Kingston Health Sciences Centre Research Articles

Ten-Year Review of the Postpartum Maternal Health Clinic at the Kingston Health Sciences Centre

ObjectivesThe postpartum Maternal Health Clinic (MHC) sees patients who have experienced pregnancy complications identified as pregnancy-related cardiovascular disease (CVD) risk indicators (hypertensive disorders of pregnancy, gestational diabetes, placental abruption, idiopathic preterm delivery, and intrauterine growth restriction) at 6 months postpartum for CVD risk screening. This project aimed to summarise the past 10 years of the MHC and identify trends in patient characteristics, patient CVD risk assessments, and clinic attendance over time. MethodsPatients included in this study have experienced 1 or more pregnancy-related CVD risk indicator(s) and have delivered between April 2011 and April 2021. MHC patient data and the Better Outcomes Registry Network database were utilised to compare eligible and participating patient data during clinically significant time periods. ResultsThe clinic has seen 1030 patients in the last 10 years and their characteristics have remained largely consistent. However, there has been an increase in the proportion of patients seen because of a hypertensive disorder and an increase in the proportion of patients with obesity, abnormal total cholesterol, and elevated fasting glucose. Additionally, CVD risk scores and the prevalence of metabolic syndrome have remained consistent over the years. Regarding the clinic’s outreach, patient eligibility for the MHC has been increasing while attendance has been decreasing over time. ConclusionsOverall, there remains a need to screen these patients for CVD risk and counsel them on risk reduction. There is also an opportunity to increase patient recruitment to improve attendance and to address the increased need for CVD risk screening and counselling in the community.

Improving Access to Care, Patient Costs, and Environmental Impact Through a Community Outreach Lung Cancer Rapid Assessment Clinic.

In Southeastern Ontario, increased patient distance from the regional lung cancer diagnostic assessment program (LDAP) is associated with a lower likelihood of patient care via LDAP while receiving care via LDAP is associated with improved survival. We implemented an LDAP outreach clinic to provide specialist assessment for patients with suspected lung cancer at a regional community hospital and assessed the impact on timeliness and accessibility of care. The Kingston Health Sciences Centre LDAP team engaged with community hospital partners to develop and launch the LDAP outreach clinic. We performed a retrospective chart review of LDAP patients (N = 1,070) before (August-November 2021; n = 234) and after implementation of the outreach clinic (November 2021-October 2022; n = 836). Descriptive data are reported as No. (%). Unpaired t tests and statistical process control charts assess for significance. A cost analysis of out-of-pocket patient costs related to travel and parking is presented in 2022 Canadian dollars (CAD). Compared with a 3-month matched time period before (August-October 2021) and after outreach clinic (August-October 2022), the mean time from referral to assessment and time from referral to diagnosis decreased from 20.3 to 14.4 days (P = .0019) and 40.0 to 28.9 days (P = .0007), respectively. Over 12 months, the total patient travel was reduced by 8,856 km, which combined with parking cost-savings, resulted in patient out-of-pocket savings of CAD $5,755.60 (CAD $47.60/patient). Accounting for physician travel, the total travel saved was 5,688 km, corresponding to reduced CO2 emissions by 1.9 tCO2. Implementation of a lung cancer outreach clinic led to improved timeliness of care, patient cost-savings, and reduced carbon footprint while serving patients in their community.

A149 SAFETY AND EFFICACY OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR ESOPHAGOGASTRIC NEOPLASMS IN A CANADIAN SETTING

Abstract Background Endoscopic submucosal dissection (ESD) is a technique that has been developed in Japan and is increasingly being adopted by western countries for treatment of superficial gastrointestinal neoplasms. Aims In this study, we aim to present the safety and efficacy of ESD for esophageal and gastric neoplasms in a Canadian setting, given the limited data regarding the outcomes of ESD in North America Methods Data of 100 patients with superficial upper GI neoplasms (esophageal and gastric) who underwent ESD between 2016 and 2022 in Kingston Health Sciences Centre, a tertiary hospital in Kingston, Ontario, were retrospectively reviewed. Demographics and lesion characteristics, ESD technique, and outcomes in terms of efficacy and safety were analyzed. Results 100 patients were included in the study. 67% of the lesions were esophageal. The median diameter was 4.6cm and median area was 11.94cm2. Outcomes were favorable with technical success 98%, en bloc resection 96%, R0 resection 89% and curative resection 80%. Upstage in pathology from index biopsy was seen in 42% of the lesions. Adverse events were infrequently encountered (8%) and included delayed bleeding, aspiration, and pain. Conclusions ESD is a safe and effective modality for accurately diagnosing and treating early and superficial esophagogastric neoplasms when performed by trained endoscopists. Further research is required, however, to increase the adoption of this technique across Canada. Procedural Details Funding Agencies None

Pandemic Patient Engagement Success: Maintaining Family Presence Through Partnership

