Practice In Care Settings Research Articles

Development of Interprofessional Competencies Through the Process of Collaborative Clinical Reasoning: A Qualitative Study.

Effective interprofessional (IP) collaboration is essential for managing complex patient cases. Collaborative clinical reasoning (CCR) is an approach where IP teams collectively analyze and address complex clinical cases, facilitating a shared understanding of patient management. While simulation and case-based learning are established methods for fostering IP collaboration, the process by which students develop a shared mental model for patient management after a simulated home visit and how this approach promotes the development of IP competencies is unknown. Understanding this process is critical for advancing IP competences that are fundamental to case management practice. The purpose of this study was to explore students' perceptions of the CCR processes used to develop an integrated care plan following a simulated home visit. Home care and community-based practice settings. A qualitative descriptive approach was employed to explore PT and nursing student teams' perceptions of the CCR processes used to develop an integrated care plan following a simulated home visit. Written responses to five reflection questions were analyzed using conventional content analysis among n =87 physical therapy and nursing students. There were three overarching themes: clarifying roles; developing a mutual approach; embracing shared values. Students' perceptions reflected skills needed to develop IP competencies including CCR. More research is needed to explore how student teams resolve disputes and use interdisciplinary knowledge in the process of CCR. Findings highlight the importance of IP collaboration in clinical case management, emphasizing the need for case managers to facilitate clear role clarification, mutual approaches, and shared values among IP teams to enhance integrated care planning and improve patient outcomes. These insights can inform training and development programs for case managers on IP teams, promoting the adoption of CCR in practice.

The Utility of Multitarget Stool DNA Testing for Colorectal Cancer Screening After a Normal Colonoscopy.

Multitarget stool DNA (MT-sDNA) tests (here, Cologuard®) are currently used in average-risk patients as a primary method of screening for colorectal cancer. However, MT-sDNA testing has also been used in patients who previously underwent colonoscopy who wish to avoid repeat colonoscopy. Here, in a large primary care practice setting, our aim was to evaluate the diagnostic performance of MT-sDNA testing in patients with a previously normal colonoscopy. This retrospective cohort study included 5827 patients from 35 different primary locations in South Carolina. Patients aged 45 and above with a previously documented normal, high-quality colonoscopy prior to the MT-sDNA test date were included. High-risk patients and those with a previous negative MT-sDNA result were excluded. Of 5827 ordered MT-sDNA tests, 248 patients had a prior normal colonoscopy. The average time from initial colonoscopy to MT-sDNA testing was 7.3years. Of the 63 patients who had a positive MT-sDNA test, 41 patients (65%) completed follow-up colonoscopy and 40 patients had complete colonoscopy data. Of these 40 patients, 12 patients (30%) had advanced adenomas and none had colorectal cancer. Compared to patients without a previous colonoscopy, patients with prior colonoscopies had fewer adenomas of all types (1.6 vs 2.4) and fewer advanced adenomas (1.4 vs 2.0). Patients with a previously negative colonoscopy and subsequent positive MT-sDNA test were found to have a high rate of advanced adenomas on follow-up colonoscopy (30%). Thus, in patients with a previously negative colonoscopy, MT-sDNA testing may be a reasonable alternative screening option.

Undergraduate Student Nurses' Satisfaction, Self-confidence, and Perception of High-fidelity Simulation-based Learning on Critically-ill Patients.

