Direct Oversight Research Articles

9.N. Practice session: From Data to Action – Joining forces to close the inequity gap in adolescent health

Abstract Persistent adolescent health inequalities exist in Europe, necessitating interventions that address both individual and societal factors, especially those pertinent to youths in unfavourable contexts. Collaborative efforts involving cross-sectoral partnerships and adolescent engagement are crucial in identifying and mitigating these disparities. Three case studies exemplify this approach. Case study 1: Effective intervention development hinges upon the translation of epidemiological insights into tangible actions. Heiko Schmengler will discuss how individual and contextual-level data is made actionable for the development of ePro-schools, an e-health intervention to promote healthy dietary habits and physical activity amongst adolescents in socially disadvantaged settings. ePro-schools brings together stakeholders from academia, the health sector, the education system, and local communities. This collaborative approach ensures that the intervention is not only grounded in solid scientific evidence but also fits the specific cultural, social, and economic contexts of the adolescents it aims to serve. Case study 2: Adolescents are not passive consumers of interventions, but active agents who frequently understand best what they need to improve regarding their health. Lourdes Cantarero Arevalo will share innovative methodologies and best practices for involving adolescents in data collection, intervention design, and policy development processes with the final aim to empower the voices of adolescents in vulnerable situations while addressing problems that are relevant for them. Case study 3: Filipa Alves da Costa will draw attention to the health concerns of adolescents resulting from incarceration. This talk will outline the development of a policy brief derived from UN global study data, which highlights the importance of cross-sectoral collaboration in developing actions to safeguard access to high quality healthcare for adolescents within the criminal justice system. A cross-sectoral approach is critical given that criminal justice systems typically fall outside the direct oversight of health ministries. The goal is to encourage policymakers, practitioners, and advocates to consider inter-sectoral strategies to address the complex health challenges these adolescents face. Following the presentations, we will facilitate a dynamic discussion with the audience, encouraging an exchange of ideas on strategies to address adolescent health inequalities from a multilevel perspective. This discussion aims to draw on the collective expertise of participants from diverse backgrounds, including practitioners, researchers, and policymakers. This dialogue aims to identify common barriers and opportunities, fostering a collaborative approach to tackling inequalities. The goal is to emerge from the workshop with a richer understanding of effective strategies that can be leveraged to close the gap in adolescent health across Europe. Key messages • Health inequalities among adolescents must be tackled collaboratively across different sectors and with participation of adolescents. • Participants will gain valuable insights on innovative solutions and effective methodologies from the case studies to inform their own efforts in addressing adolescent health inequalities.

The effects and potential benefits of audit committee oversight in a strategic setting

AbstractSince the passage of the Sarbanes‐Oxley Act of 2002, many notable frauds have been tied to ineffective audit committee (AC) oversight. As a result, AC oversight is of continuing interest, and regulators continue to debate this issue, garnering a growing body of research focused on the role played by the AC. But little theoretical research exists to guide analytical and empirical researchers investigating AC oversight. The purpose of this study is to provide theoretical guidance by examining AC oversight in a strategic setting. We focus on the AC's role in overseeing internal controls (ICs) and the impact of whether the AC relies on management in designing the controls. We characterize how the nature of control risk changes and how IC strength is associated with the amount of managerial fraud, expected probability of fraud detection (which, on average, equates to audit effort), and audit quality (assessed as 1 − audit risk) across two settings defined by the degree of AC oversight. As one example that highlights the need for theoretical guidance, we consider the literature's presumption that IC strength is negatively associated with audit effort. We find that this association may be positive or negative as IC changes, where the association varies with the degree of direct AC oversight and the change in payoff parameters.

Position Statement:UHMS Position Statement + Physician’s Duties in Hyperbaric Medicine - 99183

ABSTRACT Hyperbaric oxygen treatment demands a meticu- lous approach to patient management. As the com- plexity of hyperbaric patients continues to evolve, the direct oversight of qualified physicians becomes paramount to ensuring optimal patient outcomes and safeguarding against potential risks. In this statement, we outline the key reasons physician involvement is essential in every facet of HBO2, ad- dressing the technical intricacies of the treatment and the broader spectrum of patient care.

