Departmental Protocol Research Articles

Novel Coronavirus (COVID-19) Outbreak In Nigeria: How Prepared Is The Radiography Sector?

Introduction: Following the outbreak and increasing numbers of coronavirus (COVID-19) cases in Nigeria, healthcare professionals are at the forefront in dealing with the pandemic. Radiographers are among the first line care givers. The study is aim to assess the level of preparedness of the Radiography sector in Nigeria.
 Methods: A prospective cross-sectional survey was conducted using self-completion questionnaire. The questionnaire was generated on the 26th of March 2020, using online Google forms consisting of closed and open ended questions. Paired t-test statistic was used to compare the difference between "Before and After" changes in departmental protocols, using the SPSS statistical software, version 20. Statistically significant level was set at 0.05.
 Results: A total of 107 radiographers from across the country responded to the questionnaire. Of these, 78(72%) were male and 27.1% female, giving a male to female ratio of 3:1. Following the outbreak of COVID-19, 86% of the respondents report that there have been changes in the departmental procedures. Sixty-seven percent said "No" to the availability of an appointment system, guidelines to reduce human to human contact(57%) and auditing for suspected COVID-19 cases (58.9%). Only 16(15%) of the respondents had received emergency training towards the fight against COVID-19. Of these, 6(37.5%) were trained in patient care, only 1(6.3%) on emergency response while 9 (56.3%) received training in limiting human to human transmission.
 Conclusion: Findings in this study, suggest inadequate preparedness, with evidence of inadequate provision of equipment (Mobile X-ray and Ultrasound machines) for the diagnosis and management of cases in departments and isolation centers. In addition, emergency training on COVID-19 issues is low. The foregoing calls for adoption of urgent and immediate remedial measures.
 Implications for practice: This study identify areas of practice that may detract from achieving optimum service delivery and safety during the pandemic.

The Impact of COVID-19 on Radiation Oncology and Cancer Care: A Perspective from the Cancer Belt Region of India

A pandemic coronavirus, termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes a respiratory illness called coronavirus disease 2019 (COVID-19) that is often severe or life threatening. Considering the low immunity status of cancer patients due to multimodality treatment, they seem to be more prone to COVID-19. Given the rapidity with which the novel coronavirus (SARS-CoV-2) is spreading, we can expect an increased burden of cancer patients diagnosed with COVID-19 at oncology treatment clinics and a need to address the issues associated. As of the date of this writing, United States has been witnessing an increase in confirmed cases, not far behind are the large outbreaks of European countries. Patients with cancer may have compromised immunity due to their disease or its ongoing treatment, and early reports suggest cancer is a risk factor for severe COVID-19. Since the outbreak in Wuhan, Chinese researchers have published on their experience with COVID-19 and have highlighted high-risk groups, including the elderly and patients with comorbidities, including cancer. In one of the largest series reported from Wuhan, elderly patients were at a higher risk for disease severity with an 8.0% case fatality rate in those aged between 70 and 79 years, and 14.8% in those aged 80 years and older. The case fatality rate for cancer patients in that cohort was notably higher than noncancer patients at 5.6 versus 2.1% in the whole sample. This review focuses on the pandemic-driven strategies that need to be adopted to overcome the radiation oncology clinics burden, especially in this region of India popularly termed as the cancer belt. Although colleagues around the world have dealt with enormous service pressures in the face of natural disaster or infection previously, the global scale and challenge of COVID-19 are unprecedented. Our aim is to highlight the quintessential point that even within these circumstances the morbidity and mortality associated with cancer should not be taken lightly. Departmental protocols should be regularly upgraded to provide smooth and efficient functioning of the department.

