Evaluation of a Transitional Patient Navigation Protocol for People Living With Hepatitis C Virus in the New York City Jail System.

We evaluated outcomes from a telephone-based transitional patient navigation (TPN) service for people living with hepatitis C virus (HCV) upon returning to the community after incarceration in New York City (NYC) jails. NYC Health + Hospitals/Correctional Health Services offered referrals for TPN services provided by the NYC local health department patient navigation staff. We compared rates of connection to care among people referred for TPN services with those who were not referred. People living with HIV had a higher connection to care rate at three months (65.0% vs 39.8%, p≤.05) and people with opioid use disorder had a higher connection rate at six months (55.1% vs 36.1%, p≤.05) compared with people without these conditions. However, there was not an improved connection to HCV care associated with referral to TPN services for the overall cohort. Further research, including qualitative studies, may inform improved strategies for connection to HCV care after incarceration.

Using 42 CFR part 2 revisions to integrate substance use disorder treatment information into electronic health records at a safety net health system.

BACKGROUND: Regulations put in place to protect the privacy of individuals receiving substance use disorder (SUD) treatment have resulted in an unintended consequence of siloed SUD treatment and referral information outside of the integrated electronic health record (EHR). Recent revisions to these regulations have opened the door to data integration, which creates opportunities for enhanced patient care and more efficient workflows. We report on the experience of one safety-net hospital system integrating SUD treatment data into the EHR. METHODS: SUD treatment and referral information was integrated from siloed systems into the EHR through the implementation of a referral order, treatment episode definition, and referral and episode-related tools for addiction therapists and other clinicians. Integration was evaluated by monitoring SUD treatment episode characteristics, patient characteristics, referral linkage, and treatment episode retention before and after integration. Satisfaction of end-users with the new tools was evaluated through a survey of addiction therapists. RESULTS: After integration, three more SUD treatment programs were represented in the EHR. This increased the number of patients that could be tracked as initiating SUD treatment by 250%, from 562 before to 1,411 after integration. After integration, overall referral linkage declined (74% vs. 48%) and treatment episode retention at 90-days was higher (45% vs. 74%). Addiction therapists appreciated the efficiency of having all SUD treatment information in the EHR but did not find that the tools provided a large time savings shortly after integration. CONCLUSIONS: Integration of SUD treatment program data into the EHR facilitated both care coordination in patient treatment and quality improvement initiatives for treatment programs. Referral linkage and retention rates were likely modified by a broader capture of patients and changed outcome definition criteria. Greater preparatory workflow analysis may decrease initial end-user burden. Integration of siloed data, made possible given revised regulations, is essential to an efficient hub-and-spoke model of care, which must standardize and coordinate patient care across multiple clinics and departments.

"Listen with your ears and eyes and heart and your minds and your soul": Implications for decolonising consultation and occupational therapy from case studies on "Closing the Gap" policy implementation.

BACKGROUND: Including Aboriginal and Torres Strait Islander people and communities through consultation has been a key feature of policy implementation throughout the Australian Government's "Closing the Gap" (CTG) strategy. However, consultation often reinforces power imbalances between government and local community and can undervalue or marginalise Indigenous knowledge and leadership. Occupational therapy has a short history of examining colonial power structures within the profession, but there has been limited progress to decolonise consultation and practice. METHODS: Drawing on decolonising research methodology and positioned at the interface of knowledge, comparative case studies were used to understand policy implementation in two regions. In Shepparton, Victoria, CTG policy was implemented predominately through an Aboriginal Community Controlled Health Organisation, and in Southern Adelaide, South Australia, CTG policy was implemented through mainstream state government and non-government providers in the absence of a local Aboriginal-controlled organisation. Findings were examined critically to identify implications for occupational therapy. RESULTS: Our case studies showed that policy stakeholders perceived consultation to be tokenistic and partnerships were viewed differently by Aboriginal and non-Indigenous participants. Participants identified the need to move beyond a rhetoric of "working with" Aboriginal and Torres Strait Islander people, to promote Aboriginal leadership and really listen to community so that policy can respond to local need. The findings of this research show that Aboriginal-controlled services are best positioned to conduct and respond to community consultation. CONCLUSION: A decolonising approach to consultation would shift the status quo in policy implementation in ways that realign power away from colonial structures towards collaboration with Indigenous leadership and the promotion of Aboriginal-controlled services. There are lessons for occupational therapy from this research on policy implementation on authentic, decolonised consultation as a key feature of policy implementation. Shifting power imbalances through prioritising Indigenous leadership and honouring what is shared can drive change in CTG policy implementation processes and outcomes.

