Formal Consultation Research Articles

Interactions between U.S. biofuels policy and the Endangered Species Act

The Renewable Fuel Standard (RFS) is the primary policy governing the use of biofuels in the United States. Following the 2007 enactment of the RFS, there has been substantial expansion in the use of cropland to produce biofuel feedstocks, including corn and soybeans. Both the conversion of land and the ongoing cultivation of these crops can, depending on management practices, lead to negative environmental outcomes including degraded water quality, increased water use, increased greenhouse gas emissions, and loss or degradation of wildlife habitat. These outcomes have the potential to affect threatened and endangered species protected under the U.S. Endangered Species Act (ESA). The ESA requires federal agencies to consult with the U.S. Fish and Wildlife Service or the National Marine Fisheries Service to ensure that an agency's actions are not likely to jeopardize the existence of imperiled species, nor result in the destruction or adverse modification of their habitat. However, formal consultation has not yet been completed between the U.S. Environmental Protection Agency—the agency charged with implementing the RFS—and the wildlife services, thereby hindering mitigation or remediation of potential impacts. This analysis explores the likely effects of the RFS on land use changes and critical habitat, illustrates example pathways by which threatened and endangered species may be affected, and proposes solutions to help redress this harm. The findings suggest a need for further consultation and assessment of the interactions between the RFS and ESA as well as additional research to support the species-conservation and policymaking processes.

Accidental and Abusive Mandible Fractures in Infants and Toddlers.

Mandible fractures are uncommon injuries in infants and young children and may raise concern for nonaccidental trauma. Our study describes several children with mandible fractures to identify features that might differentiate abuse from accident. Records and imaging were reviewed for children aged 24 months and younger who were diagnosed with mandible fractures at 2 tertiary pediatric care centers. Twenty-one cases were included, 8 of whom had formal child abuse consultations. Cases were reviewed for mechanisms of injury, physical examination findings, and occult injuries identified, as well as the final abuse determination. Among children with child abuse consultations, 5 injuries (62.5%) were determined to be accidental, 1 (12.5%) was abusive, and 2 were indeterminate for abuse or accident (25%). In each accidentally injured child, the reported mechanism of injury was a short fall with evidence of facial impact. No accidentally injured child had unexpected occult injuries or noncraniofacial cutaneous injuries. Infants and young children can sometimes sustain mandible fractures accidentally after well-described short falls with evidence of facial impact. Abuse remains in the differential diagnosis, and children should be evaluated accordingly. We propose that accidental injury be considered when a well-evaluated child with an isolated mandible fracture has a history of a short fall.

Listening to Caregivers: Narratives of Health Seeking for Children Under Five with Pneumonia and Diarrhea: Insights from the NIGRAAN Trial in Pakistan.

Understanding health-seeking behaviors of caregivers is important to reduce child mortality. Several factors influence decision-making related to childhood illnesses. The objective of this study was to gather caretaker narratives to develop a comprehensive understanding of the context and process of caregiving at household level during all stages of an episode of diarrhea and pneumonia in children <5. Using a narrative interview approach, stories from caregivers of children <5 were collected from a rural district in Sindh Pakistan. Eleven households with children <5 were randomly selected and purposive sampling was done to interview 20 caregivers. All data collection was conducted privately in participants' homes and informed consent taken. Manual content analysis was carried out by three independent researchers and emerging themes drawn. The role of joint family system is integral in making decisions and the child's paternal grandmother, is an important and trusted source of information regarding child sickness in the household. They often promote home remedies with considerable authority prior to formal consultation with the health care system. Caregivers were generally dissatisfied with doctors in the public sector who were perceived to be providing free consultation with a poor quality of care and long waiting time as compared to private doctors. Financial considerations and child support were favorably addressed in households with a joint family system. The joint family system provides a strong support system, but also tends to reduce parental autonomy in decision-making and delay first contact with formal health providers. Prevalent home remedies, and authority of elders in the family influence management practices. Interventions for reducing improving child mortality should be cognizant of the context of decision-making and social influences at the household level.

