Direct Patient Care Research Articles

Blood borne infections and Hepatitis B virus immunization levels among medical students in India

BackgroundMedical students are actively involved in direct patient care during their training and subsequent medical practice, making them susceptible to acquiring blood-borne pathogens, including HBV. This study aimed to assess the occurrence of blood-borne infections and the Hepatitis B immunization status among medical students. Furthermore, it sought to identify gaps in risk assessment for blood-borne pathogens among medical students at a Medical College in New Delhi. MethodsThe study included 108 medical students who participated in a blood donation camp. Blood samples collected from these individuals underwent testing for blood-borne pathogens in accordance with standard screening protocols at the blood bank. The quantitative estimation was performed for anti-HBs IgG using ELISA. ResultsAll 108 participants were pursuing their undergraduate or postgraduate medical degrees. All students tested negative for HBsAg and HIV markers and showed no reactivity to Syphilis and Malaria. However, one student tested positive for HCV. Two postgraduate students had a history of needlestick injuries. Eighty-one (75%) students had received Hepatitis B vaccination. Among the vaccinated students, 34 (41.97%) were immunized before the age of five years, 22 (27.16%) after the age of five years, while 25 (30.86%) couldn't recall the exact age of their Hepatitis B vaccination. Protective anti-HBs titer of anti-Hepatitis B antibodies (>10 mIU/ml) were detected in 48.15% (52/108) of students. ConclusionsOver 50% of medical students did not possess sufficient immunity against HBV infection, putting them at a heightened risk of acquiring HBV during their active participation in patient care in the near future. It is imperative to establish a policy for routine anti-HBs titer assessment and ensure easy access to Hepatitis B immunization for medical students, thereby enhancing their protection against this infectious agent.

Home Care Practices that Improve Performance of Activities of Daily Living of Patients Post-stroke:A Systematic Review.

Evidence is inconsistent on the effectiveness of home rehabilitation for patients post-stroke. This review aims to explore home care practices that improve the performance of activities of daily living of patients post-stroke. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), clinical trials and mixed-methods studies published from 2012 to 2022 were gathered from PubMed, ScienceDirect, EBSCO, and ProQuest in December 2022. The Mixed Method Appraisal Tool (MMAT) was used for quality appraisal. Narrative synthesis approach was utilized to present the findings. A total of 758 articles were screened, and 10 were included in the final analysis. Five out of ten programs were found superior compared with usual care. Factors that influence the effectiveness of the programs include the age of the participants, severity of disabilities, family participation, and presence of a multidisciplinary team. A multidisciplinary healthcare team approach toward the enhancement of knowledge, skills, and behaviors of patients and their families is common in effective home care. The role of nurses is emphasized not only as providers of direct patient care but also as coordinators of the healthcare team and patients and their families. This study provides insights for policymakers in developing healthcare system for post-stroke care. J. Med. Invest. 71 : 197-204, August, 2024.

Weight-based continuous infusions preparation time in PICU reduces nursing time available for direct patient care

Weight-based continuous infusions preparation time in PICU reduces nursing time available for direct patient care

The Role of Telehealth in Transforming Nursing Care: Opportunities and Challenges

