Completed Checklists Research Articles

Self-reported checklists and quality scoring tools in radiomics: a meta-research.

To evaluate the use of reporting checklists and quality scoring tools for self-reporting purposes in radiomics literature. Literature search was conducted in PubMed (date, April 23, 2023). The radiomics literature was sampled at random after a sample size calculation with a priori power analysis. A systematic assessment for self-reporting, including the use of documentation such as completed checklists or quality scoring tools, was conducted in original research papers. These eligible papers underwent independent evaluation by a panel of nine readers, with three readers assigned to each paper. Automatic annotation was used to assist in this process. Then, a detailed item-by-item confirmation analysis was carried out on papers with checklist documentation, with independent evaluation of two readers. The sample size calculation yielded 117 papers. Most of the included papers were retrospective (94%; 110/117), single-center (68%; 80/117), based on their private data (89%; 104/117), and lacked external validation (79%; 93/117). Only seven papers (6%) had at least one self-reported document (Radiomics Quality Score (RQS), Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD), or Checklist for Artificial Intelligence in Medical Imaging (CLAIM)), with a statistically significant binomial test (p < 0.001). Median rate of confirmed items for all three documents was 81% (interquartile range, 6). For quality scoring tools, documented scores were higher than suggested scores, with a mean difference of - 7.2 (standard deviation, 6.8). Radiomic publications often lack self-reported checklists or quality scoring tools. Even when such documents are provided, it is essential to be cautious, as the accuracy of the reported items or scores may be questionable. Current state of radiomic literature reveals a notable absence of self-reporting with documentation and inaccurate reporting practices. This critical observation may serve as a catalyst for motivating the radiomics community to adopt and utilize such tools appropriately, thereby fostering rigor, transparency, and reproducibility of their research, moving the field forward. • In radiomics literature, there has been a notable absence of self-reporting with documentation. • Even if such documents are provided, it is critical to exercise caution because the accuracy of the reported items or scores may be questionable. • Radiomics community needs to be motivated to adopt and appropriately utilize the reporting checklists and quality scoring tools.

"With group antenatal care, pregnant women know they are not alone": The process evaluation of a group antenatal care intervention in Ghana.

An essential component to improving maternal and newborn outcomes is antenatal care. A trial of group antenatal care was implemented in Ghana where 7 health care facilities were randomized to be intervention sites and 7 control sites continued traditional antenatal care. Group antenatal care, where 10-14 women with similar due dates meet together for visits, includes traditional components such as risk assessment with increased opportunity for education and peer support. The study aim was to assess and report the process evaluation of the implementation of a group antenatal care intervention. Process evaluation data were collected alongside intervention data and included both quantitative and qualitative data sources. Midwives at the health facilities which were randomized as intervention sites completed tracking logs to measure feasibility of the intervention. Research team members traveled to intervention sites where they conducted structured observations and completed fidelity and learning methods checklists to determine adherence to the model of group antenatal care delivery. In addition, midwives facilitating group antenatal care meetings were interviewed and focus groups were conducted with women participating in group antenatal care. In the majority of cases, midwives facilitating group antenatal care completed all components of the meetings with fidelity, following best practices such as sitting with the group rather than standing. Across 7 intervention sites, 7 groups (622 pregnant women) were documented in the tracking logs and of these participants, the majority (74%) attended more than half of the meetings, with 32% attending all 8 group meetings. Three themes were identified in both the midwife interviews and focus groups with pregnant women: 1) information sharing, 2) sense of community, and 3) time management challenges. An additional theme emerged from the focus groups with the women: women who had already given birth noticed a disconnect between what they learned and treatment received during labor and birth. This process evaluation determined that group antenatal care can be implemented with fidelity in low and middle-income countries. Time management was the biggest challenge, however both midwives and pregnant women found the model of care not only acceptable, but preferable to traditional care. The knowledge shared and sense of community built during the meetings was a valuable addition to the individual model of antenatal care.