NURSING HOME PALLIATIVE CARE DURING THE PANDEMIC: DIRECTIONS FOR THE FUTURE

Abstract For this qualitative, pilot study, seven Massachusetts nursing home Directors of Nursing (DONs) were interviewed remotely about palliative care provision before and during the COVID-19 pandemic. Interview data were analyzed using thematic analysis. Palliative care addresses physical, emotional, psychological, and spiritual suffering that accompanies serious illness. Symptom management and goals of care is especially valuable for seriously ill nursing home residents. We investigated the solutions nursing home staff developed to provide palliative care during the COVID-19 pandemic despite restrictions on external resources. Before the pandemic, palliative care was delivered primarily by nursing home staff depending on formal and informal consultations from palliative care specialists affiliated with hospice providers. When COVID-19 lockdowns precluded these consultations, nursing staff did their best to provide palliative care, but were often overwhelmed by shortfalls in resources, resident decline brought on by isolation and COVID-19 itself, and a sense that their expertise was lacking. Advance care planning conversations focused on hospitalization status and options for care given COVID-19 resource constraints. Nevertheless, nursing staff discovered previously untapped capacity to provide palliative care on-site as part of standard care, building trust of residents and families. Nursing staff rose to the palliative care challenge during the COVID-19 pandemic, albeit with great effort nursing home payment and quality standards should support development of in-house staff capacity to deliver palliative care while expanding access to the formal consultations and family involvement that were restricted by the pandemic.

540. Impact on Clinical Decision Making of Microbial Broad Range Metagenomic Cell-Free DNA at a Single Academic Medical Center, a Retrospective Study

Abstract Background Broad-range metagenomic cell-free DNA testing (Karius®) can identify a variety of pathogens from a single blood sample to help in diagnosis of deep seated and bloodstream infections. Few studies have evaluated the impact of Karius testing on clinical decision making when compared to more conventional diagnostic methods. Methods We performed a retrospective cohort study of adult patients who had Karius tests at University of Iowa Hospitals and Clinics between 01/2020 and 10/2021. Chart review was conducted to obtain patient characteristics and clinical course including patient age, immunocompromising conditions, involvement of Infectious Disease (ID) consultant, reason for the test, and final diagnosis. Results of the Karius tests and conventional tests were compared for concordance. Clinical impact and change in management due to Karius testing were determined using previously established criteria outlined by Hogan et al.(Clin Infect Dis. 2021 Jan 27;72(2):239-245) Results Out of 26 patients who had Karius testing, 20 patients (77%) had an immunocompromising condition, the most common of which was hematologic malignancy (17 patients, 65%). Twenty-four patients (92%) had received a formal ID consultation prior to the test. The most common finding prior to testing was the presence of pulmonary infiltrates on imaging (20 patients, 77%). Karius testing was positive in 18/26 cases (69%). Organisms detected by Karius and conventional testing were concordant in 9/18 cases (50%). Karius test result had a positive clinical impact in 3 cases (12%), an indeterminant impact in 1 case (3%) and no impact in 22 cases (85%). Reasons for a positive impact are as follows: 1 case with initiation of antituberculosis therapy due to earlier diagnosis of tuberculosis, 1 case with de-escalation of antifungal therapy based on negative Karius results, and 1 case of clearance for urgent lung transplantation based on negative Karius results in the setting of mobile echo density on echocardiogram in the absence of other stigmata of endocarditis. Conclusion The impact of Karius testing on patient management appears limited. Further studies will be needed to identify patient populations or disease factors in which this testing have clinical impact. Disclosures All Authors: No reported disclosures.

