Evidence-based Care Pathways Research Articles

Interprofessional insights in Agitation in Alzheimer's disease: An interview with the experts from Emory Integrated Memory Care

Agitation in Alzheimer's disease (AAD) is a troubling condition experienced by many of the 6.9 million people living with Alzheimer's disease in the United States. The Gerontological Society of America (GSA) initially published an evidence-based care pathway to treat this condition, Agitation in Alzheimer's Disease: A Decision Tree for Healthcare Providers, in 2022 and updated this resource in 2023 with the International Psychogeriatric Association (IPA) consensus definition of agitation. A new, research-informed screening tool launched in November 2023, the Agitation in Alzheimer's Screener for Caregivers (AASCTM), supports care teams in identifying individuals with AAD who can benefit from the evidence-based care outlined in the decision tree. This column features an interview with interprofessional dementia care experts from Emory Integrated Memory Care who share their insights into AAD, the significance of the condition, and how care teams can use the AASCTM and other strategies to detect AAD. By detecting AAD and implementing person-centered care to address the condition, care teams can improve quality of life for the individual with the condition and their caregiver.

An evidence-based nipple care pathway for new breastfeeding mothers: a Delphi study

Background/Aims Only 1% of UK mothers maintain exclusive breastfeeding for the first 6 months, as per global recommendations. Early breastfeeding cessation often involves complex issues, with nipple-related injuries being a common cause. This study aimed to develop an evidence-based tool for early identification and management of breastfeeding-related nipple injuries through expert consensus. Methods A mixed method approach was used, including a 5-stage scoping review and a modified Delphi consensus technique with 26 UK-based maternal health experts and experienced breastfeeding mothers. Results Consensus (80% agreement) was reached on recommendations, including the provision of realistic information, early peer support engagement and Lanolin use. Some commonly recommended practices, such as letting the nipple air dry, did not reach consensus, highlighting a misalignment between expert consensus and published guidance. Conclusions This study generated evidence-based, expert-validated self-management guidance, emphasising the need for improved stakeholder engagement in policy development.

The impact of a patient-centred care pathway for patients treated with oral anticancer drugs: A multicentre pre-posttest study in Flanders.

In the Collaborative Network To Take Responsibility for Oral Anticancer Therapy (CONTACT) project, an evidence-based and patient-centred care(PCC) pathway was implemented in 12 oncology departments in Flanders. The care pathway was developed in cocreation by an interdisciplinary project team, and tailored to the local hospital context. In this study, the impact of the care pathways on quality of PCC and other patient outcomes was investigated. A pre-posttest study was performed in nine of the participating oncology departments. The primary outcome was quality of PCC. Furthermore, level of patient self-management, medication adherence, satisfaction with information about the oral anticancer drug and quality of life were measured as secondary outcomes. Linear mixed models were used to investigate differences in outcomes between the pre- and posttest group. Quality of PCC, as well as all secondary outcomes improved after implementation of the care pathway. However, the changes in pre- and posttest scores were not significant. The overall quality of PCC increased from 3.72 to 3.88, measured on a five-point Likert scale (p = 0.124). This study showed small, however, no significant improvements in the quality of PCC and other patient outcomes. The lack of significant changes can be attributed to the complexity of the care pathway development, poor or unstable implementation of the care pathway and limited changes in follow-up care. More insight in the actual implementation of the care pathway and potential contextual factors influencing its effect is needed to help understand the outcomes of this pre-posttest study.