Contextual barriers and enablers to establishing an addiction-focused consultation team for hospitalized adults with opioid use disorder.

BACKGROUND: Hospitalization presents an opportunity to begin people with opioid use disorder (OUD) on medications for opioid use disorder (MOUD) and link them to care after discharge; regrettably, people admitted to the hospital with an underlying OUD typically do not receive MOUD and are not connected with subsequent treatment for their condition. To address this gap, we launched a multi-site randomized controlled trial to test the effectiveness of a hospital-based addiction consultation team (the Substance Use Treatment and Recovery Team (START)) consisting of an addiction medicine specialist and care manager team that provide collaborative care and a specified intervention to people with OUD during the inpatient stay. Successful implementation of new practices can be impacted by organizational context, though no previous studies have examined context prior to implementation of addiction consultation services (ACS). This study assessed pre-implementation context for implementing a specialized ACS and tailoring it accordingly. METHODS: We conducted semi-structured interviews with hospital administrators, physicians, physician assistants, nurses, and social workers at the three study sites between April and August 2021 before the launch of the pragmatic trial. Using an analytical framework based on the Consolidated Framework for Implementation Research, we completed a thematic analysis of interview data to understand potential barriers or enablers and perceptions about acceptability and feasibility. RESULTS: We interviewed 28 participants across three sites. The following themes emerged across sites: (1) START is an urgently needed model for people with OUD; (2) Intervention adaptations are recommended to meet local and cultural needs; (3) Linking people with OUD to community clinicians is a highly needed component of START; (4) It is important to engage stakeholders across departments and roles throughout implementation. Across sites, participants generally saw a need for change from usual care to support people with OUD, and thought the START was acceptable and feasible to implement. Differences among sites included tailoring the START to support the needs of varying patient populations and different perceptions of the prevalence of OUD. CONCLUSIONS: Hospitals planning to implement an ACS in the inpatient setting may wish to engage in a systematic pre-implementation contextual assessment using a similar framework to understand and address potential barriers and contextual factors that may impact implementation. Pre-implementation work can help ensure the ACS and other new practices fit within each unique hospital context.

Comparison of recruitment methodologies for clinical trials: Results from the time for living and caring (TLC) intervention study.

BACKGROUND: Recruiting participants for research studies is a critical yet challenging task. Community-engaged recruitment strategies have gained prominence as effective means to engage diverse populations and ensure the representativeness of study samples. This case study aims to investigate the cost and effectiveness of various recruitment methods in enhancing research participation. METHODS: A comparative approach was employed to assess the outcomes of five different recruitment strategies used in the Time for Living & Caring (TLC) research study. Data on recruitment success, participant demographics, and retention rates were collected and analyzed using descriptive statistics, including ANOVA and Chi-squares, to statistically compare the outcomes associated with 5 different recruitment methodologies. The recruitment methodologies included two community-engaged strategies (community partner referral and community-based recruiters), a clinical database, social media, and word-of-mouth referral. CONCLUSION: The meta-data used to build this methodological case study describe different recruitment methodologies that may be used for clinical trials. This data-driven evaluation provides examples and considerations for researchers when developing budgets and proposals for future clinical trials. The primary finding is that there are tradeoffs in terms of cost, time, labor, and ultimately the representativeness of the sample, based on the type of recruitment methodology chosen.

What's age got to do with it? A study of the implementation of the discharge medicines service for paediatric patients.