Set-up Errors and Determination of Planning Target Volume Margins Protocol for Different Anatomical Sites in a Newly Established Tertiary Radiotherapy Centre in India

Objective Our study aimed to assess the set-up errors for image-guided radiotherapy at a newly established tertiary radiation center in India and to establish the departmental protocol of clinical target volume–planning target volume (CTV–PTV) margins for different anatomical sites. Materials and Methods This study enrolled the first 200 patients who were treated with curative intent at All India Institute of Medical Sciences, Patna, from February 2019 to September 2019. Number of patients were 53, 26, 53, 11, 6, 47, and 4 for head and neck, brain, breast, thorax, abdomen, pelvis, and craniospinal irradiation (CSI), respectively. The translational vectors for total 1,463 kV cone-beam computed tomography (CBCT) images were collected from the treatment record. Results For the systematic error, the largest value is found for the thoracic subset on the X and Y directions, and for breast patients on Z axis, whereas the smallest values were found for CSI. For random error, the largest value was found for pelvic in the X, Y direction, and for breast subset on Z axis, whereas the smallest values on X and Z axes were found in the brain and for head and neck on the Y axis. Largest value for systemic error is smaller than 5 mm in all directions and for all anatomical subsets. The highest random error value is 5.07 mm in Y axis for pelvic subset. The largest values for CTV–PTV margin are found for thoracic subset and the smallest for CSI followed by the brain. Significant reduction of set-up error observed for the last hundred patients as compared to the first half of the patient population. Conclusion Use of thermoplastic cast along with breast board and respiratory motion management should be recommended to reduce set-up error for breast and thoracic subset. Six degrees of freedom robotic couch system can also further rectify the set-up error in image-guided radiotherapy.

Implementation of COVID-19 Protocols and Tele-Triage in an Academic Ophthalmology Department

Abstract Background The coronavirus disease-2019 (COVID-19) pandemic has affected academic ophthalmology departments globally, causing changes in educational, research, and clinical operations in the short and long term. Healthcare workers are at higher risk of contracting the disease and given early reports suggestive of transmission through the tear film in COVID-19 cases with conjunctivitis, and close proximity during examination, eye care providers in particular may be at increased risk. Objective To provide the experience from a single academic ophthalmology program in responding to the COVID-19 pandemic. Methods This article describes the changes executed in the Department of Ophthalmology and Visual Sciences at the University of Illinois at Chicago, Illinois Eye and Ear Infirmary, with emphasis on the implementation of a tele-triage process for urgent visits. Results In response to the pandemic, our department made rapid changes to its departmental protocols for education, research, and patient management. Early measures focused on limiting face-to-face interactions among patients, staff, residents, and faculty, decreasing the risk of exposure to disease while also providing access for patients in urgent need of care. Conclusion We hope that the UIC experience will assist other academic tertiary referral centers in maximizing their opportunities to deliver excellent patient care while minimizing risks to patient and provider, all while continuing to provide a quality graduate medical educational experience during and beyond the pandemic.

Combating the pandemic of COVID-19 in India: health care worker perspective

As the pandemic of COVID-19 intensifies there is a huge burden on the health care system of each country. As predicted by epidemic model, India with 1.3 billion population and only 0.76 doctors per thousand people will have 1 million people affected by COVID-19 needing ventilatory support. This situation focusses on the substantial thrust on health care workers in India while dealing with the pandemic and protection of the health care workers from COVID-19 infection is significant as they are the key-groups in health system to procure win-battle status against COVID-19. Henceforth, after meticulously comparing various countries’ strategies to protect their HCWs this brief study is being prepared and few recommendations has been suggested which may enable the protection of HCWs in India. Un-interrupted supply of appropriate PPE, phenomenon of presenteeism among HCWs, burn-outs among HCWs, front-line department protocol for protection of HCWs, need of constant psycho-analysis among HCWs, stigma in society for HCWs, prophylaxis for HCWs against COVID-19 and HCWs’ family concerns are some of the issues which are being highlighted in this paper.

Acute stroke care algorithm in a private tertiary hospital in the Philippines during the COVID-19 pandemic: A third world country experience

Background and purposeSince the declaration of the Novel Coronavirus Disease (COVID-19) pandemic, ensuring the safety of our medical team while delivering timely management has been a challenge. Acute stroke patients continue to present to the emergency department and they may not have the usual symptoms of COVID-19 infection. Stroke team response and management must be done within the shortest possible time to minimize worsening of the functional outcome without compromising safety of the medical team. MethodsInfection control recommendations, emergency department protocols and stroke response pathways utilized prior to the COVID 19 pandemic within our institution were evaluated by our stroke team in collaboration with the multidisciplinary healthcare services. Challenges during the COVID-19 scenario were identified, from which a revised acute stroke care algorithm was formulated to adapt to this pandemic. ResultsWe formulated an algorithm that incorporates practices from internationally devised protocols while tailoring certain aspects to suit the available resources in our system locally. We highlighted the significance of the following: team role designation, coordination among different subspecialties and departments, proper use of personal protective equipment and resources, and telemedicine use during this pandemic. ConclusionsThis pandemic has shaped the stroke team's approach in the management of acute stroke patients. Our algorithm ensures proper resource management while optimizing acute stroke care during the COVID-19 pandemic in our local setting. This algorithm may be utilized and adapted for local practice and other third world countries who face similar constraints.