Improving routine use of clinical pathway decision support through integration of an EHR with a clinical library resource designed to provide evidence-based guidance within oncology workflows

BackgroundThe rapid evolution, complexity, and specialization of oncology treatment makes it challenging for physicians to provide care based on the latest and best evidence. We hypothesized that physicians would use evidence-based trusted care pathways if they were easy to use and integrated into clinical workflow at the point of care.MethodsWithin a large integrated care delivery system, we assembled clinical experts to define and update drug treatment pathways, encoded them as flowcharts in an online library integrated with the electronic medical record, communicated expectations that clinicians would use these pathways for every eligible patient, and combined data from multiple sources to understand usage over time.ResultsWe were able to achieve > 75% utilization of eligible protocols ordered through these pathways within two years, with > 90% of individual oncologists having consulted the pathway at least once, despite no requirements or external incentives associated with pathway usage. Feedback from users contributed to improvements and updates to the guidance.ConclusionsBy making our clinical decision support easily accessible and actionable, we find that we have made considerable progress toward our goal of having physicians consult the latest evidence in their treatment decisions.

"She's a Family Member": How Community Health Workers Impact Perinatal Mothers' Stress Through Social-Emotional Support and Connections to Programs and Resources.

This study examines whether being a client in the Northwest Ohio Pathways HUB program reduces stress and improves mental wellbeing for perinatal mothers. The HUB works to improve health by connecting mothers to community health workers (CHWs) who assess mothers' risk factors and connect them to evidence-based care pathways to reduce known risks associated with adverse birth outcomes. A one-time survey of 119 mothers in the program and monthly semi-structured interviews with 41 mothers, totaling 220 interviews. Almost all mothers reported significantly reduced stress after joining the program. The majority also reported an improved sense of safety, security, and hope. Interviews show additional moderate reductions in stress over time while being a program client. Interviews also indicate that mothers' relationship with their CHW is key to these improvements: CHW provide social-emotional support, access to tangible goods, and help navigating social service bureaucracies. The results support the broader literature on the health benefits of community health workers and address identified gaps within the literature, which has infrequently studied CHWs in the perinatal context. CHWs may be one way to address racial inequity in birth outcomes linked to infant mortality, given research on the links between inequitable exposure to stressors, the impacts of racism-induced stress, and preterm and low birth weight babies. Further, the findings indicate the need to better support CHWs, and the programs that utilize them, with increased funding, insurance reimbursement, and certification.

Clinical Care Pathway and Management of Major Bleeding Associated with Nonvitamin K Antagonist Oral Anticoagulants: A Modified Delphi Consensus from Saudi Arabia and UAE.

The nonvitamin K antagonist oral anticoagulants (NOACs) have become the mainstay anticoagulation therapy for patients requiring oral anticoagulants (OACs) in the Gulf Council Cooperation (GCC) countries. The frequency of NOAC-associated major bleeding is expected to increase in the Emergency Department (ED). Nonetheless, we still lack local guidelines and recommendations for bleeding management in the region. The present Delphi-based consensus aims to establish a standardized and evidence-based clinical care pathway for managing NOAC-associated major bleeding in the Kingdom of Saudi Arabia (KSA) and the United Arab Emirates (UAE). We adopted a three-step modified Delphi method to develop evidence-based recommendations through two voting rounds and an advisory meeting between the two rounds. A panel of 11 experts from the KSA and UAE participated in the consensus development. Twenty-eight statements reached the consensus level. These statements addressed key aspects of managing major bleeding events associated with NOACs, including the increased use of NOAC in clinical practice, clinical care pathways, and treatment options. The present Delphi consensus provides evidence-based recommendations and protocols for the management of NOAC-associated bleeding in the region. Patients with major DOAC-induced bleeding should be referred to a well-equipped ED with standardized management protocols. A multidisciplinary approach is recommended for establishing the association between NOAC use and major bleeding. Treating physicians should have prompt access to specific reversal agents to optimize patient outcomes. Real-world evidence and national guidelines are needed to aid all stakeholders involved in NOAC-induced bleeding management.

Accountable care organization initiatives to improve the cost and outcomes of specialty care.

