Automatic Referral Research Articles

A Review of Disparities in Cardiac Rehabilitation: EVIDENCE, DRIVERS, AND SOLUTIONS.

Cardiac rehabilitation (CR) has been shown to improve functional status, quality of life, and recurrent cardiovascular disease (CVD) events. Despite its demonstrated compelling benefits and guideline recommendation, CR is underutilized, and there are significant disparities in CR utilization particularly by race, ethnicity, sex, and socioeconomic status. The purpose of this review is to summarize the evidence and drivers of these disparities and recommend potential solutions. In this review, key studies documenting disparities in CR referrals, enrollment, and completion are discussed. Additionally, potential mechanisms for these disparities are summarized and strategies are reviewed for addressing them. There is a wealth of literature demonstrating disparities among racial and ethnic minorities, women, those with lower income and education attainment, and those living in rural and dense urban areas. However, there was minimal focus on how the social determinants of health contribute to the observed disparities in CR utilization in many of the studies reviewed. Interventions such as automatic referrals, inpatient liaisons, mitigation of economic barriers, novel delivery mechanisms, community partnerships, and health equity metrics to incentivize health care organizations to reduce care disparities are potential solutions.

Integrating social determinants of health screening and referral during routine emergency department care: evaluation of reach and implementation challenges

BackgroundDespite the importance of social determinants in health outcomes, little is known about the best practices for screening and referral during clinical encounters. This study aimed to implement universal social needs screening and community service referrals in an academic emergency department (ED), evaluating for feasibility, reach, and stakeholder perspectives.MethodsBetween January 2019 and February 2020, ED registration staff screened patients for social needs using a 10-item, low-literacy, English-Spanish screener on touchscreens that generated automatic referrals to community service outreach specialists and data linkages. The RE-AIM framework, specifically the constructs of reach and adoption, guided the evaluation. Reach was estimated through a number of approaches, completed screenings, and receipt of community service referrals. Adoption was addressed qualitatively via content analysis and qualitative coding techniques from (1) meetings, clinical interactions, and semi-structured interviews with ED staff and (2) an iterative “engagement studio” with an advisory group composed of ED patients representing diverse communities.ResultsOverall, 4608 participants were approached, and 61% completed the screener. The most common reason for non-completion was patient refusal (43%). Forty-seven percent of patients with completed screeners communicated one or more needs, 34% of whom agreed to follow-up by resource specialists. Of the 482 participants referred, 20% were reached by outreach specialists and referred to community agencies. Only 7% of patients completed the full process from screening to community service referral; older, male, non-White, and Hispanic patients were more likely to complete the referral process. Iterative staff (n = 8) observations and interviews demonstrated that, despite instruction for universal screening, patient presentation (e.g., appearance, insurance status) drove screening decisions. The staff communicated discomfort with, and questioned the usefulness of, screening. Patients (n = 10) communicated a desire for improved understanding of their unmet needs, but had concerns about stigmatization and privacy, and communicated how receptivity of screenings and outreach are influenced by the perceived sincerity of screening staff.ConclusionsDespite the limited time and technical barriers, few patients with social needs ultimately received service referrals. Perspectives of staff and patients suggest that social needs screening during clinical encounters should incorporate structure for facilitating patient-staff relatedness and competence, and address patient vulnerability by ensuring universal, private screenings with clear intent.Trial registrationClinicalTrials.gov, NCT04630041.

OA05.02 Acceptability of Automatic Referrals to Supportive and Palliative Care, by Patients Living with Advanced Lung Cancer: A Co-Design Process