Replicating critical care practice settings in high-fidelity simulation (HFS) provides more learning opportunities to develop competencies, improve self-confidence, and learner satisfaction in a safe environment. Simulation is increasingly adopted globally as an alternative teaching strategy. Yet, data on the HFS experience of Filipino undergraduate nursing students is limited. This study describes the satisfaction, self-confidence, and perception of undergraduate nursing students on the use of HFS-based learning on critically-ill adult and pediatric patients requiring advanced life support (ALS). A quantitative, descriptive, correlational study was conducted using purposive sampling on all fourth-year BS Nursing students enrolled in Critical Care Nursing course in a state university. Data were collected through an online survey on demographic data, and the students' perceptions towards high-fidelity simulation-based learning (SBL) using three tools, namely: Simulation Design Scale, Educational Practices Questionnaire, and Student Satisfaction and Self-confidence in Learning. T-test and ANOVA were used to compare the means of the variables. Bivariate analysis (Pearson's product-moment correlation) was performed to find the relationship between variables. A total of 86 students participated in the survey. Overall, the students were highly satisfied with the simulation experience (4.46 out of 5.0, SD=0.47), and had high ratings of self-confidence in SBL (4.44 out of 5.0, SD=0.42). Overall satisfaction level was positively related to student's perception on simulation design (r=0.61, p<0.01) and educational practices (r=0.59, p<0.01). Similarly, the students' overall self-confidence with SBL was also positively correlated with their perceptions of the simulation design (r=0.32, p<0.01), and educational practices (r=0.34, p<0.01). Effective use of technology through HFS-based learning is useful in increasing satisfaction and self-confidence of Filipino undergraduate nursing students in caring for critically-ill patients needing ALS. Educators must highly consider all parameters of simulation design and educational practices in planning and implementing HFS-based learning to achieve meaningful learner experience.

Workplace Violence Against Primary Care Clinicians: A Narrative Review.

Workplace violence (WPV) is a commonly reported occupational hazard in healthcare and its prevalence is increasing. WPV occurs in all types of practice settings, but little is known about WPV in primary care settings in the United States (US). Because primary care practice settings differ from the inpatient settings, further examination of WPV in primary care is warranted. Our objective was to summarize the available literature highlight important gaps. We conducted a search using Pubmed and OVID for US studies of WPV in US-based adult primary care practices. Studies including only pediatric populations were excluded. Due to the lack of available literature conducted in US primary care settings, we expanded our search to include international studies. We identified 70 studies of which 5 were US based. Due to the lack of significant numbers of US-based studies, we opted to conduct a narrative review of all available studies. The evidence shows that WPV is a common occurrence in primary care settings in many countries and that the majority of primary care clinicians have experienced at least some form of non-physical violence in their careers. Most of the studies conducted were cross-sectional in design and reported on both non-physical and physical forms of WPV. There was not a consistent trend between genders in experiencing the major forms of WPV, but women were consistently more likely to be subjected to sexual harassment. Potential root causes for WPV could generally be categorized as patient-level, clinician-level, clinical encounter specific, and operational root causes. While most WPV was found to be non-physical, it still had significant emotional and job-related impacts on clinicians. These troubling results highlight the need for further studies to be conducted in the US.

A qualitative investigation into care-leavers' experiences of accessing mental health support.

People who grew up under the care of children's social services are a highly vulnerable group, with 50% of this population meeting the criteria for a mental health problem at any one time. Emerging evidence suggests that there is a disparity between the number of people who require support, and those that receive it, and that they face several barriers to accessing timely and effective mental health support. We have a limited understanding of how to support the mental health of this group as they 'age out' of children's social services, and the transition to independence, which occurs around the age of 18. We aimed to explore how care-leavers understand their experiences of help-seeking from formal mental health services. We used qualitative interviews, and Interpretative Phenomenological Analysis with 9 care-experienced young people aged between 18 and 25 years old. This work was co-produced by a team of care-experienced adults, from the conception of the study to write-up. Qualitative analysis revealed several themes which centred around: (1) taking reluctant steps towards recovery, (2) challenges with being understood and the importance of gaining an understanding of yourself, (3) navigating trust and (4) the legacy of not having your mental health needs met. We identified several important implications for health and social care practice, across primary and secondary health care settings. This work highlights ways to better support this highly vulnerable group in accessing evidence-based mental health support, and how to maintain engagement.