To assess initiatives to manage the cost and outcomes of specialty care in organizations that participate in Medicare accountable care organizations (ACOs). Cross-sectional analysis of 2023 ACO survey data. Analysis of responses to a 12-question web-based survey from 101 respondents representing 174ACOs participating in the Medicare Shared Savings Program or the Realizing Equity, Access, and Community Health ACO model in 2023. Improving specialist alignment was a high priority for 62% of the 101 respondents and a medium priority for 34%. Only 11% reported that employed specialists were highly aligned and 7% reported that contracted specialists were highly aligned. A subset of ACOs reported major efforts to engage specialists in quality improvement projects (38%) and to convene specialists to develop evidence-based care pathways (30%). They also reported supporting primary care physicians through providing specialist directories (44%), specialist e-consults (23%), and sharing specialist cost data (20%). The most common challenges reported were the influence of fee-for-service payment on specialist behavior (58%), lack of data to evaluate specialist performance (53%), and insufficient bandwidth or ACO resources to address specialist alignment(49%). Engaging specialists in accountable care is an emerging area for ACOs but one with numerous challenges. Making better data on specialist costs and outcomes available to Medicare ACOs is essential for accelerating progress.

AO Spine/Praxis Clinical Practice Guidelines for the Management of Acute Spinal Cord Injury: An Introduction to a Focus Issue.

Narrative overview and summary. The objective of this introductory manuscript is to provide an overview of the effort that was undertaken to establish clinical practice guidelines for a number of important topics in spinal cord injury (SCI). These topics included: 1. The role and timing of surgical decompression after acute traumatic SCI; 2. The hemodynamic management of acute traumatic SCI; and 3. The definition, diagnosis, and management of intra-operative SCI. Here, we introduce the rationale for the guidelines, the methodology utilized, and summarize how the topics are addressed within various manuscripts of this Focus Issue. The key clinical questions were defined using the PICO format for treatment reviews (patient; intervention; comparison; outcomes) or PPO format (patient, prognostic factor, outcomes) for risk factor review. Multi-disciplinary, international guideline development groups (GDGs) were established to evaluate and collate the available evidence in a rigorous, systematic manner, followed by a review of systematically obtained evidence within the framework of the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) criteria and application of the Evidence to Decision process. Consensus meetings, using a modified Delphi approach, were held with the multidisciplinary, international GDGs using online video-conferencing technology and anonymous voting to develop the final recommendations for each of the topics addressed. All systematic review protocols followed PRISMA standards and were registered on PROSPERO; all potential conflicts were vetted in an open and transparent manner. The funders (AO Spine and Praxis Spinal Cord Institute) had no influence over editorial content or the guidelines process). Updated guidelines were established for the timing of surgical decompression after acute SCI, with surgical decompression within 24hours of injury now "recommended" as a treatment option. Updated guidelines were also established for hemodynamic management, with an expanded target range for mean arterial pressure (MAP) of 75-80 to 90-95mmHg for between 3 to 7days post-injury now "suggested" as a treatment option. The available literature mandated scoping and systematic reviews on the topic of intra-operative SCI, and this resulted in manuscripts to address the definition, frequency, and risk factors, to define the role of intra-operative neuromonitoring, and to suggest an evidence-based care pathway for management. A rigorous process following GRADE standards was undertaken to review the available evidence and establish guideline recommendations around the role and timing of surgery in acute SCI, optimal hemodynamic management of acute SCI and the prevention, diagnosis and management of intraoperative SCI. This effort also identified key knowledge gaps and future directions for study, which will serve to refine these recommendations in the future.

A Multimodal Intervention to Reduce C. difficile Infections and Stool Testing.