The global healthcare sector is experiencing significant transitions, with the emergence of telehealth into the nursing profession at the cutting edge of this development. The emergence of telehealth technology has not only changed the way healthcare is administered, but it has also given nursing practitioners with new potential and difficulties. Telehealth has eliminated geographical restrictions, allowing nurses to remotely supervise and care for patients in the privacy of their own homes. This interdependence provides real-time health evaluations, rapid treatments, and ongoing patient interaction possible. Nurses can reach underprivileged groups by using the potential of telehealth, making healthcare more accessible and inclusive than ever before [1]. 
 The use of telehealth technologies improves nursing operations, lowering administrative hassles and allowing for more effective resource utilization. Nurses may now use digital platforms to conduct virtual consultations, remote patient monitoring, and manage electronic health records. This not only speeds up and increases the accuracy of information sharing, but it also allows nurses to focus more on direct patient care. As telehealth becomes more integrated into nursing practice, ethical concerns emerge. Patient privacy, data security, and the possibility of a digital divide must all be properly handled. Nurses must manage these ethical difficulties while maintaining patient confidentiality and ensuring that technology is used to empower rather than divide [2]. 
 While telehealth has great potential, there are obstacles to overcome, such as the digital divide, technological literacy, and access concerns. Nurses are critical in bridging these gaps, pushing for fair access to telehealth services, and educating both healthcare professionals and patients. In the future, nurses' roles in a digital healthcare landscape will continue to expand. To educate nurses with the skills needed to understand and exploit the promise of telehealth technology, continuous education and training will be critical. Nurse leaders must advocate an innovation culture, ensuring that the profession adapts to new technology while upholding the profession's essential principles of compassion and patient-centered care [3]. 
 In conclusion, the use of telehealth into nursing care gives an enormous amount of potential to improve patient outcomes, increase efficiency, and reinvent healthcare delivery. To take advantage of all these benefits, however, nurses must actively participate in creating the future of telehealth, resolving ethical concerns, and pushing for technology that promotes healthcare justice. Let us welcome the promise of telehealth to elevate the nursing profession and, more significantly, to improve the well-being of those we serve as we start on this revolutionary journey.

Healthcare professionals' perceived stigmatization about direct care of COVID-19 Patients: development and validation of the discrimination about COVID-19 (DisCOV-19) instrument.

The novel coronavirus disease 2019 (COVID-19) is a public health concern worldwide. Healthcare professionals are among the most vulnerable groups in the fight against COVID-19 because they are directly involved in the care of at-risk persons and patients with Covid-19. This study aimed to measure the level to which healthcare workers feel that they can be discriminated due to their involvement in the direct care of COVID-19 patients. A cross-sectional online survey was conducted among healthcare professionals in Nigeria. A nineteen-item discrimination against COVID-19 (DisCOV-19) questionnaire was developed and validated for the study. Descriptive statistics and One-Way Analysis of Variance were used for data analysis. P<0.05 was considered statistically significant. Out of the 286 healthcare practitioners that participated in the study, 58.4% and 30.1% were pharmacists and physicians, respectively. The majority of the participants were at least "moderately concerned" about disability (60.9%), death (71.7%), unknown complications (65.1%), and risk of infecting family members and friends (83.2%) if asked to provide care for COVID-19 patients. The physicians had a significantly higher mean discrimination score compared to the pharmacists (p=0.041). Pharmacists had a significantly lower mean discrimination score than the nurses (p=0.011). Many of the healthcare professionals reported a certain level of concern and perceived that they could face some forms of discrimination for providing care to COVID-19 patients.

The relationship between quick return shift schedules and burnout among nurses: A prospective repeated measures multi-source study

BackgroundIn today's world, essential health care services are expected round the clock, leading to distinct shift work requirements. A notable aspect is the “quick return,” where the rest interval between nursing shifts is <11 h. Preliminary research suggests a potential association between quick return schedules, diminished sleep quality, and possible nurse burnout. Yet, the motivation of nurses could potentially moderate this relationship. ObjectiveTo examine a moderated-mediation model, whereby sleep duration and nurse's motivation act together to mediate the link between quick return schedules and nurse's burnout. DesignA prospective repeated measures (4–5 nursing shifts per nurse) multi-source (self-report and objective measures) study. SettingInternal and surgical departments across one large and one medium scale teaching hospitals in Israel. ParticipantsRegistered nurses who provide direct patient care (n = 79) across 369 shifts. MethodsNurses completed a questionnaire containing personal information and information regarding their shifts during the study week. They wore an accelerometer (a wrist worn device that monitors and records an individual's activity level) during a work-week to objectively determine their sleep duration, completed a motivation questionnaire at the beginning of each shift, and completed a burnout questionnaire at the end of the week. Mixed-model regression analysis was used to test a moderated-mediation model following Hayes' recommendations, whereby the joint effect of sleep duration and motivation mediates the link between quick return schedules and burnout. ResultsThe moderated-mediation model was supported. Quick return schedules were negatively statistically significantly associated with sleep duration (b = −126.54, SE = 20.85, p < 0.001); so that more frequent quick return schedules were related to shorter sleep duration. However, no direct correlation was observed between sleep duration and burnout (p = 0.171). A statistically significant interaction was observed between sleep duration and motivation (b = 0.00, SE = 0.00, p < 0.001) concerning burnout. Thus, nurses with lower motivation were prone to experiencing higher levels of burnout with shorter sleep duration compared to nurses with higher motivation. ConclusionsThe mediating role of sleep duration, moderated by motivation, plays a role in the connection between quick return schedules and burnout. This indicates that nurses can sustain their work motivation even within the demands of quick return schedules, consequently mitigating burnout levels. To prioritize employees' well-being, organizations should adopt shift work structures that minimize quick return schedules and extend nurses' sleep duration. Consequently, managers must employ strategies to enhance nurses' motivation when addressing scenarios that necessitate quick return schedules.

