Clinical Practice Improvement Research Articles

Global estimates of rehabilitation needs and disease burden in tracheal, bronchus, and lung cancer from 1990 to 2019 and projections to 2045 based on the global burden of disease study 2019.

The global cancer burden is substantial and spiraling. Although rehabilitation specialists could offer assistance, oncologic rehabilitation is still underutilized and not a routine part of clinical oncology guidelines worldwide. Global investigations of disease prevalence and years lived with disability (YLDs) for tracheal, bronchus, and lung (TBL) cancer are valuable for facilitating clinical practice improvement and health resource management. The objective of this study is to report the global estimates of rehabilitation needs and disease burden of TBL cancers from 1990 to 2019 and provide predictions for 2045. To estimate the need for rehabilitation, the data used from the Global Burden of Disease Study 2019 to calculate the prevalence, YLDs, and the attributable risk factors of TBL cancer. The Bayesian age-period-cohort model and Auto-Regressive Integrated Moving Average model were established to forecast the future health burden. All analyses were done at the global level and then some in the aggregation with the seven World Bank regions. All the data were analyzed by R software (x64 version 4.2.1) and Microsoft Excel (version 2019). Globally in 2019, 3,212,307 cases of TBL cancer (95% UI 2,937,037-3,488,346) could have benefitted from rehabilitation, contributing to 544,215 (95% UI 396,134-700,099) YLDs. Over the past 30 years, the age-standardized rate (ASR) of prevalence (EAPC = 0.51) and YLDs (EAPC = 0.03) increased. Throughout this period, the global prevalence and YLDs counts were greater in males than females. The ASR of prevalence and YLDs are projected to show a slight downward trend by 2045 on the global scale, the overall prevalence and YLDs due to TBL cancer are likely to increase further, but all indicators show a growing trend in females. TBL cancer remains one of the major public health issues globally. According to the forecasted results, the burden of YLDs due to TBL cancer will continue to rise, and the increment is higher in females than males. A rising number of patients worldwide will benefit from rehabilitation services in the future to achieve precise control and management throughout the TBL cancer patient lifecycle.

The long-term effect on nurses’ self-efficacy of father support by implementing a father-friendly neonatal intensive care unit

The role of fathers in childcare is changing; therefore, nurses' care must change to more family-centered care. This follow-up study investigated the long-term effects of implementing a father-friendly neonatal intensive care unit on nurses’ self-efficacy in guiding and supporting fathers.Forty-one nurses (98%) responded to the follow-up questionnaire 5 years after the implementation of the father-friendly neonatal intensive care unit, of which 22 completed the questionnaire (post-implementation). From the post-to follow-up questionnaire, a significant decrease was found for the mother's questions (8.71 vs. 9.16, p = 0.05) and a non-significant decrease for the father's questions (8.52 vs. 9.02, p = 0.07). ConclusionAfter the initial implementation of improvements in clinical practice, it is important to have an organizational strategy to maintain and continue developing nurses’ skills and culture in guiding and involving the entire family to ensure requested patient care.

Collaborating to DrEaM bigger and better: the challenges in using digital data to drive quality improvement in clinical practice

Background: Supporting patients to Drink, Eat and Mobilise (DrEaMing) within 24 h of major surgery is associated with reduced length of hospital stay and late complications.1 This quality metric was assigned a financial incentive in the 2022 NHS England CQUIN scheme with a compliance target of 60–70% for specific surgical patient cohorts. Beyond the CQUIN, we wanted to deliver DrEaMing to all surgical patients and embed a culture change by reinvigorating core concepts of enhanced recovery pathways. Optimal use of our electronic healthcare record, EPIC, was key to our strategy, aiming to provide surgical teams with sustainable real-time data to drive quality improvement (QI) through electronic extraction of CQUIN metrics. Methods: CQUIN specialty data were extracted from EPIC quarterly. Anaesthetic registrars worked as DrEaMing champions alongside clinical nurse specialists (CNS) to facilitate collaborative working within the perioperative team. Key stakeholders were educated on how to record DrEaMing instructions and provision allowing electronic audit of CQUIN compliance with accurate time stamps. A total of 26 ward staff involved in DrEaMing provision on postoperative surgical wards were surveyed on barriers to DrEaMing. Results: EPIC data from 2022–23 showed varying CQUIN compliance rates across surgical specialties. Gynae-oncology documentation of postoperative DrEaMing instructions increased from 0% in April to 100% by January, however, postoperative DrEaMing provision plateaued around 60–70%. Overall CQUIN attainment across the year was <50%. Colorectal CQUIN compliance was limited by poor documentation of postoperative eating instructions and subsequent poor ward eating provision (Fig. 6), reflecting the heterogenous nature of colorectal procedures undertaken and varied recovery approach by teams. Surveys of ward staff across women’s health and colorectal surgery revealed burden of documentation, lack of access to means to document and unclear surgical postoperative instructions were important barriers to ward documentation of DrEaMing provision. Conclusion: DrEaMing compliance using EPIC data extraction at UCLH remains poor, despite motivated staff and a culture of QI, but was significantly higher with manual review of the notes trawl highlighting disparity between clinical practice and use of new EPIC builds. Our aim to make DrEaMing data easily accessible for QI requires further buy-in from surgical teams and engagement with ward staff. Permanent CNS act as pivotal change champions, through education and raising awareness. 1.Oliver CM, Warnakulasuriya S, McGuckin D, et al. Br J Anaesth 2022; 129: 114–26