Regional anesthesia in Canadian emergency departments: Emergency physician practices, perspectives, and barriers to use.

Regional anesthesia has many applications in the emergency department (ED). It has been shown to reduce general anesthetic dose, requirement for post-procedural opioids, and recovery time. We sought to characterize the use of regional anesthesia by Canadian emergency physicians, including practices, perspectives and barriers to use in the ED. A cross-sectional survey was administered to members of the Canadian Association of Emergency Physicians (CAEP), consisting of sixteen multiple choice and numerical response questions. Responses were summarized descriptively as percentages and as the median and inter quartile range (IQR) for quantitative variables. The survey was completed by 149/1144 staff emergency physicians, with a response rate of 13%. Respondents used regional anesthesia a median of 2 (IQR 0-4) times in the past ten shifts. The most broadly used applications were soft tissue repair (84.5% of respondents, n = 126), fracture pain management (79.2%, n = 118) and orthopedic reduction (72.5%, n = 108). Respondents agreed that regional anesthesia is safe to use in the ED (98.7%) and were interested in using it more frequently (78.5%). Almost all (98.0%) respondents had point of care ultrasound available, however less than half (49.0%) felt comfortable using it for RA. Respondents indicated that they required more training (76.5%), a departmental protocol (47.0%), and nursing assistance (30.2%) to increase their use of RA. Canadian emergency physicians use regional anesthesia infrequently but express an interest in expanding their use. While equipment is available, additional training, protocols, and increased support from nursing staff are modifiable factors that could facilitate uptake.

Barriers and Facilitators to Clinician Readiness to Provide Emergency Department–Initiated Buprenorphine

Treatment of opioid use disorder (OUD) with buprenorphine decreases opioid use and prevents morbidity and mortality. Emergency departments (EDs) are an important setting for buprenorphine initiation for patients with untreated OUD; however, readiness varies among ED clinicians. To characterize barriers and facilitators of readiness to initiate buprenorphine for the treatment of OUD in the ED and identify opportunities to promote readiness across multiple clinician types. Using data collected from April 1, 2018, to January 11, 2019, this mixed-methods formative evaluation grounded in the Promoting Action on Research Implementation in Health Services framework included 4 geographically diverse academic EDs. Attending physicians (n = 113), residents (n = 107), and advanced practice clinicians (APCs) (n = 48) completed surveys electronically distributed to all ED clinicians (n = 396). A subset of participants (n = 74) also participated in 1 of 11 focus group discussions. Data were analyzed from June 1, 2018, to February 22, 2020. Clinician readiness to initiate buprenorphine and provide referral for ongoing treatment for patients with OUD treated in the ED was assessed using a visual analog scale. Responders (268 of 396 [67.7%]) were dichotomized as less ready (scores 0-6) or most ready (scores 7-10). An ED-adapted Organizational Readiness to Change Assessment (ORCA) and 11 focus groups were used to assess ratings and perspectives on evidence and context-related factors to promote ED-initiated buprenorphine with referral for ongoing treatment, respectively. Among the 268 survey respondents (153 of 260 were men [58.8%], with a mean [SD] of 7.1 [9.8] years since completing formal training), 56 (20.9%) indicated readiness to initiate buprenorphine for ED patients with OUD. Nine of 258 (3.5%) reported Drug Addiction Treatment Act of 2000 training completion. Compared with those who were less ready, clinicians who were most ready to initiate buprenorphine had higher mean scores across all ORCA Evidence subscales (3.50 [95% CI, 3.35-3.65] to 4.33 [95% CI, 4.13-4.53] vs 3.11 [95% CI, 3.03-3.20] to 3.60 [95% CI, 3.49-3.70]; P < .001) and on the Slack Resources of the ORCA Context subscales (3.32 [95% CI, 3.08-3.55] vs 3.0 [95% CI, 2.87-3.12]; P = .02). Barriers to ED-initiated buprenorphine included lack of training and experience in treating OUD with buprenorphine, concerns about ability to link to ongoing care, and competing needs and priorities for ED time and resources. Facilitators to ED-initiated buprenorphine included receiving education and training, development of local departmental protocols, and receiving feedback on patient experiences and gaps in quality of care. Only a few ED clinicians had a high level of readiness to initiate buprenorphine; however, many expressed a willingness to learn with sufficient supports. Efforts to promote adoption of ED-initiated buprenorphine will require clinician and system-level changes.