This presentation is relevant for patients of hospitals and residents of long-term care facilities, their loved ones and essential partners in care, and staff and leadership of healthcare facilities.
 A painful pandemic challenge for patients, families and staff in hospitals was the absence of loved ones or essential care partners through Family Presence/Visitor Policy restrictions. Leadership at Kingston Health Sciences Centre (KHSC) worked proactively with the Patient and Family Advisory Council and a small, diverse group of Patient Experience Advisors to plan for possible restrictions and consider how best to approach ongoing changes and challenges to the policy expected in the face of the pandemic. The group continues to work together at this time of uncertainty.
 An initial meeting of eight advisors and leaders took place prior to the World Health Organization’s official announcement of the pandemic. Due to growing concern about hospital infections, the meeting venue was a local coffee shop, hence the group became known throughout the hospital as The Balzac’s Group. Synchronous virtual meetings and asynchronous communication were employed by the group to address concerns and create family presence opportunities on a rapid response basis. Group collaboration remains evident as new concerns arise with the ongoing ebb and flow of COVID-19 hospitalizations, staff shortages and less restrictive family presence policies. This partnership has been pivotal to the organization’s pandemic planning and response, enabling family presence while respecting government directives, organizational challenges, and patient/family priorities.
 This collaboration informed several new and sustained initiatives including: a virtual visits process, ePostcards, a Care Partner Program, expanded cell phone use in restricted areas, resources for loved ones traveling distances, careful and measured increases in family presence and a family presence policy Exceptions Committee.
 An unexpected outcome was an increased level of respect and strengthened patient engagement. Factors influencing this success were transparency and trust in sharing sensitive or confidential information, mutual decision-making, frank and honest sharing of both personal and professional perspectives, and active listening. Many KHSC advisors increased their patient partnership activities during the pandemic and felt an enhanced sense of agency in their efforts to improve the patient experience in healthcare.
 
 This initiative may be a source of new ideas, inspiration, and encouragement for patient partners and hospital leaders to actively partner in co-design and delivery of compassionate person-centred policies and care, especially during times of crisis.
 The group continues to be the “go-to” group for family presence policy questions. The strengthened relationship with Patient Advisors has had a spillover effect more broadly into other hospital initiatives and increased awareness of the value of their input. We hope to continue to share this success story broadly to encourage other healthcare facilities to partner with the precious resource of patients, families, and patient advisors, at all levels of health care. We are considering a Patient Advisor led publication in the future.

Modern Scurvy and Hematology: A Retrospective Chart Review in Kingston, Ontario

DISCUSSION Historically known as scurvy, Vitamin C deficiency is a rare disorder in developed countries that can lead to bleeding diathesis. A recognized increase in the number of patients found to have Vitamin C deficiency at Kingston Health Sciences Centre (KHSC) prompted a need to re-evaluate the prevalence, predisposing factors, and management of this nutritional deficiency. We conducted a retrospective chart review of patients evaluated by the Hematology service at KHSC between March 2017 and June 2023 who were found to be Vitamin C deficient, defined as a Vitamin C level <25 μmol/L. Twenty-three patients were identified. Data collected included patient demographics, socioeconomic status, co-morbidities, clinical presentation, concurrent hematologic abnormalities, and treatment strategies. Twenty-three patients with Vitamin C deficiency were evaluated by Hematology at KHSC between March 2017 and June 2023. Almost half (43.5%, n=10) of patients were first assessed in the General Hematology clinic, while 30.4% (n=7) were seen by the inpatient Hematology consult service and 26.1% (n=6) were first seen in the Bleeding Disorders clinic. Most patients (65.2%, n=15) were assigned male sex at birth. All adult age ranges were represented: 30.4% (n=7) were younger than 40, 56.5% (n=13) were ages 40 through 65, and 13.0% (n=3) were older than 65. Four (17.4%) patients had previously undergone weight loss surgery, while five (21.7%) had Type 2 diabetes mellitus. Close to half (43.7%, n=10) of patients were taking a proton pump inhibitor daily, while 78.3% (n=18) were taking nutritional supplements other than Vitamin C. Over one quarter (26.2%, n=6) of patients reported significant alcohol use, defined as greater than or equal to 10 drinks per week on average. The majority (69.6%, n=16) of individuals used recreational substances daily, including cigarettes, alcohol, or marijuana. The primary source of income for 30.4% (n=7) of individuals was government-funded income support, while 30.4% (n=7) were retired and 26.1% (n=6) were actively employed. The most common reasons for referral to Hematology was assessment for bleeding disorders (43.5%, n=10) and cytopenia(s) (43.5%, n=10), followed by splenomegaly (n=1), pulmonary embolism (n=1), and macrocytosis (n=1). Seven patients (30.4%) experienced major bleeding, defined as bleeding that required hospitalization or guideline-directed transfusion of red blood cells. Common symptoms at presentation included menorrhagia (42.9% of female patients, n=3), gingival bleeding (34.8%, n=8), hematoma (30.4%, n=7), epistaxis (30.4%, n=7), subjective easy ecchymosis (30.4%, n=7), and subjective delayed wound healing (26.1%, n=6). A Vitamin C level ($20.50 CAD per test at KHSC) was ordered on the first assessment by Hematology in 73.7% (n=14) of patients. The Vitamin C level was undetectable (<5 μmol/L) in 47.8% (n=11) of patients. The mean Vitamin C level among patients in which it was detectable was 13.5 μmol/L. Vitamin C levels were repeated in four patients and remained low in one. Studies for von Willebrand Disease ($268.76 CAD per patient at KHSC) were obtained in 43.5% (n=10) of patients; one of these patients was diagnosed with acquired von Willebrand disease. Nearly one third (30.4%, n=7) of patients were also Vitamin B12 deficient, while 39.1% (n=9) were iron deficient and 13.0% (n=3) were Vitamin D deficient. The mean hemoglobin when first assessed by Hematology was 126 g/L among females and 117 g/L among males. Three patients (13.0%) were treated with intravenous Vitamin C; the remainder were treated with oral Vitamin C supplementation or dietary modifications. Ten patients (43.5%) were referred to a dietician as part of their treatment plan. Three patients (13.0%) were prescribed tranexamic acid for bleeding symptoms. Despite its perceived rarity in modern times, Vitamin C deficiency has contributed to a variety of presentations of bleeding diathesis encountered by Hematologists in Kingston, Ontario in recent years. Thus, detailed dietary and social histories, with consequent consideration of Vitamin C status, should be undertaken in the assessment of undifferentiated bleeding disorders. Increased awareness of the prevalence and presentation of Vitamin C deficiency could facilitate earlier diagnosis and appropriate management, including a decrease in costly testing for other bleeding disorders.