Understanding the Factors that Affect the Assessment of Student Performance in Pharmacy Practicums

ObjectiveThe purpose of this study was to explore factors that may influence a practice educator’s assessment of an entry-to-practice pharmacy student during inpatient direct patient care practicums. MethodsThis was a qualitative analysis of semi-structured interviews of existing practice educators from a variety of hospital practice environments. Participants were asked to assess a fictional case of a student’s work, which provided a framework for a broader discussion of assessment practices. Interviews were transcribed and subjectively analyzed for themes and factors that each study participant considered for the case and in their past precepting experiences. ResultsA total of 13 participants consented and were interviewed. Identified themes included the quality of student work, key aspects of the student’s performance, professionalism, and the complexity of the patient assigned to the student. There was significant heterogeneity in both the assessment of the fictional student and the factors that influenced each participant’s assessment. It was clear that not all guidance provided by the academic institution is read or followed. Participants described challenges in applying the assessment rubric, including lack of time, training, resources, knowledge of the degree requirements/structure, and psychological factors inherent in high-stakes courses. ConclusionComplex, varied, and often contradictory factors are used by experiential practice educators in their assessment of pharmacy students on practicum. These findings lead to inconsistency and heterogeneity when assessing a mock case and actual students. Educators should consider mandatory training to ensure those who assess students have an understanding of practicum course expectations and assessments.

ADDRESSING BENZODIAZEPINE PRESCRIBING PRACTICES AMONGST ELDERLY PTSD VETERANS DURING THE COVID-19 PANDEMIC

Abstract Psychotropic medication prescribing amongst elderly veterans has increased over the course of the COVID-19 pandemic despite the fact that psychotropics such as benzodiazepines, when being prescribed for a period over 2 weeks, are considered as relatively contraindicated amongst such patients with an additional Post-Traumatic Stress Disorder (PTSD) diagnosis due to a worsening of disease state symptoms. The objectives of my study are to inform clinicians and healthcare providers regarding the true extent of current benzodiazepine prescribing practices amongst elderly Veterans with PTSD and to provide a clinical aid/tool for education and improvement of such practices within the setting of the Veterans Affairs Medical Center. A one-page summarized aid will be drafted based upon provider feedback as well as from current Pharmacy Benefits Management Network resources to improve clinical practices with regards to the topics of benzodiazepine recommended length of use, risks of use amongst elderly Veterans, and risks amongst PTSD populations. While benzodiazepine prescribing practices have increased recently during the time of the COVID-10 pandemic, clinical tools may be drafted to improve such practices. Further studies are needed to determine the true impacts of such a tool on the national level as well as upon direct patient care.

Esophagectomy versus observation following endoscopic submucosal dissection of pT1b esophageal adenocarcinoma.