1768. Characteristics and Impact of Penicillin Allergy Mislabeling Among People with HIV

Abstract Background Rates of penicillin allergy mislabeling (PAM) are prevalent and lead to suboptimal antibiotic selection. However, data regarding PAM are lacking for people with HIV (PWH). We aimed to characterize the penicillin allergy labels for PWH at the University of California, San Diego’s (UCSD) HIV primary care clinic, evaluate the impact of penicillin allergy labels on treatment choice for syphilis and gonorrhea, and implement a quality improvement project to address PAM. Methods We conducted a cross-sectional study of PWH with a penicillin allergy label in their medical record who were seen in our clinic between 2018 and 2022. We collected demographic information, type of allergic reaction listed, whether patients tolerated other beta-lactam antibiotics, whether patients were referred for formal Allergy consultation, and, where relevant, what treatment they received for syphilis and/or gonorrhea. Results Among the 4,702 people with HIV receiving care in our clinic between 2018 and 2022, 427 (9.1%) had a penicillin allergy label in the medical record. This cohort reflected the demographics of the general clinic population (Table 1). Even though the majority of allergic reactions (327, 77%) were labeled as IgE-mediated, 282 (66%) patients tolerated another beta-lactam antibiotic (Table 2). Referrals to Allergy Clinic were rare (52, 12%). The majority of patients with syphilis (91/140, 65%) received 2nd line therapy with doxycycline. However, most patients with gonorrhea (65/88, 74%) were treated with a preferred ceftriaxone-based regimen. When relevant, we updated penicillin labels for 209/268 (77.9%) patients to indicate that they had tolerated other beta-lactam antibiotics and created a tiered referral process to prioritize the highest-risk patients for Allergy Clinic referral (Figure 1). Conclusion Penicillin allergy labels were prevalent in our cohort of PWH and often resulted in receiving 2nd line therapy for treatment of syphilis. We updated allergy labels for a substantial number of patients and created a triage system to refer patients to Allergy clinic for further testing based on risk in order to decrease PAM. Disclosures All Authors: No reported disclosures.

Get vaccinated or else…employees' perspective on mandatory vaccination in the retail sector in Zimbabwe.

The emergence of COVID-19 has resulted in many changes in the world of work. Measures such as remote working, physical distancing, compulsory use of face masks, sanitization among others. With time, a number of medical interventions to deal with the pandemic were developed and availed. Zimbabwe's retail sector was not spared of different vaccines which were meant to curb the virus. Most Zimbabwean organizations made it mandatory for their employees to get vaccinated or risked losing employment. However, less is known about the perceptions of employees toward voluntary vaccination. This gap is important given the strategic nature of employees in an organization. This paper poses the following questions (1) to what extent were employees consulted on the compulsory vaccination? (2) What are the employees' perceptions toward compulsory vaccination? (3) How are employees coping with the mandatory vaccination? The study was premised on the classical work of Kurt Lewin on types of leadership, specifically autocratic-democratic styles. Twenty shopfloor employees from two major retail outlets with functional human resource departments and works councils in Masvingo were purposively sampled and interviewed using a semi-structured interview guide. The sample composed of women and men of different age groups. Thematic analysis was used to analyze data. The paper argues that employees have a right to be involved in issues that concern them. The study has established four levels of consultation existing on a continuum namely formal and genuine consultations, formal but less genuine consultations, informal consultations, and no consultation at all. The fourth level emerged to have been the most popular among most participants. With regards to employees' perceptions of mandatory vaccination by management, findings have revealed three categories which are, perceived good decision, perceived tight hands on the part of management and the them and us perceptions. Concerning reactions to mandatory vaccination, the study has shown that employees in the retail sector had a number of options to follow. Some went for full vaccination willingly or under duress, while others settled for a single dose. Most participants highlighted that they fraudulently obtained some vaccination cards. These findings support the relevance of engaging employees on matters that affect them. The study has therefore established the importance of genuine consultations between management and employees on issues that pertains the latter.

The Dense Breast Clinic: Initial Experience of a Patient-Centered Breast Imaging Clinic.