Urgent care-seeking and injury severity for intimate partner violence during COVID-19: a Canadian retrospective chart review

BackgroundEarly reports raised alarms that intimate partner violence (IPV) increased during the COVID-19 pandemic, but initial studies showed that visits to emergency departments (EDs) decreased. This study assessed the impact of the prolonged pandemic and its associated restrictions on both rates of urgent care-seeking and injury severity for IPV.MethodsData from the Kingston Health Sciences Centre’s (KHSC) ED were utilized to compare IPV presentations during ‘Pre-COVID’ (December 17, 2018 – March 16, 2020) and ‘COVID’ (March 17, 2020 – June 16, 2021), as well as three periods of heightened local restrictions: ‘Lockdown-1’ (March 17 – June 12, 2020), ‘Lockdown-2’ (December 26, 2020 – February 10, 2021) and ‘Lockdown-3’ (April 8 – June 2, 2021). The primary outcomes were incidence rate of IPV visits and injury severity, which was assessed using the Clinical Injury Extent Score (CIES) and Injury Severity Score (ISS).ResultsA total of 128 individuals were included. This sample had mean age of 34 years, was comprised of mostly women (97%), and represented a variety of intimate relationship types. Some individuals presented multiple times, resulting in a total of 139 acute IPV presentations. The frequency of IPV visits during COVID was similar to the Pre-COVID time period (67 vs. 72; p = 0.67). Incidence rate was 13% higher during COVID, though this difference was non-significant (6.66 vs. 5.90; p = 0.47). IPV visit frequency varied across lockdown periods (11 in Lockdown-1, 12 in Lockdown-2 and 6 in Lockdown-3), with the highest incidence rate during Lockdown-2 (12.71). There were more moderate and severe injuries during COVID compared to Pre-COVID, but mean CIES was not statistically significantly different (1.91 vs. 1.69; p = 0.29), nor was mean ISS (11.88 vs. 12.52; p = 0.73).ConclusionsDuring the 15-months following the start of COVID-19, there were small, but non-significant increases in both incidence rate and severity of IPV presentations to the KHSC ED. This may reflect escalation of violence as pandemic restrictions persisted and requires further investigation.

Primary Care Management Pathways to Reduce Wait Times in Hematology: Monoclonal Gammopathy of Undetermined Significance

Background:Prolonged wait times are a worsening barrier to accessing specialist care in Canada and other countries across the globe. The flow of patients between primary care and specialists has been a recognized area for improvement (Liddy et al., 2020; Moir & Barua, 2021). Kingston Health Sciences Centre (KHSC) has aimed to optimize referrals through the implementation of primary care management pathways (PCMPs). PCMPs are diagnostic and/or treatment algorithms, co-developed by local primary care physicians and specialists with input from patients. They are designed to support primary care providers in managing low risk medical conditions in the community while more quickly identifying patients with higher risk conditions to be seen by specialists. A PCMP was implemented in June 2021 for Monoclonal Gammopathy of Undetermined Significance (MGUS) (https://kingstonhsc.ca/refer/hematology). This asymptomatic condition with low levels of monoclonal protein in the blood or urine has an approximately 1% per year risk of transforming to a hematological malignancy such as multiple myeloma (Kyle et al., 2018). The MGUS PCMP outlines diagnostic criteria, management, and monitoring instructions for low-risk MGUS along with patient information. “Red flag” features, such as renal impairment, anemia or significantly increased monoclonal protein levels, are used to highlight those who need urgent referral. The aim of this study is to evaluate the impact of an MGUS PCMP on wait times in Hematology in Kingston, Ontario. Methods:All consecutive outpatient Hematology referrals received at KHSC from January 2021 to December 2022 were reviewed. Monthly outcome measures included the number of new referrals and median wait times for patients seen. Number of MGUS referrals deferred to the PCMP was included as a process measure. Monthly balancing measures included number of re-referrals of PCMP patients, number of deaths without being seen for MGUS, and number of new multiple myeloma diagnoses. To compare 6-month pre-PCMP implementation (January 2021 to June 2021) with 18-month post-PCMP implementation (July 2021 to December 2022), generalized linear regression analysis was conducted. p < 0.05 was considered statistically significant. A survey of primary care providers was distributed through the regional Primary Care Physicians' Council to assess primary care satisfaction with the PCMP. Results: Between January 2021 and December 2022, 4504 Hematology referrals were received, 278 (6%) of which were MGUS referrals. 76 (27%) of MGUS referrals were deferred to the PCMP. There was a significant increase in monthly Hematology referrals from a mean (± standard deviation (SD)) of 163.0 (± 13.9) pre-PCMP to 195.9 (± 27.3) post-PCMP (p<0.0001). There was no significant difference in mean monthly MGUS referrals pre-and post-PCMP (11.7 ± 4.7 versus 11.6 ± 3.5). Hematology's median wait time for those seen fell from a median (interquartile range (IQR)) of 51.3 days (13) pre-PCMP to 28.5 days (11) post-PCMP (p < 0.0001). The MGUS median wait time also fell from a median (IQR) of 40.5 days (59) to 37.0 days (32.5) (p < 0.0001). No significant difference was noted in the balancing measures. Pre-PCMP to post-PCMP, the mean number of deaths without being seen for MGUS (0.17 ± 0.41 versus 0.17 ± 0.38, p=0.36) and mean monthly new multiple myeloma diagnoses (5.17 ± 1.94 versus 5.17 ± 2.50, p = 0.54) remained stable. There were 7/76 (9.2%) re-referrals of patients deferred to the PCMP, with a median (IQR) time to re-referral of 64 days (348). A survey to assess primary care provider satisfaction with the PCMP included a total of 28 respondents; 19/28 (67.9%) reported using PCMPs. On a scale of 0 to 5, where 5 is the highest satisfaction, the median (IQR) overall experience was 4/5 (1.5) and impacts on supporting patient care and changing management were also 4/5 (1). The most common concern, raised by 7/28 respondents (25%), was the downloading of more work to primary care. Conclusion: The MGUS PCMP was associated with reduction in wait times for overall Hematology and MGUS despite an increase in referrals. Limitations of this study include concurrent changes in the program, including staffing and the COVID-19 pandemic. These results suggest that PCMPs may be an effective tool to address Hematology wait times, likely best complemented with other strategies to avoid overburdening primary care providers.