(027) Considerations of Mid-Urethral Sling Procedures: Patient and Provider Perspectives on Outcomes and Experiences

Abstract Introduction The mid-urethral sling procedure (MUSP) treats symptoms of stress urinary incontinence. Recent studies have identified the potential for negative outcomes following MUSP; however, there is a limited understanding of the patient and healthcare provider perspectives on procedural experiences and outcomes. Specifically, there is discordance surrounding the role of female periurethral tissue in sexual responses, and limited knowledge of post-MUSP outcomes and symptoms as perceived by patients. Further understanding of current counselling and resource practices is needed, especially regarding informed consent and risk disclosure. Objective To investigate the experiences associated with MUSP from patients who have reported bothersome symptoms following MUSP, and from providers who routinely perform the procedure. Furthermore, to characterize recent patient experiences, explore factors which may influence current provider decision-making, and outline patient-used and provider-recommended counselling and resources. Methods Patients (n=10) who underwent MUSP and reported negative outcomes, and providers (n=22) with experience performing MUSP were recruited. Patients first completed an online survey which captured demographic information, medical history, and sexual function. Both patients and providers completed semi-structured interviews relating to MUSP outcomes and experiences. Interview responses were transcribed using Trint, and qualitative analyses were completed using NVivo 12. Results Perspectives and experiences gathered from patient and provider interviews revealed discordant narrative surrounding MUSP outcomes and treatment. Analysis of patient narratives revealed a unique symptom profile including periurethral pain and numbness, altered lubrication and loss of desire. In addition, patients discussed post-MUSP infections, as well as pain, weakness, and lower limb impairment having impacts on and extending to other aspects of life, including social relationships, work obligations, and day-to-day responsibilities. Patients described a preference for informed pre-procedural care, and supportive and comprehensive post-procedural counselling. Provider narratives revealed aims of fostering open discussions and efforts to offer procedural support. However, providers referenced limitations in time, experience, and understanding of the adverse outcome symptom profile. Further, regarding post-procedural care, both providers and patients discussed limitations in currently available counselling routes and resources. Conclusions The results of this study highlight discordance between the perceptions of patients and providers regarding MUSP outcomes and experiences. There are differences in the understanding of post-MUSP negative outcome experiences as perceived by patients, compared to providers. These findings support the need for improvements in post-MUSP support and targeted counselling, and resources. Differences in the knowledge of symptoms and negative outcome experiences as related to sexual function are emphasized in this context, highlighting, and encouraging the need for improvements in clinical practice which includes sexual health conversations and accessible resources. Disclosure No

Antimicrobial stewardship programme implementation in the UAE: perspectives of key stakeholders using Consolidated Framework for Implementation Research

Many studies report antimicrobial stewardship programme (ASP) implementation, but these are limited by a lack of theoretical underpinning. This may lead to missing key factors that are likely to influence the successful or unsuccessful implementation. To explore key stakeholders' perspectives of ASP implementation in UAE hospitals, with a focus on facilitators and barriers. The study employed a qualitative approach using semi-structured interviews conducted with ASP stakeholders involved in clinical use of antimicrobials at the individual patient level and including ASP team members and non-members. An interview schedule based on published literature and grounded in the Consolidated Framework for Implementation Research (CFIR) was developed, reviewed, and piloted. Recruitment was via purposive and snowball sampling. Interviews were recorded, transcribed, and thematically analysed by two independent researchers using CFIR as a coding framework. Data saturation was achieved at 31 interviews. Multiple CFIR constructs were identified as implementation facilitators or barriers. Facilitators included external policy requirements (both national and international), leadership support, stakeholders' engagement, collaborative culture, effective communication, and forward planning. Barriers included blame culture, complexity of ASP implementation, and a shortage of expert personnel. Numerous facilitators and barriers to ASP implementation from a stakeholders' perspective were identified in this research. The value of early leadership engagement to support provision of required resources, a need for effective planning and establishment of multiple engagement techniques, and valuable communication with healthcare providers are the main recommendations emerging to support improvement in clinical practice.

