team Cognition Functions and Outcomes in Two Handoff Processes.

OBJECTIVE: This study investigates how team cognition occurs in care transitions from operating room (OR) to intensive care unit (ICU). We then seek to understand how the sociotechnical system and team cognition are related. BACKGROUND: Effective handoffs are critical to ensuring patient safety and have been the subject of many improvement efforts. However, the types of team-level cognitive processing during handoffs have not been explored, nor is it clear how the sociotechnical system shapes team cognition. METHOD: We conducted this study in an academic, Level 1 trauma center in the Midwestern United States. Twenty-eight physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) participated in semi-structured interviews. We performed qualitative content analysis and epistemic network analysis to understand the relationships between system factors, team cognition in handoffs and outcomes. RESULTS: Participants described three team cognition functions in handoffs-(1) information exchange, (2) assessment, and (3) planning and decision making; information exchange was mentioned most. Work system factors influenced team cognition. Inter-professional handoffs facilitated information exchange but included large teams with diverse backgrounds communicating, which can be inefficient. Intra-professional handoffs decreased team size and role diversity, which may simplify communication but increase information loss. Participants in inter-professional handoffs reflected on outcomes significantly more in relation to system factors and team cognition (p < 0.001), while participants in intra-professional handoffs discussed handoffs as a task. CONCLUSION: Handoffs include team cognition, which was influenced by work system design. Opportunities for handoff improvement include a flexibly standardized process and supportive tools/technologies. We recommend incorporating perspectives of the patient and family in future work.

Human-centered design of team health IT for pediatric trauma care transitions.

BACKGROUND: As problems of acceptance, usability and workflow integration continue to emerge with health information technologies (IT), it is critical to incorporate human factors and ergonomics (HFE) methods and design principles. Human-centered design (HCD) provides an approach to integrate HFE and produce usable technologies. However, HCD has been rarely used for designing team health IT, even though team-based care is expanding. OBJECTIVE: To describe the HCD process used to develop a usable team health IT (T3 or Teamwork Transition Technology) that provides cognitive support to pediatric trauma care teams during transitions from the emergency department to the operating room and the pediatric intensive care unit. METHODS: The HCD process included seven steps in three phases of analysis, design activities and feedback. RESULTS: The HCD process involved multiple perspectives and clinical roles that were engaged in inter-related activities, leading to design requirements, i.e., goals for the technology, a set of 47 information elements, and a list of HFE design principles applied to T3. Results of the evaluation showed a high usability score for T3. CONCLUSIONS: HFE can be integrated in the HCD process through a range of methods and design principles. That design process can produce a usable technology that provides cognitive support to a large diverse team involved in pediatric trauma care transitions. Future research should continue to focus on HFE-based design of team health IT.

Scenario-Based Evaluation of Team Health Information Technology to Support Pediatric Trauma Care Transitions.

BACKGROUND: Clinicians need health information technology (IT) that better supports their work. Currently, most health IT is designed to support individuals; however, more and more often, clinicians work in cross-functional teams. Trauma is one of the leading preventable causes of children's death. Trauma care by its very nature is team based but due to the emergent nature of trauma, critical clinical information is often missed in the transition of these patients from one service or unit to another. Teamwork transition technology can help support these transitions and minimize information loss while enhancing information gathering and storage. In this study, we created a large screen technology to support shared situational awareness across multiple clinical roles and departments. OBJECTIVES: This study aimed to examine if the Teamwork Transition Technology (T3) supports teams and team cognition. METHODS: We used a scenario-based mock-up methodology with 36 clinicians and staff from the different units and departments who are involved in pediatric trauma to examine T3. RESULTS: Results of the evaluation show that most participants agreed that the technology helps achieve the goals set out in the design phase. Respondents thought that T3 organizes and presents information in a different way that was helpful to them. CONCLUSION: In this study, we examined a health IT (T3) that was designed to support teams and team cognition. The results of our evaluation show that participants agreed that T3 does support them in their work and increases their situation awareness.

Gene drives for vertebrate pest control: Realistic spatial modelling of eradication probabilities and times for island mouse populations.

Invasive alien species continue to threaten global biodiversity. CRISPR-based gene drives, which can theoretically spread through populations despite imparting a fitness cost, could be used to suppress or eradicate pest populations. We develop an individual-based, spatially explicit, stochastic model to simulate the ability of CRISPR-based homing and X chromosome shredding drives to eradicate populations of invasive house mice (Mus muculus) from islands. Using the model, we explore the interactive effect of the efficiency of the drive constructs and the spatial ecology of the target population on the outcome of a gene-drive release. We also consider the impact of polyandrous mating and sperm competition, which could compromise the efficacy of some gene-drive strategies. Our results show that both drive strategies could be used to eradicate large populations of mice. Whereas parameters related to drive efficiency and demography strongly influence drive performance, we find that sperm competition following polyandrous mating is unlikely to impact the outcome of an eradication effort substantially. Assumptions regarding the spatial ecology of mice influenced the probability of and time required for eradication, with short-range dispersal capacities and limited mate-search areas producing 'chase' dynamics across the island characterized by cycles of local extinction and recolonization by mice. We also show that highly efficient drives are not always optimal, when dispersal and mate-search capabilities are low. Rapid local population suppression around the introduction sites can cause loss of the gene drive before it can spread to the entire island. We conclude that, although the design of efficient gene drives is undoubtedly critical, accurate data on the spatial ecology of target species are critical for predicting the result of a gene-drive release.