P005: Regional anesthesia in Canadian emergency departments: Emergency physician practices and impressions

Introduction: The use of regional anesthesia (RA) by emergency physicians (EPs) is expanding in frequency and range of application as expertise in point-of-care ultrasound (POCUS) grows, but widespread use remains limited. We sought to characterize the use of RA by Canadian EPs, including practices, perspectives and barriers to use in the ED. Methods: A cross-sectional survey of Canadian EPs was administered to members of the Canadian Association of Emergency Physicians (CAEP), consisting of sixteen multiple choice and numerical responses. Responses were summarized descriptively as percentages and as the median and inter quartile range (IQR) for quantitative variables. Results: The survey was completed by 149/1144 staff EPs, with a response rate of 13%. EPs used RA a median of 2 (IQR 0-4) times in the past ten shifts. The most broadly used applications were soft tissue repair (84.5% of EPs, n = 126), fracture pain management (79.2%, n = 118) and orthopedic reduction (72.5%, n = 108). EPs agreed that RA is safe to use in the ED (98.7%) and were interested in using it more frequently (78.5%). Almost all (98.0%) respondents had POCUS available, however less than half (49.0%) felt comfortable using it for RA. EPs indicated that they required more training (76.5%), a departmental protocol (47.0%), and nursing assistance (30.2%) to increase their use. Conclusion: Canadian EPs engage in limited use of RA but express an interest in expanding their use. While equipment is available, additional training, protocols, and increased support from nursing staff are modifiable factors that could facilitate uptake of RA in the ED.

P082: Ethical management of incidental findings in emergency care: A critical interpretive literature review

Introduction: Incidental findings (IFs) are findings discovered in the course of healthcare (e.g., blood tests, genetic tests, imaging) that are unrelated to the primary purpose for which a test was sought. Some IFs constitute new knowledge that have implications for patient autonomy and welfare. IFs found in emergency departments (EDs) are difficult to manage, with one study reporting that of 392 patients with IFs, 122 had no follow-up and 242 had no electronic record of the finding. Methods: A critical interpretive literature review was conducted to explore current practices regarding identification, disclosure, and management of IFs in EDs, and to identify ethical challenges that require research focus and policy reform. The search strategy included ‘incidental findings’ AND ‘emergency’ and derivatives, retrieving 12,021 studies from databases including PubMed, Scopus, and Web of Science, as well as handsearching and reference list searching. Following screening, 97 studies were included. Data was extracted, analyzed using descriptive statistics, and then critically interpreted to capture key ideas. Results: Of 97 included articles, 75 have relevant empirical data. Of the 75, most literature (89%) presented the frequency of IFs in EDs, with an average frequency of 34%. Most (84%) did not report on patient disclosure rates or follow-up rates. When reported, patient notification rates are as low as 2.6% with an average of 15% over 12 studies. Empirical studies included in the review do not address ethical principles or patient preferences on disclosure. The literature reveals suggestions to manage IFs in EDs, including implementation of automatic feedback or alert mechanisms, clarification of responsibilities within treating teams, protocols in radiology departments, and improvements to patient documentation. Test results by letter are noted as insufficient because patients are unable to ask questions. Authors suggest further research on optimal follow-up recommendations to alleviate patient and physician distress. Further results will be presented, critically interpreted, and discussed, with attention to ethical implications and challenges. Conclusion: The literature on IFs in EDs focuses too narrowly on frequency, with ad hoc suggestions for practice, research, and policy changes to improve the ethical management of IFs. Numerous factors, including crucial knowledge gaps, contribute to inadequate management of IFs arising in EDs. Research and ethics informed policy guidance is needed.