The introduction of multiplex gastrointestinal panels at our institution resulted in increased Clostridioides difficile (C. difficile) detection and stool test utilization. We aimed to reduce hospital-onset C. difficile infections (HO-CDIs), C. difficile detection, and overall stool testing by 20% within 1 year. We conducted a quality improvement project from 2018 to 2020 at a large children's hospital. Interventions included development of a C. difficile testing and treatment clinical care pathway, new options for gastrointestinal panel testing with or without C. difficile (results were suppressed if not ordered), clinical decision support tool to restrict testing, and targeted prevention efforts. Outcomes included the rate of HO-CDI (primary), C. difficile detection, and overall stool testing. All measures were evaluated monthly among hospitalized children per 10 000 patient-days (PDs) using statistical process-control charts. For balancing measures, we tracked suppressed C. difficile results that were released during real-time monitoring because of concern for true infection and C. difficile-related adverse events. HO-CDI decreased by 55%, from 11 to 5 per 10 000 PDs. C. difficile detection decreased by 44%, from 18 to 10 per 10 000 PDs, and overall test utilization decreased by 29%, from 99 to 70 per 10 000 PDs. The decrease in stool tests resulted in annual savings of $55 649. Only 2.3% of initially suppressed positive C. difficile results were released, and no patients had adverse events. Diagnostic stewardship strategies, coupled with an evidence-based clinical care pathway, can be used to decrease C. difficile and improve overall test utilization.

Dissecting the rationale for thromboprophylaxis in challenging surgical cases

Pulmonary embolism (PE) is a leading preventable cause of death in surgical patients, and rates of fatal PE are increasing. Individual assessment, to balance the risks of thrombosis and bleeding, is the key to providing appropriate prophylaxis. The risk assessment process includes use of evidence-based guidelines, literature published since the latest guidelines, large registries, and risk scoring systems together with clinical experience and judgment. Risk assessment is a dynamic process and needs to be updated both during the hospital stay and just prior to discharge since clinical events may change the level of risk. The final assessment may identify patients who require ongoing anticoagulant prophylaxis after discharge. The Caprini risk score is widely used in surgical patients and is a composite of the number of risk factors and their relative weights. The Caprini risk score set point for risk levels requiring anticoagulant prophylaxis varies depending on the type of surgical procedure, surgical population, and number of risk factors. Mandatory implementation of evidence-based care pathways is helpful in lowering PE-related mortality. This review presents several challenging cases, emphasizing the importance of employing all available assessment tools, including dynamic assessment of risk during hospitalization. Finally, the limitations of evidence-based guidelines in complex scenarios and the need to employ all available tools to properly protect very high–risk patients are emphasized.

Delineating family needs in the transition from hospital to home for children with medical complexity: part 2, a phenomenological study

BackgroundA systematic literature review on the transition from hospital-to-home (H2H) of families with a child with medical complexity (CMC), resulted in nine overarching themes. These demonstrated common needs and experiences despite the widely differing CMC diagnoses and family characteristics. However, none of the reported studies was conducted in the Netherlands, which hampers the creation of a tailored H2H care pathway, deemed essential for our recently established Transitional Care Unit in the Netherlands: the ‘Jeroen Pit Huis’. Therefore, the aim of this study was to gain a deeper understanding of the needs and experiences of Dutch CMC parents on H2H transition and integrate these insights with the literature review into an evidence-based H2H care pathway for CMC and their families.MethodsA descriptive phenomenological approach was applied. Heterogeneous purposeful sampling methods were used to recruit participants according to the following criteria: parents of CMC from various regions in the Netherlands, who spoke Dutch fluently and who had been discharged home from a tertiary hospital within the previous five years. Semi-structured, open-ended interviews were conducted via video call by two researchers, who transcribed the audio recordings verbatim. Thematic analysis methods were used to identify emerging themes from the individual transcripts, involving a third and fourth researcher to reach consensus.ResultsBetween March and August 2021, 14 mothers and 7 fathers participated in 14 interviews. They elaborated on the H2H transition of 14 CMC with a wide range of underlying diseases: 7 male, 7 female, aged 6 months to 10 years. Eight overarching themes, consistent with the results of the systematic review, represent CMC parental needs and experiences during the H2H process in the Netherlands: (1) autonomy, (2) division of tasks and roles, (3) family emotions, (4) impact on family life, (5) communication, (6) coordination of care, (7) support system and (8) adaptation.ConclusionsThe H2H needs and experiences reported by the CMC families in this study align with the results of our systematic review. The H2H transition process is not linear but continuous, and should extend beyond the specific medical needs of the CMC to holistic care for the family as a whole. The overarching care needs and experiences, expressed by all CMC families, regardless of underlying symptoms and diagnoses, inform the H2H care pathway and its future evaluation. Our studies highlight the necessity to focus on the family needs rather than on the specific illness of the child, as well as the value of our interdisciplinary care team partnering with parents in the ‘Jeroen Pit Huis’ towards a safe and sustainable transition home.