Care transition of trauma patients: Processes with articulation work before and after handoff.

While care transitions influence quality of care, less work studies transitions between hospital units. We studied care transitions from the operating room (OR) to pediatric and adult intensive critical care units (ICU) using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling. We interviewed twenty-nine physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) and administered the AHRQ Hospital Survey on Patient Safety Culture items about handoffs, care transitions and teamwork. Care transitions are complex, spatio-temporal processes and involve work during the transition (i.e., handoff and transport) and preparation and follow up activities (i.e., articulation work). Physicians defined the transition as starting earlier and ending later than nurses. Clinicians in the OR to adult ICU transition without a team handoff reported significantly less information loss and better cooperation, despite positive interview data. A team handoff and supporting articulation work should increase awareness, improving quality and safety of care transitions.

Dataset of seized wildlife and their intended uses.

The illegal wildlife trade (IWT) threatens conservation and biosecurity efforts. The Internet has greatly facilitated the trade of wildlife, and researchers have increasingly examined the Internet to uncover illegal trade. However, most efforts to locate illegal trade on the Internet are targeted to one or few taxa or products. Large-scale efforts to find illegal wildlife on the Internet (e-commerce, social media, dark web) may be facilitated by a systematic compilation of illegally traded wildlife taxa and their uses. Here, we provide such a dataset. We used seizure records from three global wildlife trade databases to compile the identity of seized taxa along with their intended usage (i.e., use-type). Our dataset includes c. 4.9k distinct taxa representing c. 3.3k species and contains c. 11k taxa-use combinations from 110 unique use-types. Further, we acquired over 45k common names for seized taxa from over 100 languages. Our dataset can be used to conduct large-scale broad searches of the Internet to find illegally traded wildlife. Further, our dataset can be filtered for more targeted searches of specific taxa or derived products.

Text classification to streamline online wildlife trade analyses.

Automated monitoring of websites that trade wildlife is increasingly necessary to inform conservation and biosecurity efforts. However, e-commerce and wildlife trading websites can contain a vast number of advertisements, an unknown proportion of which may be irrelevant to researchers and practitioners. Given that many wildlife-trade advertisements have an unstructured text format, automated identification of relevant listings has not traditionally been possible, nor attempted. Other scientific disciplines have solved similar problems using machine learning and natural language processing models, such as text classifiers. Here, we test the ability of a suite of text classifiers to extract relevant advertisements from wildlife trade occurring on the Internet. We collected data from an Australian classifieds website where people can post advertisements of their pet birds (n = 16.5k advertisements). We found that text classifiers can predict, with a high degree of accuracy, which listings are relevant (ROC AUC ≥ 0.98, F1 score ≥ 0.77). Furthermore, in an attempt to answer the question 'how much data is required to have an adequately performing model?', we conducted a sensitivity analysis by simulating decreases in sample sizes to measure the subsequent change in model performance. From our sensitivity analysis, we found that text classifiers required a minimum sample size of 33% (c. 5.5k listings) to accurately identify relevant listings (for our dataset), providing a reference point for future applications of this sort. Our results suggest that text classification is a viable tool that can be applied to the online trade of wildlife to reduce time dedicated to data cleaning. However, the success of text classifiers will vary depending on the advertisements and websites, and will therefore be context dependent. Further work to integrate other machine learning tools, such as image classification, may provide better predictive abilities in the context of streamlining data processing for wildlife trade related online data.

Development of an influenza pandemic decision support tool linking situational analytics to national response policy.

National influenza pandemic plans have evolved substantially over recent decades, as has the scientific research that underpins the advice contained within them. While the knowledge generated by many research activities has been directly incorporated into the current generation of pandemic plans, scientists and policymakers are yet to capitalise fully on the potential for near real-time analytics to formally contribute to epidemic decision-making. Theoretical studies demonstrate that it is now possible to make robust estimates of pandemic impact in the earliest stages of a pandemic using first few hundred household cohort (FFX) studies and algorithms designed specifically for analysing FFX data. Pandemic plans already recognise the importance of both situational awareness i.e., knowing pandemic impact and its key drivers, and the need for pandemic special studies and related analytic methods for estimating these drivers. An important next step is considering how information from these situational assessment activities can be integrated into the decision-making processes articulated in pandemic planning documents. Here we introduce a decision support tool that directly uses outputs from FFX algorithms to present recommendations on response options, including a quantification of uncertainty, to decision makers. We illustrate this approach using response information from within the Australian influenza pandemic plan.

Dissemination of child abuse clinical decision support: Moving beyond a single electronic health record.

BACKGROUND: Child maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs. METHODS: Using the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS. RESULTS: Over an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves. CONCLUSIONS: Dissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS.