P115: Improving the diagnosis of pulmonary embolism in the emergency department

Background: Emergency physicians (EPs) can choose from several evidence-based pathways to diagnose pulmonary embolism (PE), however literature suggests that EPs frequently use computer tomography (CT) scanning as a stand-alone test for PE. This is a program of research to improve adherence to evidence-based PE diagnosis in the emergency department (ED). Aim Statement: To create a novel approach to PE diagnosis in the ED based on a framework explaining EP diagnostic PE behaviour and barriers to using evidence-based PE testing. Measures &amp; Design: We conducted two types of qualitative interviews: 1). EPs in 5 Canadian cities watched videos of 2 simulated cases and then explained how they would test the patient. 2). Semi-structured EP interviews using the theoretical domains framework (TDF). The results of our analyses informed the construction of an explanatory framework for common EP diagnostic PE behaviours. Barriers to evidence-based behaviour were classified into domains. A Canadian EP expert group reviewed these results along with the existing evidence on ED PE diagnostic implementation. We developed a new approach to diagnosis of PE in the ED which addresses each of our domains. Evaluation/Results: We conducted 71 interviews. We identified 4 domains, each addressed in our pathway. ‘PE in a mythical and deadly beast’ PE kills and can masquerade so EPs look for PE in places where it does not exist and are rewarded for ‘over-testing’. Response: Creating a departmental conversation about missing PE, talking about the facts, busting the myths. EP feedback on PE testing including positive rate. ‘The end goal is CTPE’ PE creates anxiety for EPs and ordering a CTPE hands over responsibility to the radiologist. Response: A departmental protocol for PE testing which starts with D-dimer for every patient. Shifting focus to ruling out PE with D-dimer. Protocol is automated once initiated by EP. ‘PERC eases anxiety’ PERC is documented when it is negative and allows EP to stop. Response: EPs can choose to use and document PERC. ‘No-one has been fighting for the Wells score’ Poor understanding of purpose and function. Often at odds to Gestalt. Response: Protocol does not use Wells score. Discussion/Impact: We have developed a new diagnostic PE pathway which addresses current barriers to evidence-based practice which we will evaluate further.

Management of radiation therapy-induced vaginal adhesions and stenosis: A New Zealand survey of current practice.

IntroductionVaginal dilation is often indicated as an intervention for the management of radiation therapy‐induced vaginal adhesions and stenosis (RTVAS). However, limited research exists underpinning this intervention and diversity in patient recommendations internationally are reported. In the absence of New Zealand (NZ) national guidelines regarding the management of RTVAS, a survey of NZ radiation therapy departments was conducted to gain an overview of current practice.MethodsA two‐section online survey was developed to capture RTVAS education and management overview across NZ. Section one focused on departmental resourcing and section two on local standard practice regarding vaginal dilator usage. One RTVAS education representative from each department was invited to complete the survey.ResultsEight of nine NZ departments completed the survey. Consistent treatment indications were identified for RTVAS patient education with the involvement of diverse staffing groups at various time‐points throughout the treatment process. Protocols for RTVAS management existed in each RT department with staff commonly trained by informal peer observation. Dilator usage was recommended regardless of patient sexual activity. Agreement was shown regarding the recommended start time of dilator usage and frequency. The recommended duration of dilator use post‐treatment varied from 6 months to greater than 36 months.ConclusionsThis work illustrates both concordance and diversity in practice and contributes to the limited body of literature available. Further research is warranted to explore patterns of practice between departmental protocols and individual practitioners in further detail.