Cross-sectional study on the availability of essential medicines at public health facilities in Jur River County, South Sudan

Introduction: The availability of essential medicines in health facilities in Jur River County (JRC), South Sudan, is below expectations. This is despite the requirement that all citizens should be provided with adequate quality health care services. The objective of the study was to assess the availability of essential medicines and inventory management practices in JRC.Method: This was a cross sectional study conducted in 31 of the 51 health facilities in JRC. These were 23 primary health care units (PHCUs) and eight primary health care centres (PHCCs). Data were collected using a structured questionnaire, logistics management information system (LMIS) data reports and checklist forms. All the completed checklists and questionnaires were analysed using IBM SPSS statistics version 20.0 and LMIS data was analysed using excel spreadsheet.Results: The main findings were stockouts and overstocking of essential medicines, low skilled health workers (HWs) and ineffective rotation of medicines in the health facilities. From January – August 2021, the stockouts of essential medicines in PHCUs and PHCCs were 44% and 34% respectively, whereas the incidences of over stockings were 22% and 31% respectively. Almost all (97%) of the health facilities kept records of essential medicines, revealing stockouts of 90.3% on the day of the visit. Of the 31 HWs interviewed 23 (74.9%) were community health workers (CHWs), four (12.9%) nurses and four (12.9%) pharmacy technicians; most (87.1%) had attained secondary education.Conclusion: The quantities of essential medicines were inadequate and able to cover only two months. The major reasons were inadequate supply of essential medicines; recruitment of CHWs and nurses, instead of pharmacy technicians in the management of supplies; ineffective rotation of medicines within and other health facilities. More research is needed on the factors affecting the availability of medicines at the health facilities in JRC.

Use of an NTSV Checklist to Identify the Cause of Racial Disparities in Cesarean Birth Rates [ID: 1380461

INTRODUCTION: Despite reductions in our overall nulliparous, term, singleton, vertex (NTSV) cesarean birth rates with targeted initiatives, nationally recognized racial disparities also exist at our institution. Implementation of an NTSV checklist in February 2022 enabled evaluation for racial disparities in NTSV care implementation. METHODS: In this IRB-approved, single-institution, retrospective cohort study of NTSV deliveries between July 2021 and June 2022, data were abstracted using EMR reports, customized queries, and manual chart reviews. We analyzed the effect of race, comorbidities, and use of specified interventions on delivery method. The primary aim was to assess for racial disparities in implementation of institutional NTSV initiatives. Secondary aims were to assess the effect of comorbidities and checklist implementation on NTSV cesarean birth rates. RESULTS: Before February 2022, Black NTSV patients were 76% more likely than White counterparts to have cesarean births (odds ratio [OR] 1.76, CI 1.28–2.41). Post-intervention, Black NTSV patients were 6% more likely to have cesarean births (OR 1.06, CI 0.70–1.60). Comparing Black NTSV patients with completed checklists to White counterparts showed no statistically significant difference in likelihood of cesarean birth (OR 1.36, CI 0.49–3.74) or having no NTSV intervention utilized (OR 1.10, CI 0.30–4.03). Black NTSV patients were more likely than White counterparts to have gestational hypertension (OR 1.47, CI 1.05–2.06) or intrauterine growth restriction (OR 2.3, CI 1.24–4.27). CONCLUSION: The NTSV checklist did not reveal statistically significant racial disparities in use of institutional initiatives. NTSV checklist implementation may have contributed to a decreased racial disparity in NTSV cesarean birth rates. A larger sample size would strengthen analysis of the effect of comorbidities, institutional initiatives, and checklist implementation on delivery mode.

Pivoting during a Pandemic: Reimagining Intern Orientation EPA-Based OSCE.

Objective structured clinical examinations (OSCEs) provide reliable and standardized means for assessing the performance of specific clinical skills. Our previous experience with entrustable professional activity-based multidisciplinary OSCEs suggests that this exercise offers just-in-time baseline information regarding critical intern skills. The coronavirus disease 2019 pandemic forced medical education programs to reimagine such educational experiences. For the safety of all of the participants, the Internal Medicine and Family Medicine residency programs pivoted from an in-person OSCE to a hybrid model (combination of in-person and virtual encounters) while maintaining the goals of the OSCEs administered in previous years. Here, we describe an innovative hybrid approach to redesigning and implementing the existing OSCE model while maximizing risk mitigation. In total, 41 interns from Internal Medicine and Family Medicine participated in the 2020 hybrid OSCE. Five stations allowed for clinical skills assessment. Faculty completed skills checklists with global assessments and simulated patients completed communication checklists with global assessments. Interns, faculty, and simulated patients completed a post-OSCE survey. Informed consent, handoffs, and oral presentation were the lowest performing stations (29.2%, 53.6%, 53.6%, respectively) as assessed by faculty skill checklists. One hundred percent of interns (41/41) indicated that immediate faculty feedback was the most valuable part of the exercise, and all of the participating faculty believed that the format was efficient, allowing ample time to provide feedback and complete checklists. Eighty-nine percent of simulated patients cited they would be willing to participate again if the same assessment were to be held during the pandemic. The limitations of the study included the lack of demonstration of physical examination maneuvers by interns. A hybrid OSCE to assess interns' baseline skills during orientation using Zoom technology could be delivered successfully and safely during the pandemic without compromising the program's goals or satisfaction.