Establish a radiologist-run consultation clinic to review breast density and supplemental screening exams (SSEs) directly with patients in response to breast density reporting laws. Breast radiologists opened and staffed a clinic for formal patient consultations regarding breast density and SSEs. An IRB-approved questionnaire assessed patient knowledge of breast density, SSEs, and encounter satisfaction. Comparative statistical analyses were performed on knowledge-based questions. From February 2019 to February 2021, 294 reimbursable consultations were performed with 215 patients completing pre- and post-consultation questionnaires (survey response rate, 73%). Median patient age was 58 years (range, 34-86 years) and 9% (19/210) had a personal history of breast cancer. An increase in patient knowledge of breast density and SSEs was observed as follows: breast density categories (9% correct pre-consultation (20/215), 86% correct post-consultation (185/215), P < 0.001), dense breast effects on cancer risk (39% correct pre-consultation (83/215), 84% post-consultation (180/215)), mammogram sensitivity (90% correct pre-consultation (193/215), 94% post-consultation (201/215)), and increased cancer detection with SSEs (82% correct pre-consultation (177/215), 95% post-consultation (205/215)) (P < 0.001). Post-consultation, 96% (200/209) were satisfied with the usefulness of information, 89% (186/209) strongly agreed they had sufficient knowledge of SSEs, and 81% (167/205) agreed they would like future opportunities to meet with a breast radiologist. A consultation clinic staffed by breast radiologists focused on breast density and supplemental breast cancer screening can provide personalized patient counseling, engage patients in shared decision making, assist referring clinicians, and support high quality patient-centered care.

Economic Analysis of Infectious Disease Consultation for Staphylococcus aureus Bacteremia Among Hospitalized Patients

Staphylococcus aureus bacteremia is associated with a significant burden of mortality, morbidity, and health care costs. Infectious disease consultation may be associated with reduced mortality and bacteremia recurrence rates. To evaluate the cost-effectiveness of infectious disease consultation for Staphylococcus aureus bacteremia. In this economic evaluation, a decision-analytic model was constructed comparing infectious disease consult with no consult. The population was adult hospital inpatients with Staphylococcus aureus bacteremia diagnosed with at least 1 positive blood culture. Cost-effectiveness was calculated as deaths averted and incremental cost-effectiveness ratios. Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. Costs and outcomes were calculated for a time horizon of 6 months. The analysis was performed from a societal perspective and included studies that had been published by January 2022. Patients received or did not receive formal bedside consultation after positive blood cultures for Staphylococcus aureus bacteremia. The main outcomes were incremental difference in effectiveness (survival probabilities), incremental difference in cost (US dollars) and incremental cost-effectiveness ratios (US dollars/deaths averted). This model included 1708 patients who received consultation and 1273 patients who did not. In the base-case analysis, the cost associated with the infectious disease consult strategy was $54 137.4 and the associated probability of survival was 0.77. For the no consult strategy, the cost was $57 051.2, and the probability of survival was 0.72. The incremental difference in cost between strategies was $2913.8, and the incremental difference in effectiveness was 0.05. Overall, consultation was associated with estimated savings of $55 613.4/death averted (incremental cost-effectiveness ratio, -$55613.4/death averted). In the probabilistic analysis, at a willingness-to-pay threshold of $50 000, infectious disease consult was cost-effective compared with no consult in 54% of 10 000 simulations. In cost-effectiveness acceptability curves, the consult strategy was cost-effective in 58% to 73%) of simulations compared with no consult for a willingness-to-pay threshold ranging from $0 to $150 000. These findings suggest that infectious disease consultation may be a cost-effective strategy for management of Staphylococcus aureus bacteremia and that it is associated with health care cost-savings.

The effect of a family-centered advance care planning intervention for persons with cognitive impairment and their family caregivers on end-of-life care discussions and decisions.

