Implementation Of Care Pathway Research Articles

Supported exercise TrAining for Men wIth prostate caNcer on Androgen deprivation therapy (STAMINA): study protocol for a randomised controlled trial of the clinical and cost-effectiveness of the STAMINA lifestyle intervention compared with optimised usual care, including internal pilot and parallel process evaluation

BackgroundUK national clinical guidance recommends that men with prostate cancer on androgen deprivation therapy are offered twice weekly supervised aerobic and resistance exercise to address iatrogenic harm caused by treatment. Very few NHS trusts have established adequate provision of such services. Furthermore, interventions fail to demonstrate sustained behaviour change. The STAMINA lifestyle intervention offers a system-level change to clinical care delivery addressing barriers to long-term behaviour change and implementation of new prostate cancer care pathways. This trial aims to establish whether STAMINA is clinically and cost-effective in improving cancer-specific quality of life and/or reducing fatigue compared to optimised usual care. The process evaluation aims to inform the interpretation of results and, if the intervention is shown to benefit patients, to inform the implementation of the intervention into the NHS.MethodsMen with prostate cancer on androgen deprivation therapy (n = 697) will be identified from a minimum of 12 UK NHS trusts to participate in a multi-centre, two-arm, individually randomised controlled trial. Consenting men will have a ‘safety to exercise’ check and be randomly allocated (5:4) to the STAMINA lifestyle intervention (n = 384) or optimised usual care (n = 313). Outcomes will be collected at baseline, 3-, 6- and 12-month post-randomisation. The two primary outcomes are cancer-specific quality of life and fatigue. The parallel process evaluation will follow a mixed-methods approach to explore recruitment and aspects of the intervention including, reach, fidelity, acceptability, and implementation. An economic evaluation will estimate the cost-effectiveness of the STAMINA lifestyle intervention versus optimised usual care and a discrete choice experiment will explore patient preferences.DiscussionThe STAMINA lifestyle intervention has the potential to improve quality of life and reduce fatigue in men on androgen deprivation therapy for prostate cancer. Embedding supervised exercise into prostate cancer care may also support long-term positive behaviour change and reduce adverse events caused by treatment. Findings will inform future clinical care and could provide a blueprint for the integration of supervised exercise and behavioural support into other cancer and/or clinical services.Trial registrationISRCTN 46385239, registered on 30/07/2020. Cancer Research UK 17002, retrospectively registered on 24/08/2022.

Implementation of a Provincial Long COVID Care Pathway in Alberta, Canada: Provider Perceptions.

A novel, complex chronic condition emerged from the COVID-19 pandemic: long COVID. The persistent long COVID symptoms can be multisystem and varied. Effective long COVID management requires multidisciplinary, collaborative models of care, which continue to be developed and refined. Alberta's provincial health system developed a novel long COVID pathway. We aimed to clarify the perspectives of multidisciplinary healthcare providers on the early implementation of the provincial long COVID pathway, particularly pathway acceptability, adoption, feasibility, and fidelity using Sandelowki's qualitative description. Provider participants were recruited from eight early-user sites from across the care continuum. Sites represented primary care (n = 4), outpatient rehabilitation (n = 3), and COVID-19 specialty clinics (n = 2). Participants participated in structured or semi-structured virtual interviews (both group and 1:1 were available). Structured interviews sought to clarify context, processes, and pathway use; semi-structured interviews targeted provider perceptions of pathway implementation, including barriers and facilitators. Analysis was guided by Hsieh and Shannon as well as Sandelowski. Across the eight sites that participated, five structured interviews (n = 13 participants) and seven semi-structured interviews (n = 15 participants) were completed. Sites represented primary care (n = 4), outpatient rehabilitation (n = 3), and COVID-19 specialty clinics (n = 2). Qualitative content analysis was used on transcripts and field notes. Provider perceptions of the early implementation outcomes of the provincial long COVID pathway revealed three key themes: process perceptions; awareness of patient educational resources; and challenges of evolving knowledge.

The development and implementation of the Northern Health lung cancer digital care pathway: a case study in service change.

This case study details the approach utilised to establish an easy to use, accessible and sustainable method for routine collection of Patient Reported Outcome Measures for patients newly diagnosed with lung cancer. We sought to enhance communication with patients and their families, particularly around shared decision making, their quality of life and symptoms, as well as the impacts of their care or treatment. We detail the co-design methodology utilised with consumers and healthcare providers to develop and implement a multi-lingual, fully automated digital care pathway which has been proven to be highly impactful and powerful for both healthcare providers working within the service and consumers enrolled within the digital pathway. This innovative initiative has changed the practice of the lung cancer service across a health service. Furthermore, its success has evolved the organisational strategy, to embed 'Outcomes for Impact' across the health service.