The Accuracy of Students&amp;#39; Self-Assessment-How Useful Is a Checklist in EAP Writing

Checklists, as a form of self-assessment, have been provided to students by educators as a way to promote learner autonomy. However, due attention has not been paid to the accuracy of those completed checklists. Through a survey, interviews, and comparison of students&amp;rsquo; and researchers&amp;rsquo; completed checklists, the research intends to investigate the accuracy of students&amp;rsquo; self-assessment of their writing in a Sino-foreign university in China. Suggestions on checklist design and pedagogical implications on how to improve learners&amp;rsquo; self-assessment are made.

Reducing urinary catheter use in geriatric patients - results of a single-center champion-led intervention

BackgroundIndwelling urinary tract catheters (UTC) are a well-known risk factor for urinary tract infections (UTI). Because geriatric patients are at high risk of infection, an intervention with a focus on appropriate and minimal UTC use was introduced in 4 acute care geriatric wards.MethodsBetween 11/2018 and 1/2020, unit-based data on UTC use and nosocomial UTI was collected in accordance with the methods of the German national surveillance system KISS. From 6/2019 to 1/2020, a champion-led intervention was implemented which focused on: (i) feedback of surveillance data, (ii) education and training in aseptic UTC insertion and maintenance, (iii) HCW’s daily assessment of UTC necessity based on a checklist and (iv) timely removal of unnecessary UTCs. UTC use, incidence, and incidence densities for catheter-associated UTI (CAUTI) were calculated before and during the intervention. In addition, we analyzed adherence to a scheduled daily assessment of UTC necessity. Rate ratios (RR) with 95% confidence intervals (95%CI) were calculated. Differences based on the quality of checklist completion were evaluated using the Kruskal Wallis test.ResultsWe analyzed the data of 3,564 patients with a total 53,954 patient days, 9,208 UTC days, and 61 CAUTI. Surveillance data showed a significant decrease in the pooled UTC utilization rate from 19.1/100 patient days to 15.2/100 patient days (RR = 0.80, 95%CI 0.77–0.83, p < 0.001). CAUTI per 100 patients dropped from 2.07 to 1.40 (RR = 0.68, 95%CI 0.41–1.12, p = 0.1279). Overall, 373 patients received a UTC during the intervention. Of those patients 351 patients had an UTC ≥ 2 days. The analysis of these patients showed that 186 patients (53%) received a checklist as part of their chart for daily evaluation of UTC necessity. 43 (23.1%) of the completed checklists were of good quality; 143 (76.9%) were of poor quality. Patients in the group whose checklists were of good quality had fewer UTC days (median 7 UTC days IQR (3–11)) than patients whose checklists were of poor quality (11 UTC days IQR (6–16), p = 0.001).ConclusionWe conclude that a champion-led, surveillance-based intervention reduces the use of UTC among geriatric patients. Further research is needed to determine to what extent the use of checklists in daily medical UTC assessment affects the prevention of CAUTI. The fact that patients whose checklists were completed well had fewer UTC days should encourage a conscientious and thorough daily review of the need for UTC.

A checklist-based survey for early mobilization of stroke unit patients in an Italian region.

Although early mobilization (EM) is recommended by most guidelines in acute stroke patients, there is a paucity of tools to perform a standardized patient risk assessment prior to EM in stroke units (SUs). This survey aimed at assessing (1) the usefulness of an ad hoc checklist for a standardized approach to EM in SUs and (2) the relationship between EM achieved by this checklist and SU characteristics. This survey was carried out in 10 SUs in Piedmont, Italy. The EM checklist was based on 15 "items", including quantitative/qualitative, clinical and management features. A total of 250 completed checklists were assessed. EM, defined as out-of-bed activity within 72h of admission, was reached by 174 patients (69.6%), according to the checklist. There was a statistically significant association between the admission NIHSS score and EM. Hypotension at mobilization was observed in 29/250 patients (11.6%) and was significantly associated with EM. A total of 6 falls (2.4%) were reported. Nurses were most frequently involved in EM, either alone (40.8%) or with another professional. A large percentage of acute stroke patients managed to achieve a safe EM in the SUs that adopted the novel checklist. These results suggest that this checklist may well be a user-friendly, reliable tool to assist SU professionals in deciding whether to mobilize or not, by means of a standardized approach.

Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-Saharan Africa: A Co-Creation Consensus Approach.

Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa, as well as to implement the checklist in health institutions in four African countries. The AMS checklist tool was developed using a modified Delphi approach to achieve local expert consensus on the items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, Ghana and the UK were invited to review, score and comment on items from a published global AMS checklist. Following their feedback, 8 items were rephrased, and 25 new items were added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites. The final tool comprised 54 items. Across the 14 sites, the completed checklists consistently showed improvements for all the AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). The elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing the quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions. Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist, which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. This study extends the existing AMS materials for low- and middle-income countries and provides empirical evidence for successful use in practice.

The Redesign of a Checklist for Evaluating Driver Impairment: A Human Factors and Ergonomics Approach.

The Cantonal Police of Zurich, Switzerland, use a checklist to identify impaired drivers when conducting traffic stops. This checklist was developed by subject-matter experts and has been in use for eight years. The goal of this study was to redesign the checklist while considering human factors and ergonomics principles in combination with findings from a retrospective analysis of a set of 593 completed checklists. The checklist was amended in accordance with the results of the retrospective analysis by adding missing items and discarding superfluous ones. In addition, a hierarchical cluster analysis of the retrospective data suggested an improved spatial organization of checklist elements and the grouping of similar items of the checklist. Furthermore, aspects related to Fitts’s law, visual complexity, and an optimized direction of processing the checklist underpinned the design process. The results of an evaluation of the redesigned checklist by 11 laypeople and 13 police officers indicated an improved usability of the redesigned checklist over the original.

Developing and implementing a self-monitoring toolkit for a coordinated multinational randomized acupuncture trial

BackgroundIn 2019, investigators from China, South Korea and the United States of America initiated a coordinated multinational trial. The trial included three parallel randomized studies with a planned pooled analysis of individual patient data, to test the effectiveness of acupuncture on hot flash-related symptoms in hormone receptor-positive breast cancer patients prescribed adjuvant endocrine therapy. Given the study's approach, there was no central coordinating center or data monitoring committee for the study, so a site performance self-monitoring toolkit was developed and implemented to support study teams in collecting and maintaining high-quality regulatory information, and consistent review of study data and documentation.MethodsThe site performance self-monitoring toolkit was created based on best practices related to post-approval quality assurance/quality improvement (QA/QI) procedures that support data quality. The toolkit included: (1) a binder of essential study management documents and related monitoring logs for sites to complete and maintain (herein called regulator binder), (2) a study start-up checklist, (3) a self-assessment study conduct and oversight checklist to be completed regularly, and (4) a study close-out checklist. In addition, a process of regular virtual meetings to discuss documentation progress coupled with periodic external remote review of completed logs and checklists provided accountability checks.ResultsOver the course of the study, the sites in China and South Korea completed the entirety of the site performance self-monitoring toolkit, and successfully submitted their completed materials for review. The process of implementing a self-monitoring toolkit in a multinational integrative medicine study is described qualitatively. Periodic external review of the completed toolkit materials revealed categories of findings. Written follow-up reports were provided to sites and discussion of the documents occurred via separate virtual meetings.ConclusionsSite study team self-monitoring provides a feasible, consistent, and effective way to review the collection and maintenance of data and regulatory documentation for quality assessment in minimal risk clinical research studies and can augment formal study monitoring activities in higher risk studies. Iterative feedback and support appeared to drive a disciplined approach to maintaining regulatory document compliance and helped sustain investigator and study team engagement in the process.Trial registrationClinicalTrials.gov Identifier NCT03783546 (21/12/2018).