Obsidian in the Valley of Volcanoes, Peru

The Andagua Valley in the Department of Arequipa of southern Peru has only recently seen systematic archaeological investigations, revealing ancient agricultural communities that, despite apparent geographic isolation, were integrated economically with the wider Andean world. Portable x-ray fluorescence analysis of 137 obsidian artifacts recovered from sites in the lower Andagua Valley identifies the transfer of obsidian from Peru’s three largest sources, with > 90% of the analyzed artifacts coming from the Alca-1 source northwest of the valley. In addition to Alca-1 obsidian, small amounts of obsidian from the distant sources of Chivay and Quispisisa appeared in distinct contexts associated with local pre-Inka occupations, corresponding with the Middle Horizon and Late Intermediate Periods (600 – 1000 and 1000 – 1400 Common Era). Obsidian from the Alca-4 and Alca-5 sources, originating on the adjacent plateau, was also transported to Andagua during these periods, possibly continuing under Inka imperial expansion after 1400 CE.Because there is no archaeological evidence of either Wari or Tiwanaku states in the lower Andagua Valley, the probable mechanisms of obsidian transfer include direct or down-the-line exchange between plateau-based camelid pastoralists and valley farmers. Therefore, at least some long-distance obsidian transfers in southern Peru were carried out without direct oversight from Wari or Tiwanaku, though these transfers may have been facilitated by region-scale economic integration during the Middle Horizon and Late Intermediate Period. Tracing the distribution of obsidian in the Andagua Valley highlights both intra-valley and inter-zonal relationships between the Valley of the Volcanoes and specific areas of the high-elevation Andean plateau while illuminating dynamic economic and social connections along the central Andes in the pre-Hispanic past.

Influences Encouraging Alcohol Use among Bachelor of Medicine and Surgery Students at Kampala International University, Western Campus, Ishaka Bushenyi, Western Uganda

Alcohol consumption poses a significant public health concern, especially among university students who often experience newfound independence from direct parental oversight. This study aimed to identify the factors driving alcohol consumption among Kampala International University's Bachelor of Medicine and Surgery students. Employing a descriptive cross-sectional approach and self-administered questionnaires, data collection focused on alcohol-consuming students via snowball sampling. Statistical Package for Social Sciences (SPSS) software facilitated data analysis. Of the 384 participating students who consumed alcohol, nearly half (47.7%) fell within the 20-24 age range, evenly representing both genders. Notably, no substantial correlations emerged between alcohol use and age, gender, religion, or academic year. A majority of students initiated alcohol consumption at 16 years or older (41.4%). Significant associations were found between alcohol consumption and upbringing, as well as university residence. Urban upbringing and off-campus residency correlated with higher alcohol consumption. Psychologically, family structure played a role, with 59.4% of participants living with both parents reporting alcohol consumption. Peer influence was prevalent, with a substantial number introduced to alcohol by friends, either at university (32%) or at home (35.2%). While 97.7% recognized alcohol as a mood-altering stimulant, only 29.1% acknowledged the link between young adult binge drinking and future alcoholism development. Merely 12.5% believed that early alcohol exposure increased the risk of dependence, yet 93.5% recognized its association with academic underperformance or dropout. Alcohol abuse among university students appears normative, shaped by family norms and peer pressure. Supervision by family and university staff, coupled with educational interventions highlighting the health risks and consequences of excessive alcohol consumption, stand as effective measures to address this societal issue. Keywords: risk factors, alcohol, students

Getting machines to do your dirty work

AbstractAutonomous systems are machines that can alter their behavior without direct human oversight or control. How ought we to program them to behave? A plausible starting point is given by the Reduction to Acts Thesis, according to which we ought to program autonomous systems to do whatever a human agent ought to do in the same circumstances. Although the Reduction to Acts Thesis is initially appealing, we argue that it is false: it is sometimes permissible to program a machine to do something that it would be wrong for a human to do. We advance two main arguments for this claim. First, the way an autonomous system will behave can be known in advance. This knowledge can indirectly affect the behavior of other agents, while the same may not be true at the time the system actually executes its programming. Second, a lack of knowledge of the identities of the victims and beneficiaries can provide a justification during the programming phase that would be unavailable to an agent at the time the autonomous system executes its programming.