Management following endoscopic submucosal dissection (ESD) of pT1b esophageal adenocarcinoma (EAC) remains controversial. This study compared pathological and survival outcomes of patients after endoscopic resection (ER) of pT1b EAC followed by either en bloc esophagectomy or observation. From 1/12 to 12/22, all patients with pT1b EAC treated with ER were identified from a prospectively maintained departmental database. ESD was curative (all of: Submucosal invasion < 500 μm; G1/2, LVI/PNI-; deep margin-) or non-curative (one or more of Submucosal invasion ≥ 500 μm; G3; LVI/PNI+; deep margin+). Patients were allocated to observation (OBS) or esophagectomy (SURG) based on patient factors/preference and pathological variables. 56/171 ERs met the inclusion criteria. ER was curative in 8/56 (14%) and non-curative in 48/56 (86%). OBS was undertaken after 8/27 (30%) curative and 19/27 (70%) non-curative resections. All 29 SURG patients had non-curative ERs and were younger, had lower Charlson comorbidity scores and had more deep margin + lesions than OBS patients. Post-esophagectomy, 15/29 (52%) had no residual disease within the surgical specimen while pT+N-/pT-N+/pT+N+ occurred in 5/3/6 (17%/10%/21%) patients. Of those with residual disease in the surgical specimen, 12/14 (86%) had deep margin + ERs; however, only ESD instead of EMR was independently associated with a lower risk of residual disease (OR 0.431, 95% CI - 0.016 to 1.234, p = 0.045). OBS and SURG patients had equivalent overall survival outcomes and recurrence was low in both groups even following non-curative ER. Follow-up was 28 months (0-102) and 30 months (0-97), respectively. In select patients, including some of those with a non-curative ESD resection of pT1B EAC, surveillance alone may be appropriate. Alternatives beyond traditional pathological features is needed to direct patient care more accurately.

Circadian Rhythms Characteristics of Nurses Providing Direct Patient Care: An Observational Study

BackgroundIn today's modern world, longer working hours, shift work, and working at night have become major causes of the disruption of our natural circadian rhythms. This study aimed to investigate the effects of the type of shift work (rotating vs. fixed day), duty period (on-duty vs. off-duty), and working period within each shift (nighttime vs. daytime) on the circadian rhythm characteristics of nurses who provide direct patient care. MethodsThis cross-sectional study used a purposive sampling method. Cosinor analysis was applied to analyze the actigraphy data of nurses providing direct patient care for seven consecutive days. The linear mixed effects model was then used to determine any variances between shift type, duty period, and working period within each shift for the nurses. ResultsThe mesor value did not differ according to nurses' shift type, duty period, and working period within each shift. The amplitude was statistically higher in on-duty nurses and in daytime working hours. The acrophase was significantly delayed in nighttime working hours. As well as nurses in rotating shift had experience. ConclusionOur findings revealed that the peak activity of nurses occurs significantly later at night while working and nurses working during nighttime hours may have a weaker or less distinct circadian rhythm. Thus, this study suggests that limits be placed on the number of rotating nighttime shifts for nurses.

The role of the clinical pharmacist in the respiratory or sleep multidisciplinary team.

The role of the pharmacist has evolved significantly, not least over the last 20 years. It delivers a skilled profession with a vital role in medicines optimisation and the management of patients with a respiratory or sleep disorder. While pharmacists are capable of acting as independent practitioners delivering direct patient care, this article explores their contribution to multidisciplinary teams within asthma, COPD, cystic fibrosis, tuberculosis, interstitial lung disease and sleep medicine. Having identified patient cohorts needing specialist medicines support, notably those with poor medicines adherence or specific medicines-related needs (for example during adolescence, or women who are pregnant or breastfeeding), these pharmacists work within primary, secondary and specialist tertiary care. The aim of this review is to share and inspire innovative models of working to include more pharmacists in respiratory and sleep medicine.

How fear of Covid‐19 predicts differential attitudes between nonphysician healthcare workers and other essential occupations

AbstractWe examine two competing hypotheses about how individual differences in fear of Covid‐19 influence attitudes toward nurses, hospital janitors and garbage collectors. On one hand, fear of Covid‐19 can predict less warmth toward nurses because fear may lead to avoidance and contempt. On the other hand, fear of Covid‐19 can predict greater warmth toward nurses because greater fear of Covid‐19 could alternatively imply greater cognizance of the contribution that nurses make, and the risk they undertake. Also, we hypothesize that fear of Covid‐19 does not predict greater warmth toward hospital janitors or garbage collectors. Findings of two studies (cross‐sectional and longitudinal) generally showed that increased fear of Covid‐19 (mainly on the psychological dimension) predicted greater warmth toward nurses, but not toward hospital janitors and garbage collectors. In the pandemic context, it appears that healthcare workers directly involved in patient care are not so much stigmatized, as appreciated, for their risk and contribution. However, other essential workers that are not involved in direct patient care appear less valued.