Potential application of ultra-low field portable MRI in the ICU to improve CT and MRI access in Canadian hospitals: a multi-center retrospective analysis.

To highlight the value of Portable MRI in ICU and to recommend use case scenarios for portable MRI in ICU patients that may increase capacity for fixed CT and MRI units. Urgent neuroimaging is commonly required in ICU. Typically, ICU patients are transported to Radiology for assessment in fixed CT and MRI units. Portable MRI use in Canadian ICU settings offers the potential advantages of reduced transport risk, earlier diagnosis, improved triaging, as well as the ability to perform frequent re-imaging at the bedside. This frees up time on fixed CT and MRI units, leading to enhanced capacity to perform CT and MRI on other patients. Portable MRI use case scenarios in Canadian institutions have not been established and potential beneficial effect on wait times has not been analyzed. A retrospective semi-quantitative descriptive analysis was performed using all ICU neuroimaging requisitions (CT and MRI) over a 12-month period between January and December 2021, at Kingston Health Sciences Centre, Queen's University (Kingston, Ontario) and St. Michael's Hospital, Unity Health, University of Toronto (Toronto, Ontario). Indications for portable MRI in ICU patients were established. The number of ICU patients who could potentially undergo portable MRI was determined. Fixed CT and MRI scan times saved were calculated. In ICU patients, portable MRI could potentially replace fixed CT in 21% and fixed MRI in 26.5% of cases. This equates to annual capacity increase of 1,676 additional patients being able to undergo fixed CT scans and 324 additional patients being able to undergo fixed MRI. Implementation of portable MRI in the ICU for select neurological indications can have a significant positive impact on CT and MRI wait times in Canadian hospitals.

Utility of routine postoperative chest radiography in patients undergoing clavicle fixation: a retrospective chart review.

Although uncommon, pneumothorax is a potentially serious complication following open reduction and internal fixation (ORIF) of clavicle fractures. In many centres it is routine practice to obtain postoperative chest radiographs following ORIF of clavicle fractures to assess for iatrogenic pneumothorax. Given the need to contain health care costs, the low sensitivity for detecting small pneumothorax and a desire to decrease patient radiation exposure, the practice of ordering chest radiographs following ORIF of clavicle fractures may be unnecessary. All patients undergoing ORIF of clavicle fractures with plate and screw fixation at Kingston Health Sciences Centre between April 2009 and June 2020 were identified from the Discharge Abstract Database (inpatient) and National Ambulatory Care Reporting System (outpatient) using relevant Canadian Classification of Health Intervention procedure codes. Charts were manually reviewed to confirm diagnosis and procedure, and patients with preoperative pneumothorax were excluded. The frequency of postoperative chest radiograph and pneumothorax detection were calculated. Among the 292 patients who underwent ORIF of clavicle fractures during the study period, 17 were excluded for having a pneumothorax on preoperative chest radiograph. Of the remaining 275 patients, 101 (36.7%) had postoperative chest radiographs, of whom none were found to have postoperative iatrogenic pneumothorax. Since 2009, the rate of routine postoperative chest radiography following ORIF of clavicle fractures is 36.7% at our centre. During this time period, none of the 101 patients who had postoperative chest radiographs had a postoperative iatrogenic pneumothorax. To our knowledge, this is the largest series of patients available, and our findings confirm those of several smaller studies. Owing to the low rate of postoperative iatrogenic pneumothorax, we conclude that postoperative chest radiography is unnecessary following ORIF of clavicle fractures.