Advanced care planning (ACP) includes advance directives (AD), which can specify provisions for palliative care and types of life-sustaining treatments for an individual requiring end-of-life (EoL) care. ACP for persons in the early stages of cognitive decline can decrease anxiety and conflict for family members needing to make decisions about EoL-care, which is especially critical for family caregivers (FCGs) if they play a role as a surrogate regarding healthcare decisions. However, ACP for persons with cognitive impairment (PWCIs) is often overlooked. This study explored the effects of a family-centered ACP intervention on decisions about EoL-care, life-sustaining treatment decisions, and discussions of related topics among PWCIs and FCGs. The study was conducted in outpatient clinics of regional teaching hospitals in northern Taiwan. Participants were dyads consisting of persons diagnosed with mild cognitive impairment or mild dementia and their FCGs. The family-centered ACP intervention was provided by an ACP-trained senior registered nurse. A one-group, pretest-posttest design was used to evaluate the effect of the intervention on 44 dyads. Four structured questionnaires collected data regarding familiarity with ACP, intention to engage in ACP, participation in personal discussions between the dyads about ACP, and consistency between PWCIs and FCGs for decisions about life-sustaining treatments at EoL. Paired t, Kappa, and McNemar tests were used to compare differences between pre-intervention data (pretest) and post-intervention data (posttest). There were significant increases in familiarity with ACP, components of ACP, and the number of topics PWCIs and FCGs personally discussed surrounding EoL-care decisions. There was no change for either group in wanting to have a formal ACP consultation and only modest increases in consistency between PWCIs and FCGs for life-sustaining treatment decisions after completion of the family-centered ACP intervention. Clinicians caring for PWCIs should incorporate family-centered ACP interventions and support ongoing discussions about life-sustaining medical treatments to ensure their preferences regarding EoL-care are respected. The accessibility and availability of consultations about ACP should also be provided.

Brain Cancer Detection by Using Cluster Evaluation Technique

The diagnosis of brain cancer is made by a radiologist using a Magnetic Resonance Imaging scan, which takes a long time. The majority of brain tumour recognition approaches provide detailed information on the tumour and need providing an accurate report on tumour proximity. So a formal consultation with a radiologist is required, that becomes an unnecessary expense if a non-tumor understanding is discovered. The goal of the paper is to provide a supporting system that will assist radiologist in knowing the results ahead of time, reducing the time spent on the core worry of tumour disclosure. The following stages are included in the suggested procedure. The Magnetic Resonance Image of Brain is initially obtained from the Brain MRI Image instructional collection. The selected MRI image is sent to Pre-Processing in the second stage, where the film workmanship markings are erased. The large repeated regions of the MRI image are removed in the third step utilizing separate filtering techniques. Finally, in this suggested study, the proposed approach explores the optimum improved methodology, called as Ant Colony Optimization (ACO). The proposed strategies reduce the time irregularity in the region of brain tumour, resulting in increased precision. The MRI images of brain are used as data in this study. The end users examine the report of MRI on their own, without the assistance of a radiologist.

Prospective, randomized trial of streamlined genetic education and testing for patients with high grade epithelial ovarian, fallopian and peritoneal cancer (040)

<b>Objectives:</b> Genetic testing for underlying germline mutations is universally recommended for patients with epithelial ovarian cancer (EOC). Traditionally, formal genetic consultation prior to testing has been recommended to mitigate patient anxiety and distress around the testing process. The objective of this study was to determine if the implementation of a streamlined model of genetic service delivery negatively impacted patients psychologically compared to the traditional model of counseling followed by testing. <b>Methods:</b> A prospective, multi-institutional randomized study was conducted at two academic medical centers between July 1, 2019, and August 1, 2021. Patients with newly diagnosed high-grade EOC were enrolled and randomized within their first five cycles of chemotherapy to either <i>(1)</i> traditional arm, which included pre-test consultation with an ABMG certified genetic counselor (CGC), or <i>(2)</i> streamlined arm, which involved video-assisted pre-test education, but no formal pre-test counseling, followed by the option for immediate testing with an ovarian focused multi-gene panel. Both arms had test results disclosed in a similar manner by a CGC. The primary outcome of patient psychological impact was measured using the validated Multi-dimensional Impact of Cancer Risk Assessment Scale (MICRA) for all patients after disclosure of testing results (higher scores were equated with negative psychological impact; range: 0-125). Secondary outcomes included patient distress as measured by the Impact of Events Scale (IES) after <i>a)</i> pre-test education or counseling; and <i>b)</i> after results disclosure. A two-sample t-test was used to assess the differences between the treatment arms. <b>Results:</b> A total of 59 women were enrolled in the study; 28 were randomized to the traditional arm and 31 to the streamlined arm. Baseline patient demographics, health literacy, and genetic alteration identification incidence were similar between the two groups. All patients who enrolled and completed study activities agreed to genetic testing. Mean baseline IES scores were similar between the two arms. Mean IES scores following pre-test education or counseling were higher (i.e., greater distress) in the traditional arm (16.2 vs 8.8, p=0.6), although this was not statistically significant. This trend in IES scores was also observed post-results disclosure (13.3 vs 6.7, p=0.07). No significant difference in psychologic impact was observed as measured by MICRA scores between patients enrolled on the streamlined and traditional arms (mean 19.4 vs 20.6, p=0.782). <b>Conclusions:</b> Mean patient IES and MICRA scores were not significantly different between patients who received streamlined, video-assisted genetic education versus standard pre-test genetic consultation. In the setting of universal genetic testing recommendations for patients with EOC, alternative pre-test educational models may simplify the genetic education and testing process without negatively impacting patients.