Enhanced Recovery After Surgery (ERAS) in Saudi Arabian Surgical Practice: A Comprehensive Analysis of Surgical Outcomes, Patient Satisfaction, and Cost-Effectiveness.

Introduction Surgical procedures present substantial healthcare costs, patient discomfort, and potential adverse outcomes. In response, enhanced recovery after surgery (ERAS) protocols have emerged as comprehensive, evidence-based preoperative care pathways designed to optimize preoperative, intra-operative, and postoperative management. These protocols incorporate various interventions, such as preoperative education, nutritional optimization, minimally invasive techniques, multimodal pain management, early mobilization, and patient engagement. Despite their global success and growing popularity, the adoption and influence of ERAS protocols in Saudi Arabia have not been extensively explored. This study aims to assess the ERAS effects on surgical outcomes and evaluate its relationship with patientsatisfaction, considering factors such as cost-effectiveness and compliance in the Saudi context. Methods This cross-sectional study encompassed data collection from 1,452 patients who underwent surgical procedures such as bariatric surgery and cholecystectomy, employing systematic random sampling across multiple healthcare facilities in Saudi Arabia. Data were gathered through structured questionnaires, medical records, and cost-effectiveness analysis within the period spanning from January to August 2023. The relationship between ERAS protocol implementation, surgical outcomes, patient satisfaction, and cost-effectiveness was analyzed using statistical tests, including correlation, regression analysis, and chi-square tests. A statistical significance threshold was set at p < 0.05, and Statistical Product and Service Solutions (SPSS, version 28.0) (IBM SPSS Statistics for Windows, Armonk, NY) was used for data analysis. Results Among the 1,452 respondents, 1,152 (79.3%) reported the implementation of ERAS protocols during their surgical procedures. Those receiving ERAS protocols exhibited significantly lower rates of surgical complications, readmissions, and reduced dependency on pain medication (p < 0.001). Additionally, participants subjected to ERAS protocols reported significantly higher satisfaction levels based on the mean satisfaction scale score, with a p-value of less than 0.001. Conclusion The results highlight substantial improvements associated with the implementation of ERAS protocols, particularly in terms of reduced surgical site infections, shortened hospitalization periods, and decreased pain management-related complications. Moreover, ERAS protocol implementation demonstrated enhanced surgical outcomes, increased postoperative satisfaction, and overall improved recovery experiences. These findings underscore the potential benefits of integrating ERAS protocols into the surgical practices of Saudi Arabia. This research contributes to a better understanding of the advantages offered by ERAS protocols and their potential for enhancing healthcare delivery in the region.