OBJECTIVES: The discharge medicines service (DMS) was introduced as an essential service for all community pharmacies in England through the Community Pharmacy Contractual Framework (CPCF) in February 2021. This study aimed to describe the implementation of this service for paediatric patients and to identify any barriers to referrals. METHODS: The study was undertaken in a 24-bed paediatric ward in a District General Hospital from September 2022 to February 2023. All paediatric inpatients on long-term medications were eligible for inclusion. Out of 169 eligible participants, 149 were referred. Community pharmacists accessed referrals through PharmOutcomes® and could accept, complete, or reject referrals on this platform. KEY FINDINGS: Of the 149 referred patients, 24 (16.1%) were accepted but not yet actioned; 63 (42.3%) were fully or partially completed; 19 (12.8%) were rejected, and 43 (28.9%) there was no response (remained as referred). Younger children (<2 years) were more likely to have their referral rejected than older children (6 years and older). The feedback from parents was overwhelmingly positive (93.5%) and two families reported that they believed the DMS service prevented readmission to the hospital for their children. No children were involved in the community pharmacist consultation. Barriers to referrals included patients not having a nominated pharmacy and a lack of confidence in completing paediatric referrals. CONCLUSIONS: This study demonstrates the value of completing referrals for paediatric patients. More research is required to explore how community pharmacists can be supported to complete paediatric DMS referrals.

Navigating Transitions in Oncology Care: From Emergency Department to Outpatient Clinic.

OBJECTIVE: This quality improvement project was a collaborative effort with Penn Medicine's emergency department (ED) and oncology nurse navigators (ONNs). The goal of the project was to streamline patient transitions from the ED to the outpatient oncology clinic by developing a standardized referral process. The main objectives were to simplify and automate the referral process using the electronic medical record, improve multidisciplinary communication across the care continuum, ensure timely follow-up, and address barriers to oncology care. METHODS: The ED providers placed a consult to ONNs. The ONNs reached out to the patient within 48 hours of the consult. They maintained a database of patient referrals and collected information such as patient demographics, reason for referral, insurance, and patient outcomes. RESULTS: The ED providers referred 204 patients to the ONNs from April 2022 to September 2023. The development of a standardized referral process from the ED to the outpatient oncology clinic proved successful. Of the patients referred, the ONNs facilitated 98 cancer diagnoses and 80 of those patients are receiving oncology care at Penn Medicine. The median time to the patient's first appointments was seven days, diagnosis was 15 days, and treatment initiation occurred within 32 days. CONCLUSION: The project team achieved their goal of facilitating timely access to oncology care, ensuring continuity, and addressing patient-specific barriers. IMPLICATIONS FOR NURSING PRACTICE: This quality improvement initiative highlights the ONNs' role in enhancing access and equity in cancer care delivery. The success of the project underscores the ONN's expertise and leadership in addressing healthcare disparities in oncology care. Collaboratively, the teams created a new referral workflow improving care transitions from the ED to the outpatient oncology clinic. The project sets a precedent for optimizing patient care transitions, demonstrating the positive impact of ONNs as key members of the multidisciplinary healthcare team.

Adherence to Emergency Department Referral Criteria in a Direct-to-Consumer Telemedicine Center.

Background: The safety of direct-to-consumer telemedicine (TM) is closely related to red flag detection and correct referrals. The adherence to referral criteria from current guidelines is not well quantified. Objective: To analyze the emergency department (ED) referral rate and adherence to referral guidelines in TM encounters of acutely ill patients calling a center that adopts stewardship protocols. Methods: This is a retrospective observational unicentric study, between March 2020 and March 2022, with patients who spontaneously sought direct-to-consumer urgent virtual medical assistance. A video-based teleconsultation was provided immediately after connection. Physicians managed situations according to their clinical judgment. Current guidelines, containing specific guidance for referral if red flags were identified, were available for consultation. Physicians' semiannual performance feedback was carried out. We analyzed the patterns for referral to immediate face-to-face medical evaluation and the agreement degree with the institutional guidelines. Results: A total of 232,197 patients were available, and 14,051 (6.05%) patients were referred to ED. A total of 8,829 (68.4%) referrals were based in specific guidelines according to the International Classification of Diseases hypothesis, and 8,708 (98.6%) were justified according to guidelines. Diarrhea had the highest guidelines' adherence to referral (97.6%), followed by COVID-19 (90%), headache (84.2%), and conjunctivitis (78.8%). Policies did not support 5,222 (31.6%) referrals, though 5,100 (97.6%) of these were justified according to the doctor's clinical judgment. Conclusion: TM doctors' assessment of acutely ill patients has high rates of adherence to guidelines regarding referral. Stewardship protocol adoption provides high rates of red flag description, even in the referral of nonpolicy diseases.