The Impact of an Overactive Bladder Care Pathway on Longitudinal Patient Management.

Implementation of an overactive bladder (OAB) care pathway may affect treatment patterns and progression. This study aimed to assess the effect of OAB care pathway implementation on treatment patterns for women with OAB. This retrospective cohort study evaluated women with OAB, before (January 1, 2015-December 31, 2017) and after (January 1, 2019-December 31, 2021) care pathway initiation. Care pathway use included standardized counseling, early introduction of therapy, and close follow-up. Primary outcomes included OAB medication use, follow-up visits, third-line therapy, and time to third-line therapy. A total of 1,349 women were included: 1,194 before care pathway implementation and 155 after. Patients after implementation were more likely to have diabetes mellitus (P = 0.04) and less likely to smoke (P = 0.01). Those managed via a care pathway were more likely to use any medication or third-line therapy within 1 year after consultation (61.3% vs 25.0%; P < 0.001). This included higher proportions receiving a medication (50.3% [95% confidence interval (CI), 41.8%-57.6%] vs 23.3% [95% CI, 20.9%-25.7%]; P < 0.001) and progressing to third-line therapy (22.6% [95% CI, 15.7%-28.9%] vs 2.9% [95% CI, 2%-3.9%]; P < 0.001). Among those who underwent third-line treatment, care pathway use was associated with shorter time to third-line therapy (median, 10 days [interquartile range, 1-56 days] vs 29 days [interquartile range, 7-191 days]; P = 0.013). Those managed via a care pathway were less likely to have additional clinic visits for OAB within 1 year after initial consultation (12.3% vs 23.9%; P < 0.001). Use of an OAB care pathway was associated with higher rates of oral medication and third-line therapy yet decreased follow-up office visits. Use of an OAB care pathway may promote consistent and efficient care for women with OAB.

Nurse coordinators and IPAs in Parkinson's expert centers: what are their roles?

The creation of Parkinson's expert centers (PEC) led to the emergence of new nurses, known as coordination nurses. And in 2018, the emergence of advanced practice nursing led to the creation of a new category of professionals, advanced practice nurses (APN). Nurses coordinators and APN play a major role in meeting the public health challenges posed by Parkinson's disease. They are the guarantors of the implementation of a personalized care pathway, the aim of which is to offer patients an optimized quality of life. They forge an indispensable link between the city's healthcare services and the PEC, collaborating with the many healthcare professionals who work with people suffering from Parkinson's disease.

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.

Understanding barriers and facilitators to long-term participation needs in children and young people following acquired brain injuries: a qualitative multi-stakeholder study.

Background This study focused on exploring the longer-term participation needs of children and young people with acquired brain injury (CYP-ABI) and their families in one region of the UK and identifying the barriers and facilitators of their participation and well-being to inform the development of a behavioural change intervention for clinical implementation. Methods Qualitative interviews were conducted with CYP-ABI and parents. Focus groups were created with health, education, care and charity stakeholders. The International Classification of Functioning, Disability and Health (ICF) and the Behaviour Change Wheel (BCW) were used to map needs, barriers and facilitators. Results A total of 10 CYP/parent dyads (n = 20) and 17 health, education, care and charity stakeholders were included in this study. Unmet participation needs were mapped to the ICF and barriers/facilitators to the BCW. Significant unmet needs impacting CYP-ABI participation and family well-being were found. Barriers spanned 'Capability', 'Opportunity' and 'Motivation', the greatest being knowledge, skills, social influences, environmental context and resources, social identity and emotion. Facilitators included increasing awareness and understanding, supporting parents, long-term access to specialist assessment and rehabilitation, peer support and integrated collaborative pathways. Conclusion The long-term impact of ABI on CYP and families' participation and well-being were significant, with barriers spanning every sector and level of society. Implementation of collaborative, cross-sector (education, health and social care) accessible and family-centred care pathways is needed to meet the long-term needs of CYP-ABI and their families, ensuring equity of access. Multi-modal, family-centred, needs-led, theory-based interventions should be co-developed with CYP, families and stakeholders to improve the health and well-being outcomes and the lives of CYP-ABI and their families.