Implementation of surgical site infection surveillance in 16 health facilities in Sierra Leone

Background: Surgical site infections (SSIs) are associated with increased healthcare costs, antibiotic resistance, morbidity, and mortality. In low- and middle-income countries (LMICs), SSIs account for most healthcare-acquired infections (HAIs). In Africa, up to 20% of women who undergo a caesarean section develop a wound infection. Surveillance has been shown to be an essential component in the overall strategy to reduce SSIs. Methods: Surgical site infection surveillance is being implemented in 16 health facilities in Sierra Leone, with at least 1 from each of the 5 US Census regions: Eastern, Western, Northern, Northwestern, and Southern. These health facilities were selected based on the availability of a dedicated infection prevention and control (IPC) focal person. Women were observed for 30 days after caesarean section. A standardized surgical safety and surveillance checklist including case definitions and observable criteria (eg, purulent drainage, wound abscess, or intentional reopening) was used. Clinical staff were trained to collect data and to conduct in-person and phone interviews with patients on days 3, 7, and 30 after caesarean section. Results: From March 2021 to July 2021, a total of 2,529 women had caesarean sections in 15 health facilities; most occurred in the Northern region (785 of 2,529). Among these 2,529 women, 1,522 (60%) had an SSI surveillance checklist started, and of those 1,522, 632 (42%) had a completed checklist. Health facilities in most of the rural regions, (Eastern, Northwestern, and Southern) had no completed checklists. The overall SSI rate for the 15 health facilities was 3% (70 of 2,529). The Southern region had the highest SSI rate at 50% (35 of 70), but the Western region did not report any SSIs. Of the 70 cases, 49 (70%) were identified through active inpatient surveillance and 21 (30%) were identified through postdischarge surveillance. Conclusions: One of the priorities of Sierra Leone’s National IPC Action Plan is to establish HAI surveillance. Surgical site surveillance is an essential component of HAI surveillance and leads to timely identification so infections can be treated quickly. This study was limited by inadequate data collection and patients lost to follow-up after discharge. However, this study illustrates that surveillance leads to the diagnosis of most SSI cases after caesarean section while patients are still hospitalized. Simple yet effective SSI surveillance can be conducted in LMICs to identify and ultimately treat SSI after caesarean section. More support is needed in rural and smaller facilities for better implementation of SSI surveillance in Sierra Leone.Funding: NoneDisclosures: None

Family Assistance Spills Over Into Prosocial Behaviors Toward Friends and Positive Academic Behaviors.

We investigate how daily family assistance predicts prosocial behaviors toward friends and positive academic behavior. Adolescents (N = 375, 57% girls, Mage = 14.57) completed diary checklists for 14 days, reporting whether they provided instrumental assistance or emotional support to family and friends, and their positive academic behaviors (e.g., studied). When adolescents provided emotional support to family, they were more likely to provide instrumental support to friends the next day. When adolescents provided emotional support to family, they were more likely to also provide emotional support to friends the next day, and vice versa (a bidirectional association). When adolescents provided instrumental support to the family, they were more likely to have at least one positive academic experience the next day.

Fitness facility staff demonstrate high fidelity when implementing an evidence-based diabetes prevention program.

Translating evidence-based diabetes prevention programs into the community is needed to make promising interventions accessible to individuals at-risk of type 2 diabetes. To increase the likelihood of successful translation, implementation evaluations should be conducted to understand program outcomes and provide feedback for future scale-up sites. The purpose of this research was to examine the delivery of, and engagement with, an evidence-based diet and exercise diabetes prevention program when delivered by fitness facility staff within a community organization. Ten staff from a community organization were trained to deliver the diabetes prevention program. Between August 2019-March 2020, 26 clients enrolled in the program and were assigned to one of the ten staff. Three fidelity components were accessed. First, staff completed session-specific fidelity checklists (n = 156). Second, two audio-recorded counseling sessions from all clients underwent an independent coder fidelity check (n = 49). Third, staff recorded client goals on session-specific fidelity checklists and all goals were independently assessed for (a) staff goal-setting fidelity, (b) client intervention receipt, and (c) client goal enactment by two coders (n = 285). Average self-reported fidelity was 90% for all six sessions. Independent coder scores for both counseling sessions were 83% and 81%. Overall staff helped clients create goals in line with program content and had a goal achievement of 78%. The program was implemented with high fidelity by staff at a community organization and clients engaged with the program. Findings increase confidence that program effects are due to the intervention itself and provide feedback to refine implementation strategies to support future scale-up efforts.