Preserving awareness for oversight – towards a resilient system at social level over centuries and millennia

Abstract. A resilient system at social level can be understood as one where society, at any point in time, takes responsibility for the repository system and acts to preserve the basic conditions for future generations to take responsibility and responsible decisions. The idea of societal responsibility is included in the notion of oversight, which was introduced by the Nuclear Energy Agency (NEA, 2011) and taken up by the International Commission on Radiological Protection (ICRP, 2013) for its guidance in the field of geological disposal of long-lived radioactive waste. In ICRP (2013) oversight is defined as “`watchful care' [that] refers to society `keeping an eye' on the technical [repository] system and the actual implementation of plans and decisions”. Oversight is a crucial concept in the ICRP's system of radiological protection, since “the level of oversight affects the capability to control the source, i.e. the waste and the repository, and to avoid or reduce potential exposures”. Three categories or “levels” of oversight are distinguished: “direct oversight”, when the waste is still easily accessible; “indirect oversight”, when sections or all of the repository is sealed, and the waste is no longer readily accessible; and “no oversight”, when there is no “watchful care” of the repository anymore. In a collective statement on the preservation of records, knowledge and memory (RK&M), the Radioactive Waste Management Committee (RWMC) of the NEA asserts the relevance of maintaining oversight over geological repositories for as long as practicable and states that there is no intention to abandon geological repositories, either before or after closure. The RWMC adds, “Preparing for future RK&M preservation is best addressed while waste management plans are being designed and implemented, and funding is available for this important component of long-term planning” (NEA, 2014); i.e. it is considered a relevant topic today. But while the RWMC has explicitly adopted the ICRP position on the relevance of maintaining oversight for as long as practicable, some other institutions do not mention oversight in their guidance, leaving the degree to which the guidance mentioned is approved of in the community somewhat open. While societal decisions on how to organise and exercise post-closure (i.e. “indirect”) oversight may be decades away, the discussion on preservation strategies for RK&M has indeed started, a first milestone being NEA (2019). At a recent conference in Dessel, Belgium, organised by the NEA's Expert Group on Awareness Preservation (EGAP), new ideas and aspects were presented. The discussions revealed, however, that participants felt that a “common vision” in the community (meaning both the international expert community and any interested parties) would be beneficial to help focus discussions on RK&M preservation strategies. At the panel session, it should be discussed – by international experts in the fields of awareness preservation and oversight and the plenary – whether the ICRP and NEA position on oversight could be the conceptual basis for such “vision building” in the community. If so, the original question of what needs to be done today with respect to the preservation of RK&M would be projected onto the question of what needs to be done in the future with respect to organising and exercising post-closure oversight. Hence, the panel session aims to facilitate an exchange on the concept of indirect oversight promoted by the ICRP (2013) and its relation to the preservation of RK&M today.

Engineering Expansion: The U.S. Army and Economic Development, 1787–1860 by William D. Adler