Improving access to vision rehabilitation care: implementation of the South East Ontario Vision Rehabilitation Service

ObjectiveTo investigate the effect of the South East Ontario Vision Rehabilitation Service (SOVRS), a centrally administered, regionally delivered vision rehabilitation service, on access to vision rehabilitation care. DesignPre-implementation (n = 1196) and post-implementation (n = 414) observational study. ParticipantsPatients referred for low-vision assessment at the hospital-based Kingston Health Sciences Centre Vision Rehabilitation Clinic and community-based Southeastern Vision Loss Rehabilitation Ontario clinics from 2014 to 2019. MethodsMarkers for access to care (e.g., patient rurality, diversity of referral source, distance and time travelled, and wait times) were compared before and after SOVRS implementation. ResultsAfter SOVRS implementation, there was a significant increase (p < 0.001) in the number of rural patients seen in the community. After SOVRS implementation, the hospital-based Vision Rehabilitation Clinic site experienced a significant increase in referrals from outside of Kingston (p < 0.001) and non-eye-care clinicians (p < 0.001), a significant reduction in patient time and distance travelled (p < 0.001), a 6% decrease in median wait time for low-vision assessments, and a significant reduction in wait time between referral and first available appointment (p = 0.011). ConclusionSOVRS, a novel service-delivery model for vision rehabilitation care, improved the delivery of and access to vision rehabilitation care in southeast Ontario through the integration of regional resources and services.

A252 LONG-TERM OUTCOMES IN INFLAMMATORY BOWEL DISEASE PATIENTS WITH PRIMARY SCLEROSING CHOLANGITIS: KINGSTON HEALTH SCIENCES CENTER LOCAL EXPERIENCE

Abstract Background IBD-PSC remains a poorly understood entity due to it’s low incidence and the heterogeneity found within this patient population. Patients with IBD-PSC have 0.3-2.8% lifetime risk of developing hepatocellular carcinoma, up to a 20% lifetime risk of developing Cholangiocarcinoma and a 20-30% lifetime risk of developing Colorectal Cancer (Fung et al. World J Gastroenterol 2019). To better understand long-term outcomes in this population, the use of large population level data can be useful but requires case validation. Purpose A large multicenter Canadian retrospective cohort study is ongoing with the goals of identifying an algorithm to identify IBD-PSC patients and compare long-term outcomes of IBD-PSC patients with a matched IBD cohort (Ricciuto et al, ongoing). This abstract describes the local data within Kingston Health Sciences Centre (KHSC) from this Canadian multi-center study and evaluates the use of ICD codes for the identification of IBD-PSC. Method This is a single centre retrospective cohort study of patients with IBD-PSC within KHSC from January 1993 - December 2021. Patients with potential IBD-PSC were initially identified locally using ICD codes for IBD and cholangitis. Charts were reviewed and IBD-PSC diagnosis was confirmed using pathology from liver biopsies and imaging. Those confirmed to have IBD-PSC then had data manually extracted from the local health administrative system. Outcomes of interest were divided into patient demographics, disease phenotype at diagnosis of IBD-PSC and therapies. Patients were followed until death, leaving the KHSC network or the end of the follow-up period. Result(s) Of the 862 patients identified using ICD codes, 16 (2%) were confirmed to have IBD-PSC after chart review. 50% of included patients had other autoimmune diseases. The median age of diagnosis of PSC was 34 years (IQR=22-43) while the median age of diagnosis of IBD was 22 (IQR=15-38). Large duct PSC was found in 88% of patients. Six patients had disease that was exclusively intra-hepatic. Two patients were found to have PSC with auto-immune hepatitis overlap. Mean ALP at diagnosis was 402 (IQR=208-506). Four patients developed cirrhosis, two of which experienced hepatic decompensation. Three patients underwent liver transplant. 81% of patients had ulcerative colitis. At the index lower endoscopy, 33% of patients had Mayo 3 colitis and 75% had involvement of the right colon. During follow up in our study, 81% of patients required systemic steroids and 33% required biologic therapy. Conclusion(s) ICD codes alone cannot reliably identify patients with IBD-PSC. The characteristics of the patients in our local experience are in keeping with existing literature. Completion of this multi-center study will allow for a greater sample size, a matched control group and a better understanding of the long-term impacts of this disease. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Neurological Impairment in Critically Ill Patients on Dialysis: Research Letter for the INCOGNITO-AKI Feasibility Study.

Acute kidney injury (AKI) resulting in kidney replacement therapy is rising among critically ill adults. Long-term kidney replacement therapy and critical illness are independently linked to acute and prolonged cognitive impairment, and structural brain pathology. Poor regional cerebral oxygenation (rSO2) may be a contributing factor. To assess the feasibility of testing the association between intradialytic rSO2 and acute and long-term neurological outcomes. Longitudinal observational study. We enrolled patients initiating continuous kidney replacement therapy or intermittent hemodialysis in the Kingston Health Sciences Centre (KHSC) Intensive Care Unit (ICU). rSO2 was monitored during the first 72 hours of continuous kidney replacement therapy or throughout each intermittent hemodialysis session. We measured acute neurological impairment by daily delirium screening and long-term neurocognitive outcomes using the Kinarm robot, Repeatable Battery for the Assessment of Neuropsychological Status, and brain magnetic resonance imaging. Of 484 ICU patients, 26 met the screening criteria. Two declined, and 13 met at least one exclusion criteria. Eleven patients were enrolled. Eight died in ICU, one died 2 months after discharge, and one declined follow-up. Data capture rates were high: rSO2/vitals (91.3%), and delirium screening and demographics (100%). Longitudinal testing was completed in 50% (1 of 2) of survivors. Enrollment was low due to a variety of factors, limiting our ability to evaluate long-term outcomes. rSO2 and delirium data collection is feasible in critically ill patients undergoing kidney replacement therapy; high mortality limits follow-up.