Relevance of BEST-CLI trial endpoints in a tertiary care limb preservation program

ObjectiveMajor adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial represented a highly selected subgroup of patients seen in clinical practice; thus, we examined the endpoint of MALE-FS in an all-comers tertiary care practice setting. MethodsThis is a single-center retrospective study of consecutive, unique patients who underwent technically successful infrainguinal revascularization for chronic limb-threatening ischemia (2011-2021). MALE was major amputation (transtibial or above) or major reintervention (new bypass, open bypass revision, thrombectomy, or thrombolysis). ResultsAmong 469 subjects, the mean age was 70 years, and 34% were female. Characteristics included diabetes (68%), end-stage renal disease (ESRD) (16%), Wound, Ischemia, and foot Infection (WIfI) stage 4 (44%), Global Limb Anatomic Staging System (GLASS) stage 3 (62%), and high pedal artery calcium score (pMAC) (22%). Index revascularization was autogenous vein bypass (AVB) (30%), non-autogenous bypass (NAB) (13%), or endovascular (ENDO) (57%). The composite endpoint of MALE or death occurred in 237 patients (51%) at a median time of 189 days from index revascularization. In an adjusted Cox model, factors independently associated with MALE or death included younger age, ESRD, WIfI stage 4, higher GLASS stage, and moderate-severe pMAC, whereas AVB was associated with improved MALE-FS. Freedom from MALE-FS, MALE, and major amputation at 30 days were 90%, 92%, and 95%; and at 1 year were 63%, 70%, and 83%, respectively. MALE occurred in 144 patients (31%) and was associated with ESRD, WIfI stage, GLASS stage, pMAC score, and index revascularization approach. AVB had superior durability, with adjusted 2-year freedom from MALE of 72%, compared with 66% for ENDO and 51% for NAB. Within the AVB group, spliced vein conduit had higher MALE compared with single-segment vein (hazard ratio, 1.8; 95% confidence interval, 0.9-3.7; P = .008 after inverse propensity weighting), but there was no statistically significant difference in major amputation. Of the 144 patients with any MALE, the first MALE was major reintervention in 47% and major amputation in 53%. Major amputation as first MALE was associated with non-AVB index approach. Indications for major reintervention were symptomatic stenosis/occlusion (54%), lack of clinical improvement (28%), asymptomatic graft stenosis (16%), and iatrogenic events (3%). Conversion to bypass occurred after 6% of ENDO cases, two-thirds of which involved distal bypass targets at the ankle or foot. ConclusionsIn this consecutive, all-comers cohort, disease complexity was associated with procedural selection and MALE-FS. AVB independently provided the greatest MALE-FS and freedom from MALE and major amputation. Compared with the BEST-CLI randomized trial, MALE after ENDO in this series was more frequently major amputation, with relatively few conversions to open bypass.

Reliability and Validity of Measures Commonly Utilized to Assess Nurse Well-Being.

A healthy nursing workforce is vital to ensuring that patients are provided quality care. Assessing nurses' well-being and related factors requires routine evaluations from health system leaders that leverage brief psychometrically sound measures. To date, measures used to assess nurses' well-being have primarily been psychometrically tested among other clinicians or nurses working in specific clinical practice settings rather than in large, representative, heterogeneous samples of nurses. This study aimed to psychometrically test measures frequently used to evaluate factors linked to nurse well-being in a heterogeneous sample of nurses within a large academic health system. This cross-sectional, survey-based study used a convenience sample of nurses working across acute care practice settings. A total of 177 nurses completed measures, which included the Professional Quality of Life, the short form of the Professional Quality of Life measure, the two-item Connor-Davidson Resilience Scale, the five-item World Health Organization Well-Being Index, the Secondary Traumatic Stress Scale, and the single-item Mini-Z. Internal reliability and convergent validity were assessed for each measure. All the measures were found to be reliable. Brief measures used to assess domains of well-being demonstrated validity with longer measures, as evident by significant correlation coefficients. This study provides support for the reliability and validity of measures commonly used to assess well-being in a diverse sample of nurses working across acute care settings. Data from routine assessments of the nursing workforce hold the potential to guide the implementation and evaluation of interventions capable of promoting workplace well-being. Assessments should include psychometrically sound, low-burden measures, such as those evaluated in this study.