People living with advanced lung cancer often experience high symptom burden and emotional distress. Over a decade ago, a randomized controlled trial demonstrated that patients with metastatic non-small cell lung cancer who received early palliative care (PC) lived longer and had significantly improved quality of life and mood. Nevertheless, timely access to supportive and PC services remains a challenge. Barriers to accessing PC services include stigma around PC, and inconsistences in clinician referrals due to competing tasks and varied education, experience, interest, and understanding of palliative care. A proposed solution is to trigger an automatic referral process to PC by pre-determined clinical criteria, without the need for a formal clinician referral. However, patient acceptability of automatic referrals is unknown. To study whether an automatic process is acceptable, our group- Palliative Care Early and Systematic (PaCES), sought to co-design with patients and providers the operational processes and communication pieces for automatic PC referral for patients newly diagnosed with stage IV lung cancer. In Step 1 of this work, nine semi-structured one on one phone interviews were conducted with advanced lung cancer patients on their perspectives on the acceptability of phone contact by a specialist PC provider triggered by an automatic referral process. Interviews were thematically analysed using Sekhon’s Theoretical Framework of Acceptability as a guiding framework for analysis. Step 2: Patient advisors, healthcare providers (oncologists, nurses from oncology and PC, clinical social worker, psychologist), and researchers were invited to join a co-design working group to develop and provide input on the operational and communication processes needed for the automatic referral process. Using the findings from step 1, the group developed the automatic referral process and met biweekly (virtually) over the course of 5 months. From patient interviews, the concept of an automatic referral process and being phoned directly by a PC provider offering a consult was perceived to be acceptable and beneficial for patients with advanced lung cancer. Patients emphasized the need for timely support, access to peer and community resources. Patients also identified important components necessary for the automatic referral process such as the naming of the service, timing of the referral, and information needed from the phone call. Using these findings, the co-design working group identified the eligibility criteria for identifying newly diagnosed stage IV lung cancer patients using the cancer centre electronic health record, co-developed a telephone script for specialist PC providers, a patient handout about supportive care, and handout on supportive care resources. Additionally, interview and survey guides for evaluating the implemented automatic process were refined. A co-design process ensures stakeholders are involved in program development and implementation from the very beginning, to make outputs relevant and acceptable for stage IV lung cancer patients. The next phase of this work will use Sekhon’s Theoretical Framework of Acceptability through mixed-methods to evaluate the acceptability of an automatic referral process from the perspective of the patients called and healthcare providers.

SEX DIFFERENCES IN THE IMPACT OF SYMPTOMS OF ANXIETY AND DEPRESSION ON CARDIAC REHABILITATION PARTICIPATION AND OUTCOMES

SEX DIFFERENCES IN THE IMPACT OF SYMPTOMS OF ANXIETY AND DEPRESSION ON CARDIAC REHABILITATION PARTICIPATION AND OUTCOMES

Improving referrals to survivorship: A patient-driven initiative.

44 Background: Patients often feel lost in the transition from cancer patient to survivor. As cancer treatment improves, the number of survivors in the US is expected to approach 22 million by the year 2029. Smaller increases in the MD workforce coupled with long-term effects of new treatments necessitate the creation survivorship clinics led by advanced practice providers (APP) who are disease-specialized and specifically trained to manage unique survivor needs. Although the institutions Survivorship program was established more than a decade ago, the average referral rate to the program is only 30%. Given the high levels of patient satisfaction with the program, we sought to understand and address clinician awareness and referral obstacles. Methods: Based on patient input, members of our Patient & Family Advisory Council for Quality (PFACQ) put forth a proposal aimed at increasing referrals to the Survivorship program. A multidisciplinary working group comprising patients, clinicians, administrators and process engineers was assembled. Process Improvement training was conducted, and a primary goal was developed: increase Survivorship referrals by 25%. Central to the approach was engagement with referring physicians and APPs on a service-by-service basis. A four-question survey was developed to address timing of initial discussion, challenges to referring, knowledge of visit elements, and materials needed to support referrals. A customized ‘roadshow’ presentation was created and delivered by a PFACQ member at a faculty meeting. Highlights included: the importance of Survivorship care to patients and details of the visit, survey responses, and additional faculty discussion and input. Results: Four roadshows were completed from August 2020-June 2021: Gynecologic Surgery, Endocrine, Breast Medicine and Lymphoma. Based on survey responses and dialogue with providers, new material to support patient discussions and education have been developed: a patient-facing brochure, clinician- & patient-facing video, and clinician talking points. Methods to facilitate identifying eligible patients were also discussed, as well as automatic referrals to Survivorship for selected services. Data reveal a significant increase in referral rates from GYN and Endocrine services (follow up > 6 months) of 63% and 228%, respectively. (Breast Medicine and Lymphoma with shorter follow up will be reported.) Engagement with other services is underway. Conclusions: Results have exceeded the goal of increasing referral rates to the program. This process suggests that ongoing engagement with referring clinicians is essential to achieving and maintaining higher referral rates. The patient voice throughout this process has been a powerful tool in raising clinician awareness of their experiences and expectations for comprehensive follow up care, which can be delivered on a greater scale by survivorship providers.