Pregnancy outcomes after implementation of an induction of labor care pathway

BackgroundInduction of labor is common, however the optimum clinical strategy for induction is less clear. Variation in clinical practices related to labor induction may lead to increased complications and longer induction times. ObjectiveThe objective of this study was to analyze whether implementation of an evidence-based standardized care pathway improved clinical outcomes associated with induction of labor. Study DesignThis was an approved quality improvement project implementing a clinical care pathway for induction of labor. We conducted a retrospective cohort study of inductions for 5 months before (January through May 2018) and 14 months after pathway implementation (August 2018 through September 2019). The primary outcome was time from admission to delivery. Time from admission to delivery was stratified by mode of delivery. Secondary outcomes included chorioamnionitis, endometritis, NICU admissions, cesarean delivery, postpartum hemorrhage, and a composite of unanticipated outcomes (chorioamnionitis, endometritis, NICU admissions, cesarean delivery, and postpartum hemorrhage). Pathway adherence was also analyzed. Outcomes were analyzed with two tailed t-tests for continuous data, and Fisher's Exact Test and Chi-square tests for categorical data. Propensity score matching was used to assess for confounding by potential covariates. ResultsWe reviewed a total of 1,471 inductions, 392 before and 1,079 after pathway implementation. The pathway was associated with a non-significant reduction in time from admission to delivery by 1.2 hours (23.4 hours to 22.2 hours, p=0.08). There was a non-significant increase in time to cesarean delivery before (28.2 hours) and after protocol implementation (28.8 hours), p = 0.71. There was a significant decrease in time to delivery by 1.7 hours for vaginal deliveries, from 22.2 hours to 20.5 hours after protocol implementation, p = 0.02. There was a significant decrease in chorioamnionitis (12.5% to 6%, OR 0.44, 0.29-0.67), a significant decrease in endometritis (6.9% to 2.6%, OR 0.36, 0.2-0.65), and a significant decrease in composite unanticipated outcomes (56.9% to 36.6%, OR 0.46, 0.34-0.56) following pathway implementation. There were no significant differences in postpartum hemorrhage (7.9% to 6.1%, OR 0.76, 0.48-1.22), NICU admissions (18.1% to 14%, OR 0.74, 0.54-1.02) or cesarean deliveries (19.6% to 20.1%, OR 1.03, 0.76-1.4) following pathway implementation. Pathway adherence varied, ranging from 50% to 89%. ConclusionsIntroduction of a standardized induction of labor pathway is associated with a non-significant reduction in time from admission to delivery by 1.2 hours, and improved pregnancy outcomes including decreased infections and unanticipated outcomes. Further opportunities for improvements in clinical outcomes may be realized with increased compliance with the care pathway.

HPB P29 Improving the management of pain and cachexia in pancreatic cancer: Development of a patient-centred evidence-based pathway

Abstract Background Incidence of pancreatic cancer is increasing worldwide and is likely to become the third commonest cause of cancer death in UK by 2030. Approximately 75% of people with pancreatic cancer suffer with pain and over 50% have cachexia (weakness and wasting of the body). However, there is considerable uncertainty regarding management of these distressing symptoms. We aim to identify the best interventions through systematic reviews and meta-analyses; and then will perform surveys and focus groups to reach a consensus in development of a care pathway that is acceptable to patients and ready to assess for feasibility of introduction in NHS. Methods We will compare the relative benefits and harms of different interventions for pain in unresectable pancreatic cancer and for prevention and treatment of cachexia due to pancreatic cancer, through systematic reviews (SR) and network meta-analysis. Data obtained will feed into two online surveys. (1) Patients/carers will rank interventions (identified from SR) in order of preference/acceptability. (2) Healthcare professionals will score interventions (identified from SR) on scale 1-10 according to feasibility of delivery in NHS. Four focus groups will be conducted to evaluate findings and discuss areas of contention, to enable consensus in the development of the care pathway. Results Project is currently in progress. Funding was awarded from April 2022 (NIHR202727). Both systematic review protocols were prospectively registered on PROSPERO in May 2022 (CRD42022333239/CRD42022333241). Approval by University College London Research Ethics Committee (23563/001) was received in December 2022. Data analysis is underway, expected to end by October 2023. Surveys and focus groups will be conducted thereafter. The online surveys will be primarily distributed via Pancreatic Cancer UK, but website links will also be made available on the PROSPERO records. The project is due to end in April 2024 and results will be published within 12 months of project completion. Conclusions This will be the first systematic review and network meta-analysis on these topics, thus enabling multiple treatment comparisons, additive effects and interaction models for different treatment combinations. We will also identify gaps in existing research that cause uncertainty in decision-making in management of pain and cachexia in pancreatic cancer. Through the surveys and focus group discussions, key stakeholders including patients, carers, and healthcare professionals, will facilitate the development of an evidence-based care pathway, ensuring both end-user acceptability and feasibility of delivery within NHS. Findings will be disseminated through patient group websites, conferences, and publication, irrespective of results, in peer-reviewed journals.