Low sports participation is associated with withdrawn and depressed symptoms in urban, school-age children

BackgroundThe association between sports participation and mental health has not been studied in primary care samples of school-age children, nor in underrepresented minority children. We assessed the relationship between number of sports played and psychiatric symptoms in children ages 6-11 at well-child visits in an urban clinic. MethodsGuardians of 206 children (85% Latinx) ages 6-11 completed Child Behavior Checklists (CBCL) in Spanish (66.5%) or English at well-child visits at an urban community health center. We performed linear regression between number of sports played and individual CBCL syndrome scores, and multiple logistic regression with normal (T-score <60) vs. elevated (T-score ≥60) CBCL syndrome scale score as the outcome. We conducted bivariate, multiple logistic regression, and linear regression analyses between low (1 or fewer) vs. high (2 or more) sports participators and subscales of interest. ResultsFewer sports played was associated with higher Withdrawn/Depressed CBCL syndrome scale T-scores (p = 0.019), but not with other CBCL syndrome scale scores nor number of syndrome scale elevations (p = 0.638). Low participators had higher odds of an elevated Withdrawn/Depressed T-score (p = 0.033) than high participators. LimitationsOur dataset did not contain certain details about sports played, nor information about income and insurance, and our results may not generalize to other populations. ConclusionsPlaying fewer sports is associated with higher withdrawn/depressed symptoms in urban, predominantly Latinx, school-age children. Therefore, urban school-age children with low sports participation may be at risk for depression, and sports participation might protect against depressive symptoms in childhood.

Interactive Digital Health Tools to Engage Patients and Caregivers in Discharge Preparation: Implementation Study.

BackgroundPoor discharge preparation during hospitalization may lead to adverse events after discharge. Checklists and videos that systematically engage patients in preparing for discharge have the potential to improve safety, especially when integrated into clinician workflow via the electronic health record (EHR).ObjectiveThis study aims to evaluate the implementation of a suite of digital health tools integrated with the EHR to engage hospitalized patients, caregivers, and their care team in preparing for discharge.MethodsWe used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to identify pertinent research questions related to implementation. We iteratively refined patient and clinician-facing intervention components using a participatory process involving end users and institutional stakeholders. The intervention was implemented at a large academic medical center from December 2017 to July 2018. Patients who agreed to participate were coached to watch a discharge video, complete a checklist assessing discharge readiness, and request postdischarge text messaging with a physician 24 to 48 hours before their expected discharge date, which was displayed via a patient portal and bedside display. Clinicians could view concerns reported by patients based on their checklist responses in real time via a safety dashboard integrated with the EHR and choose to open a secure messaging thread with the patient for up to 7 days after discharge. We used mixed methods to evaluate our implementation experience.ResultsOf 752 patient admissions, 510 (67.8%) patients or caregivers participated: 416 (55.3%) watched the video and completed the checklist, and 94 (12.5%) completed the checklist alone. On average, 4.24 concerns were reported per each of the 510 checklist submissions, most commonly about medications (664/2164, 30.7%) and follow-up (656/2164, 30.3%). Of the 510 completed checklists, a member of the care team accessed the safety dashboard to view 210 (41.2%) patient-reported concerns. For 422 patient admissions where postdischarge messaging was available, 141 (33.4%) patients requested this service; of these, a physician initiated secure messaging for 3 (2.1%) discharges. Most patient survey participants perceived that the intervention promoted self-management and communication with their care team. Patient interview participants endorsed gaps in communication with their care team and thought that the video and checklist would be useful closer toward discharge. Clinicians participating in focus groups perceived the value for patients but suggested that low awareness and variable workflow regarding the intervention, lack of technical optimization, and inconsistent clinician leadership limited the use of clinician-facing components.ConclusionsA suite of EHR-integrated digital health tools to engage patients, caregivers, and clinicians in discharge preparation during hospitalization was feasible, acceptable, and valuable; however, important challenges were identified during implementation. We offer strategies to address implementation barriers and promote adoption of these tools.Trial RegistrationClinicalTrials.gov NCT03116074; https://clinicaltrials.gov/ct2/show/NCT03116074.

Infant mental health home visiting therapists' fidelity to the Michigan IMH-HV model in community practice settings.

Implementation research suggests that fidelity to a therapeutic model is important for enhancing outcomes, yet can be difficult to achieve in community practice settings. Furthermore, few published studies have reported on characteristics of treatment fidelity. The present study examined fidelity to the Infant Mental Health Home Visiting (IMH-HV) model among 51 therapists with a range of experience practicing in community settings across the state of Michigan. IMH therapists completed fidelity checklists after every session with participating families to track use of 15 treatment strategies central to the IMH-HV model across the 12-month study period. Results indicated that the most commonly endorsed components utilized in home visits were developmental guidance and infant-parent psychotherapy, followed by the provision of emotional support. Use of IMH-HV components did not vary over time for the entire sample; however, patterns of strategies used showed somewhat more variability among more experienced therapists and when serving higher risk families. Findings demonstrate that IMH-HV therapists report a range of adherence to the model in community settings, with greatest fidelity to several model core components. Ongoing training in the flexible use of all core strategies may further enhance fidelity and contribute to positive outcomes for caregivers and their children receiving IMH-HV services.