Global burden of hematologic malignancies and evolution patterns over the past 30 years

Hematologic malignancies are among the most common cancers, and understanding their incidence and death is crucial for targeting prevention, clinical practice improvement, and research resources appropriately. Here, we investigated detailed information on hematological malignancies for the period 1990–2019 from the Global Burden of Disease study. The age-standardized incidence rate (ASIR), the age-standardized death rate (ASDR), and the corresponding estimated annual percentage changes (EAPC) were calculated to assess temporal trends in 204 countries and territories over the past 30 years. Globally, incident cases of hematologic malignancies have been increasing since 1990, reaching 1343.85 thousand in 2019, but the ASDR for all types of hematologic malignancies has been declining. The ASDR for leukemia, multiple myeloma, non-Hodgkin lymphoma, and Hodgkin lymphoma were 4.26, 1.42, 3.19, and 0.34 per 100,000 population in 2019, respectively, with Hodgkin lymphoma showing the most significant decline. However, the trend varies by gender, age, region, and the country’s economic situation. The burden of hematologic malignancies is generally higher in men, and this gender gap decreases after peaking at a given age. The regions with the largest increasing trend in the ASIR of leukemia, multiple myeloma, non-Hodgkin lymphoma, and Hodgkin lymphoma were Central Europe, Eastern Europe, East Asia, and Caribbean, respectively. In addition, the proportion of deaths attributed to high body-mass index continued to rise across regions, especially in regions with high socio-demographic indices (SDI). Meanwhile, the burden of leukemia from occupational exposure to benzene and formaldehyde was more widespread in areas with low SDI. Thus, hematologic malignancies remain the leading cause of the global tumor burden, with growing absolute numbers but sharp among several age-standardized measures over the past three decades. The results of the study will inform analysis of trends in the global burden of disease for specific hematologic malignancies and develop appropriate policies for these modifiable risks.

567 Outcomes of an Education Program on the Rehabilitation of Face and Neck Burns

Abstract Introduction Face and neck burns bring unique complications and often require specific training and experience for the burn physical rehabilitation professional. The COVID-19 Pandemic created a need for virtual learning during a time when in-person learning was not possible. While this format can meet some needs, it does not allow for practice and interaction with instructors. There are limited education and training opportunities for burn therapists which include such extensive practical opportunities. This unique didactic training program provided mentorship and tangible skills of a complex and specialized area of burn rehabilitation. Methods • Learning Objectives were determined using the Burn Therapist Competency Tool-Version 2 • Developed curriculum for each facial/neck regions as well as various scar management techniques throughout the continuum of care • Individual modules were developed by Occupational Therapists, Physical Therapist and Speech and Language Pathologist with experience in the field • The in-person course consisted of 4 hours of lecture and 8 hours of hands-on splinting and scar management training • Instructors provided interactive and collaborative feedback for every participant Pre &amp; Post testing completed to assess learning • Feedback from participants was assessed for quality improvement • Follow up questionnaire was provided to assess implementation into clinical practice and self-perceived level of experience related to rehabilitation of face/neck burns Results 24 Occupational, Physical and Speech Therapists participated in the 2-day course. Results of the post-test indicate increased knowledge pertaining to the learning objectives. 21 participants remained for the second day of the hands-on splinting and scar management portions and demonstrated learned knowledge of these intervention techniques. Post-course assessments attest to increased comfort with new skills. Participant follow up gaged overall effectiveness of clinical practice improvements. Conclusions Participant feedback provided valuable insight into the ongoing need for training and mentoring of burn therapists. This is vital in developing additional training resources, including step-by-step explanation and video content for repetition and learning. Ultimately, implementation of these new skills into each participant’s clinical practice was the desired outcome of this course. Applicability of Research to Practice This project highlighted the gap in knowledge for burn therapists when it came to face and neck burns.

Posttraumatic stress disorder in diverse populations: Testing for assessment bias in a nationally representative sample.

A growing body of research has emerged to characterize differences in posttraumatic stress disorder (PTSD) symptom presentations in individuals from diverse racial and ethnic groups. However, less research has examined if these observed differences can be attributed to bias within PTSD assessments. Knowledge about potential bias in PTSD assessment is essential for interpreting group differences. If PTSD assessments do not perform similarly across diverse demographic groups, then observed differences may be artificial products of inaccurate measurement, new assessments could be required for individuals from different demographic groups, and we would be unable to accurately detect PTSD treatment effects in patients from diverse groups. We evaluated PTSD assessment bias through tests of measurement invariance for the semistructured, clinician-administered AUDADIS-5 diagnostic assessment of participants in the National Epidemiologic Survey on Alcohol and Related Conditions-III. Participants included those who reported having experienced at least one potentially traumatic event in their lifetime (N = 23,936). Measurement invariance was assessed for participants who identified from several demographic groups (Asian, Native Hawaiian, or Pacific Islander; Hispanic; American Indian/Alaskan Native; and Black) compared to participants who identified as White (non-Hispanic). Overall, PTSD assessment was largely invariant across groups, while small amounts of measurement invariance were detected that can inform future research and clinical adaptations. This work validates prior research that relies on a common conceptualization of PTSD, and it provides several paths for future improvement in research and clinical practice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Patient-Reported Outcomes in Ovarian Cancer: Facilitating and Enhancing the Reporting of Symptoms, Adverse Events, and Subjective Benefit of Treatment in Clinical Trials and Clinical Practice.