Content or context? A study protocol for a three-arm parallel randomised controlled trial of Re-PROGRAM, a brief internet-based intervention for patients with functional seizures

IntroductionFunctional seizures (FS) mimic epilepsy but are not caused by epileptic electrical activity in the brain and are believed to have a psychological origin. There is a well-documented gap between...

Clinician consensus on “Inappropriate” presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland

BackgroundUtilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the “appropriateness” of attendances to the ED in Ireland.MethodsThe Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels.ResultsThe National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered “inappropriate” (k = 0.341; p < 0.001). For attendances deemed “appropriate” the admission rate was 47% compared to 0% for “inappropriate” attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites.ConclusionsMultidisciplinary clinicians agree that “inappropriate” use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.

Perspective of Speech and Language Therapists in Turkey on Primary Progressive Aphasia

Primary progressive aphasia (PPA) is a neurodegenerative disease characterized by the insidious and progressive loss of speech and language skills. However, there is no standardized intervention method applied in patients with PPA. It was conducted a virtual survey of SLTs across Turkey, to collect information about the assessment, intervention and management of patients with PPA. A total of 285 SLTs participated the survey; 76.8% ( n = 219) of the respondents were female, 58.9% ( n = 168) were 1 to 2 years post graduation, 62.8% ( n = 179) of them were master’s degree, and 46% ( n = 131) were working in a rehabilitation center. All 285 participants included in the study stated that they did not create a therapy process for their clients with PPA and they performed the therapy processes applied in the classical aphasia treatment. Two hundred sixty-eight participants stated that they had more than six sessions with their clients, and 280 respondents. It is very important for all participants to plan functional interventions that require joint participation with the patient and their family/caregiver or friends, which will support communication and language and communication-oriented intervention. However, there is a need to develop specific evidence-based care pathways for people with PPA so that more efficient interventions can be made. Raising awareness among SLTs and other clinical service providers that rehabilitation is effective can increase the accessibility of interventions for individuals with PPA and lead to a more robust support system for individuals affected by PPA.

Participatory development and implementation of a dementia care pathway with intervention bundles in acute care during the coronavirus pandemic: A process evaluation study.

To explore the implementation of a dementia care pathway in an acute care setting. Dementia care in acute settings is often constrained by contextual factors. We developed an evidence-based care pathway with intervention bundles, and implemented it on two trauma units, with the aim to empower staff and improve quality care. Process evaluation using quantitative and qualitative methods. Pre-implementation, unit staff completed a survey (n = 72) assessing family and dementia care skills and level of evidence-based dementia care. Post-implementation, champions (n = 7) completed the same survey, with additional questions on acceptability, appropriateness and feasibility, and participated in a focus group interview. Data were analysed using descriptive statistics and content analysis guided by the Consolidated Framework for Implementation Research (CFIR). Standards for Reporting Qualitative Research Checklist. Pre-implementation, staff's perceived skills in family and dementia care were moderate overall, with high skills in 'building relationships' and 'sustaining personhood'. Evidence-based interventions were delivered seldom to frequent, with 'individualized care' scoring lowest and 'assessing cognition' scoring highest. Implementation of the care pathway/intervention bundles was overshadowed by the pandemic, and failed due to major organisational- and process-related barriers. Acceptability scored highest and feasibility lowest, with concerns relating to complexity and compatibility of pathways/bundles when introduced into clinical routines. Our study implies that organisational and process factors are the most influential determinants to the implementation of dementia care in acute settings. Future implementation efforts should draw on the evolving evidence within implementation science and dementia care research to ensure effective integration and improvement process. Our study provides important learning around improving care for persons with dementia and their families in hospitals. A family caregiver was involved in the development of the education and training programme.