Feasibility testing of an interprofessional education intervention to support collaborative practice in home care for older stroke survivors with multiple chronic conditions

ABSTRACT This mixed-methods study examined the feasibility of implementing a new six-month, theory-based, interprofessional education intervention, and explored its effects and impact on collaborative practice among home care providers caring for older adult stroke survivors (≥65) with multiple chronic conditions. The evaluation utilized a qualitative descriptive and one group repeated measures design which included participant questionnaires, focus groups and field notes. Participants included 37 home care providers (registered nurses, physiotherapists, occupational therapists, personal support workers, care coordinators, and their supervisors) in Ontario, Canada. The intervention was feasible and acceptable to home care providers. Perceived benefits included improved communication and collaboration within teams, enhanced role understanding, increased learning with and from each other, and increased appreciation of all team members’ expertise. From 3 to 6 months post initial IPE training, there was a statistically significant improvement in three domains of collaborative practice as measured by the Collaborative Practice Assessment Tool (communication/information exchange; community linkage and coordination of care; decision-making and conflict management) and one domain of collaborative practice, as measured by the 19-item Team Climate Inventory (task orientation). Implications for implementing interprofessional education in home care practice settings are described. Further testing in other populations and settings is warranted.

Evidence-based medicine: new in the search for evidence

The review is focused on discussing new trends in DM, rethinking the evidence base medicine with an emphasis on demonstrating the efficacy and safety of new therapeutic agents and medical technologies, from gene editing to AI algorithms. At the same time, clinical trials of drugs are also not standing still, there is active development, new approaches, methods and designs are being developed. The process of drug development, registration and market launch of any drug takes a significant period of time, requires high financial costs and human resources. The gold standard of evidence-based medicine was initially considered to be RCTs, but at the same time, they have objective disadvantages: limited sample, inability to control all factors; insufficient follow-up time,negative impact on participants, inability to determine cause-and-effect relationships; limited measurement methods, limited budget and others. This review discusses the trends in the methodology of clinical research. The active implementation of new designs such as Adaptive Clinical Trials, "Master" protocols including Umbrella Study, Basket Study, Platform Studies, Master Observational Trials and the increased use of Single Patient Trials (N-of-1 trials) are allowing studies to become more efficient, relevant and applicable to real-life health care practice settings and patient-centered. In the review, we also look at both the pros and cons of the expanded use of biomarkers and Digital Endpoints in clinical trials and virtual clinical trials, which use mathematical models to study patient heterogeneity and its impact on various therapeutic questions. The process of expertise and regulatory approval continues to slow down the entry of drugs into the pharmaceutical market. The review considers changes in the approaches of regulators (FDA, EMEA and Russian Ministry of Health) to the drug registration procedure. The COVID-19 pandemic and sanctions have led to the need to expand the list of drugs with authorized accelerated registration. However, accelerated registration raises many questions regarding the sufficiency of the level of evidence and safety. As we can see a deep synthesis and integration of all available data is needed to achieve the next generation of evidence-based medicine. The major challenge in the next two decades will be to exploit the potential of multidimensional evidence generation by extracting, collating and generating large data sets of natural course of disease, genomics and all other omics analyses, all published clinical trials, RWD to provide next generation evidence.

Real-world utilization of guideline-directed genetic testing in inherited cardiovascular diseases.

Cardiovascular disease continues to be the leading cause of death globally. Clinical practice guidelines aimed at improving disease management and positively impacting major cardiac adverse events recommend genetic testing for inherited cardiovascular conditions such as dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), long QT syndrome (LQTS), hereditary amyloidosis, and familial hypercholesterolemia (FH); however, little is known about how consistently practitioners order genetic testing for these conditions in routine clinical practice. This study aimed to assess the adoption of guideline-directed genetic testing for patients diagnosed with DCM, HCM, LQTS, hereditary amyloidosis, or FH. This retrospective cohort study captured real-world evidence of genetic testing from ICD-9-CM and ICD-10-CM codes, procedure codes, and structured text fields of de-identified patient records in the Veradigm Health Insights Ambulatory EHR Research Database linked with insurance claims data. Data analysis was conducted using an automated electronic health record analysis engine. Patient records in the Veradigm database were sourced from more than 250,000 clinicians serving over 170 million patients in outpatient primary care and specialty practice settings in the United States and linked insurance claims data from public and private insurance providers. The primary outcome measure was evidence of genetic testing within six months of condition diagnosis. Between January 1, 2017, and December 31, 2021, 224,641 patients were newly diagnosed with DCM, HCM, LQTS, hereditary amyloidosis, or FH and included in this study. Substantial genetic testing care gaps were identified. Only a small percentage of patients newly diagnosed with DCM (827/101,919; 0.8%), HCM (253/15,507; 1.6%), LQTS (650/56,539; 1.2%), hereditary amyloidosis (62/1,026; 6.0%), or FH (718/49,650; 1.5%) received genetic testing. Genetic testing is underutilized across multiple inherited cardiovascular conditions. This real-world data analysis provides insights into the delivery of genomic healthcare in the United States and suggests genetic testing guidelines are rarely followed in practice.