The Feasibility of a Transitional Care Unit for Patients Newly Started on In-Center Hemodialysis: A Research Letter.

Patients with end-stage kidney disease face high mortality and morbidity after dialysis initiation. Transitional care units (TCUs) are typically 4- to 8-week structured multidisciplinary programs targeted toward patients starting hemodialysis during this high-risk time in their care. The goals of such programs are to provide psychosocial support, provide dialysis modality education, and reduce risks of complications. Despite apparent benefits, the TCU model may be challenging to implement, and the effect on patient outcomes is unclear. To assess a newly created multidisciplinary TCUs' feasibility for patients newly started on hemodialysis. Before-and-after study. Kingston Health Sciences Centre hemodialysis unit in Ontario, Canada. We considered all adult patients (age 18+) who initiated in-center maintenance hemodialysis eligible for the TCU program, although patients on infection control precautions and evening shifts were not able to receive TCU care due to staffing limitations. We defined feasibility as eligible patients completing the TCU program in a timely fashion without additional need for space, no signal of harm, and without explicit concerns from TCU staff or patients at weekly meetings. Key outcomes at 6 months included mortality, proportion hospitalized, dialysis modality, vascular access, initiation of transplant workup, and code status. The TCU care consisted of 1:1 nursing and education until predefined clinical stability and dialysis decisions were satisfied. We compared outcomes among the pre-TCU cohort who initiated hemodialysis between June 2017 and May 2018, and TCU patients who initiated dialysis between June 2018 and March 2019. We summarized outcomes descriptively, along with unadjusted odds ratios (ORs) and 95% confidence intervals (CIs). We included 115 pre-TCU patients and 109 post-TCU patients, of whom 49/109 (45%) entered and completed the TCU. The most common reasons for not participating in the TCU included evening hemodialysis shifts (18/60, 30%) or contact precautions (18/60, 30%). The TCU patients completed the program in a median of 35 (25-47) days. We observed no differences in mortality (9% vs 8%; OR = 0.93, 95% CI = 0.28-3.13) or proportion hospitalized (38% vs 39%; OR = 1.02, 95% CI = 0.51-2.03) between the pre-TCU cohort and TCU patients. There was also no difference in use of home dialysis (16% vs 10%; OR = 1.67, 95% CI = 0.64-4.39), non-catheter access (32% vs 25%; OR = 1.44, 95% CI = 0.69-2.98), initiation of transplant workup (14% vs 12%; OR 1.67; 95% CI = 0.64-4.39), and choosing "do not resuscitate" (DNR) orders (22% vs 19%; OR = 1.22, 95% CI = 0.54-2.77). There was no negative patient or staff feedback on the program. Small sample size and potential for selection bias given inability to provide TCU care for patients on infection control precautions or evening shifts. The TCU accommodated a large number of patients, who completed the program in a timely fashion. The TCU model was determined to be feasible at our center. There was no difference in outcomes due to the small sample size. Future work at our center is required to expand the number of TCU dialysis chairs to evening shifts and evaluate the TCU model in prospective, controlled studies.

Interpretation Services in a Canadian Emergency Department: How Often Are They Utilized for Patients With Limited English Proficiency?

Introduction Patients with limited English proficiency (LEP) face barriers to communication leading to inferior health outcomes when compared with English-proficient patients. Professional interpretation services have been shown to improve healthcare outcomes for patients with LEP but are often underutilized. Methods We conducted a retrospective chart review of all patients who visited the Kingston Health Sciences Centre's ED and urgent care centre between July 2015 and August 2021 and identified as having a non-English preferred language. The demographic and visit information of LEP patients who used LanguageLine (Monterey, CA) were compared to LEP patients who did not use the service. Variables were analysed using t-tests and chi-squared tests. A survey distributed to ED physicians and residents collected perspectives on the facilitators/barriers to LanguageLine use. Results Of the 37,500 visits from LEP patients between 2015 and 2021, 118 (0.31%) used LanguageLine. LEP patients were more likely to access LanguageLine if they were younger (p < 0.001), had a more acute Canadian Triage Acuity Scale (CTAS) score (p < 0.001), and spoke Arabic (p<0.001). All 16 staff/residents who responded to the survey (30% response rate) had at least one LEP patient in the preceding month, and 3/16 (19%) accessed LanguageLine for these patients. Further, 5/16 (31%) reported never using the service, with 4/5 (80%) unaware the service existed. Among those aware of LanguageLine, 7/12 (58%) reported the availability of an ad-hoc interpreter as a reason for not accessing the service. Conclusion Interpretation services are underutilized for LEP patients in the ED, with less than 1% of these patients accessing LanguageLine. Patients were more likely to access LanguageLine if they were younger, spoke Arabic, and had a more acute triage score. Most ED physicians were either unaware of or not accessing LanguageLine despite seeing LEP patients. Future work should aim to improve the use of language services and patient-centred care for LEP patients in the ED.