Cervical cancer screening programmes and age-specific coverage estimates for 202 countries and territories worldwide: a review and synthetic analysis

SummaryBackgroundCervical cancer screening coverage is a key monitoring indicator of the WHO cervical cancer elimination plan. We present global, regional, and national cervical screening coverage estimates against the backdrop of the 70% coverage target set by WHO.MethodsIn this review and synthetic analysis, we searched scientific literature, government websites, and official documentation to identify official national recommendations and coverage data for cervical cancer screening for the 194 WHO member states and eight associated countries and territories published from database inception until Oct 30, 2020, supplemented with a formal WHO country consultation from Nov 27, 2020, to Feb 12, 2021. We extracted data on the year of introduction of recommendations, the existence of individual invitation to participate, financing of screening tests, primary screening and triage tests used, recommended ages and screening intervals, use of self-sampling, and use of screen-and-treat approaches. We also collected coverage data, either administrative or survey-based, as disaggregated as possible by age and for any available screening interval. According to data completeness and representativeness, different statistical models were developed to produce national age-specific coverages by screening interval, which were transformed into single-age datapoints. Missing data were imputed. Estimates were applied to the 2019 population and aggregated by region and income level.FindingsWe identified recommendations for cervical screening in 139 (69%) of 202 countries and territories. Cytology was the primary screening test in 109 (78%) of 139 countries. 48 (35%) of 139 countries recommended primary HPV-based screening. Visual inspection with acetic acid was the most recommended test in resource-limited settings. Estimated worldwide coverage in women aged 30–49 years in 2019 was 15% in the previous year, 28% in the previous 3 years, and 32% in the previous 5 years, and 36% ever in lifetime. An estimated 1·6 billion (67%) of 2·3 billion women aged 20–70 years, including 662 million (64%) of 1·0 billion women aged 30–49 years, had never been screened for cervical cancer. 133 million (84%) of 158 million women aged 30–49 years living in high-income countries had been screened ever in lifetime, compared with 194 million (48%) of 404 million women in upper-middle-income countries, 34 million (9%) of 397 million women in lower-middle-income countries, and 8 million (11%) of 74 million in low-income countries.InterpretationTwo in three women aged 30–49 years have never been screened for cervical cancer. Roll-out of screening is very low in low-income and middle-income countries, where the burden of disease is highest. The priority of the WHO elimination campaign should be to increase both screening coverage and treatment of detected lesions; however, expanding the efforts of surveillance systems in both coverage and quality control are major challenges to achieving the WHO elimination target.FundingInstituto de Salud Carlos III, European Regional Development Fund, Secretariat for Universities and Research of the Department of Business and Knowledge of the Government of Catalonia, and Horizon 2020.TranslationsFor the French, Spanish translations of the abstract see Supplementary Materials section.