Patient-reported outcomes (PROs) provide a valid, standardized way of assessing symptoms, adverse events and the subjective benefit of treatment from the patient's perspective. Assessment of PROs is critical in ovarian cancer due to the high morbidity of the disease and its treatments. Several well-validated PRO measures are available to assess PROs in ovarian cancer. Their inclusion in clinical trials can provide evidence on the benefits and harms of new treatments based on patients' experiences to guide improvements in clinical practice and health policy. Aggregate PRO data collected in clinical trials can be used to inform patients about likely treatment impacts and assist them to make informed treatment decisions. In clinical practice, PRO assessments can facilitate monitoring of a patient's symptoms throughout treatment and follow-up to guide their clinical management; in this context, an individual patient's responses can facilitate communication with their treating clinician about troublesome symptoms and their impact on their quality of life. This literature review aimed to provide clinicians and researchers with a better understanding of why and how PROs can be incorporated into ovarian cancer clinical trials and routine clinical practice. We discuss the importance of assessing PROs throughout the ovarian cancer disease and treatment trajectory in both clinical trials and clinical practice, and provide examples from existing literature to illustrate the uses of PROs as the goals of treatment change in each setting.

Effect of a CME Symposium on the Obstetrician–Gynecologist's Knowledge and Confidence Related to CGM Use in Pregnant Patients [ID: 1368750

INTRODUCTION: We sought to measure the effect of a live symposium at the American College of Obstetricians and Gynecologists followed by enduring on Medscape related to real-time continuous glucose monitoring (rtCGM) use in pregnant patients. METHODS: Pre and post questions assessed changes in knowledge and confidence. Absolute differences were calculated for the live activity. For the enduring, completers of all pre and post questions were linked and analyzed. RESULTS: There were 61 live participants: 68% were physicians, 3% NPs, 3% pharmacists, and 3% nurses. There was a 21% increase in learners who recognized time in range goals for pregnant patients with diabetes, and a 26% increase in those who reported being very or somewhat confident in using rtCGM in their patients with diabetes (24% less were not confident with this concept). 100% declared the content learned will affect their practice, and 91% reported being committed/very committed to implementing practice changes. There are 3,595 enduring learners to date (October 9, 2022), and 83 completers of all questions by August 30, 2022. 16% of ob-gyn learners improved at recognizing time in range goals for pregnant patients with diabetes. Eighteen percent of ob-gyn learners improved at recognizing the benefit of rtCGM in pregnant patients with diabetes. Thirty-nine percent of ob-gyn learners had increased confidence in using rtCGM in pregnant patients with diabetes for an average confidence shift of +79% among those with increased confidence. CONCLUSION: The outcomes gathered in this assessment are a strong indicator that live, in-person CME symposia followed by online enduring is successful at improving knowledge and confidence related to rtCGM use in pregnant patients with diabetes, and possibly promote improvements in clinical practice.

Risk Factors and Role of Antibiotic Prophylaxis for Wound Infections after Percutaneous Endoscopic Gastrostomy.

The incidence of wound infections after percutaneous endoscopic gastrostomy (PEG) varies widely in recent studies. The present study systematically investigates the underlying risk factors for the development of wound infections in a large cohort of patients over a long-term follow-up period. A retrospective cohort study of patients undergoing PEG insertion using either the pull or push technique was conducted and patients followed up for 3 years. Tube-related wound infections were identified, and pathogens regularly cultured from wound swabs. Adjusted analysis was performed via univariate and multivariate logistic regression analysis. 616 patients were included in this study. A total of 25% percent of patients developed wound infections upon PEG tube insertion and 6.5% showed recurrent infections. Nicotine abuse (p = 0.01), previous ischemic stroke (p = 0.01) and head and neck cancer (p < 0.001) showed an increased risk for wound infection after PEG placement. Moreover, radio-chemotherapy was associated with the occurrence of wound infections (p < 0.001). Infection rates were similar between pull and push cohorts. The most common bacterial pathogen detected was Enterobacterales (19.2%). Staphylococcus aureus, Pseudomonas aeruginosa and enterococci were frequently detected in recurrent infection (14.2%, 11.4% and 9.6%, respectively). Antibiotic prophylaxis showed no effect on infection rates. Wound infections after PEG placement are common and occasionally occur as recurrent infections. There is potential for improvement in everyday clinical practice, particularly regarding antibiotic prophylaxis in accordance with guidelines.

Scanxiety Conversations on Twitter: Observational Study.