Lung cancer registry to promote person-centered care.&amp;nbsp;

Introduction: Lung cancer is a leading cause of death and major burden on healthcare systems. Patient-centered outcome measurements allow the optimization of care organization and quality improvement. The aim of this project was to outline a set of variables and outcomes to evaluate the quality of care provided to lung cancer patients. &#x0D; Methods: This project took place at Hospital Italiano de Buenos Aires, a community-based tertiary care hospital in Argentina; which provides thoracic surgery, pneumology, oncology, pathology, radiology and radiotherapy services. It also has a Lung Cancer Multidisciplinary Board. All patient information is stored in a Data Repository fed by the electronic health record (EHR).&#x0D; We established a team of experts in management, IT, thoracic surgery, pneumology, oncology, and internal medicine. We reviewed care processes and patient trajectory along the usual pathway, through a retrospective EHR analysis of a consecutive sample of lung cancer patients. &#x0D; We performed a literature review to outline possible variables and health outcomes to be collected, instruments, and frequency of measurement. We determined needs, usefulness, and feasibility of collecting variables and outcomes in group meetings. &#x0D; Results: We reviewed 15 cases of lung cancer, 53% male, median age 68 years old (range: 29-85). We detected heterogeneity in the time elapsed between critical points of management (eg first visit to diagnosis 21 to 642 days; biopsy report to chemotherapy 19 to 163). The proportion of use of the healthcare system was also variable (eg: 87% consulted pneumonolory or oncology, only 13% had pain management visits and 7% received respiratory kinesic therapy). Patient-reported outcomes were not systematically evaluated.&#x0D; The selected baseline variables were: age, sex, weight loss, smoking status, comorbidities, patient-reported health status (EORTC European Organization for Research and treatment of cancer, QLC-LC30 Core quality of life questionnaire, QLC-LC13 Lung cancer-specific quality of life questionnaire), performance status (ECOG Eastern Cooperative Oncology Group), pulmonary function (VEF1), histology, clinical and pathological stage (AJCC-TNM 8th Ed), molecular tests and treatment intent. The outcomes (collected annually): clinical staging performed before treatment, time from diagnosis to treatment, performance status, patient-reported health status, major surgical complications, major chemotherapy/radiotherapy complications, time from diagnosis to treatment, completed treatment, overall survival, cause of death, treatment-related mortality, place of death, time spent in hospital at the end of life (last 30 days).&#x0D; Discussion: Cancer registries comprise a set of systematically and prospectively collected data. Quality measurements performed in the context of cancer registries could assist in monitoring and evaluating quality of care. &#x0D; Conclusions: The project determined essential variables and outcomes to be measured, considering their relevance and feasibility.&#x0D; Lessons learnt: Teamwork is essential when developing a registry, as different stakeholders' opinions are reflected. Integrated care is a useful solution to overcome fragmentation.&#x0D; Limitations: Patients did not participate directly in this development. &#x0D; Suggestions for future research: These results will assist in outlining a care pathway for patients with lung cancer, which is currently under development. Evaluation before and after the implementation of care pathways may evidence quality improvement.

Designing a Behaviour Change Wheel guided implementation strategy for a hypoxaemic respiratory failure and ARDS care pathway that targets barriers

BackgroundA significant gap exists between ideal evidence-based practice and real-world application of evidence-informed therapies for patients with hypoxaemic respiratory failure (HRF) and acute respiratory distress syndrome (ARDS). Pathways can improve...

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.

Current ED syncope management in Italian hospitals and prospects for optimization: a national survey.

To investigate current ED management of patients with syncope in Italy and opportunities for optimization, we carried out a questionnaire survey involving 102 directors of ED facilities in our country, of any complexity level, with 55.9% located in the North, 97% equipped with an ED Observation Unit (EDOU), and 21.8% with an outpatient Syncope Unit (SU). 43.6% of EDs management is not standardized. Clinical judgment and monitoring are the main factors leading management while old age and neuropsychic comorbidities the most hindering it. More than one third of ED facilities treats fewer than half of patients in EDOU. Most of respondents (73.7%) reported an admission rate within 20%, primarily in cardiology, in the case of an established or suspected cardiac etiology of syncope. In most centers, the referral to the general practitioner is the priority path at discharge from ED. Nearly 50% of participants rated syncope management in their own center as sub-optimal. To optimize it, 98% of them believe that is appropriate to implement a standardized approach, with and a large majority focusing on increasing diagnostic yield and safety; other priorities include application of guidelines, implementation of care pathways, enhancement of the role of EDOU, and direct path to the SU. This study highlights that the management of syncope patients in our country requires a further improvement, especially through standardization of pathways and adoption of innovative organizational solutions. Admissions appear to be lower than reported in the literature but this finding must be confirmed by a multicentric study based on direct collection of data.