Diaphragmatic Response to Inspiratory versus Expiratory Training in Patients with Chronic Obstructive Pulmonary Disease

Abstract Background: Chronic Obstructive Pulmonary Disease (COPD) is characterized by air flow limitation and mucus hypersecreastion. Aim of Study: The present study was conducted to inves-tigate the efficacy of inspiratory muscle training versus expiratory muscle training on thickness fraction in patients with chronic obstructive pulmonary disease. Material and Methods: Forty patients (men) with chronic obstructive pulmonary disease were included in this study, their age ranged from 40-50 years; they had Body Mass Index (BMI) ranged from 18.5-29.9 (kg/m2). Patients were selected from outpatient clinic Faculty of Medicine, Cairo University, They were assigned randomly into two equal groups: Group Expiratory Muscle Training (EMT) which received expiratory muscle training by Positive Expiratory Pressure device (PEP) in addition to routine physiotherapy program according to department protocol in form of, percussion, vibration, shaking and postural drainage. Group Inspiratory Muscle Training (IMT), whom received inspiratory muscle training by inspir-atory trainer in addition to the same physical therapy program that applied in group (EMT), both groups received treatment program 3 times/week for 12 weeks. The variable that used on this study is diaphragmatic thickness fraction measured by ultrasonography, was assessed before and after treatment program in both groups. Results: The results revealed that there was no-significant improvement in diaphragmatic thickness fraction in two groups after twelve successive weeks, also revealed no significant difference when compared the two groups after treatment. Conclusion: Within the limitation of the present study it could be concluded that EMT and IMT results in non-significant improvement in diaphragmatic thickness fraction.

Prevalence of Self-reported Neurologic and Ocular Symptoms in Early Syphilis Cases.

Neurosyphilis, a complication of syphilis, can occur at any stage of infection. Measuring the prevalence of neurosyphilis is challenging, and there are limited data on the prevalence of neurologic or ocular symptoms among patients with syphilis. We sought to describe the prevalence of neurologic and/or ocular symptoms among early syphilis (ES) cases and the clinical management of symptomatic cases enrolled in the STD Surveillance Network (SSuN) Neuro/Ocular Syphilis Surveillance project. Persons diagnosed with ES were selected for interviews based on current health department protocols in 5 participating SSuN jurisdictions from November 2016 through October 2017. All interviewed ES cases were screened for self-reported neurologic and/or ocular symptoms. Additional clinical information on diagnostic testing and treatment for cases concerning for neurosyphilis/ocular syphilis was obtained from providers. Among 9123 patients with ES who were interviewed, 151 (1.7%; 95% confidence interval [CI], 1.4%-1.9%) reported ≥ 1 neurologic or ocular symptom. Of the 53 (35%) who underwent lumbar puncture, 22 (42%) had documented abnormal cerebrospinal fluid, of which 21 (95%) were treated for neurosyphilis/ocular syphilis. Among the remaining 98 symptomatic patients with no documented lumbar puncture (65%), 12 (12%) were treated for and/or clinically diagnosed with neurosyphilis/ocular syphilis. We observed a low prevalence of self-reported neurologic and/or ocular symptoms in interviewed ES cases. Approximately one-third of ES cases who self-reported symptoms underwent further recommended diagnostic evaluation. Understanding barriers to appropriate clinical evaluation is important to ensuring appropriate management of patients with possible neurologic and/or ocular manifestations of syphilis.

Minimizing Ionizing Radiation in Evaluating Suspected Appendicitis in Children Before and After the Release of the ACEP Clinical Policy.

The aim of this study was to examine the impact of the ACEP (American College of Emergency Physicians) clinical policy regarding diagnosis of suspected appendicitis on changing practice in the pediatric emergency department (ED) in the absence of a formal departmental protocol. This was a retrospective chart review in a pediatric ED in which patients aged 2 to 18 years were evaluated for appendicitis via ultrasound, computed tomography (CT), or both, over a 7-year study period. We compared rates of CT utilization in the period before the release of the ACEP clinical policy regarding diagnosis and treatment of appendicitis (2008-2009) and the period after (2010-2014). Other metrics of interest were ultrasound results and physician response to results, as well as surrogate markers for quality of care. Seven hundred pediatric ED visits were included, with 200 prepolicy release and 500 postrelease. Computed tomography utilization decreased significantly postpolicy release from 43.5% (95% confidence interval [CI], 36.6%-50.3%) to 22.2% (95% CI, 18.5%-25.8%). The proportion of ultrasounds with indeterminate results also decreased, with 71.5% (95% CI, 65.1%-77.9%) and 55.1% (95% CI, 50.7%-59.5%) in the pre and post groups, respectively. Physicians ordered fewer CTs after indeterminate ultrasounds, decreasing from 63.7% (95% CI, 56.9%-70.5%) to 48.3%% (95% CI, 43.9%-52.7%). After the release of the clinical policy, CT utilization decreased significantly suggesting possible effectiveness of the policy in bringing about change in practice. Subsequently, there was an increase in the definitiveness in the ultrasound results. Physicians also evolved in their response to indeterminate ultrasound results, with fewer CTs ordered reflexively after indeterminate results.