Scan-associated anxiety (or "scanxiety") is commonly experienced by people having cancer-related scans. Social media platforms such as Twitter provide a novel source of data for observational research. We aimed to identify posts on Twitter (or "tweets") related to scanxiety, describe the volume and content of these tweets, and describe the demographics of users posting about scanxiety. We manually searched for "scanxiety" and associated keywords in cancer-related, publicly available, English-language tweets posted between January 2018 and December 2020. We defined "conversations" as a primary tweet (the first tweet about scanxiety) and subsequent tweets (interactions stemming from the primary tweet). User demographics and the volume of primary tweets were assessed. Conversations underwent inductive thematic and content analysis. A total of 2031 unique Twitter users initiated a conversation about scanxiety from cancer-related scans. Most were patients (n=1306, 64%), female (n=1343, 66%), from North America (n=1130, 56%), and had breast cancer (449/1306, 34%). There were 3623 Twitter conversations, with a mean of 101 per month (range 40-180). Five themes were identified. The first theme was experiences of scanxiety, identified in 60% (2184/3623) of primary tweets, which captured the personal account of scanxiety by patients or their support person. Scanxiety was often described with negative adjectives or similes, despite being experienced differently by users. Scanxiety had psychological, physical, and functional impacts. Contributing factors to scanxiety included the presence and duration of uncertainty, which was exacerbated during the COVID-19 pandemic. The second theme (643/3623, 18%) was the acknowledgment of scanxiety, where users summarized or labeled an experience as scanxiety without providing emotive clarification, and advocacy of scanxiety, where users raised awareness of scanxiety without describing personal experiences. The third theme was messages of support (427/3623, 12%), where users expressed well wishes and encouraged positivity for people experiencing scanxiety. The fourth theme was strategies to reduce scanxiety (319/3623, 9%), which included general and specific strategies for patients and strategies that required improvements in clinical practice by clinicians or health care systems. The final theme was research about scanxiety (50/3623, 1%), which included tweets about the epidemiology, impact, and contributing factors of scanxiety as well as novel strategies to reduce scanxiety. Scanxiety was often a negative experience described by patients having cancer-related scans. Social media platforms like Twitter enable individuals to share their experiences and offer support while providing researchers with unique data to improve their understanding of a problem. Acknowledging scanxiety as a term and increasing awareness of scanxiety is an important first step in reducing scanxiety. Research is needed to guide evidence-based approaches to reduce scanxiety, though some low-cost, low-resource practical strategies identified in this study could be rapidly introduced into clinical care.

Maternal and Fetal Outcome between Dated and Post-dated Pregnancy: A Comparative Study Conducted in a Tertiary Care Hospital

This prospective observational comparative study was conducted in department of Obstetrics and Gynaecology (OBGyn) of Shaheed Suhrawardy Medical College Hospital (ShSMCH), Dhaka. It was carried out from April 2019 to September 2019. The objectives was to compare the feto-maternal outcome of postdated pregnancy (40+1- 41+6 weeks) with pregnancy at term(37-40 weeks). Pregnant women admitted in ShSMCH with or without labour pain were considered as study population. Following ethical clearance from the local ethical committee and written informed consent, 59 cases of post-dated pregnancy (case) and 59 cases of term pregnancy (control) were included inthis study. Cases and control were selected by random sampling method according to inclusion and exclusion criteria. Inclusion criteria were: 1) Patients who have excellent EDD(dated by early ultrasonogram) , 2) Patients having regular menstrual cycle prior to present pregnancy and can remember exact LMP, 3) Postdated pregnancy as case and pregnancy at term as control. Exclusion criteria were: 1) Patients with eclampsia, systemic hypertension, heart disease, diabetes mellitus and renal disease, 2) Patients with multiple gestation and any congenital anomaly, 3) Pregnancy occurred during lactational amenorrhoea, 4) Pregnancy with veneral disease, 5) pregnancy with blood group incompatibility. Data were collected with a pre-designed structured questionnaire. A full assessment were done by history[age, occupation, menstrual and obstetric history, medical, surgical and family history, antenatal care(ANC)], physical examination (general, abdominal and vaginal) and ultrasonogram (USG) to assess gestational age and liquor volume. After proper counselling, induction of labour given to patients without labour pain and fetal distress. Mode of delivery, post-delivery maternal and fetal outcome and complication were recorded.This study showed that maximum number of patients in term pregnancy (control) belonged to age group (21-30 years) [control 71.2%, case 62.7%] and in post-dated pregnancy (case) belonged to &gt;30 years [control 15.5%, case 23.7%]. In both groups, maximum number of women were housewives, control 48(81.4%), case 46(78%) and service-holder 11(18.6%) in control, 13 (22%) in case. In control group 36 (61%) were primi-gravida and 23 (39%) were multi-gravida. In case group 29(49.2%) were primi-gravida, 30(50.8%) multi-gravida. Family history of post-dated pregnancy were present in 14(23.7%) of control group and 13(22%) of case group. Most of the women of both control (93.2%) and case (89.8%) received regular ANC. Large fetus were seen in 6(10.2%) of control and 9(15.3%) of case group. Vertex was common presenting feature in both control (94.9%) and case (88.1%). Liquor volume was adequate in maximum number of women of both control (69.5%) and case (62.7%) group. Uterine irritability was present in 16(27.1%) of control and 17 (28.8%) of case group. Associated complication, such as CPD and elderly primi were present in 10 (16.9%) of control and 9 (15.3%) of case group. Induction of labour was required in 33(55.9%)of control and 41 (69.5%) of case group. Normal vaginal delivery was achieved in 41 (69.5%) of control and in 33 (55.9%) of case group women. LSCS required in 18 (30.5%) of control and 25 (42.4%) of case group women. Cause of LSCS is fetal distressin (54.5%) of control and (42.4%) of case group. Post-operative complication were more in case (16.9%), versus (3.4%) in control. Fetal complication were more in case group (22%), versus control (6.8%) regarding birth asphyxia, RDS, neonatal jaundice, neonatal septicemia, meconium aspiration syndrome, macrosomia and neonatal death. So this study showed that maternal and fetal perinatal morbidiy were quite high in post-dated pregnancy. There is scope for further improvement of clinical care practices of post-dated pregnant womenwith acceptable maternal and fetal outcome. J Shaheed Suhrawardy Med Coll 2021; 13(2): 130-136