Cardiac Rehabilitation: Under-Utilized Globally.

Cardiac rehabilitation (CR) is grossly under-utilized. This review summarizes current knowledge about degree of CR utilization, reasons for under-utilization, and strategies to increase use. ICCPR's global CR audit quantified for the first time the number of additional CR spots needed per year to treat indicated patients, so there are programs they may use. The first randomized trial of automatic/systematic CR referral has shown it results in significantly greater patient completion. Moreover, the recent update of the Cochrane review on interventions to increase use has provided unequivocal evidence on the significant impact of clinician CR encouragement at the bedside; a course is now available to train clinicians. The USA is leading the way in implementing automatic referral with inpatient-clinician CR discussions. Suggestions to triage patients based on risk to less resource-intensive, unsupervised program models could simultaneously expand capacity and support patient adherence.

An Intervention to Tag Findings Suspicious for Lung Cancer on Chest Computed Tomography Has Good Sensitivity and Number Needed to Diagnose.

In 2015, Kaiser Permanente Northern California implemented an intervention to improve follow-up for pulmonary findings on diagnostic chest computed tomography (CT). The intervention includes tagging CT reports with the prefix "#PUL" followed by a character (0-6 or X) to track specific findings. #PUL5, indicating "suspicious for malignancy," triggers automatic referral for multidisciplinary care review. Among patients who obtained an index chest CT exam from August 2015 to July 2017 without an exam in the previous 2 years, we computed the frequency of lung cancer diagnosis within 120 days of CT in relation to each #PUL tag. For #PUL5, we computed sensitivity, specificity, positive and negative predictive values, and number needed to diagnose. We also performed a chart review to assess why some patients diagnosed with lung cancer were not tagged #PUL5. Of the 39,409 patients with a tagged CT report, 1105 (2.8%) had a new primary lung cancer diagnosis within 120 days. Among the 2255 patients tagged #PUL5, 821 were diagnosed with lung cancer, with a sensitivity of 74% (95% confidence interval, 72%-77%). The positive predictive value was 36% (35%-38%), number needed to diagnosis was 2.7 (2.6-2.9), and specificity and negative predictive values were > 95%. Chart review identified opportunities to improve system defaults and clarify concepts. The intervention performed well but needed improvement. Automating CT reports was simple and generalizable, and enabled reduction of care gaps and system improvement.

Automatic referrals within a cystic fibrosis multidisciplinary clinic improve patient evaluation and management