Machine Learning in CLL

Introduction: Chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are closely related diseases with similar characteristics, classified as mature B cell neoplasms. They involve the accumulation of monoclonal B lymphocytes and are considered as one disease with different manifestations. CLL is more prevalent and is usually detected through routine blood tests, while SLL is identified by primary lymph node involvement. Although many patients with CLL/SLL are asymptomatic, some may experience lymphoma-related symptoms. The diagnosis involves blood tests and immunophenotypic analysis. CLL prognosis varies, and staging systems help in determining the appropriate treatment regimen. Machine learning (ML) is being increasingly used in hematology to aid in diagnosis, treatment, and risk-stratification. This review explores the application of ML in the classification and diagnosis of CLL, discussing the performance and limitations of existing models, with the goal of encouraging further research and integration into clinical settings to improve patient care. Materials and Methods: A literature search was conducted using the PubMed/MEDLINE and EMBASE databases. EndNote and Rayyan software were used to eliminate duplicate entries and for screening the articles. In addition, the references of the identified articles were manually screened to identify additional relevant studies. Articles with primary data pertaining to the use of ML in CLL/SLL diagnosis and classification were included without language or time restrictions. Results: A total of 169 articles were identified and duplicates were removed using Endnote® and Rayyan® software, resulting in 149 articles eligible for screening. The included articles met specific criteria: they utilized ML methods, reported conclusions on the method's reliability or accuracy, and focused on CLL diagnosis and classification. Excluded articles were non-English, animal/in vitro studies, abstracts, and review articles. After screening, 14 studies met the inclusion criteria. Studies examining the potential of ML algorithms in enhancing the diagnosis of CLL used various data sources like blood smears, flow cytometry, genetic data, and histopathological images. The current evidence suggests that ML can effectively predict CLL diagnosis, aid in screening, identify potential biomarkers, and explore the underlying molecular mechanisms. Many of the ML models evaluated in this review demonstrate high accuracy, ranging from 83% to 100%. Implementing AI and ML in hematology can automate tasks involved in patient workup, risk assessment, and treatment, allowing hematologists to focus on critical aspects of patient care and research. Despite the promising potential, some important considerations should be acknowledged. First, many reviewed models had limited sample sizes from single centers, limiting their generalizability. It's crucial to develop models using larger, diverse datasets from multiple centers to improve generalizability. Second, there is a lack of prospective studies and research on the impact of ML models on patient outcomes. Future investigations should focus on prospectively assessing the effect of ML models on CLL diagnosis, prognosis, and patient outcomes. Third, the integration of ML applications into direct patient care raises ethical and medico-legal concerns, including liability, data privacy, and doctor-ML application interaction. An ethical framework specific to ML applications in healthcare is needed, and doctors should receive training on ML applications to understand their capabilities and limitations. Addressing these considerations can lead to successful implementation of ML applications in the care of CLL patients, improving diagnosis and patient outcomes. Conclusion: Our findings demonstrate the promising potential of ML algorithms in accurately predicting CLL diagnosis, conducting CLL screening, and identifying genetic biomarkers associated with CLL. Future research endeavors should prioritize the development of large, standardized datasets to effectively train ML models, conduct prospective evaluations to assess their performance, explore their impact on patient outcomes, and establish ethical frameworks to govern their utilization.

Academised nursing in direct patient care-but how?