Improving Outcomes in Patients Sent to the Emergency Department from Outpatient Providers: A Receiver-Driven Handoff Process Improvement.

BACKGROUND: Outpatient providers refer to emergency departments (EDs) due to findings requiring assessment beyond existing capabilities. However, poor communication surrounding these transitions may hinder safety and timeliness of emergency care. Receiver-driven handoff (RDH) is a process that helps ensure that all pertinent information is shared. This quality improvement project aimed to (1) improve knowledge of RDH, (2) increase satisfaction and perceptions surrounding RDH, (3) modify behaviors in relation to RDH, and (4) decrease referred patients leaving without being seen (LWBS). METHODS: The Iowa Model and Implementation Framework guided this evidence-based quality improvement project. A multidisciplinary team developed and implemented a standardized RDH process consisting of screening to determine whether a patient was referred to the ED, review of electronic health record (EHR), and use of EHR documentation. Process measures were collected via questionnaire pre- and postimplementation and were analyzed quantitatively. Outcome measures were trended by a statistical process control p-chart, which was developed to demonstrate changes in the percentage of patients who were referred to the ED from the outpatient setting and LWBS. RESULTS: The average response for the question "How satisfied are you with the handoff of patient information from referring clinic providers to the ED?" increased from 1.51 preintervention to 2.04 postintervention (p = 0.005). Respondents rated the information received during handoff higher postintervention (2.12 vs. 2.52, p = 0.04). Compliance with screening for referral to the ED was 84.0%. The proportion of patients LWBS after referral decreased by 6.2 percentage points (p < 0.001). CONCLUSION: Using RDH in conjunction with a standardized triage screening may improve quality of information shared during this vulnerable transition and may assist in reduction of referred patients LWBS. The RDH process should be adapted into everyday workflow to ensure sustainability and effectiveness.

Development and Evaluation of I-PASS-to-PICU: A Standard Electronic Template to Improve Referral Communication for Interfacility Transfers to the Pediatric ICU.

BACKGROUND: Miscommunication during interfacility handoffs to a higher level of care can harm critically ill children. Adapting evidence-based handoff interventions to interfacility referral communication may prevent adverse events. The objective of this project was to develop and evaluate a standard electronic referral template (I-PASS-to-PICU) to improve communication for interfacility pediatric ICU (PICU) transfers. METHODS: I-PASS-to-PICU was iteratively developed in a single PICU. A core PICU stakeholder group collaboratively designed an electronic health record (EHR)-supported clinical note template by adapting elements from I-PASS, an evidence-based handoff program, to support information exchange between referring clinicians and receiving PICU physicians. I-PASS-to-PICU is a receiver-driven tool used by PICU physicians to guide verbal communication and electronic documentation during PICU transfer calls. The template underwent three cycles of iterative evaluation and redesign informed by individual and group interviews of multidisciplinary PICU staff, usability testing using simulated and actual referral calls, and debriefing with PICU physicians. RESULTS: Individual and group interviews with 21 PICU staff members revealed that relevant, accurate, and concise information was needed for adequate admission preparedness. Time constraints and secondhand information transmission were identified as barriers. Usability testing with six receiving PICU physicians using simulated and actual calls revealed good usability on the validated System Usability Scale (SUS), with a mean score of 77.5 (standard deviation 10.9). Fellows indicated that most fields were relevant and that the template was feasible to use. CONCLUSION: I-PASS-to-PICU was technically feasible, usable, and relevant. The authors plan to further evaluate its effectiveness in improving information exchange during real-time PICU practice.

Lessons Learned: Evaluation of Fracture Liaison Service Quality Improvement Efforts in a Large Academic Healthcare System.