AUTOMATIC REFERRALS WITHIN A CYSTIC FIBROSIS MULTIDISCIPLINARY CLINIC IMPROVE PATIENT EVALUATION AND MANAGEMENT. BackgroundCystic fibrosis (CF) affects multiple systems beyond the pulmonary system, including the gastrointestinal and endocrine systems. Many CF clinics focus on pulmonary effects, initiating referrals to other specialties only when a condition has been identified by the primary pulmonary team. Unfortunately, many extrapulmonary manifestations of cystic fibrosis may be overlooked. Thus, implementing a multidisciplinary clinic with automatic referrals to designated subspecialists may improve patient care. MethodsThis retrospective review of medical records examined the effects of integrating a pediatric endocrinologist into the University of Massachusetts Memorial Medical Center Pediatric CF Clinic in March 2017. In this new CF/Endocrinology clinic, all patients scheduled to see a pulmonologist were automatically referred to pediatric endocrinology. We compared rates of referrals to pediatric endocrinology, oral glucose tolerance tests (OGTTs), and bone density (DEXA) scans before (2013–2016) and after (2017–2020) implementation of this clinic. We also recorded endocrine disorders being evaluated and/or treated after implementation. ResultsThe rate of referral to pediatric endocrinology increased from before (4%) to after (82%) (p < 0.0001) implementation of the CF/Endocrinology Clinic. OGTT and DEXA scan screening rates also increased from 7% to 65% (p < 0.0001) and from 6% to 63% (p = 0.0011), respectively. Before implementation, patients were evaluated by endocrinology primarily for CF-related diabetes. After implementation, the diversity of endocrine conditions under evaluation and/or management increased substantially; the most common were vitamin D insufficiency/deficiency (37.2% of clinic patients), glycemic dysregulation (36.8%), and poor weight gain/failure to thrive (17.5%). ConclusionImplementing a multidisciplinary CF clinic with automatic referrals to pediatric endocrinology improves patient care by promoting early detection and management of endocrine concerns that may have been overlooked and by increasing OGTT and DEXA screening rates.

Developing a paramedic approach to palliative emergencies

Emergency health services (EHS) have experienced a steady increase in demand from palliative patients accessing 9-1-1 during times of acute crisis, although the majority of these patients do not wish for conveyance to hospital following paramedic treatment. To address this demand, and to provide patients with the right care, the first time, the British Columbia Emergency Health Service (BCEHS) introduced the province’s first Assess, See, Treat and Refer (ASTaR) Clinical Pathway. This alternative model of care is intended to improve patient-oriented care by providing care for patients in their own home and reducing the requirement for conveyance to the emergency department, thus reducing the requirement for hospitalization. Launched in June 2019, the ASTaR Pathway includes the early recognition of patients with palliative needs accessing 9-1-1, the use of secondary triage services and the automatic notification and referral of non-conveyed patients to primary healthcare teams for patient follow-up. The following commentary outlines the early integration of the ASTaR Palliative Clinical Pathway into the BCEHS paramedic approach to palliative patient care.

Automatic Referral for Potential Thoracic Malignant Diseases Detected on Computed Tomographic Scan

Delays in care negatively affect patients with potentially resectable thoracic malignant diseases. The Alberta Thoracic Oncology Program established an automatic referral process for patients with chest computed tomographic (CT) scans suggestive of malignant disease. The objective of this study was to determine whether automatic referral was associated with decreased time to referral or differences in the quality of referral information received. A single-center retrospective review of patients referred to a Canadian tertiary thoracic surgical center was performed. The time between the CT scan and the date of referral was calculated, and the type of information provided with the referral was tabulated. Automatic and traditional referral groups were compared using the Student t test, the Mann-Whitney U test, and multivariable analysis. A total of 689 patients met inclusion criteria, and 405 of these patients were automatic referrals. Average time to referral was shorter in the automatic referral group (4.7 days vs 23.6 days; P < .001). Only 2automatic referrals took longer than 30 days, compared with more than 25% of traditional referrals. Automatic referrals were always associated with a shorter time for referral on subgroup analysis of lungnodules, different referring physician types, and patient location. There was no difference between referral types in the number of referral data provided to the center. Automatic referrals for patients with potential thoracic malignant disease have a significant beneficial impact on delays in care, and this could result in improved outcomes, such as decreased upstaging and improved survival. This was not associated with a decrease in the amount of information provided with the referral. Thus, automatic referrals may streamline patient care without compromising quality.