Comparison of Work Patterns Between Physicians and Advanced Practice Practitioners in Primary Care and Specialty Practice Settings

ImportanceDespite the increasing involvement of advanced practice practitioners (APPs; ie, nurse practitioners and physician assistants) in care delivery across specialties, the work patterns of APPs compared with physicians and how they are integrated into care teams have not been well characterized.ObjectiveTo characterize differences between physicians and APPs across specialty types related to days with appointments, visit types seen, and time spent using the electronic health record (EHR).Design, Setting, and ParticipantsThis nationwide, cross-sectional study used EHR data from physicians and APPs (ie, nurse practitioners and physician assistants) at all US institutions that used Epic Systems’ EHR between January and May 2021. Data analysis was performed from March 2022 to April 2023.Main Outcomes and MeasuresAppointment scheduling patterns, percentage of new and established and level of evaluation and management (E/M) visits, and EHR use metrics per day and week.ResultsThe sample consisted of 217 924 clinicians across 389 organizations, including 174 939 physicians and 42 985 APPs. Although primary care physicians were more likely than APPs to have more than 3 days per week with appointments (50 921 physicians [79.5%] vs 17 095 APPs [77.9%]), this trend was reversed for medical (38 645 physicians [64.8%] vs 8124 APPs [74.0%]) and surgical (24 155 physicians [47.1%] vs 5198 APPs [51.7%]) specialties. Medical and surgical specialty physicians saw 6.7 and 7.4 percentage points, respectively, more new patient visits than did their APP counterparts, whereas primary care physicians saw 2.8 percentage points fewer new patient visits than did APPs. Physicians saw a greater percentage of level 4 or 5 visits across all specialties. Medical and surgical physicians spent 34.3 and 45.8 fewer minutes per day, respectively, using the EHR than did APPs in their specialties, whereas primary care physicians spent 17.7 minutes per day more. These differences translated to primary care physicians spending 96.3 minutes more per week using the EHR than APPs, whereas medical and surgical physicians spent 149.9 and 140.7 fewer minutes, respectively, than did their APP counterparts.Conclusions and RelevanceThis cross-sectional, national study of clinicians found significant differences in visit and EHR patterns for physicians compared with APPs across specialty types. By underscoring the different current usage of physicians vs APPs across specialty types, this study helps place into context the work and visit patterns of physicians compared with APPs and serves as a foundation for evaluations of clinical outcomes and quality.

Implementation of an Evidence-Based Clinical Guideline for Depression Screening of the Adolescent

The evidence supports use of a depression screening tool to increase screening completion in the adolescent population. Clinical guidelines include use of the PHQ-9 in the adolescent population (ages 12–18). PHQ-9 screenings are currently lacking in this primary care setting. The aim of this Quality Improvement Project was to improve depression screening in a primary care practice setting located in a rural Appalachian health system. An educational offering with pretest and posttest surveys and a perceived competency scale are utilized. Focus is added to the process and guideline used to complete depression screening. As a result of the QI Project, posttest assessment of knowledge relating to educational offering increased, and use of the screening tool increased by 12.9%. The findings support the importance of education on primary care provider practice and depression screening of adolescents.