Reviewed by: Engineering Expansion: The U.S. Army and Economic Development, 1787–1860 by William D. Adler Mitchell G. Klingenberg (bio) Engineering Expansion: The U.S. Army and Economic Development, 1787–1860. By William D. Adler. (Philadelphia: University of Pennsylvania Press, 2021. Pp. 240. Cloth, $75.00.) On the eve of the Mexican-American War, the regular U.S. Army numbered just 3,554 officers and men.1 Yet by 1845 the army had emerged as an important institution in American life. After the war, though its size remained diminutive, the army’s importance to national development increased with the westward march of American settlement. How could a profession of arms—undersized and regarded with considerable skepticism by segments of the citizenry since the creation of the republic—facilitate such rapid expansion of the American economy and state? [End Page 250] William D. Adler argues in Engineering Expansion that through the U.S. Army’s use of force—and, just as important, through extensive nonvio-lent means—it was instrumental in shaping the destiny of the nineteenth-century United States. The army did this in numerous ways: by coercion, by consolidating newly acquired territory under federal control, by encouraging westward settlement, by protecting American citizens on the frontier along important routes of supply, by bringing its technical expertise to bear in developing and constructing infrastructure, by promoting science and technology, and by facilitating the flow of goods and services. In all of this, the army expanded an economy that otherwise lacked the guiding hand of a strong, centralized, and bureaucratized state. Adler’s methods reflect his academic training in political science. Throughout, he deploys robust quantitative and theoretical analysis in depicting how the army charted the nation’s economic expansion at the center, the nation’s capital and developed population centers in the East, and at the periphery, “the frontier regions of the nation” (3). His findings are multifaceted. Through force and coercion, the U.S. Army “shaped the pattern and direction of the country’s economic future,” without which the United States may well “have developed in a very different way” (55). Though the army contributed valuable engineering expertise (which officers acquired at the United States Military Academy) to the construction of roads and canals at the center, Adler finds that the army’s role in developing infrastructure was more pronounced in frontier regions. Just as intuitively, Adler finds that congressional authorities exercised stronger control over the U.S. Army in the center, whereas at the periphery officers could execute their orders to the letter or interpret them with flexibility absent direct oversight. In this respect, Adler suggests, “civilian control over the military was, at best, highly attenuated” (108). In the book’s ultimate (and strongest) chapter, Adler demonstrates how the organization of the War Department and its personnel—in particular, bureau chiefs under the secretary of war who resourced army operations at the periphery— enabled the army to influence policy makers. Bureaus such as the Corps of Topographical Engineers (the inspiration for Adler’s title) helped the War Department to achieve a degree of bureaucratic autonomy theretofore never experienced in the United States and enjoyed considerable success shaping the economic future of the nation. Engineering Expansion is a monograph in the classic sense of the term: compact, highly theoretical, and arranged as a compilation of analytical sections that read almost as articles. Its chapters, “Coercion and Economic Development,” “Building the Nation, Building the Economy,” “Who Commands?” and “Political Entrepreneurs and Institutional Capacity,” [End Page 251] build well on one another and teem with charts and tables. These depict major conflicts with Native American tribes, the expansion and contraction of the U.S. Army, road construction in the antebellum period, the various professions of United States Military Academy graduates in the first thirty-eight years of the institution’s history, fluctuations in the number of troops garrisoned at various forts across the United States from 1834 to 1840, a roster of the tenures and major socioeconomic activities of all secretaries of war from 1789 to 1860, and Senate votes to defund and reorganize the army (among other data points). Curiously, the book contains no engravings or images, a problem...

Solutions from space? A dynamic capabilities perspective on the growing use of satellite technology for managing sustainability in multi-tier supply chains

Distant upstream tiers in supply chains are hotspots for sustainability issues that expose focal firms to growing reputational, financial, operational and legal risks – yet sustainable supply chain management (SSCM) practice and research still focus on dyadic buyer-supplier relationships due to poor upstream transparency. Recently, however, focal firms have started adopting satellite technology as a tool for gaining systematic, continuous and direct oversight of issues like deforestation occurring far upstream to complement standards and certifications. This could transform multi-tier SSCM dynamics but, being a novel phenomenon, it remains unclear which organizational capabilities and collaborations focal firms apply to leverage remote sensing's potential. Combining dynamic capabilities theory and a multi-tier SSCM framework, our paper analyzes the current use of satellite technology in forest-risk commodity supply chains. Triangulating insights from interviews, documents and observations in a qualitative content analysis, the study finds that effective multi-tier SSCM relies on (a) internal resources providing four functions (traceability; monitoring; follow-up; stakeholder accountability), (b) complemented with external resources accessed through strategically selected collaborations that (c) take the form of working along supply chains, across supply chains and across sectors. The results show that technology-driven multi-tier SSCM can hold strategic benefits beyond risk reduction. Further research is needed to assess these relations.