A child health record audit of outcome comparisons for school screening referrals in Ireland

This study sought to make use of existing child health records to assess recent changes in school entry screening (hearing and vision) in Ireland. The study aims were to analyse screening protocol and staff changes; estimate newborn and school hearing screening yields; and summarise pre-school specialist referrals against later school screen outcomes. The findings included that specialist school public health nurses (PHNs) had lower hearing screen but similar vision screen referral rates compared to area public health nurses. Approximately 1% of school hearing screens had persistent otitis media, justifying audiology referral priority. Over a quarter of pre-school records audited showed a specialist referral, many with ‘speech-only delay’; this sub-group had average referral rates from later school (hearing) screening. This study found that by employing specialist school PHNs to manage school screening, audiology referrals were reduced. Additionally, pre-school speech delay without other relevant risk factors should not need automatic audiology referral.

Integrating spiritual care into an ambulatory cancer center.

205 Background: Spiritual care is identified as a core component of quality oncologic care. Unmet spiritual needs can lead to worse quality of life, lower satisfaction with care, and greater psychological distress. Despite increasing evidence that cancer outpatients also have unmet spiritual needs, professional spiritual care is often limited in the ambulatory setting. Many cancer centers provide access to professional chaplains only while patients are hospitalized. Where chaplain services are available to outpatients, access is often limited. At Mount Sinai, we embedded a full-time professional chaplain in our ambulatory cancer center. This presentation will describe our methods, results, and conclusions from a year of data on outpatient spiritual care referrals. Methods: We identified three sources of referrals to spiritual care: direct referrals from patients’ primary oncology teams, direct referrals from Supportive Oncology/Palliative Care, and automatic referrals through a question about meaning and purpose on our distress screen. We also included the opportunity for patients to self-refer to spiritual care through our distress screen. We collected data on the number of patients identified through these referral sources, time to initial contact, and the validity of the referral as assessed by our chaplain. Results: These three sources resulted in 454 referrals to spiritual care. We screened 1,410 patients through our distress screen and 16% (226) triggered a referral to spiritual care. Distress screen referrals comprised nearly 50% of all spiritual care referrals. In addition, 32% (144) of our referrals came from the patients’ clinical teams and 10% (46) from the Supportive Oncology team. Our chaplain assessed that 31% (141) had a spiritual need that required regular follow-up and 12% (56) required monitoring. Conclusions: Using multiple referral methods we were able to identify a significant number of ambulatory cancer patients with an identified spiritual need. Future projects will look at specific metrics for patient experience, improving chaplain ability to connect with patients, validating our screening question for spiritual distress, and determining an appropriate patient load for an outpatient chaplain.

PC-FACS

PC-FACS

Identification and Confirmation of Potentially Actionable Germline Mutations in Tumor-Only Genomic Sequencing.

Tumor-only genomic profiling (TGP) is increasingly advocated for all patients with cancer given the possible therapeutic implications. It is critical to develop clinical algorithms to identify and address potentially actionable germline findings identified by TGP. A multidisciplinary team analyzed publicly available data for genes in which mutations are implicated in germline cancer susceptibility and established a pipeline to automate clinical referral for evaluation of TGP findings. A total of 2,308 patients underwent TGP, with 81 patients (3.5%) identified by the automatic referral pipeline; 37 patients (1.6%) were referred outside the pipeline based on concerns by the molecular geneticist, pathologist, or oncologist regarding genotype-phenotype correlation. Thirty-one patients (38%) and 17 patients (46%) underwent germline testing from the automatic pipeline and other referrals, respectively, and of these patients, 23 (72%) and four (24%) had confirmed germline pathogenic variants (GPVs), respectively. The majority of confirmed GPVs were in automatic referral genes, with BRCA2 being most common (confirmed GPVs in 11 [85%] of 13 patients tested), followed by PALB2 (five [67%] of six patients), BRCA1 (two [40%] of five patients), MSH6 (two of three patients), and MLH1 (two of two patients). Forty-eight percent of confirmed GPVs were found in tumors known to be associated with germline mutations in the gene. Germline testing was not performed in 50 (62%) of 81 patients identified by automatic referral as a result of poor patient health or death (30%), lack of follow-up (30%), and patient refusal (30%). Of patients undergoing TGP, 5% had somatic findings triggering referral, and implementation of an automatic referral pipeline based solely on gene versus other clinical or molecular features resulted in a 74% germline confirmation. However, only 41% of referred patients underwent germline testing. Systems-based approaches are needed to identify carriers of actionable germline cancer susceptibility mutations identified by TGP.