Home Health Care Clinicians' Use of Judgment Language for Black and Hispanic Patients: Natural Language Processing Study.

A clinician's biased behavior toward patients can affect the quality of care. Recent literature reviews report on widespread implicit biases among clinicians. Although emerging studies in hospital settings show racial biases in the language used in clinical documentation within electronic health records, no studies have yet investigated the extent of judgment language in home health care. We aimed to examine racial differences in judgment language use and the relationship between judgment language use and the amount of time clinicians spent on home visits as a reflection of care quality in home health care. This study is a retrospective observational cohort study. Study data were extracted from a large urban home health care organization in the Northeastern United States. Study data set included patients (N=45,384) who received home health care services between January 1 and December 31, 2019. The study applied a natural language processing algorithm to automatically detect the language of judgment in clinical notes. The use of judgment language was observed in 38% (n=17,141) of the patients. The highest use of judgment language was found in Hispanic (7,167/66,282, 10.8% of all clinical notes), followed by Black (7,010/65,628, 10.7%), White (10,206/107,626, 9.5%), and Asian (1,756/22,548, 7.8%) patients. Black and Hispanic patients were 14% more likely to have notes with judgment language than White patients. The length of a home health care visit was reduced by 21 minutes when judgment language was used. Racial differences were identified in judgment language use. When judgment language is used, clinicians spend less time at patients' homes. Because the language clinicians use in documentation is associated with the time spent providing care, further research is needed to study the impact of using judgment language on quality of home health care. Policy, education, and clinical practice improvements are needed to address the biases behind judgment language.

Short-term medical student placements completed consecutively at a rural general practice positively impact chronic disease management

Little is known about how medical school placements in rural areas impact key stakeholders such as patients, host organisations and the wider rural community. With engagement from rural communities crucial to the success of rural medical training, this case study sought to demonstrate the benefit that rural clinical placements can have on rural general practices (systems) and likely impacts on communities (health outcomes). Specifically, we describe how a series of consecutive short-term student placements in a single rural practice were the drivers of a series of clinical audits and interventions resulting in improved management of chronic disease. Data for this project were obtained from student research reports completed as part of a rural and remote medicine rotation at an Australian medical school. For this series of projects, eight consecutive students were based at the same rural medical centre, with each attending for 6 weeks across a 15-month period, completing a report for a quality improvement activity and evaluating the outcomes. Each project related to chronic kidney disease (CKD), with CKD chosen based on the needs of the medical centre and the higher burden of this disease in rural areas. Each project was developed and delivered in consultation with the practice, taking into account student interest and skills, and related projects completed prior or concurrently. Projects were related to database management (n=2), alignment between CKD management and best-practice guidelines (n=3), patient health literacy (n=3), and a summary and staff perceptions of the preceding quality improvement activities (n=1). The combination of student projects led to tangible improvements in CKD management at a rural general practice. All doctors at the medical centre (n=4) reported using the database management tools implemented by the students and felt the interventions were sustainable, long-term solutions for ensuring clinical investigations are not being delayed or missed. Following the various interventions completed by the students, clinician knowledge and implementation of best-practice CKD management increased, and some patients became more aware of their condition and how to manage it. This case study provides evidence that short-term rural clinical placements for medical students have the potential to greatly improve health care and clinical practice in rural and remote communities, when designed around a consistent topic within a medical practice. Outcomes of the student projects in combination demonstrate that addressing CKD management longitudinally led to improvements in administrative processes, clinical practices, and patient awareness and accountability, despite each student only being at the medical centre for a short period of time. Similar approaches to structuring rural clinical placements and defining community projects for medical students should be considered more broadly.