BACKGROUND: The Fracture Liaison Service (FLS) care model, a care coordination program for patients experiencing a fragility fracture, is proven to improve management of patients with an osteoporotic fracture, but treatment initiation gaps persist. OBJECTIVE: We describe the evolution of a centralized FLS within a university-based healthcare system, including impact of adding clinical pharmacist consultation, and describe circumstances surrounding continued care gaps. DESIGN: Cohort analysis of osteoporosis medication initiation before FLS, after initial implementation, and after addition of pharmacist consultation. PATIENTS: Individuals aged 65 and older experiencing any fragility fracture between 7/1/16 and 3/31/22. INTERVENTION: A centralized team outreached eligible patients, ordered dual x-ray absorptiometry and laboratory tests as needed, and scheduled an osteoporosis-focused primary care appointment. Three years after FLS implementation, clinical pharmacist consultative review was added prior to the primary care visit. MAIN MEASURES: Initiation of osteoporosis pharmacologic therapy, completion of DXA, primary care follow-up rate, and description of circumstances where therapy was not initiated. KEY RESULTS: Of 1204 new fractures between 7/1/16 and 3/31/22, 315 patients were enrolled in one of two FLS phases, and 89 eligible historical controls were identified. Medication initiation rates went from 22/89 (25%) pre-FLS to 201/428 (47%) after-FLS phase 1 [POST1] (p<0.001) and to 106/187 (57%) after FLS phase 2 (POST2), when clinical pharmacist consultation was added (p=0.03 versus POST1). DXA was completed in 56/89 (67%) of pre-FLS patients, 364/428 (85%) POST1 patients (p<0.001 versus pre), and 163/187 (87%) POST2 (p< 0.001 versus PRE, p=0.59 versus POST1). Of 375 patients who did not initiate osteoporosis medication, more in the combined post-FLS cohorts attended a follow-up primary care appointment (233/308, 76% attended, versus pre-FLS 41/67, 61%, p=0.016). CONCLUSION: An FLS including centralized outreach and care coordination significantly improved patient follow-up, DXA, and medication initiation. Addition of de-centralized pharmacist consultation further improved medication initiation rates.

Improving Access to Specialty Pediatric Care: Innovative Referral and eConsult Technology in a Specialized Acute Care Hospital.

Background: The COVID-19 pandemic has exacerbated wait times for pediatric specialty care. Transformative technologies such as electronic referral (eReferral-automation of patient information) and electronic consultations (eConsult-asynchronous request for specialized advice by primary care providers) have the potential to increase timely access to specialist care. The objective of this study was to present an overview of the current state and characteristics of referrals directed to a pediatric ambulatory medical surgery center, with an emphasis on the innovative use of an eConsult system and to indicate key considerations for system improvement. Methods: This cross-sectional study was conducted at a specialized pediatric acute care hospital in Ottawa, Ontario. Secondary data were obtained over a 2-year period during the COVID-19 pandemic (2019-2022). To gain insights and identify areas of improvement related to the factors pertaining to referrals and eConsults at the process and system levels, quality improvement (QI) methodologies were employed. Descriptive statistics provide a summary of the trends and characteristics of referrals and the utilization of eConsult. Results: Among the 113,790 referrals received, 31,430 were denied. Most common reasons for referral denial were other/null (e.g., unspecified) (29.3%), inappropriate referrals (12.6%), and duplicate referrals (12.4%). Four clinics (e.g., endocrinology, cardiology, neurology, and neurosurgery) reported a total of 277 eConsults, with endocrinology accounting for 95.0% of all eConsults. QI findings revealed the need for standardized workflows among specialties and ensuring that eConsult options are accessible and integrated within the electronic medical record (EMR). Conclusions: Refining the pediatric referral management process and optimizing eConsult through existing clinical systems have the potential to improve the timeliness and quality of specialty care. The results inform future research initiatives targeting improved access to pediatric specialty care and serve as a benchmark for hospitals utilizing EMRs and eConsult.