2019 Canadian Surgery Forum Abstracts.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

Alcohol-related brain injury: Improving identification and management in an acute care setting

To increase detection of alcohol-related brain injury (ARBI) in patients attending hospital with an alcohol use disorder. In April 2017, we implemented an innovative clinical pathway. We developed an electronic warning system to identify those patients at risk of ARBI. Criteria for referral were developed utilising an algorithm based on the number of previous emergency department attendances or hospital admissions and concerns raised by relatives or staff. For patients meeting criteria, an automatic referral was made to …

Next steps: Incorporating patient-reported outcomes into palliative care referral for people with advanced breast cancer.

133 Background: Specialty palliative care (SPC) has been shown to improve quality of life, reduce unnecessary health care utilization, reduce overall costs, and decrease mortality in some settings for patients with advanced or metastatic cancer, however only a small proportion are being promptly referred. As interventions that respond to patient reported outcomes (PROs) have been shown to improve symptoms and decrease mortality, we hypothesized that the rates of SPC referral would be increased by documenting, tracking, and presenting PROs for oncology visits to referring oncologists. Methods: Over a period of 2 months, 74 English-speaking established patients seen in an advanced breast cancer clinic with an embedded SPC service were approached and completed the study. All patients filled out the electronic, validated PROMIS and PRO-CTCAE PRO questionnaires in the waiting room using a touch screen tablet. Results were presented to the oncologist during the encounter if the CTCAE severity score exceeded 3 in at least 1 domain. Patient demographics, clinical features and PC referrals or appointments were assessed via chart review. Results: At baseline, 9 (12.2%) patients scored a minimum of “severe” (4/5 or 5/5) in at least 1 of the 3 anxiety domains; 17 (23.0%) had moderate-severe pain; and 27 (32.1%) reported fatigue. At study entry, 25 patients (33.8%) had been referred previously to the SPC service; 19 had actually been seen (76% of referred). Of the 63 (85.1%) patients with sufficient follow-up, 13 (20.6%) reported at least “severe” in &gt;1 CTCAE domains, 6 (46.2%) of whom were previously referred to SPC. For the remaining 7 patients, median PROMIS T-score and PRO-CTCAE maximum severity score were 58.3 and 3.2, respectively; none were referred to SPC during the follow up period. Conclusions: The choice to refer (or not to refer) a patient to SPC is complex and tied to patient specific factors such as coordinating additional visits and fear of end of life conversations. To enable greater access to SPC, alternative referral mechanisms, such as group-based or personalized patient education, or automatic referrals triggered by evidence of need, may be required. #YRL/CDM contributed equally.