Therapeutic journey of adolescents and young adults with severe dysmenorrhea and endometriosis

Introduction:We aimed to appreciate the diagnostic and therapeutic journey of young women with endometriosis including disease presentation, obstacles to diagnosis and management, and impact on their life.Methods:We employed a mixed-method design, including chart review, 94-item questionnaire assembled from components of the EPHect EPQ-S and semi-structured interviews. The study setting was Kingston Health Sciences Centre in Kingston, Ontario. Participants were women under 28 years with severe dysmenorrhea. Questionnaire data was analyzed using descriptive statistics. Interviews were coded using the constant comparative analysis method by two analyzers and inter-rater reliability was calculated, then data were compared using a cross-sectional method.Results:Twenty-four participants were identified through chart review, 10 completed the questionnaire, and 5 participated in the interviews. Questionnaire participants, mean age 24.5 years ± 2.3, reported initial pelvic pain at a mean age of 13.9 years (SD 1.9). Fifty percent of participants have an endometriosis diagnosis, at a mean age of 19.2 years (SD 2.6). Three major themes emerged from our analysis. The journey with disease and therapy begins long before diagnosis and creates a culture of self-directed care. Lack of knowledge about endometriosis and women’s health by health care professionals and the public delays diagnosis and therapy. Endometriosis broadly impacts every aspect of an individual’s life.Conclusion:We found that young adults with severe dysmenorrhea and/or endometriosis present with symptoms at a young age. They encounter multiple obstacles in reaching a diagnosis and obtaining therapy. They often self-manage their pelvic pain and experience reduced quality of life.

Editorial Commentary.

No AccessUrology PracticeHealth Policy1 Sep 2022Editorial CommentaryThis article comments on the following:Does Antimicrobial Prophylaxis in Patients with Specific Comorbidities Reduce the Risk of Infection after Simple Cystourethroscopy? J. Curtis Nickel J. Curtis NickelJ. Curtis Nickel Queen’s University and Kingston Health Sciences Centre, Kington, Ontario, Canada More articles by this author View All Author Informationhttps://doi.org/10.1097/UPJ.0000000000000325.02AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Commentary." Urology Practice, 9(5), p. 421 © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesUrology Practice1 Sep 2022Does Antimicrobial Prophylaxis in Patients with Specific Comorbidities Reduce the Risk of Infection after Simple Cystourethroscopy? Volume 9Issue 5September 2022Page: 421-421 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information J. Curtis Nickel Queen’s University and Kingston Health Sciences Centre, Kington, Ontario, Canada More articles by this author Expand All Advertisement PDF downloadLoading ...

Evaluation of Opioid Prescribing Patterns and Use Following Hysterectomy for Benign Indication: A Prospective Cohort Study.

To evaluate surgeon opioid prescribing patterns for patients undergoing hysterectomy for benign indication, as well as patient use of postoperative medications and satisfaction with postoperative pain management. Patients undergoing hysterectomy for benign indications at Kingston Health Sciences Centre were invited to participate in a telephone survey 2 weeks post-surgery to review their analgesia use and pain management. Patient demographics, medical history, intraoperative surgical details, and postoperative prescriptions were gathered through patient record review. Opioid prescribing and utilization patterns were assessed, as was satisfaction with postoperative pain management. Of 124 eligible patients 110 (89%) completed the telephone survey, a mean 15.9 ± 2.3 days after surgery. The mean age of participants was 51.6 ± 11.9 years. Most surgeries (84.5%) were minimally invasive, and 45.5% of patients were discharged within 24 hours of surgery. An opioid prescription was given to 71.8% of participants, and 52.7% used at least 1 dose of opioid medication after discharge. Most participants described very good or adequate postoperative pain management (88.2%). Satisfaction with postoperative pain control was not associated with receipt of an opioid prescription (P=0.89). A greater proportion of those who used 1 or more doses of opioids versus none indicated poor or inadequate pain management (19.0% vs. 4.1%; P=0.035). Many patients do not use postoperative opioid analgesia following hospital discharge after hysterectomy, without experiencing poor pain management. Surgeons should assess each individual and tailor the analgesia plan as necessary, optimizing non-opioid options.

A133 EVALUATION OF DYSPHAGIA IN AN ACADEMIC CENTRE

BackgroundDysphagia is a common referral to gastroenterology with both benign and malignant etiologies. There is a lack of studies regarding its clinical assessment, complications and outcomes in Canada.AimsTo evaluate the assessment and outcomes of secondary and tertiary level dysphagia referrals in adult patients.MethodsWe conducted a retrospective analysis of 98 consecutive adult patients who were initially referred for dysphagia to the Division of Gastroenterology at the Kingston Health Sciences Centre in 2015. Chart reviews were performed to assess demographics, characteristics of dysphagia, time for clinical assessment and outcomes.ResultsOf the referred patients, 19 did not present for their clinic appointment. The majority of patients (60%) were >60 yrs old with an equal distribution of male and female patients. In the assessed patients, reflux was the most common etiology (55.5%) followed by oropharyngeal causes (13.5%) and motility disorders (12%). Only 3 patients of the cohort were diagnosed with esophageal cancer, 2 of whom had metastasis at the time of presentation. Time from referral to clinical assessment was <4 weeks in just 30% and >12 weeks in 55%. For the patients diagnosed with malignancy, 2 were assessed within of 2 weeks while the third patient was assessed and endoscoped at 12 weeks. In patients sent for endoscopy, 28% had an endoscopy <4 weeks after assessment while 47% had endoscopy > 12 weeks after assessment. Manometry was performed in 18% of the patients assessed. Information was available on the course of the dysphagia in 65 patients. Dysphagia had resolved or improved in 83%, remained unchanged in 14% and worsened in 3%.ConclusionsReflux-related dysphagia was by far the most common cause of dysphagia in this referral cohort. Wait times for clinical assessment greatly exceeded current CAG recommendations in the majority. Given current resource constraints, this highlights the need for improved referral information and patient care pathways in the management of patients referred with dysphagia.Funding AgenciesNone

A135 DO VISCOUS SWALLOWS IMPROVE THE DIAGNOSTIC YIELD OF HIGH-RESOLUTION MANOMETRY?