Unplanned emergency department visits after mastectomy in Alberta: Informing a quality improvement initiative.

412 Background: Same day surgery (SDS) for mastectomy increased in Alberta from 1.7% to 73% in 2022, after implementation of a perioperative care pathway in 2016. However, unplanned visits to the emergency department (ED) remained high at 22-27% with &lt;5% requiring readmission. Our study aims to explore factors associated with unplanned ED visits by 1) describing patients with unplanned ED visits within 30 days of mastectomy, and 2) exploring characteristics for unplanned ED visits from the patient perspective. Methods: A survey study was conducted of patients who underwent a mastectomy in Alberta between 07/01/2021 to 06/30/2022 by a general surgeon, and had an unplanned ED visit within 30 days. Patients were identified from the CIHI database; chart review was performed to confirm ED visit details. Patients were excluded if their presentation was unrelated to surgery. Survey questions evaluated 3 domains: medical, socioeconomic, and psychologic, as well as patient-reported experiences of post-operative care. Results: Of 549 patients who underwent mastectomy during the study period, 132 (24%) presented to ED within 30 days. The survey was sent to 87 patients meeting inclusion criteria; 38% responded. Average age was 56. Most patients had no comorbidities (30%) or 2+ (27%), and 85% had prior surgery. The majority (79%) had college education or higher. Treatment included neoadjuvant chemotherapy (24%), sentinel lymph node biopsy (39%), axillary dissection (12%), concurrent reconstruction (24%), and mastectomy alone (27%). Most patients had 2+ drains (70%). Many patients (38%) presented on a weekend, 50% stating the ED was the only choice available at the time. Comparatively, 22% reported being told to go, and 16% felt the ED was the best place for their problem. Patients were seen by an ED physician (89%), nurse (40%) and/or surgeon (28%). Most common reasons for ED visit were infection (38%) and drain concerns (38%). Re-operation and readmission rates were 25% and 19%, respectively. Overall, 84% felt prepared for surgery; only 15% felt uncomfortable with drain management. Patients identified peer support and wound information as areas lacking. While 78% of patients were mostly or very satisfied with surgery, difficulty accessing their surgical team post-operatively was reported as the main flaw. Conclusions: Our study cohort identified infection and drain concerns as the most common reason for unplanned ED visit after mastectomy. Overall, patients were satisfied with education and surgical care, but identified problems with accessing medical/surgical care after discharge. Future initiatives should focus on improved access to outpatient care, and education on post-mastectomy emergencies.

MA07.10 Co-Design and Implementation of A Digital Care Pathway for Patients with Lung Cancer

MA07.10 Co-Design and Implementation of A Digital Care Pathway for Patients with Lung Cancer

Digitally supported health care; evaluation approaches to a complex intervention embedded in a tria

Abstract Many important health care interventions do not fit the classic RCT paradigm. Drug trials have struggled with issues of non-compliance and selective withdrawal. Surgical researchers have done extensive work on incorporating operator skills and experience into trial settings. Working on innovative models of care delivery related issues arise. As part of an EU funded multi-centre stepped-wedge trial, GERONTE, of nurse-led, digitally supported, health care coordination for older people with cancer and other significant co-morbidity, we have developed and tested an outline of a novel method of evaluation, drawing on realist evaluation. There are three pieces, first the central trial outcome, quality of life, for those in the trial, analysed by intention-to-treat. Second an economic evaluation, based on care pathways, and collecting costs during the control and intervention phases in 16 centres, in 3 countries. Third, a realist evaluation of implementation, with 3 phases in each site, the first of which is underway. 1) Readiness to implement GERONTE, and documenting current practice, and identifying barriers and facilitators for change with clinical staff, technical staff and administrators; 2) Experience of implementation as the intervention is brought in over the course of the study; 3) Experience in keeping GERONTE running after the initial implementation phase. Early results show great site to site variability, in practice and in resources, but common barriers are data handling and sharing. In each phase, guided by ideas from participatory rapid appraisal, we stress the rapid feedback to participants, of their response, and the synthesis of responses to support successful implementation. One aim is to prepare an implementation guide to support future deployments of GERONTE and similar projects, drawing on lessons from all 16 sites, and filling a gap in the literature. GERONTE is funded by the Horizon 2020 research and innovation programme under grant agreement No 945218. Key messages • Innovative health care delivery, such as integrated care, requires complex assessment approaches, designed for the specific innovation. • Site-to-site variability in the implementation of novel care pathways and approaches is the norm, and needs to be considered at design stage.