Encuesta SEMI sobre la organización y actividad en interconsultas y asistencia compartida / SEMI survey on the organization and activity in consultation/referral and comanagement

Background: Currently, there is a lack of information about the activity carried out through consultations or referrals (IC), and even less about comanagement (AC). The Grupo de Trabajo de Asistencia Compartida y Medicina Hospitalista considered update the main organizational characteristics of CI and AC activities in the national territory. Material and methods: During the months of January and February 2020, SEMI members, regardless of their position, were invited to participate in an anonymous telematic survey to study the CI and AC activity of the internal medicine (IM) departments. A cross-sectional descriptive study was carried out. Results: A total of 107 hospitals participated in the survey. Shared care (AC) is provided in 75% of the centers, median of services attended with AC per hospital were 2 (0-13). Hip fracture care units predominate. Median number of staff in the IM departments were 13 (2-50), being full-time in IC/AC in 26% of them, developing the activity of IC/AC on a fixed basis in 50% of the cases. The range of patients treated in IC/AC was very wide (0-3500), with a median of 300. 42.4% of the IC/AC units have medical training. Conclusions: There has been a strong growth of CI/AC units in recent years, with dedicated full-time members and with a growing teaching weight. There is still a lack of knowledge of the basic concepts of CI/AC. (AU)

Introducción: Actualmente hay una carencia de información acerca de la actividad realizada a través de las interconsultas (IC), y menos aún sobre la asistencia compartida (AC). El Grupo de Trabajo de Asistencia Compartida y Medicina Hospitalista consideró necesario actualizar las principales características organizativas de las actividades de IC y AC en el territorio nacional. Material y métodos: Durante los meses de enero y febrero de 2020 se invitó a los miembros de la SEMI, independientemente de su cargo, a participar en una encuesta anónima telemática para conocer a actividad de IC y AC de los servicios de MI. Se realizó un estudio descriptivo transversal. Resultados: Un total de 107 hospitales participaron en la encuesta. En el 75% de los centros se realiza asistencia compartida, siendo la mediana por hospital de servicios atendidos con AC de 2 (0-13). Predominan las unidades de atención a la fractura de cadera. La mediana de adjuntos en los servicios de MI fue de 13 (2-50), siendo a tiempo completo en IC/AC en el 26% de ellos, desarrollando la actividad de IC/AC de manera fija y no rotatoria en el 50% de los casos. El rango de pacientes atendidos en IC/AC fue muy amplio (0-3500), mediana de 300. El 42,4% tiene formación MIR por la unidad de IC/AC. Conclusiones: Se está produciendo un fuerte crecimiento de unidades de IC/AC en los últimos años, con miembros dedicados a tiempo completo y con un peso docente creciente. Todavía hay un importante grado de desconocimiento de los conceptos básicos sobre IC/AC. (AU)

Assessment of functioning in Dutch primary care: Development study of a consultation tool for patients with chronic conditions and multimorbidity.

BACKGROUND: In primary care, a shift from a disease-oriented approach for patients with multimorbidity towards a more person-centred approach is needed. AIM: To transform a self-report questionnaire for patients with chronic conditions in primary care, the Primary Care Functioning Scale (PCFS), into an understandable, visually attractive and feasible consultation tool for patients and health care providers. The consultation tool consists of a web-based version of the PCFS, which is filled in by the patient and is processed to a feedback report that summarizes and visualizes the main findings. The feedback report can be discussed with the patient to facilitate a more person-centred conversation for patients with chronic conditions and multimorbidity in general practice. DESIGN AND SETTING: In this qualitative study, we developed the consultation tool by using design thinking in a participatory developmental process. METHODS: In the first phase, we constructed five different feedback report templates to summarize and display the results of a completed PCFS questionnaire in a series of two expert meetings with patients and general practitioners (GPs). In the second phase, we performed an exploratory qualitative interview study involving dyads of patients with chronic conditions and their practice nurses. In an iterative process, we explored their experiences with the consultation tool. RESULTS: Patients, as well as GPs, preferred a clear manner of presenting the results of the questionnaire in a feedback report. In 18 interviews with patients and practice nurses during three different interview rounds, we adjusted the feedback report and consultation tool based on the input from patients and practice nurses. After the final interview round, patients and practice nurses consented that the consultation tool was useful for having a more in-depth consultation about functioning and patients' preferences when integrated into the regularly scheduled consultations. CONCLUSION: We were able to develop an understandable and feasible consultation tool that is applicable in already existing chronic disease management programmes in general practice in the Netherlands. PATIENT OR PUBLIC CONTRIBUTION: To increase the understandability and feasibility of the consultation tool, we collaborated with end-users and actively involved patients, GPs and practice nurses in a participatory development process.