4:03 PM Abstract No. 362 To screen or not to screen: can we accurately limit the preoperative testing of coagulation status in patients undergoing placement of tunneled central venous catheter to only those that need it?

To determine if the preoperative screening and evaluation of coagulation status in patients undergoing placement of a tunneled central venous catheter, as reflected by the platelet count and the calculated International Normalized Ratio (INR), can be accurately limited to specific patients based upon known risk factors and relevant past medical history in accordance with the recommendations set forth in the updated SIR Guidelines for the Periprocedural Management of Bleeding Risk. We conducted a retrospective analysis of tunneled central venous catheter placements performed by interventional radiology in both the ambulatory and inpatient setting at a single institution over a 12-month period between August 1st, 2018 and July 31st, 2019. The preoperative platelet and INR values were compiled from the electronic medical record. Any encountered platelet or INR abnormalities (platelet count < 20 x 109/L, INR > 3.0) were then cross-referenced to the relevant patient medical history to determine the etiology of the coagulation deficit. A total of 578 tunneled central venous catheters (142 ports, 103 permacaths, 16 Hickman catheters, 317 Powerline catheters) were placed during the study period. Coagulation testing was performed within 3 days or 30 days of the procedure (inpatient vs. ambulatory setting, respectively) in accordance with current departmental protocol. Of the 578 tunneled catheter placements, 1 patient (0.17%) demonstrated an INR value above the threshold limit and 12 patients (2.1%) possessed a platelet count below the recommended transfusion threshold. The laboratory abnormalities in all cases were easily explained: the elevated INR was secondary to Coumadin therapy for atrial fibrillation and the thrombocytopenia was related to a hematologic malignancy in every instance. The presence of a coagulation deficit in a patient undergoing a tunneled central venous catheter placement is rare and, when encountered, explained by a review of the relevant past medical history. These findings support the updated Periprocedural Guidelines for low bleeding risk procedures recommending preoperative laboratory screening only in patients with relevant risk factors.

Esophageal Button Battery in the Pediatric Population: Experience from a Tertiary Care Center.

To highlight different patterns of clinical presentation, share authors' experience in the management of children following button battery ingestion and their outcomes. This is a single center descriptive cohort study with a total duration of 5 y (January 2014 through December 2018). Battery removal was performed by urgent rigid esophagoscopy following department protocols. Outcomes and complications were observed in the post-operative period in all children. Contrast esophagogram was performed at 4-6 wk post battery removal for assessing esophageal emptying and detecting sequelae (stricture). Fifty-two children (M:F = 31:21) with a meanage (+SD) at presentation of 47 (+27) mo were managed at authors' center during the study period. Most common source of button battery was electronic appliance remote (50%) and common symptoms at presentation were vomiting after feeds, dysphagia, chest pain etc. During endoscopic retrieval, majority (60%) of the batteries were lodged in the upper esophagus and predominant impaction was noticed at anterior wall (81%) of esophagus. Upon injury assessment, grade 3 followed by grade 2 were detected in 59% and 41% cases respectively. Five children developed complications. Two deaths due to catastrophic hemorrhage (aorto-esophageal fistula) and refractory sepsis (tracheoesophageal fistula) occurred in present cohort. While contrast esophagogram was normal in all survivors, self-limiting symptoms like mild chest pain during swallowing and cough were observed during the follow-up. Median (IQR) duration of hospital stay and follow-up were 2 d (1-2.75) and 14.5 mo (8.5-17.5) respectively. Accidental button battery ingestion can be life-threatening. Diagnosis is often delayed due to non-specific clinical presentation and unwitnessed ingestions. Esophagoscopic retrieval is the treatment modality of choice. Despite having significant esophageal injury at the time of removal, no long-term sequelae (clinical or radiological) were observed in present study.