BackgroundEsophageal motility disorders are diagnosed using high-resolution esophageal manometry (HR-EMS) using the Chicago Classification (CC V4.0) which is based on a series of 10 normal saline swallows (LS). Viscous swallows (VS; thickened liquid/applesauce) are often performed during esophageal manometry; however, they were not included within the framework of CC V4.0. Previous literature has suggested inconsistency between LS and VS in up to 25% of studies, yet it remains unclear whether routine use of VS offers any benefit to LS alone in diagnosing manometric abnormalities according to the CC V4.0.AimsTo determine if the routine use of VS improves the diagnostic yield in HR-EMSMethodsA retrospective analysis of all HR-EMS studies performed between December 2020 and July 2021 at Kingston Health Sciences Centre was completed. Demographic information including age, sex, indication for HR-EMS, surgical history, and chronic narcotic use was documented. Each study (consisting of 10 LS and 10 VS) was reviewed independently by a Gastroenterology Fellow and Neurogastroenterologist. A manometric diagnosis using CC V4.0 was made for both LS and VS. Descriptive statistics were performed.ResultsA total of 101 HR-EMS studies were reviewed (33 male, 68 female, age range 26 to 90 years). The most common indication for HR-EMS was dysphagia (87/101) with 23/101 having 2 indications, 30/101 having 3 indications, and 43/101 patients having >3 indications. Prior upper GI tract surgery and chronic narcotic use was recorded in 9/101 and 8/101 patients, respectively. Two HR-EMS studies were excluded due to incomplete protocol. In total, 38.4% (38/99) had normal HR-EMS for both LS and VS. LS and VS that resulted in a CC V4.0 diagnosis were concordant in 37.4%(37/99) and discordant in 24.2% (24/99). Of the 24 discordant studies, 6 had a CC V4.0 diagnosis for LS (4 esophagogastric outflow obstruction (EGJOO), 1 ineffective esophageal motility (IEM), 1 diffuse esophageal spasm) and normal VS. Ten studies had normal LS and a CC V4.0 diagnosis for VS (9 IEM, 1 EGJOO). Eight had differing CC V4.0 diagnoses for LS and VS.ConclusionsLS and VS resulted in concordant diagnoses in the majority of cases. However, there were discordant results in approximately 25% of cases. In nearly half of these studies, the LS was within normal limits whereas VS yielded a diagnosis of an esophageal motility disorder which may be of clinical significance to the patient’s management. The addition of VS to HR-EMS protocol may increase diagnostic yield in symptomatic patients.Funding AgenciesNone

A29 ALBUMIN UTILISATION AT A TERTIARY CARE HOSPITAL

BackgroundAlbumin is a colloidal solution with usage guided by recommendations from Canadian Blood Services (CBS). In Ontario, rates of albumin use increased substantially from 2012 to 2018 despite the lack of development of new indications for using over this time frame. Further, we recently found that >50% of albumin usage in patients with cirrhosis were non-evidence based. Albumin usage in other patient populations is not well described.AimsOur aim was to describe overall usage of albumin stratified by clinical setting, clinical indication, and dosage at a tertiary care hospital.MethodsWe retrospectively identified all albumin prescriptions during two randomly selected non-consecutive months between 2018 and 2019 at Kingston Health Sciences Centre. Data was abstracted from each hospital chart for indication, prescriber specialty, location of patient, amount of albumin ordered, and concentration (5% or 25%). Albumin prescriptions were then defined as either evidence-based or non-evidence based on published literature and guidelines. Overall cost for albumin during the study period was determined based on CBS pricing ($51.47/ 25gms).ResultsA total of 699 albumin prescriptions were dispensed to 317 individuals over December 2018 and May 2019, with a total of 38,458 grams used. Overall, 36% was prescribed for evidence-based indications. The most common indication was plasmapheresis (32%), non-sepsis volume resuscitation (23%), and cardiac surgery (17%). The majority of albumin was prescribed in dialysis unit (32%), ICU (23%), and cardiac sciences unit (11%). The largest prescribers of albumin were intensivists (26%), followed by nephrologists (17%), and cardiac surgeons (15%). There were differences in utilization based on concentration of albumin. Despite limited evidence of benefit, 25% albumin and 5% albumin were used excessively for volume resuscitation and cardiac surgery respectively. When used for an evidence-based indication, the dosing was incorrect in 45% of orders. A total of $79,176 was spent on albumin during the study period. Importantly, only $28,494 was spent on evidence-based indications with appropriate dosage and concentration.ConclusionsOverall, there is significant albumin use for indications lacking substantial evidence. This study identifies the clinical contexts in which there is opportunity to reduce non-evidence-based albumin usage and cut unnecessary expenditure. Targeted quality improvement initiatives are underway.Funding AgenciesNone