Demographic change and the resulting increase in chronic diseases, rapid developments in medicine and digitization, and the increasing shortage of skilled workers pose challenges for the German healthcare system. A rethink in patient care is required. This means that new structures, areas of action, and responsibilities must be implemented for professional nursing. The advancing academicization in nursing is leading to new role developments for professional nursing personnel in healthcare. Using the example of Klinikum Oldenburg (Oldenburg Hospital) as a maximum care provider in the region, many patients are treated in highly complex care situations that require a qualitative and evidence-based nursing practice. In order to ensure this, the concept of practice development according to McCormack, Manley, and Garbett has been implemented as a theoretical framework. Through direct evidence-based practice, complications can be reduced, which has a positive impact on mortality rate, length of stay, and readmission. Another positive factor is interprofessional collaboration and the skill-grade mix with diverse competencies. Taken together, these factors increase team satisfaction and lead to a positive outcome for patients. A prerequisite for implementing academically trained nursing professionals is good planning and preparation of the units and their stakeholders. Scientific support is also necessary to evaluate and potentially adapt the concept.

Evolution of advanced practice nursing in acute care in Germany: A cross-sectional study of nurses' scope of practice.

To describe activities and professional characteristics of nurses in expanded roles in acute care in Germany and achieve a greater understanding of the current situation of advanced practice nursing. Advanced practice nursing plays an important role in meeting increased demands in healthcare and promoting high-quality care. In Germany, advanced practice nursing is still at an early stage with a lack of studies describing the scope of practice of nurses in expanded roles. We conducted a cross-sectional-study using a paper-and-pencil questionnaire. In a nationwide convenience sample, we surveyed nurses with an academic degree, who work in an acute care hospital and take over expanded roles in direct patient care. Reporting followed the STROBE checklist. Of 108 eligible nurses, 84 (77%) completed the survey. The majority had a Master's degree (63.1%) and the average work experience was 18.2 years. Participants carried out activities in all the domains that were queried (direct clinical practice, guidance and coaching, consultation, leadership and research) with differences within and between domains. Foci were on direct clinical practice and coaching and guidance. In Germany, qualifications are nearing the international standard of advanced practice nursing. Results suggest that participants partly undertake activities within the scope of registered nurses' practice that do not correspond fully to their formal qualifications. In order to foster the role development of expanded practice nurses in Germany, political efforts are needed in terms of training (e.g. specific Master's programmes), funding of corresponding positions in practice and control mechanisms (e.g. professional registration).

Conversation starters: Understanding the facilitators and barriers to physician-initiated secure firearm storage conversations

ObjectiveThis paper aims to understand what general practice physicians (GPs) perceive as facilitators and barriers to initiating anticipatory guidance around firearm safety. MethodsWe employ qualitative interviewing to have in-depth conversations with 18 GPs. Participants were randomly selected from a national panel of physicians and screened for specialty (general practice or internist), practice setting (not hospital-based), and time spent on direct patient care (80% +). The sample was stratified at the state level by the presence of safe storage or child access protection laws, with half of the participants selected from each stratum. ResultsWe identify five physician-perceived barriers to providing secure firearm storage counseling, including inadequate screening mechanisms to trigger conversations, physician perceptions of who is at risk for firearm injury, time pressures, concerns about patient receptivity, and a need for training. ConclusionPrior to focusing on how to have conversations about firearm safety, interventions designed to increase the incidence of physician-initiated guidance need to address the structural issues of why those conversations typically do not occur. Practice implicationsFindings indicate the need for revised screening tools and improved physician education as to who is at risk for gun injury and how to best approach firearm safety conversations.

Surgical Team Structure: How Familiarity and Team Size Influence Communication Effectiveness in Military Surgical Teams.