Delay of Surgery Start Time: Experience in a Nigerian Teaching Hospital.

Background:Operating room delay has multiple negative effects on the patients, surgical team, and the hospital system. Maximum utilization of the operating room requires on-time knife on the skin and efficient turnover. Knowledge of the reasons for the delay will form a basis toward proffering solutions.Patients and Methods:This was a prospective study of all consecutive elective cases done over a 15-month period from January 2016 to March 2017. Using our departmental protocol that “knife on skin” for the first elective case should be 8.00am, the delay was defined as a surgery starting later than 8.00am for the first cases while the interval between the cases of >30 min for the knife on the skin was used for subsequent cases. Reasons for delay in all cases of delay were documented. The prevalence and causes of the delays were analyzed. P < 0.05 was considered statistically significant.Results:Of 1178 surgeries performed during the period of study, 1170 (99.3%) of cases were delayed. The mean delay time was 151 min for all cases. First on the list had a longer delay time than others; 198.9 min versus 108.5 min (P = 0.000). Delay in the first cases accounted for 47.5% of all delayed cases. Overall, patient-related factor was the most common cause of delay (31.3%) followed in descending order by surgeon-related factor (28.5%) and hospital-related factor (26.2%). Patient-related factors accounted for 43.2% of first-case delays.Conclusion:Delays encountered in this study were multifactorial and are preventable. Efforts should be directed at these different causes of delay in the theater to mitigate these delays and improve productivity.

An evaluation of factors to pre-determine the use of VMAT planning for breast and IMC patients

Keywords: IMC, VMAT, Breast Introduction: Following changes to NICE guidelines, an increasing number of breast patients now also receive radiotherapy treatment to the internal mammary chain (IMC) [1]. All patients referred for radiotherapy for breast and IMCs go through the standard breast pathway. However, a third require a re-plan to achieve dose constraints, taking up additional planners time and meaning the radiographers and doctors time at VSim had been wasted. An audit was carried out to identify factors that can be reviewed prior to VSim which would give a strong enough indication to determine if some patients can go straight to VMAT. Method: The audit was a retrospective data analysis of all patients referred for IMC radiotherapy in the last year. 41 patients were identified. Patients referred directly into the VMAT pathway before scanning, patients for bilateral treatment and patients for IMC radiotherapy adjuvant to breast radiotherapy were excluded. This left 31 patients. Results: The audit results showed a strong correlation between ipsilateral lung volume and the need for VMAT planning. Patients with an ipsilateral lung volume of 1200cm3 or less required a VMAT plan with one exception (10 out of 11 patients). This indicates that patients with an ipsilateral lung volume of 1200cm3 or less should go directly for VMAT planning. Conclusion: It is recommended that when VSim import the scan, the OARs (Ipsilateral lung and heart) are volumed as per departmental protocol and the ipsilateral lung volume measured. If this is found to be 1200cm3 or less, they would then discontinue the VSim pathway and refer directly for VMAT planning. This will be re-audited in 6 months to evaluate efficacy. Numerical References [1] National Institute for Health and Care Excellence (2018) Early and locally advanced breast cancer: diagnosis and management; Evidence reviews for breast radiotherapy, Available at: https://www.nice.org.uk/guidance/ng101/evidence/evidence-review-h-breast-radiotherapy-pdf-4904666613 (accessed 20 July 2019)

Promoting Time-Efficient Care for Suicidal Patients in the Emergency Department

Patients who present to an emergency department are in a vulnerable state of mind. The population in the emergency department is continuously growing. Acute stages of mental health problems can bring patients to the emergency department for care. Psychiatric disorders such as schizophrenia, living alone, depression, hopelessness, previous suicide attempts, self-devaluation, agitation, and insomnia are some risk factors that predispose individuals to suicide. Suicidal patients’ care in the emergency department can be challenging for healthcare professionals due to the complex environment and numerous other emergencies occurring altogether. Suicidal patients do not get the timely medical attention they need from clinicians. As a result, there are little information and few protocols in emergency departments about the correlation of the timely care and how it can affect the patients during the emergency department visit.