Prehabilitation prior to elective surgery for frail elderly – protocol for a scale-up analysis

Abstract Background Elderly patients frequently develop a frailty syndrome. Frailty is characterized by reduced physical reserves which increases the risk of perioperative complications and, thus, of patients needing long-term care. Prehabilitation before elective surgery can reduce risk factors and is currently evaluated as a new and sustainable care pathway for frail elderly in a randomized trial (NCT04418271). If found to be effective (the primary outcome being the level of care dependency 12 months after surgery), the pathway will be recommended for national scale-up. This protocol outlines the analyses intended to prepare for scale-up. Methods We will perform a scale-up analysis to assess whether and how prehabilitation can be implemented into routine care in Germany, including: (i) a Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis of facilitating factors and barriers from the perspective of health care providers and patients (via semi-structured interviews, and a realist review); (ii) a scalability analysis using the Intervention Scalability Assessment Tool (ISAT) in an expert advisory board; (iii) a subgroup analysis to identify patients in the PRAEP-GO trial for whom prehabilitation was particularly effective; and (iv) a budget impact analysis based on routine data to estimate the total cost of implementing prehabilitation from a payer's perspective. The scale-up analysis will identify challenges and opportunities for the implementation of prehabilitation. It will contribute to the development of an implementation strategy, including specific proposals on how to finance the intervention. The budget impact analysis will provide an estimate of the financial impact of routine implementation of prehabilitation on the health budget. Conclusions If prehabilitation for the frail elderly is evaluated positively, its implementation should be prepared based on our study results, which includes establishing required infrastructures and defining financing concepts. Key messages • The proposed scale-up analysis will examine scalability of the implementation of prehabilitation for frail elderly into routine care in Germany. • The implementation of a new care pathway having a positive effect on patients’ level of care dependency can be considered sustainable.

‘Enhanced recovery after surgery’: tijd voor de standaard in chirurgie?

Enhanced recovery after surgery: towards a new standard in surgery? In a changing healthcare landscape and the hospital of the future, a crucial question remains how to maintain a good quality of care for patients in a healthcare system under pressure. Enhanced recovery after surgery (ERAS) may provide the answer to this question and focuses on a multimodal, multidisciplinary patient-centered care pathway. The pathophysiological core of ERAS consists of reducing the surgical stress response and the associated inflammation to limit the degree of organ dysfunction and to enhance recovery. ERAS programs include (but are not limited to) evidence-based guidelines regarding a reduced fasting time and allowing the intake of carbohydrate-rich drinks up to 2 hours prior to surgery, minimally invasive surgery, multimodal opioid-sparing analgesia, normovolemia, normothermia, the avoidance or early removal of drains, and the early restart of nutrition and mobilization. With an increased compliance to ERAS elements, the outcome becomes better. Ample evidence exists that ERAS programs lead to a reduced length of stay, less complications, less readmissions, less reoperations and a reduced mortality. Additionally, ERAS programs are cost-saving. The implementation of ERAS care pathways requires a policy focused on ‘change’ management, teamwork, leadership, vision, communication and a continuous audit of the entire care process.

Shortened time to diagnosis for patients suspected of urinary bladder cancer managed in a standardized care pathway was associated with an improvement in tumour characteristics.

To evaluate whether the implementation of standardized care pathway (SCP) for patients with suspected urinary bladder cancer (UBC) was associated with changes in tumour characteristics. Additionally, the study aims to explore whether there was a shift in the selection of patients prioritized for immediate evaluation regarding suspicion of UBC. The study included all patients diagnosed with UBC in the NU Hospital Group between 2010 and 2019. To evaluate changes associated with SCP, patients were divided into two diagnostic time periods, either before (2010-2015) or during (2016-2019) the implementation of the SCP. To evaluate which patients were prioritized for prompt evaluation within 13 days, logistic regression analysis was performed on all patients before and during SCP. Median time to transurethral resection of the tumour in urinary bladder (TURBT) decreased from 29 days (interquartile range [IQR] 16-48) before SCP to 12 days (IQR 8-19) during SCP (p< 0.001) with a clear break from 2016. The proportion of cT2 + tumours decreased during SCP from 26% to 20% (p= 0.035). In addition, tumours detected during SCP were smaller (p= 0.023), but with more multiple lesions (p= 0.055) and G3 tumours (p= 0.007). During SCP, there was no statistically significant difference between the groups of patients with TURBT within or after 13 days. In contrast, before SCP, a majority of the patients treated within 13 days had advanced tumours and were admitted from the emergency ward. The implementation of an SCP for suspected UBC was associated with improved tumour characteristics. Interestingly, during SCP, there were no substantial differences in patients' or tumours' characteristics among those who underwent TURBT within or after 13 days. This indicates that the 13-day timeframe for TURBT might be prolonged, especially in less urgent cases in order to facilitate a prioritization of more severe cases with treatable disease.