Abstract 941: Assessment of the completeness, accuracy, and scalability of commercial abstraction for a large prostate cancer biospecimen repository

Abstract Background: Large repositories of biospecimens collected from patients at cancer centers can provide a valuable resource in the development and validation of new biomarker assays to guide therapeutic decision-making. In order to utilize such repositories for biomarker studies, biospecimens must be annotated with the clinical context of each sample. The main source of clinical data is typically an unstructured electronic medical record, which can require a significant amount of time and resources to manually curate. Methods: We developed a database comprised of disease-specific clinical data elements for a large repository of prostate cancer blood samples collected between 2006 – 2022 at a comprehensive cancer center. To provide clinical context for these samples, we contracted and trained a data abstraction company on entry practices with strict adherence to our standardized data dictionary and source hierarchy. After data abstraction and review of an initial training set, we performed a formal evaluation of data quality (completeness and accuracy) through a 100-patient blinded comparison to gold-standard abstraction by a medical oncologist using all available data sources. Subsequently, data entry was completed for an additional 2500 patients and included in longitudinal analysis. Results: Comparison to medical oncologist reference determined that the commercial annotations demonstrated similar completeness for most data elements. For some elements such as stage at diagnosis (M1 vs. M0), commercial abstraction achieved lower completeness (80%) than a medical oncologist (100%). Overall, the accuracy of the commercial annotations varied by element but was suitable for the purpose of identifying samples for use in context-specific biomarker studies. Data regarding disease-related events showed low median variance in the timing of first metastasis (0 months) and castration-resistance (-2.1 months), with substantial observed variance trending towards earlier event calling. Longitudinal analysis of 2500 abstractions showed relatively stable completeness in staging data over time, suggesting that missing data is at least partially attributable to imposed restrictions in data source hierarchy rather than inexperience. Targeted retraining mid-way after 1300 annotations considerably increased the speed of data entry without noticeable changes in data completeness. Conclusions: Commercial data abstraction can be effectively utilized to perform clinical data annotation for large biospecimen repositories with acceptable levels of completeness and accuracy. With appropriate training and direct oversight by an experienced on-site research team, this represents a scalable method for extracting valuable clinical data from largely unstructured patient medical records. Citation Format: Emily A. Carbone, Ethan S. Barnett, Niamh M. Keegan, Samantha E. Vasselman, Barbara Nweji, Ria N. Gajar, Karen A. Autio, Wassim Abida, Howard I. Scher, Konrad H. Stopsack. Assessment of the completeness, accuracy, and scalability of commercial abstraction for a large prostate cancer biospecimen repository [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 941.

Counterpoint: The value of including patients in prerounding.

Counterpoint: The value of including patients in prerounding.

Assessing Pharmacist Interventions at an Outpatient Renal Transplant Clinic Under a Collaborative Pharmacy Practice Agreement.

Background: Collaborative pharmacist practice agreements (CPPAs) advance the role of pharmacists by granting prescriptive authority without direct oversight from participating physicians. Objective: To assess the quantity of prescriptions authorized by pharmacists and frequency and types of interventions performed under a CPPA in an outpatient renal transplant clinic. Practice description: Clinical pharmacists in the outpatient renal transplant clinic began prescribing medications under a CPPA in March 2017. Practice innovation: Under the CPPA, pharmacists perform interventions to improve medication management. After identifying gaps in medication therapy, pharmacists tracked their interventions to improve patient care. Methods: An ambispective cohort study evaluated the number of prescriptions and interventions performed under a CPPA. Patients with a prescription generated by pharmacists between January 2019 through June 2019 were included. Pharmacists prospectively collected the number and types of interventions performed; the number of pharmacist-generated prescriptions was retrospectively collected. Interventions were categorized into three groups: medical record assessments, medication counseling, and resolution of barriers to medication continuation. Results: Pharmacists under a CPPA placed 5793 prescriptions and performed 3852 interventions for 1233 patients. The most common intervention categories were medical record assessments, medication counseling, and resolution of barriers to medication continuation. Conclusion: Pharmacists within a CPPA performed medical record assessments to identify untreated or under treated health conditions, eliminate duplicate therapy, and monitor narrow therapeutic drugs. Expanding pharmacists' prescriptive authority within the renal transplant clinic is a successful strategy to ensure patients are taking medications correctly and to avoid barriers to medication persistence.