Proposed international standard on auditing financial statements of less complex entities: IAASB IAAER roundtables—Breakout 1 authority and groups

AbstractThis commentary summarizes stakeholder views voiced during roundtables on the 2021 International Auditing and Assurance Standards Board's (IAASB) Exposure Draft: Proposed International Standard on Auditing of Financial Statements of Less Complex Entities (ED LCE). For EDs, IAASB's due process includes seeking stakeholder views in a formal consultation format on a specified number of issues deemed relevant to further improve the proposed standard. Following its mission, the International Association for Accounting Education and Research—together with the IAASB—facilitated roundtables linking audit practitioners, academics, and financial statements users. The three roundtables followed a structured agenda including the same (but not all) topics on which the IAASB seeks views. In this commentary, we summarize views heard during the first roundtable breakout session focused on authority and groups and provide recommendations to the IAASB regarding the way forward.

Protocol for Home-Based Solution for Remote Atrial Fibrillation Screening to Prevent Recurrence Stroke (HUA-TUO AF Trial): a randomised controlled trial

IntroductionCurrent international guidelines recommend ECG monitoring after an ischaemic stroke to detect atrial fibrillation (AF) in order to prevent stroke recurrence. However, optimal strategies to detect AF and the downstream...

How to Create a Consolidated Infection Prevention Program Across a Health Care System with Diverse Member Organizations

BackgroundAn evaluation of an infection prevention and control program of a healthcare system with diverse member organizations and 12,000 employees throughout one state, revealed inconsistent infection prevention policies and procedures. These inconsistencies led to confusion among staff who worked at a variety of facilities and further led to evidenced based Infection Prevention principles not being well implemented or practiced.MethodsThrough a retrospective program analysis evaluation, the Infection Prevention System Council within the health care system was able to identify areas of improvement to standardize practice across the system including the development of a new system wide leadership position, formal consultations for infection prevention needs and policy and procedural development at the system level as opposed to an individual member organization level. A total of 10 hospitals and 7 separate entities such as medical transport and home care and hospice participated in this program restructure.ResultsSignificant increase in employee engagement from infection preventionists across the system as a result of the restructure, which led to systemized policies and procedures. Additionally, the Infection preventionists in each facility had more autonomy as subject matter experts and were utilized in key events such as the COVID 19 pandemic. The cohesive approach to infection prevention also led to greater support from senior leadership which resulted in the Infection prevention team being allotted financial resources for pivotal initiatives to improve healthcare associated infections.ConclusionsA single consistent Infection Prevention approach across an entire health care system provides a more engaged workforce with greater autonomy and resources which in turn lead to resource allocation and improved evidenced based infection prevention principles being implemented for the safety of both health care staff and patients.

Managing Ethics Challenges in Social Work Organizations

Social workers are keenly aware of ethical challenges in professional practice. Formal ethics education strives to acquaint social workers with common ethical dilemmas in practice and decision-making protocols and frameworks. However, the social work literature includes relatively little information about practical resources promoted in allied professions that can be useful to social workers who encounter ethics challenges. This article discusses the role of four principal resources: informal ethics conversations among social workers and other colleagues (“curbside consults”), formal ethics consultations, agency-based ethics committees, and ethics rounds. The author includes illustrative examples demonstrating social workers’ use of these resources to manage ethics challenges skillfully.

Level of integration in current undergraduate curricula of two private-sector medical colleges in Karachi

BackgroundDiverse strategies are employed globally to integrate medical curricula. Nevertheless, a gap exists in assessing the role of medical instructors in meaningful integration. We developed and used a tool to explore the current level of integration, score medical instructors’ individual practices for integration, and investigate contextual elements minimizing integration.MethodologyThis cross-sectional study, conducted in September-November-2020, used convenience-sampling. The study participants were basic-sciences and clinical instructors at two private-sector medical colleges in Karachi-Pakistan (with a response rate of 53.5%, n = 107). We validated a paper-based questionnaire through a pilot study on five participants. This tool with 11 close-ended questions on a 5-point Likert scale generated instructors’ integration scores, and six open-ended questions probed instructors’ perspectives.ResultsThe mean integration score was 37.4±6.7. Participants’ perspectives indicated a need for participation of clinical faculty in teaching initial undergraduate years, involving lecturers in curriculum meetings, and integration of assessment. The questionnaire Cronbach-alpha was 0.732 with satisfactory principal-component-analysis.ConclusionMedical instructors facilitated integration mainly through concurrent timetabling of similar topics. Moreover, formal consultation through committee meetings, with discipline-based and integrated approaches complementing each other, were in practice to achieve curricular goals.