Attitudes and knowledge of palliative care of Chinese undergraduate nursing students: A multicenter cross-sectional study

BackgroundHelping patients and families to relieve severe pain and manage grief are issues that palliative care is designed to address, but integrating these topics in nursing education and practice requires increased attention. It is necessary to understand the knowledge and attitudes of nursing students to develop a targeted approach toward integrating palliative care in practice settings. ObjectivesTo investigate attitudes and knowledge toward palliative care among undergraduate nursing students in China and to explore correlations and associated factors. DesignA cross-sectional study. SettingsSeven comprehensive universities in China. ParticipantsA total of 582 undergraduate nursing students participated. MethodsOnline questionnaires were available from December 2020 to February 2021. The Frommelt Attitude Toward Care of the Dying Scale and the Palliative Care Quiz for Nursing were used to measure students' attitude and knowledge of palliative care. Descriptive and correlational methods were used to analyse the associated factors and their correlation with knowledge and attitudes. ResultsAttitude scores showed significant differences in gender, education level, religious preference, previous education in palliative care, experience in caring for dying patients and previous experience with bereavement. Knowledge of palliative care was influenced by gender, religious preference, prior education in palliative care, experience in caring for dying patients, and previous experience with bereavement. A positive correlation exists between knowledge and attitudes toward palliative care among undergraduate nursing students. ConclusionsThe findings highlight the need to offer palliative care courses in nursing education and practice settings in Chinese health care settings. Nurse educators need to integrate the concept of palliative care into the curriculum of nursing education programs. Healthcare administrators and nurse leaders should promote investment and training in the education of nurses in practice settings to deliver high-quality palliative care services.

PS-C31-1: SIGNIFICANCE OF SCREENING AND DIAGNOSING PRIMARY ALDOSTERONISM (PA) IN GENERAL MEDICINE

Background: Primary aldosteronism (PA) is a frequent secondary hypertension that is more frequently associated with cerebrovascular disease than essential hypertension, and thus requires appropriate diagnosis and treatment. The Japan Endocrine Society has published the new guideline for the diagnosis and treatment of primary aldosteronism, following the change of aldosterone measurement system in 2021. In this presentation, we will discuss a case of PA experienced at a dental school hospital. Case 75 years old male Current medical history: He had been diagnosed as hypertensive more than 10 years ago and had been prescribed antihypertensive medication, but he had stopped taking it. When he visited an oral surgeon for a tooth extraction, hypertension was noted and he was referred to internal medicine. &lt;Physical findings&gt; Blood pressure: 208/120 mmHg, Pulse: 83/min, &lt;Biochemistry&gt; Cre 1.09 mg/dL, Na 139mEq/L, K 3.7mEq/L. &lt;Endocrine metabolism&gt; fT4 0.95ng/dL, TSH 2.58micro-IU/mL, Plasma renin activity: PRA (EIA method) 0.6ng/mL/hr, Plasma aldosterone concentration: PAC (CLEIA method) 130pg/mL. &lt;Abdominal CT&gt; There was a nodule on the right adrenal gland. &lt;Progress and discussion&gt; The patient had a high aldosterone-renin ratio: ARR = PAC/PRA = 130/0.6 = 217 at the time of initial examination, and PA was suspected. CT showed a nodule in the right adrenal gland, raising suspicion of unilateral disease. Because of the high basal plasma aldosterone level and low K level, we referred the patient to a specialized facility because we thought that if PA was confirmed by functional confirmation testing, the case could be aggressively localized and typed by adrenal vein sampling (AVS). In this presentation, we would like to discuss the significance of screening and diagnosis of PA in primary care and general practice settings such as dental school hospitals, based on the results of functional confirmation testing at specialized facilities, and in light of current guidelines.

Transferability of Mental Health Simulation Skills to Practice: A Nursing Post-Graduate Follow-Up Study.

The purpose of the current descriptive qualitative follow-up study was to explore perceptions of post-graduate nurses regarding transferability of student-learned mental health simulation knowledge and skills to actual acute care practice settings. The study used a survey design of eight questions on SurveyMonkey® and there were 11 participants. Questions were specific to knowledge and skills learned as students in three mental health simulation labs and whether they transferred to post-graduate acute care practice settings. Thematic analysis identified the following main themes: Learned Effective De-Escalation Techniques, Felt More Prepared With Psychiatric Assessments, and Feeling Empathy for Patients Hearing Voices. Subthemes were Being Therapeutic With Patients and More Confident in Psychiatric Emergencies. Post-graduate nurses described being able to transfer use of student-learned mental health simulation knowledge and skills to acute care practice settings. [Journal of Psychosocial Nursing and Mental Health Services, 61(7), 39-45.].