Improving VTE prophylaxis in ward and ICU surgical urology patients: a Six-Sigma DMAIC methodology improvement project

PurposeThis study intends to improve the quality of venous thromboembolism (VTE) prophylaxis practices including proper VTE risk assessment and the appropriate prophylaxis measures for surgical urology patients.Design/methodology/approachThe authors applied the Six-Sigma define, measure, analyze, improve and control (DMAIC) improvement methodology in a pre–post interventional study that involved all adult patients above 18 years old indicated and scheduled for urology surgical interventions including endoscopic urological surgeries in a urology specialized 60-bed hospital. The pre-intervention sample included all patients meeting the inclusion criteria over a period of six months. Post-intervention sample included all patients meeting the inclusion criteria over a period of six months. The improvement areas included both the VTE risk assessment as well as the VTE prophylaxis prescription.FindingsDMAIC methodology has achieved a substantial sustained improvement in surgical urology VTE prophylaxis practices with an average of 70% on both levels; VTE risk assessment practices and VTE prophylaxis prescribing practices were statistically significant. The post-intervention results also showed a statistically controlled process with no special cause variations. Based on the study results, the Six-Sigma DMAIC methodology can be considered of high value when applied in healthcare clinical practice improvement projects.Research limitations/implicationsThe project study includes some pitfalls that can be addressed as follows: 1. The lack of VTE rate incidence tracking. This limitation can be partly refuted when the authors conduct a literature review and explore that the VTE prophylaxis effectiveness had been proven with sufficient evidence to an extent that pushed several scientific societies to develop their own guidelines to support VTE prophylaxis. (Algattas et al., 2018). 2. Another limitation of this study can be that it handled only surgical patients and more specifically surgical urology patients. Of course, VTE prophylaxis is a crucial life-threatening problem not only for the surgical admitted patients but also for all the medical admitted patients either in hospital wards or ICUs. However, the prediction that surgical patients especially surgical urology patients are more prone to VTE development risk as they have -in several cases-two or three main additive risk factors which are age, procedure duration and malignancy in elderly men. (Tikkinen et al., 2014). So, the authors consider the study project to be a prototype that hopefully can be utilized for future study projects that will manage both other surgical specialty patients and medical patients on the national level and can track accurately and effectively report the VTE incidence rates.Practical implicationsSeveral recommendations can be extracted from the research project that is summarized in the following points: Paying focused attention to continuous healthcare quality improvement initiatives and projects as a main approach for healthcare improvement especially for the public health-related problems. This might be achieved through periodic region-specific or specialty-specific focus groups from which public health problems could be addressed and prioritized to be considered as a part of country healthcare campaigns regarding cost-utility and feasibility studies. The adoption of a system thinking approach in dealing with the improvement strategies; all efforts and resources are to be employed to achieve a common objective. This includes the generation of a national-wide electronic health information system that can aid in healthcare resource allocation and direct the healthcare efforts towards the most important, high-priority public health problems. Electronic national-wide health record is really an effort, and resources consuming activity, but actually, it's worth exerting efforts, and its valuable outcomes may be seen several years later. 3. Development of unified national specialized VTE prophylaxis pathways to standardize the patient-specific VTE prophylaxis plans. Standardization of healthcare pathways enables healthcare professionals to follow an evidence-based practice which will be reflected on the improvement of healthcare quality level, cost-effectiveness enhancement, and timely patient care on all levels especially in high critical areas like ER and ICU. 4. Incorporation of VTE prophylaxis costs in the universal health insurance diagnosis-related group (DRG) insurance packages and service pricing. Universal health insurance is a nationwide strategy that is aiming to cover all Egypt residents by the year 2030. Universal health insurance is being following the DRG reimbursement policy that is thought to control all the healthcare-associated costs so, the VTE prophylaxis costs shall be added as the main cost item to encourage all healthcare facilities to follow an evidence-based VTE prophylaxis pathway taking into consideration the high-risk patient categories who will definitely represent a high-cost burden on the long run if they suffer a VTE event.Originality/valueDMAIC improvement methodology applications in healthcare are still relatively limited, especially on the clinical level. The study can be considered one of a kind in Egypt dealing with a comprehensive DMAIC methodology application on the clinical level.

Patient, family member, and ambulance staff experiences of prehospital acute pain management in adults: A systematic review and meta-synthesis.

We aimed to synthesize the qualitative experiences of patients, their family members, and ambulance staff involved in the prehospital management of acute pain in adults and generate recommendations to improve the quality of care. A systematic review was conducted following the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines. We searched from inception to June 2021: MEDLINE, CINAHL Complete, PsycINFO and Web of Science (search alerts were screened up to December 2021). Articles were eligible for inclusion if they reported qualitative data and were published in the English language. The Critical Appraisal Skills Program for qualitative studies checklist was used to assess risk of bias, thematic synthesis was performed on included studies and recommendations for clinical practice improvement were generated. Twenty-five articles were included in the review, representing over 464 patients, family members, and ambulance staff from 8 countries. Six analytical themes and several recommendations to improve clinical practice were generated. Strengthening the patient-clinician relationship by building trust, promoting patient empowerment, addressing patient needs and expectations, and providing a holistic approach to pain treatment is key to improving prehospital pain management in adults. Shared pain management guidelines and training across the prehospital and emergency department intersection should improve the patient journey. Interventions and guidelines that strengthen the patient-clinician relationship and span the prehospital and emergency department phase of care are likely to improve the quality of care for adults suffering acute pain in the prehospital setting.