Paramedic Clinical Consults with a Paramedic or Nurse in an EMS Communications Center Compared to Traditional Online Physician Consults

Objectives In many emergency medical services (EMS) systems, a direct medical oversight physician is available to paramedics for mandatory and/or elective consultations. At the time of this study, a clinical support desk (CSD) was being implemented within the medical communications center of a provincial EMS system in addition to the physician resource. The CSD was initially staffed with a registered nurse or an advanced care paramedic. The objective of the current study was to compare CSD “peer to peer” consults versus physician consults with regards to consultation patterns, transport dispositions, and patient safety measures. Methods This retrospective cohort study analyzed 2 months before (September 1 to October 31, 2012) and 2 months after (September 1 to October 31, 2013) implementation of the CSD. In the before period, all clinical consults were fielded by the direct medical oversight physician. In the after period, consults were fielded by the physician, CSD or both. EMS databases were queried, and manual chart review and abstraction of audio recordings were done. Relapses back to EMS within 48 hours of non-transport were measured. Results 1621 consults were included, with 764 consults in the before period and 857 after (p = 0.02). The number of physician consults decreased from 764 before to 464 after (39.2%, p < 0.001), with the CSD taking 325 (37.9%) consults. The CSD was consulted more for police custody and trip destination. The physician was consulted more for cease resuscitation and clinical consults prior to medication administration. Overall non-transport rates were 595/764 before (77.9%), and 646/857 after (75.4%) (p = 0.2). Non-transports were 233/325 (71.7%) via the CSD, 364/464 (78.4%) via the physician, and 49/68 (72.1%) when both were involved (p = 0.07). Rate of relapse to EMS was similar before (25/524, 4.8%) and after (26/568, 4.6%) (p = 0.76), and between CSD (12/216, 5.5%) and physician consults (13/325, 4.0%) in the after period (p = 0.41). Conclusion The introduction of a novel “peer-to-peer” consult program was associated with an increased total number of consults made and reduced call volume for direct medical oversight physicians. There was no change in the patient safety measure studied.

Capital and Kin: English Women's Intimate Networks and Property in Barbados

AbstractThis article explores how women in England, using a range of economic and legal tools and methods, managed wealth and property in Barbados during the seventeenth century. Being distant from the colony had implications for how English women managed their property in Barbados, as direct oversight was impossible. Instead, women were forced to broker arrangements with overseers and agents who could act on their behalf. We can make sense of how they established these connections through the lens of women's intimate networks, as they appointed trusted friends, family, and associates to manage their affairs. Women's intimate networks are a lens through which we can explain not just how women acquired property, but also their continued investment in plantation economies and slavery during the first decades of English colonisation in Barbados.

Utilization and Effect of Direct Medical Oversight during Out-of-Hospital Cardiac Arrest