“Never waste a good crisis”: A qualitative study of the impact of COVID-19 on palliative care in seven hospitals using the Dynamic Sustainability Framework

Background: The COVID-19 pandemic led to rapid adaptations among palliative care services, but it is unclear how these adaptations vary in relation to their unique organizational contexts. Aim: Understand how the pandemic impacted the implementation of new and existing palliative care programs in diverse hospital systems using the Dynamic Sustainability Framework. Design: Twelve in-depth interviews with 15 key informants representing palliative care programs from seven hospital systems between April and June 2020. Setting: Public, not-for-profit private, community, and academic teaching hospitals in the San Francisco Bay Area with existing palliative care programs that were expanding services to new clinical areas (e.g. new outpatient clinic or community-based care). Results: Six themes characterized how palliative care programs were impacted and adapted during the early stages of the COVID-19 pandemic: palliative care involvement in preparing for surge, increased emphasis on advance care planning, advocating for visitors for dying patients, providing emotional support to clinicians, adopting virtual approaches to care, and gaps in chaplaincy support. There was variation in how new and existing programs were able to adapt to early pandemic stresses; systems with new outpatient programs struggled to utilize their programs effectively during the crisis onset. Conclusions: The fit between palliative care programs and practice setting was critical to program resiliency during the early stages of the pandemic. Reconceptualizing the Dynamic Sustainability Framework to reflect a bidirectional relationship between ecological system, practice setting, and intervention levels might better guide implementers and researchers in understanding how ecological/macro changes can influence interventions on the ground.

Using Artificial Intelligence as a Diagnostic Decision Support Tool in Skin Disease: Protocol for an Observational Prospective Cohort Study.

BackgroundDermatological conditions are a relevant health problem. Each person has an average of 1.6 skin diseases per year, and consultations for skin pathology represent 20% of the total annual visits to primary care and around 35% are referred to a dermatology specialist. Machine learning (ML) models can be a good tool to help primary care professionals, as it can analyze and optimize complex sets of data. In addition, ML models are increasingly being applied to dermatology as a diagnostic decision support tool using image analysis, especially for skin cancer detection and classification.ObjectiveThis study aims to perform a prospective validation of an image analysis ML model as a diagnostic decision support tool for the diagnosis of dermatological conditions.MethodsIn this prospective study, 100 consecutive patients who visit a participant general practitioner (GP) with a skin problem in central Catalonia were recruited. Data collection was planned to last 7 months. Anonymized pictures of skin diseases were taken and introduced to the ML model interface (capable of screening for 44 different skin diseases), which returned the top 5 diagnoses by probability. The same image was also sent as a teledermatology consultation following the current stablished workflow. The GP, ML model, and dermatologist’s assessments will be compared to calculate the precision, sensitivity, specificity, and accuracy of the ML model. The results will be represented globally and individually for each skin disease class using a confusion matrix and one-versus-all methodology. The time taken to make the diagnosis will also be taken into consideration.ResultsPatient recruitment began in June 2021 and lasted for 5 months. Currently, all patients have been recruited and the images have been shown to the GPs and dermatologists. The analysis of the results has already started.ConclusionsThis study will provide information about ML models’ effectiveness and limitations. External testing is essential for regulating these diagnostic systems to deploy ML models in a primary care practice setting.

'Staying strong': A constructivist grounded theory of how registered nurses deal with the impact of trauma-related events in rural acute care practice.