Preventable patient harm has persisted in health care despite recent advances to reduce errors. There is increasing recognition that non-technical skills, including communication and relationships, greatly impact interprofessional team performance and health care quality. Team familiarity and size are critical structural components that potentially influence information flow, communication, and efficiency. In this exploratory, prospective, cross-sectional study, we investigated the key structural components of surgical teams and identified how surgical team structure shapes communication effectiveness. Using total population sampling, we recruited surgical clinicians who provide direct patient care at a 138-bed military medical center. We used statistical modeling to characterize the relationship between communication effectiveness and five predictors: team familiarity, team size, surgical complexity, and the presence of surgical residents and student anesthesia professionals. We surveyed 137 surgical teams composed of 149 multidisciplinary clinicians for an 82% response rate. The mean communication effectiveness score was 4.61 (SD = 0.30), the average team size was 4.53 (SD = 0.69) persons, and the average surgical complexity was 10.85 relative value units (SD = 6.86). The surgical teams exhibited high variability in familiarity, with teams co-performing 26% (SD = 0.16) of each other's surgeries. We found for every unit increase in team familiarity, communication effectiveness increased by 0.36 (P ≤ .05), whereas adding one additional member to the surgical team decreased communication effectiveness by 0.1 (P ≤ .05). Surgical complexity and the influence of residents and students were not associated with communication effectiveness. For military surgical teams, greater familiarity and smaller team sizes were associated with small improvements in communication effectiveness. Military leaders can likely enhance team communication by engaging in a thoughtful and concerted program to foster cohesion by building familiarity and optimizing team size to meet task and cognitive demands. We suggest leaders develop bundled approaches to improve communication by integrating team familiarity and team size optimization into current evidence-based initiatives to enhance performance.

Evaluating Inpatient Care Team Models in Hematology and Oncology Fellowship Programs in the United States

Introduction. In response to a growing and increasingly older population with complex medical needs, the hematology and oncology (HO) care system has integrated the hospitalist model into inpatient systems alongside HO trainees and faculty. The inclusive workforce is comprised of hospitalists and advanced practice providers (APPs) who co-manage patients with specialists or form separate non-trainee (NT) teams. Despite multiple advantages of the hospitalist model, the optimal care team structure and the impact on HO fellowship training have not been previously explored. We aimed to survey HO fellowship programs in the United States to identify the structure of inpatient HO staffing models implemented at their institution, and collect data on perceptions of the NT model within the fellowship programs. Methods. We constructed and distributed two national web-based surveys targeting all adult HO fellowship program directors (PDs) and fellows from Accreditation Council for Graduate Medical Education (ACGME)-accredited programs. The surveys were designed to assess various aspects of HO inpatient services, including team compositions, individual responsibilities, and availability of NT services. We also assessed the PDs' and fellows' perception on the impact of NT teams on their training and education. The surveys were emailed weekly between 6/20/23-7/29/23. Results.We identified 147 HO training programs.A total of 35 PDs and 101 fellows responded our survey (Table 1). The majority of PDs (83%) were from university training programs in the Midwest (43%) and Northeast (33%), with fellow class sizes of 6-12 (47%). Most (67%) programs had both trainee (T) and NT teams included in their inpatient medicine models (Figure 1). The most commonly reported NT team was the bone marrow transplant and cellular therapy service (BMT) (57%), supported primarily by APPs (55%). Only 33% of respondents reported a dedicated sickle cell disease (SCD) inpatient team within their institution. Hospitalists were included in the care model of the inpatient oncology (27%), inpatient malignant hematology (23%) and SCD (13%) teams. Most PDs agreed that the fellows are primarily responsible for most inpatient tasks and over 50% agreed that APPs are responsible for direct patient care, admissions and discharge planning. 83% of PDs reported that their program had an appropriate balance between inpatient and outpatient care. Half (50%) of PDs reported that fellows had a positive perception of NT teams at their institution, and 35% were neutral. The fellows who responded were predominantly second-year fellows (43%) in Northeastern (43%) university hospitals (92%) from programs with 6-12 fellows (63%). Most (71%) respondents had both T and NT teams included in their inpatient model. Inpatient malignant hematology (53%) and inpatient solid oncology (53%) teams were the most commonly reported NT teams, followed by BMT (40%) (Figure 1). Fellows reported their primary responsibilities to include procedures and tumor board discussions (94%), communication with outpatient teams (91%) and resident education and supervision (89%). APPs were primarily responsible for discharge planning (63%), admissions (59%) and direct patient care (58%). Most (85%) fellows agreed that their program had an appropriate balance between inpatient and outpatient care. Most fellows (69%) reported the impact of NT teams on fellows' inpatient and training experience to be neutral. Fellows from institutions without NT teams responded that the addition on NT team would have a positive impact in their training experience (69%). Most PDs and fellow respondents perceived a financial barrier to the implementation of NT teams at their institutions. Conclusions.Our findings highlight the existing heterogeneity in the distribution and composition of services among HO programs nationwide. PD respondents and fellows without NT teams perceived these teams as a beneficial addition to the program, in contrast to fellows in programs with existing NT teams who reported a neutral impact. Further investigation of the reasons for this discrepancy is essential to identify areas of improvement. Additional insights from the ongoing survey will be presented during the meeting.