Optimizing the pathway for simple stable fractures.

In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs. In this retrospective cohort study, patients were included if a radiologist diagnosed a fracture on a radiograph requested by the GP from August to October 2019 (control group) or August to October 2020 (research group), on weekdays between 8.30 am and 4.00 pm. The study compared various outcomes between groups, including the length of the initial hospital visit, frequency of hospital visits and medical procedures, extent of imaging, and healthcare expenses. A total of 634 patients were included. The results show a median reduction of 25 minutes in duration of initial hospital visits, one fewer hospital visit, overall fewer medical procedures, and a decrease in healthcare costs of €303.40 per patient in the research group compared to the control group. No difference was found in the amount of imaging. The implementation of the new care pathway has resulted in a substantial reduction in healthcare use and costs. Moreover, the pathway provides advantages for patients and helps prevent crowding at the ED. Hence, we recommend immediately referring all minor trauma patients to the traumatology OC instead of the ED.

Single-Center Experience With Lung Transplant Evaluation Referrals of Acute Respiratory Distress Syndrome Patients During the COVID-19 Pandemic: How Do You Make Up For Lost Time?

Transfer of select, medically refractory acute respiratory distress syndrome patients to lung transplant centers requires extensive resources. Here, we report 270 consecutive lung transplant patient referrals to our center for medically refractory ARDS from June 2021 to April 2022, following the implementation of clinical care pathways for intake of these patients. Eighty-seven of 270 patients (32.2%) met screening criteria and were evaluated for transfer within a median of 12 days, during which 38 of 87 patients (43.7%) died and 12 of 87 patients (13.8%) transferred elsewhere. Thirty-seven of 87 patients (42.5%) were accepted for transfer of which 16 of 37 patients (43.2%) successfully transferred to our center with a median transfer waiting period of 12 days. Because of resource constraints, 21 of 37 accepted patients (56.8%) could not be transferred of which 9 of 21 patients (42.9%) died while waiting. Nine of 16 transferred patients (56.2%) eventually underwent lung transplantation with over 80% 6-month survival. ARDS patients referred for transplantation have high risk of mortality and, therefore, require well-described pathways for evaluation and transfer.

1049 Reducing Postoperative Length of Stay After Thyroidectomy by Implementing Standardized Post-Operative Pathways

Abstract Aim Reducing length of stay programme (RLoS) was conceived to ensure better outcome and experience while preserving capacity. Our unit was an outlier in length of stay after thyroidectomy according to British Association of Endocrine and Thyroid Surgeons (BAETS) annual report. We present the results of implementation of a standardized postoperative care pathway to reduce the length of stay. Method Patient expectations were managed for an early discharge. A multidisciplinary postoperative care pathway was developed to facilitate early discharge. Protocol was well publicized among the surgical team and the nursing staff. We evaluated the implementation and efficacy of the pathway. Discharge data was collected on all total thyroidectomies prospectively over 12 months. Comparison was made with two years data of thyroidectomies prior to implementation of protocol. Results Prior to protocol implementation, 29 Thyroidectomies were done for benign disease. They were discharged, on post-operative day one 0% (67%), day two 45% (23%), day three 41% (6%), day four 0% (3%) and day five 7% (1%). Figures in parenthesis are national figures from BAETS annual report. After protocol implementation, 17 thyroidectomies were carried out for benign disease. 87% were discharged on first postoperative day and 13% on second day. No patients stayed longer than two days. There were no patient safety events as a result of implementation of protocol and early discharge. Conclusions A structured and well publicized post-operative care protocol and managing patient expectations can significantly reduce postoperative length of stay after thyroidectomy without compromising patient safety.