Palliative Care Consultation is Associated with Decreased Rates of In-Hospital Mortality Among Patients Undergoing Major Amputation

Despite advancements in medical care and surgical techniques, major amputation continues to be associated with risks for morbidity and mortality. Palliative care programs may help alleviate symptoms and align patients' goals and the care they receive with their treatment plan. Access to specialty palliative medicine among vascular surgery patients is limited. Here, we aim to describe utilization and impact of formal palliative care consultation for patients receiving major amputations. This is a retrospective, secondary data analysis project examining the records of patients who received major amputations by the vascular surgery team between 2016 and 2021. Demographics, operative, and postoperative outcomes were recorded. The primary outcome variable was palliative care consultation during index admission (the admission in which the patient received their first major amputation). Secondary outcomes were in-hospital mortality and code status at the time of death, if death occurred during the index admission, location of death, and discharge destination. The cohort comprised of 292 patients (39% female, 53% Black, mean age 63), who received a lower extremity major amputation. Most patients (65%) underwent amputation for limb ischemia. One-year mortality after first major amputation was 29%. Average length of stay was 20days. Thirty-five (12%) patients received a palliative care consultation during the hospitalization in which they received their first major amputation. On multivariable analysis, patients were more likely to receive a palliative care consult during their index admission if they had undergone a thorough knee amputation (OR=2.89, P=0.039) or acute limb ischemia (OR=4.25, P=0.005). A formal palliative care consult was associated with lower likelihood of in-hospital death and increased likelihood of discharge to hospice (OR=0.248, P=0.0167, OR=1.283, P<0.001).There were no statistically significant differences in the code status of patients who received a palliative care consultation. In a large academic medical center, palliative medicine consultation was associated with lower in-hospital mortality among patients with advanced vascular disease and major limb amputation. These data will hopefully stimulate much needed prospective research to develop and test tools to identify patients in need and derive evidence about the impact of palliative care services.

Nursing Home Palliative Care During the Pandemic: Directions for the Future.

Background and ObjectivesPalliative care addresses physical, emotional, psychological, and spiritual suffering that accompanies serious illness. Emphasis on symptom management and goals of care is especially valuable for seriously ill nursing home residents. We investigated barriers to nursing home palliative care provision highlighted by the coronavirus disease 2019 (COVID-19) pandemic and the solutions nursing home staff used to provide care in the face of those barriers.Research Design and MethodsFor this descriptive qualitative study, seven Massachusetts nursing home directors of nursing were interviewed remotely about palliative care provision before and during the COVID-19 pandemic. Interview data were analyzed using thematic analysis.ResultsBefore the pandemic, palliative care was delivered primarily by nursing home staff depending on formal and informal consultations from palliative care specialists affiliated with hospice providers. When COVID-19 lockdowns precluded these consultations, nursing staff did their best to provide palliative care, but were often overwhelmed by shortfalls in resources, resident decline brought on by isolation and COVID-19 itself, and a sense that their expertise was lacking. Advance care planning conversations focused on hospitalization decisions and options for care given resource constraints. Nevertheless, nursing staff discovered previously untapped capacity to provide palliative care on-site as part of standard care, building trust of residents and families.Discussion and ImplicationsNursing staff rose to the palliative care challenge during the COVID-19 pandemic, albeit with great effort. Consistent with prepandemic analysis, we conclude that nursing home payment and quality standards should support development of in-house staff capacity to deliver palliative care while expanding access to the formal consultations and family involvement that were restricted by the pandemic. Future research should be directed to evaluating initiatives that pursue these aims.