AN INTEGRATED, REGION-WIDE CARDIAC REHABILITATION SYSTEM: IMPACT ON HOSPITAL UTILIZATION & LENGTH OF STAY

The benefits of cardiovascular rehabilitation programs (CRP) are well established for individuals after a cardiac event, and completion of CRP is standard-of-care worldwide. However, as participation in CRP remains alarmingly low, individual-level benefits are not translated to population-health gains or societal returns on healthcare spending. Healthcare systems must develop alternatives to “traditional CRP” to provide these medically necessary, highly efficacious services equitably to entire populations. Regional delivery models for healthcare services, in contrast to institutionally-based models, have been shown to improve quality, effectiveness and cost efficiency, but have not been well studied in CRP. Further, it will be important to ensure that benefits observed in individuals in “traditional CRP” translate to regionally-delivered CRP. To assess the impact of regionally-delivered CRP on hospital utilization. One health region in Ontario designed and implemented a regionally-delivered, integrated cardiovascular rehabilitation and secondary prevention system. Key features included: harmonized referral criteria; automatic hospital inpatient referral; region-wide coordinating center; and CRP services delivered by a regional workforce at one of 14 local, community-based sites available within a 30-minute drive from most locations in the region. Using province-wide administrative databases, one-year hospital utilization was compared for patients referred to CRP vs. a matched-control cohort of patients not referred to CRP. Matching included age, sex, year of referral, socioeconomic status, and cardiac condition at hospital discharge. Only patients surviving six months after index hospitalization were included. Patients who completed CRP had both lower utilization (9.7% vs. 14.4%, respectively) and fewer hospitalizations (any reason) (0.13±0.45 vs. 0.22±0.63 hospitalizations, respectively) compared to patients not referred to CRP (p<0.001). Additionally, patients who completed CRP and lower total (0.69±3.57 vs. 1.73±9.55 days, respectively) and acute (0.67±3.34 vs. 1.61±9.00 days, respectively) LOS when hospitalization was required (p<0.001). Patients who started but did not complete CRP had no difference in hospitalizations (any reason) and patients who were referred but did not start CRP had more hospitalizations and longer LOS (p<0.0001) compared to patients not referred to CRP. Hospital utilization is reduced in patients completing regionally-delivered CRP whereas hospital utilization was increased in patients not completing or enrolling in CRP.

Improving patient and caregiver outcomes in oncology: Team-based, timely, and targeted palliative care.

Over the past decade, a large body of evidence has accumulated supporting the integration of palliative care into oncology practice for patients with advanced cancer. The question is no longer whether palliative care should be offered, but what is the optimal model of delivery, when is the ideal time to refer, who is in greatest need of a referral, and how much palliative care should oncologists themselves be providing. These questions are particularly relevant given the scarcity of palliative care resources internationally. In this state-of-the-science review directed at the practicing cancer clinician, the authors first discuss the contemporary literature examining the impact of specialist palliative care on various health outcomes. Then, conceptual models are provided to support team-based, timely, and targeted palliative care. Team-based palliative care allows the interdisciplinary members to address comprehensively the multidimensional care needs of patients and their caregivers. Timely palliative care, at its best, is preventive care to minimize crises at the end of life. Targeted palliative care involves identifying the patients most likely to benefit from specialist palliative care interventions, akin to the concept of targeted cancer therapies. Finally, the strengths and weaknesses of innovative care models, such as outpatient clinics, embedded clinics, nurse-led palliative care, primary palliative care provided by oncology teams, and automatic referral, are summarized. Moving forward, more research is needed to determine how different health systems can best personalize palliative care to provide the right level of intervention, for the right patient, in the right setting, at the right time. CA Cancer J Clin. 2018;680:00-00. 2018 American Cancer Society, Inc.

Computerised sepsis protocol management. Description of an early warning system

IntroductionNew strategies need to be developed for the early recognition and rapid response for the management of sepsis. To achieve this purpose, the Multidisciplinary Sepsis Team (MST) developed the Computerized Sepsis Protocol Management (PIMIS). The aim of this study was to evaluate the convenience of using PIMIS, as well as the activity of the MST. MethodsAn analysis was performed on the data collected from solicited MST consultations (direct activation of PIMIS by attending physician or telephone request) and unsolicited ones (by referral from the microbiology laboratory or an automatic referral via the hospital vital signs recording software [SIDCV]), as well as the hospital department, source of infection, treatment recommendation, and acceptance of this. ResultsOf the 1581 first consultations, 65.1% were solicited consultations (84.1% activation of PIMIS and 15.9% by telephone). The majority of unsolicited consultations were generated by the microbiology laboratory (95.2%), and 4.8% from the SIDCV. Referral from solicited consultations were generated sooner (5.63days vs 8.47days; p<0.001) and came from clinical specialties rather than from the surgical ward (73.0% vs 39.1%; p<0.001). A recommendation was made for antimicrobial prescription change in 32% of first consultations. The treating physician accepted 78.1% of recommendations. ConclusionsThe high rate of solicited consultations and acceptance of recommended prescription changes suggest that a MST is seen as a helpful resource, and that PIMIS software is perceived to be useful and convenient to use, as it is the main source of referral.