"Finding a General Surgeon: Self-Referral in the Digital Era".

BACKGROUND: As technology becomes more prominent in today's society, more patients turn to the Internet to self-refer for a range of surgical problems. Frequently, patients search a nearby hospital's website in order to find a physician. We hypothesized that the variability in hospital websites would make it difficult for patients to find a general surgeon for their care. METHODS: We used the US News and World Report's Hospital Rankings 2018-2019 for this study. The "Find A Doctor" page within each hospital's website was searched for the following conditions: "hernia" and "gallbladder." Information on all suggested providers was collected, including medical specialty and gender. Descriptive statistics were used to analyze the data. RESULTS: The median number of providers listed in each search was 18 (range: 1-204). For "hernia," general surgeons were not the majority of providers suggested at 12/16 institutions. For "gallbladder," general surgeons were not the majority of providers suggested at 14/16 institutions, and 3/16 institutions did not suggest any. All 16 institutions suggested a strong majority of male providers (range: 62-100% male; median: 83% male). DISCUSSION: Considerable variation exists in the suggestion of medical providers for common general surgical problems among the top academic hospitals. Most notably, general surgeons are not listed as the primary providers for these conditions which they commonly manage. Health systems need to examine how their website suggest providers and ensure that patients can easily find the physician most suitable for their care.

NHS 111 Clinical Assessment Services: paediatric consultations.

Around the UK, commissioners have different models for delivering NHS 111, General Practice (GP) out-of-hours and urgent care services, focusing on telephony to help deliver urgent and emergency care. During the (early phases of the) COVID-19 pandemic, NHS 111 experienced an unprecedented volume of calls. At any time, 25%-30% of calls relate to children and young people (CYP). In response, the CYP's Transformation and Integrated Urgent Care teams at NHS England and NHS Improvement (NHSE/I) assisted in redeploying volunteer paediatricians into the integrated urgent care NHS 111 Clinical Assessment Services (CAS), taking calls about CYP. From this work, key stakeholders developed a paediatric 111 consultation framework, as well as learning outcomes, key capabilities and illustrations mapped against the Royal College of Paediatrics and Child Health (RCPCH) Progress curriculum domains, to aid paediatricians in training to undertake NHS 111 activities. These learning outcomes and key capabilities have been endorsed by the RCPCH Curriculum Review Group and are recommended to form part of the integrated urgent care service specification and workforce blueprint to improve outcomes for CYP.

Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of Critical Care Medicine.

OBJECTIVES: The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions. DATA SOURCES AND STUDY SELECTION: Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product. DATA EXTRACTION AND SYNTHESIS: The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations. CONCLUSIONS: Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.

Falling through the cracks: Evaluating the role of nonacute surgical liaison personnel during COVID-19-A narrative review.

BACKGROUND: In March 2020, in response to the COVID-19 pandemic, the New Zealand government instituted a 4-level alert system, which resulted in the rapid dissolution of nonurgent surgical services to minimize occupational exposure to both patients and staff, with the primary health sector bearing most of the diverted caseload. Consequently, the study authors sought to collate information around the establishment of a supportive nonacute surgical liaison role in a public hospital surgical department, with an interest in establishing this role in New Zealand. METHODS: The narrative review conducted systematically in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases searched included Pubmed, MEDLINE, Embase, and Cochrane Controlled Register of Trials. A deductive analysis was applied using a demand management model developed by the Institute for Innovation and Improvement at Waitemata District Health Board. All included studies were rated using the Oxford Centre for Evidence-Based Medicine Levels of Evidence tool. RESULTS: Collation of 19 studies resulted in 3 key findings: first, that a surgical liaison could be utilized at the primary care to specialist interface to improve communication and workflow between services. Second, a liaison could be utilized directly communicating with patients as a means of increasing engagement and self-management. Finally, this service can be offered through multiple modalities including a noncontact telehealth service. CONCLUSION: Evidence of nonacute surgical liaisons both internationally and specifically within New Zealand has been collated to provide evidence for its application.