Clinician Consensus on “Inappropriate” Presentations to the Emergency Department in the Better Data, Better Planning (BDBP) Census: A Cross-sectional Multi-center Study of Emergency Department Utilization in Ireland

Introduction:Utilization of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing avoidable attendance is an important area for intervention in the prevention of ED crowding. This study aims to develop a consensus among clinicians across care settings about the “appropriateness” of attendance at the ED in Ireland.Method:The Better Data, Better Planning study was a multi-center, cross-sectional study investigating factors influencing ED utilization in Ireland. Following ethical approval, data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels.Results:The National Panel determined that 11% (GP) to 38% (EMC) of n=306 lower acuity presentations could be treated by a GP within 24-48h (k=0.259; p&lt;0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered “inappropriate” (k=0.341; p&lt;0.001). For attendances deemed “appropriate” the admission rate was 47% compared to 0% for “inappropriate” attendees. There was no consensus on 45% of charts (n=136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0-59% and for inappropriate attendances ranged from 0-29%. For the Local Panel review (n=306) consensus on appropriateness ranged from 40-76% across sites.Conclusion:Multidisciplinary clinicians agree that “inappropriate” use of Irish EDs is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogeneous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.

Management of Pain and Cachexia in Pancreatic Cancer: Protocol for Two Systematic Reviews, Network Meta-Analysis, Surveys, and Focus Groups

Approximately 75% of people with pancreatic cancer experience pain, and >50% of them have cachexia (weakness and wasting of the body). However, there is considerable uncertainty regarding the management of these distressing symptoms. Our primary objectives are to compare the relative benefits and harms of different interventions for pain in people with unresectable pancreatic cancer and for prevention and treatment of cachexia due to pancreatic cancer, through systematic reviews and network meta-analysis. Our secondary objectives are to develop an evidence-based clinical care pathway to manage pain and prevent and treat cachexia in people with pancreatic cancer through surveys and focus groups involving patients, carers, and health care professionals. We will perform 2 systematic reviews of the literature related to pain and cachexia in people with pancreatic cancer using searches from Cochrane Library, MEDLINE, Embase, Science Citation Index, and trial registries. Two researchers will independently screen for eligibility and identify randomized controlled trials (no language or publication status restriction), comparing interventions for pain or cachexia based on full-texts for articles shortlisted during screening. We will assess risk of bias in the trials using the Cochrane risk of bias tool (version 2.0) and obtain data related to baseline prognostic characteristics, potential effect modifiers and outcome data related to overall survival, health-related quality of life, treatment-related complications, and resource utilisation. We aim to conduct network meta-analysis on outcomes with multiple treatment comparisons where possible, otherwise, meta-analysis with direct comparisons, or narrative synthesis. We will perform various subgroup and sensitivity analyses. Using information obtained from both systematic reviews, we will conduct 2 surveys: one directed to patients or carers to assess acceptability of interventions, and the other to health care professionals to assess feasibility of delivery in the National Health Service. Four mixed focus groups will be conducted to evaluate findings and foster consensus in the development of the care pathway. Funding was awarded from April 2022 (NIHR202727). Both systematic review protocols were prospectively registered on PROSPERO in May 2022. Formal searches began thereafter. Approval by the University College London Research Ethics Committee (23563/001) was received in December 2022. Data collection began in January 2023; data analysis will begin in May 2023 (completion expected by October 2023). This study will comprehensively encompass major interventions for management of pain in people with unresectable pancreatic cancer, and prevention and treatment of cachexia in people with pancreatic cancer. Key stakeholders will facilitate the development of an evidence-based care pathway, ensuring both acceptability and feasibility. The project ends in April 2024 and published results are expected within 12 months of completion. We aim to present the findings through patient group websites, conferences, and publications, irrespective of the findings, in a peer-reviewed journal. DERR1-10.2196/46335.