PROMs and PREMs in routine perinatal care: mixed methods evaluation of their implementation into integrated obstetric care networks

BackgroundIn the transition towards value-based healthcare, patient-reported outcome and experience measures (PROM and PREM) are recommended by international collaborations and government programs to guide clinical practice and quality improvement. For many conditions, using PROM/PREM over the complete continuum of care requires implementation across care organizations and disciplines. Along PROM/PREM implementation in obstetric care networks (OCN), we aimed to evaluate implementation outcomes and the processes influencing these outcomes in the complex context of care networks across the continuum of perinatal care.MethodsThree OCN in the Netherlands implemented PROM/PREM in routine practice, using an internationally developed outcomes set with care professionals and patient advocates. Their aim was to use PROM/PREM results individually to guide patient-specific care decisions and at group-level to improve quality of care. The implementation process was designed following the principles of action research: iteratively planning implementation, action, data generation and reflection to refine subsequent actions, involving both researchers and care professionals. During the one-year implementation period in each OCN, implementation outcomes and processes were evaluated in this mixed-methods study. Data generation (including observation, surveys and focus groups) and analysis were guided by two theoretical implementation frameworks: the Normalization Process Theory and Proctor’s taxonomy for implementation outcomes. Qualitative findings were supplemented with survey data to solidify findings in a broader group of care professionals.ResultsCare professionals in OCN found the use of PROM/PREM acceptable and appropriate, recognized their benefits and felt facilitated in their patient-centered goals and vision. However, feasibility for daily practice was low, mainly due to IT issues and time constraints. Hence PROM/PREM implementation did not sustain, but strategies for future PROM/PREM implementation were formulated in all OCN. Processes contributing positively to implementation outcomes were internalization (understand the value) and initiation (driven by key-participants), whereas challenges in relational integration (maintain confidence) and reconfiguration (refine activities) affected implementation negatively.ConclusionAlthough implementation did not sustain, network-broad PROM/PREM use in clinic and quality improvement matched professionals’ motivation. This study provides recommendations to implement PROM/PREM meaningfully in practice in ways that support professionals in their drive towards patient-centered care. In order for PROM/PREM to fulfill their potential for value-based healthcare, our work highlights the need for sustainable IT infrastructures, as well as an iterative approach to refine their complex implementation into local contexts.

Vancomycin audit in the paediatric population: Patterns of use and appropriateness of therapeutic drug monitoring.

This study aims to investigate prescribing and therapeutic drug monitoring (TDM) practices for vancomycin in paediatrics at the Jordan University Hospital and to determine the impact of inaccuracies in TDM data on dosing decisions. Patterns of vancomycin prescriptions, appropriateness of vancomycin dosing, duration, TDM, and the accuracy of the recorded dosing/sampling times were determined prospectively based on prespecified criteria. Finally, Monte Carlo simulations were undertaken using the mrgsolve-package in R to assess the effect of inaccuracies in recording dosing/sampling times on subsequent dose adjustments. Four hundred forty-two vancomycin courses were analysed. Vancomycin prescriptions were mainly empirical (77.4%). Initial vancomycin doses were appropriate in 73.1% of vancomycin courses. Prolonged use (>5days) was found in 45.7% of admissions with negative cultures; this was related to the diagnosis of suspected sepsis unadjusted-OR: 1.8 (1.1-2.9). TDM was appropriately ordered in 90.7% of concentrations. Discrepancies between the recorded and actual times were noted in 83.9% and 82.7% of audited times of dose administration and sample collection, respectively. Based on simulations, these discrepancies were predicted to result in inappropriate dose adjustment in 37.9% of patients. Inappropriate empirical and prolonged vancomycin use and inaccuracies in recording dosing/sampling times are important areas of improvement in the current clinical practice.

An evaluation of the implementation of an intraventricular haemorrhage care bundle from a nursing perspective

The aim of this study is to explore the implementation and evaluation of a neonatal nursing intraventricular haemorrhage (IVH) care bundle, to determine areas for improvement in clinical practice. Overall, nurses felt confident in their knowledge about the implementation of the intraventricular haemorrhage care bundle and felt their nursing practice had changed as a result. An increase in nursing workload was reported by some which is exacerbated by shortages of neonatal nurses in the United Kingdom and should be considered during implementation. A cohesive teaching package with areas of ongoing learning is vital to avoid any confusion in the clinical setting, with guidelines and information packs available to staff. Nursing staff had an overall positive experience with the implementation of the intraventricular haemorrhage prevention care bundle and felt it significantly benefits neonates at risk of intraventricular haemorrhage and brings change in practice.