Exposure to endocrine disrupting chemicals and behaviors associated with ADHD in adolescents

TPS 731: Neurological effects in children, Exhibition Hall, Ground floor, August 26, 2019, 3:00 PM - 4:30 PM Background: Phthalates and parabens are endocrine disrupting chemicals (EDCs) commonly found in personal care products. Studies suggest that exposure to EDCs may influence childhood behaviors associated with attention deficit/hyperactivity disorder (ADHD), but the relationship during adolescence has not been studied. Methods: Urinary biomarker concentrations of phthalates and parabens commonly found in personal care products were quantified in 152 adolescents (age ~15 yrs) in the New Bedford Cohort, a birth cohort study among residents near the New Bedford Harbor Superfund site, Massachusetts. ADHD-associated behavior was assessed with multiple indices from self, parent, and teacher completed behavioral checklists using the Conners’ Attention Deficit Scale and the Behavior Assessment System for Children, 2nd ed., where higher scores indicate more problem behaviors. We used a repeated measures analysis with negative binomial models to estimate the adjusted association of each analyte with these multiple measures of ADHD-related behavior. Results: In this racially diverse (38% non-white or Hispanic) and socioeconomically disadvantaged (31% in low income households, 43% had unmarried mothers, 59% had mothers with a high school education or less) population, a doubling in urinary concentration of the molar sum of paraben biomarkers was associated with an 2% increase in behavior score associated with ADHD in girls (95% CI: 1.01, 1.04), but not boys; this association appeared to be driven by propyl and methyl paraben. We also observed a 3% increase in the ADHD-related behavior score in both sexes with a doubling of the molar sum of urinary phthalate biomarkers commonly found in personal care products (95% CI: 1.01, 1.04); this association was predominantly driven by monobutyl phthalate (%diff: 1.04, 95% CI: 1.02, 1.07), although we observed a smaller significant association with mono-iso-butyl phthalate. Conclusion: Our findings suggest that exposure to some parabens and phthalates during adolescence may be associated with behaviors characteristic of ADHD.

Pilot implementation of a monitoring and enforcement system for the International Code of Marketing of Breast-milk Substitutes in Cambodia.

Globally, monitoring and enforcement mechanisms for the World Health Organization's International Code of Marketing of Breast‐milk Substitutes are often lacking. The Cambodian government adopted the Code as the national standard in Sub‐Decree 133 on Marketing of Products for Infant and Young Child Feeding. Following the formation of a multisectoral Oversight Board and development of detailed guidance documents for the implementation and enforcement of Sub‐Decree 133, a 7‐month pilot was conducted in 2017 to trial a monitoring system in four urban areas of Cambodia. The pilot included training of monitors from the Ministries of Health and Commerce, screening for violations at retail locations and health facilities, testing reporting mechanisms, and taking actions against violators. During the pilot, 85 national‐ and subnational‐level monitors were trained, 392 site visits were made, 2,377 monitoring checklists were completed, and 11 warning letters were issued to violators. Half of the completed checklists (52.9%) indicated Code violations, yet monitors submitted zero violation reports. The pilot revealed modifications needed to the monitoring system: integrate monitor trainings into existing ministry training curricula for sustainability; enhance targeting of monitors for Sub‐Decree training; delineate clear roles and responsibilities for the national and subnational levels; simplify monitoring checklists and violation reports; and improve integration of monitoring activities into routine ministry operations. Before the Sub‐Decree 133 monitoring and enforcement system is implemented throughout Cambodia, revisions must be made to ensure the viability of this system. Challenges and lessons learned can also guide Code monitoring efforts being undertaken by other countries.

Burden of adverse childhood experiences in children attending paediatric clinics in South Western Sydney, Australia: a retrospective audit

ObjectivesAdverse childhood experiences (ACE) are associated with poor short, medium and long-term health outcomes. South Western Sydney (SWS) has a large culturally diverse population, including many disadvantaged population groups. Our...