Better Together: A team-based approach to improve prior authorization efficiencies and wellness in physicians and advanced care providers.

55 Background: The burden of prior authorizations (PAs) required for costly oncologic treatments is high. Upon PA denials, peer-to-peer requests are performed. These requests consume time and effort of physicians and advanced care providers (APPs) contributing to burnout and may have a negative impact on patient care. We aimed to assess the degree to which the PA process contributed to burnout among oncology clinicians prior to implementation of a new streamlined workflow aimed at improving clinician wellness. Methods: A baseline wellness survey was sent to all hematology-oncology faculty and APPs at the largest clinical site of our academic cancer center. Burn out, our primary outcome, was measured using the work-related Copenhagen Burnout Inventory. We included selected questions from the American Medical Association (AMA) surveys regarding physician perceived impact of PAs on clinical workload and care delivery. We asked physicians and APPs to rate the impact of PAs on burnout on a scale of 0-100. Analysis was conducted using descriptive statistics. This study was sponsored by our Office of Well-Being and Resilience. Results: The wellness survey was completed by 35 physicians and 21 APPs with a response rate of 53% in both (Table). The median Copenhagen burnout score for physicians was 46.43 (35.71-60.71) with higher burn out scores among those identifying as females, in practice less than 15 years and with more than 60% time in direct patient care. The median burn out score for APPs was 64.28 (50-83.03). Similar to physicians, APPs with less clinical experience had higher burn out scores. When asked about the impact of PAs on burnout, physicians reported a lower median of 13.5 (5.5-40.25), compared to APPs who reported a median of 53.5 (24-68.25). Conclusions: Physicians and APPs report high baseline rates of burnout and dedicate a significant portion of the week to completing PAs. Importantly, APPs perceived the PAs to have a high impact on their burn out compared to physicians. We will use these data to determine the efficacy of a new process that utilizes a single EMR platform for finance and cancer registry teams to abstract and document all of the required elements to streamline the PA process for intravenous/injection cancer treatments with the goal to reduce the number of PAs and improve wellness. [Table: see text]

Abstract 228: Suboptimal Door‐to‐Puncture Times: Challenges Faced in the Stroke Alert Workflow

Introduction Advances in stroke care have led to more patients eligible for thrombectomy. With these advances, it has become imperative to create a seamless workflow for thrombectomy candidates to ensure rapid door‐to‐puncture times and, ultimately, improve patient outcomes. We sought to determine what barriers are causing delays in patients’ door‐to‐puncture time. Methods A survey was distributed to all members of the Neurology PGY2, PGY3, PGY4 classes and vascular fellows at our single‐center, Comprehensive Stroke Center. The survey allowed participants to freely respond to questions regarding obstacles they encountered that led to delays in door‐to‐puncture times. All survey responses were anonymized. Results The survey was sent to 32 participants, with 26 responses. Of the 26 responses, 11 respondents (42%) noted that obtaining IV access for CTA/CTP scans was a significant cause of delay. Other responses included lack of availability of family for collateral (23%), CT scanner availability (15%), and length of time to decide if the patient is a thrombectomy candidate (15%). Conclusion The goal of this study was to collect data from the individuals involved in the direct care of acute stroke patients who are thrombectomy candidates. We used their experience to determine which points in the stroke alert workflow led to delays in door‐to‐puncture time. Our survey showed the most consistent delay is obtaining proper IV access for CTA and CTP imaging. This information was valuable and has led to the creation of a coalition between the neurology and emergency medicine departments, nursing, and CT technologists to create a “CODE IV” protocol to be implemented into the stroke alert workflow. We aim to report the change in door‐to‐puncture time after the implementation of this new protocol.