Study Objective Direct medical oversight (DMO), where emergency medical services (EMS) clinicians contact a physician for real-time medical direction, is used by many EMS systems across the United States. Our objective was to characterize the recommendations made by DMO during out-of-hospital cardiac arrests (OHCA) and to determine their effect on EMS transport decisions and patient outcomes. Methods This is a secondary analysis of DMO call recordings from OHCA cases in the Portland, Oregon metropolitan area from January 1, 2018 to February 28, 2021. Data extracted from the audio recordings were linked to OHCA cases in the Portland Cardiac Arrest Epidemiologic Registry (PDX Epistry). The primary outcomes are recommendations made by DMO: transport, continued field resuscitation, or termination of resuscitation (TOR). Secondary outcomes include EMS transport decisions, survival to hospital admission, and survival to hospital discharge. We used descriptive statistics, unpaired t-tests, and chi-square tests as appropriate for data analysis. Results There were 239 OHCA cases for which DMO was contacted by EMS. The median time from EMS arrival to DMO contact was 25.6 min, and EMS requested TOR for 72.0% of patients. Compared to patients where EMS requested further treatment advice, patients for whom EMS requested TOR had poor prognostic signs including older age, asystole as an initial rhythm, and lower rates of transient return of spontaneous circulation prior to DMO call compared with cases where EMS did not request TOR. DMO recommended transport, continued field resuscitation, or TOR in 21.8%, 18.0%, and 60.2% of patients, respectively. Of the 239 patients, 59 (24.7%) were ultimately transported by EMS to the hospital, 14 (5.9%) survived to admission, and only 1 patient (0.4%) survived to hospital discharge and had an acceptable neurologic outcome (Cerebral Performance Category score of 2). Conclusions Patients for whom EMS contacts DMO for further treatment advice or requesting field TOR after prolonged OHCA resuscitation have poor outcomes, even when DMO recommends transport or further resuscitation, and may represent opportunities to reduce unnecessary DMO contact or patient transports. More research is needed to determine which OHCA patients benefit from DMO contact.

Emergency Medical Services Clinicians’ Perspectives on Pediatric Non-Transport

Objectives Emergency medical services clinicians do not transport one-third of all children assessed, even without official pediatric non-transport protocols. Little is known about how EMS clinicians and caregivers decide not to transport a child. Our objectives were to describe how EMS clinicians currently decide whether or not to transport a child and identify barriers to and enablers of successfully implementing an EMS clinician-initiated pediatric non-transport protocol. Methods We conducted six virtual focus groups with EMS clinicians from the mid-Atlantic. A PhD trained facilitator moderated all groups using a semi-structured moderator guide. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus. Results We recruited 50 participants, of whom 70% were paramedics and 28% emergency medical technicians. There was agreement that caregivers often use 9-1-1 for low acuity complaints. Participants stated that non-transport usually occurs after shared decision-making between EMS clinicians and caregivers; EMS clinicians advise whether transport is necessary, but caregivers are responsible for making the final decision and signing refusal documentation. Subthemes for how non-transport decisions were made included the presence of agency protocols, caregiver preferences, absence of a guardian on the scene, EMS clinician variability, and distance to the nearest ED. Participants identified the following features that would enable successful implementation of an EMS clinician-initiated non-transport process: a user-friendly interface, clear protocol endpoints, the inclusion of vital sign parameters, resources to leave with caregivers, and optional direct medical oversight. Conclusions EMS clinicians in our study agreed that non-transport is currently a caregiver decision, but noted a collaborative process of shared decision-making where EMS clinicians advise caregivers whether transport is indicated. Further research is needed to understand the safety of this practice. This study suggests there may be a need for EMS-initiated alternative disposition/non-transport protocols.

Necessary but not Sufficient: Assurance Mechanisms for Enhancing Trust in AI-enabled Job Screening

The use of algorithms and artificial intelligence (AI) in recruitment is now commonplace, yet research indicates candidates are wary of their use. This paper takes an institution-based trust perspective to investigate whether assurance mechanisms can enhance trust and acceptance of AI use in job applicant screening. Two experiments provide preliminary evidence for this proposition. In Study 1 (N = 267), we found that assurance in the form of governance by an ethical review board (compared to no information about review), enhanced candidate trust and acceptance of an AI applicant screening tool. Study 1 findings were broadly replicated in Study 2 (N = 653) which further showed that a combination of ethical review and direct human oversight of AI output enhanced trust and acceptance, but direct human oversight alone did not. However, low mean values of trust and acceptance suggest that even with assurance mechanisms in place, candidates were still sceptical. Qualitative findings indicate that human oversight and the use of AI tools to support human decisionmaking is important for people to trust AI use in recruitment and selection. Taken together, findings suggest that assurance mechanisms are necessary but not sufficient to garner trust and acceptance of AI use in recruitment.