Optimised prophylactic vaccination in metapopulations.

A highly effective method for controlling the spread of an infectious disease is vaccination. However, there are many situations where vaccines are in limited supply. The ability to determine, under this constraint, a vaccination strategy which minimises the number of people that become infected over the course of a potential epidemic is essential. Two questions naturally arise: when is it best to allocate vaccines, and to whom should they be allocated? We address these questions in the context of metapopulation models of disease spread. We discover that in practice it is generally optimal to distribute all vaccines prophylactically, rather than withholding until infection is introduced. For small metapopulations, we provide a method for determining the optimal prophylactic allocation. As the optimal strategy becomes computationally intensive to obtain when the population size increases, we detail an approximation method to determine an approximately optimal vaccination scheme. We find that our approximate strategy is consistently at least as good as three strategies reported in the literature across a wide range of parameter values.

A guide to using the internet to monitor and quantify the wildlife trade.

The unrivaled growth in e-commerce of animals and plants presents an unprecedented opportunity to monitor wildlife trade to inform conservation, biosecurity, and law enforcement. Using the internet to quantify the scale of the wildlife trade (volume and frequency) is a relatively recent and rapidly developing approach that lacks an accessible framework for locating relevant websites and collecting data. We produced an accessible guide for internet-based wildlife trade surveillance. We detailed a repeatable method involving a systematic internet search, with search engines, to locate relevant websites and content. For data collection, we highlight web-scraping technology as an efficient way to collect data in an automated fashion at regularly timed intervals. Our guide is applicable to the multitude of trade-based contexts because researchers can tailor search keywords for specific taxa or derived products and locations of interest. We provide information for working with the diversity of websites used in wildlife trade. For example, to locate relevant content on social media (e.g., posts or groups), each social media platform should be examined individually via the site's internal search engine. A key advantage of using the internet to study wildlife trade is the relative ease of access to an increasing amount of trade-related data. However, not all wildlife trade occurs online and it may occur on unobservable sections of the internet.

Resumen Una Guía para Usar el Internet para Monitorear y Cuantificar el Mercado de Fauna El crecimiento incomparable del comercio en línea de animales y plantas representa una oportunidad sin precedentes para monitorear el mercado de fauna y así orientar a la conservación, la bioseguridad y la aplicación de la ley. El uso del internet para cuantificar la escala del mercado de fauna (volumen y frecuencia) es una estrategia relativamente reciente y de rápido desarrollo que carece de un marco de trabajo accesible para la localización de sitios web relevantes y para la recolección de datos. Realizamos una guía accesible para la vigilancia del mercado de fauna en internet. Detallamos un método repetible que involucra una búsqueda sistemática por internet, por medio de buscadores, para localizar sitios web y contenidos relevantes. Para la recolección de datos, resaltamos la tecnología de web scraping como una manera eficiente de obtener datos de manera automatizada a intervalos regulares de tiempo. Nuestra guía puede aplicarse a la multitud de contextos basados en el mercado porque los investigadores pueden adaptar las palabras de búsqueda a taxones específicos o productos derivados y a localidades de interés. Proporcionamos información para poder trabajar con la diversidad de sitios web que se usan para el mercado de fauna. Por ejemplo, para localizar contenido relevante en las redes sociales (p. ej.: publicaciones o grupos), cada plataforma social debería ser examinada individualmente por medio del buscador interno del sitio. Una ventaja importante de usar el internet para estudiar el mercado de fauna es el acceso relativamente sencillo a una creciente cantidad de datos relacionados con el mercado. Sin embargo, no todo el mercado de fauna ocurre en línea y puede que suceda en secciones inobservables del internet.

Comprehensive Care Improvement for Oncologic Fever and Neutropenia from a Pediatric Emergency Department.

Introduction: Rapid time to antibiotics (TTA) for pediatric patients with fever and neutropenia in an emergency department decreases in-hospital mortality. Additionally, national guidelines recommend outpatient antibiotic management strategies for low-risk fever and neutropenia (LRFN). This study had two specific aims: (1) improve the percent of patients with suspected fever and neutropenia who receive antibiotics within 60 minutes of arrival from 55% to 90%, and (2) develop and operationalize a process for outpatient management of LRFN patients by October 2018. Methods: Using Lean methodologies, we implemented Plan-Do-Check-Act cycles focused on guideline development, electronic medical record reminders, order-set development, and a LRFN pathway as root causes for improvements. We used statistical process control charts to assess results. Results: The project conducted from July 2016 to October 2018 showed special cause improvement in December 2016 on a G-chart. Monthly Xbar-chart showed improvement in average TTA from 68.5 minutes to 42.5 minutes. A P-chart showed improvement in patients receiving antibiotics within 60 minutes, from 55% to 86.4%. A LRFN guideline and workflow was developed and implemented in October 2017. Conclusions: Implementation of guidelines, electronic medical record reminders, and order sets are useful tools to improve TTA for suspected fever and neutropenia. Utilizing more sensitive statistical process control charts early in projects with fewer patients can help recognize and guide process improvement. The development of workflows for outpatient management of LRFN may be possible, though it requires further study.