This study explored how Registered Nurses (RNs) in rural practice deal with psychologically traumatic events when living and working in the same rural community over time. Rural RNs who are exposed to trauma may be at high risk for psychological distress (e.g. secondary traumatic stress, vicarious trauma and post-traumatic stress disorder), in the context of isolated practice and slower emergency response times. Charmaz's constructivist grounded theory methodology was chosen for this qualitative study. Purposeful sampling was used to recruit 19 RNs from six rural acute care hospitals. A total of 33 interviews were conducted with 19 face-to-face initial interviews, 14 follow-up telephone interviews and 14 reflective journals. Adherence to the COREQ EQUATOR guidelines was maintained. Participants were exposed to a multitude of trauma-related events, with their main concern of being intertwined with events for life. They dealt with this by staying strong, which included relying upon others, seeking inner strength, attempting to leave the past behind and experiencing transformational change over time. Being embedded in the community left them linked with these trauma-related events for life. Staying strong was a crucial element to their ability to cope and to face future events. The psychological implications of trauma-related events when working and living in rural acute care practice settings are significant and complex. Findings highlight the need for organizational support and processes and may contribute to improved psychological services and management practices. Key learnings were that rural nurses, who live and work in the same community, experience psychological changes over time from traumatic events that stay with them for life; employers fail to recognise the seriousness of this issue and trauma-informed policies with associated resources are lacking.

Minimal clinical data sets for spine-related musculoskeletal disorders in primary care and outpatient settings: a scoping review protocol

IntroductionLack of standardised clinical data collection may lead to reduced quality in musculoskeletal (MSK)-related clinical care and research. Little is known about the availability and characteristics of minimal clinical data...

752-P: Study Design and Baseline Profile for Patients with Type 2 Diabetes in the Semaglutide Once-Weekly Randomized Pragmatic Trial (SEPRA)

SEPRA (NCT03596450) is a 2-yr, multicenter, open-label, randomized pragmatic clinical trial comparing the long-term effects of once-weekly subcutaneous semaglutide vs. standard of care (both added to ≤2 oral antidiabetic medications) in US health-insured adults with T2D and physician-determined inadequate glycemic control. SEPRA will assess glycemic control, weight loss, healthcare utilization, and patient-reported outcomes by collecting individual-level data from routine clinical practice and health insurance claims. The primary endpoint is the proportion of patients achieving HbA1c &amp;lt;7.0% at yr 1. The study design was evaluated using the Pragmatic Explanatory Continuum Indicator Summary (PRECIS) -2 assessment; it scored 4-5 in all 9 domains, suggesting a highly pragmatic study. Of 1,278 patients enrolled, 54% were male with mean (± SD) age 57.4 ± 11.1 yrs, BMI 35.7± 8.0 kg/m2, diabetes duration 7.4 ± 6.0 yrs, HbA1c 8.48 ± 1.6%, and mean individualized HbA1c target 6.66 ± 0.5%. Of note, 86.9% of patients had HbA1c &amp;gt;7.0% and most required sizeable reductions in HbA1c to reach the clinician-assigned individualized target. SEPRA will provide real-world evidence on the long-term effectiveness of semaglutide in a population with a broad range of HbA1c levels and other clinical characteristics when used as intensification early on in usual T2D care practice settings. Disclosure V.Willey: Employee; HealthCore Inc. J.B.Buse: Consultant; Alkahest, Anji, AstraZeneca, Boehringer Ingelheim International GmbH, Cirius Therapeutics, Inc., Eli Lilly and Company, Fortress biotech, GentiBio, Glycadia, Glyscend, Janssen Pharmaceuticals, Inc., Mellitus Health, Moderna, Inc., Pendulum Therapeutics, Praetego, LLC, Stability Health, Valo, Zealand Pharma A/S, Other Relationship; Adocia, AstraZeneca, Eli Lilly and Company, Intarcia Therapeutics, Inc., MannKind Corporation, Novo Nordisk, Sanofi, Senseonics, vTv Therapeutics, Research Support; AstraZeneca, Dexcom, Inc., Eli Lilly and Company, Novo Nordisk, vTv Therapeutics, Stock/Shareholder; Glyscend, Mellitus Health, Pendulum Therapeutics, PhaseBio Pharmaceuticals, Inc., Praetego, LLC, Stability Health. B.Harty: None. J.L.Mitchell: None. B.P.Soule: Employee; Bristol-Myers Squibb Company, Novo Nordisk. H.N.Christensen: Employee; Novo Nordisk. M.J.Cziraky: None. S.Skibsted: Employee; Novo Nordisk. Funding Funded by Novo Nordisk Inc