The oversight of autonomous artificial intelligence: lessons from nurse practitioners as physician extenders.

The development of autonomous artificial intelligence (A-AI) products in health care raises novel regulatory challenges, including how to ensure their safety and efficacy in real-world settings. Supplementing a device-centered regulatory scheme with a regulatory scheme that considers A-AI products as a ‘physician extender’ may improve the real-world monitoring of these technologies and produce other benefits, such as increased access to the services offered by these products. In this article, we review the three approaches to the oversight of nurse practitioners, one type of physician extender, in the USA and extrapolate these approaches to produce a framework for the oversight of A-AI products. Under the framework, the US Food and Drug Administration would evaluate A-AI products and determine whether they are allowed to operate independently of physician oversight; required to operate under some physician oversight via a ‘collaborative protocol’ model; or required to operate under direct physician oversight via a ‘supervisory protocol’ model.

Implementation of a Traumatic Brain Injury Guideline at A Department of Defense Level 1 Trauma Center.

Traumatic brain injury (TBI) is one of the most prevalent diagnoses among trauma populations and places significant strain on valuable rural hospital resources. Limited studies show safety and efficacy of implementation of a Brain Injury Guideline (BIG) protocol at a Department of Defense (DoD) Level 1 trauma center. Data from patients diagnosed with traumatic brain injury during the study period were collected from our institutional trauma database. A retrospective review was performed on patients identified in the database to collect demographic and injury related data. All primary and secondary outcome data were analyzed using two-tailed Fischer's exact tests, Pearson Chi-square tests, and non-parametric Mann Whitney U tests. A total of 354 patients were included in the study, 189 pre-implementation and 165 post-implementation. Demographics, head injury severity, initial HCT findings, and BIG classification distributions were well-matched. There was a significant reduction in neurosurgical consultations (NSC) (98.4% pre- to 77.0% post-implementation, P<0.001) and ICU admissions (84.1% pre-, 74.5% post-implementation, P=0.025) following protocol implementation. There were no differences between groups in ICU LOS (P=0.239), incidence of worsening findings on RHCT (P=0.894), or in-hospital mortality (P=0.814). There was a slight reduction in hospital LOS from 4.0d pre-implementation to 3.0d post-implementation (P=0.043). Implementation of a BIG protocol at our Level 1 trauma center suggested at a relationship with fewer NSCs and ICU admissions. Management of mild and moderate TBI by acute care and trauma surgeons without direct neurosurgical oversight is safe and implies a reduction in utilization of hospital resources.

Guiding Fellows to Independent Practice: Current Trends in Pediatric Emergency Medicine Fellow Supervision.

Recent studies highlight the importance of physician readiness to practice beyond graduate training. The Accreditation Council for Graduate Medical Education mandates that pediatric emergency medicine (PEM) fellows be prepared for independent practice by allowing "progressive responsibility for patient care." Prior unpublished surveys of program directors (PDs) indicate variability in approaches to provide opportunities for more independent practice during fellowship training. The aims of the study were to describe practices within PEM fellowship programs allowing fellows to work without direct supervision and to identify any barriers to independent practice in training. An anonymous electronic survey of PEM fellowship PDs was performed. Survey items were developed using an iterative modified Delphi process and pilot tested. Close-ended survey responses and demographic variables were summarized with descriptive statistics. Responses to open-ended survey items were reviewed and categorized by theme. Seventy two of 84 PDs (88%) responded to the survey; however, not all surveys were completed. Of the 68 responses to whether fellows could work without direct supervision (as defined by the Accreditation Council for Graduate Medical Education) during some part of their training, 31 (45.6%) reported that fellows did have this opportunity. In most programs, clinical independence was conditional on specific measures including the number of clinical hours completed, milestone achievement, and approval by the clinical competency committee. Reported barriers to fellow practice without direct oversight included both regulatory and economic constraints. Current training practices that provide PEM fellows with conditional clinical independence are variable. Future work should aim to determine best practices of entrustment, identify ideal transition points, and mitigate barriers to graduated responsibility.