Pathway For Management Of Patients Research Articles

Code High Risk Abdomen - CHRA, a novel pathway for the immediate imaging and management of Emergency Laparotomy or Laparoscopy patients, a strong support to the ERAS EL Guidelines.

Code High Risk Abdomen - CHRA, a novel pathway for the immediate imaging and management of Emergency Laparotomy or Laparoscopy patients, a strong support to the ERAS EL Guidelines.

P0426 Lumeneye digital proctoscopy is safe, and streamlines management of immune checkpoint inhibitor-induced colitis

Abstract Background Immune checkpoint inhibitors (CPI) have transformed cancer outcomes, but trigger CPI-colitis in up to 46%, frequently incurring morbidity and CPI discontinuation. Diagnosis is via endoscopy, with >90% involving distal colonic inflammation. Timely diagnosis and treatment improve outcomes and reduce corticosteroid (cs) duration. The rising prevalence of CPI-colitis strains endoscopy services, risking delays in care. The Lumeneye, a cost-effective GI digital proctoscopy tool with biopsy capability, could streamline patient management pathways. Methods A prospective observational feasibility study was conducted at the Royal Marsden Hospital, UK. Patients with suspected CPI- colitis underwent Lumeneye proctoscopy with rectal biopsy sampling in an outpatient setting. Digital images were captured, and clinical data retrieved from electronic medical records. Patient comfort was evaluated using the Modified Gloucester Comfort Scale (MGCS) and, when applicable, compared to standard lower GI endoscopy performed within the previous 6 months. Clinical findings from Lumeneye and standard endoscopy were evaluated for concordance in patients who underwent both within 3 weeks. Results Forty Lumeneye procedures were performed on 37 patients (17 males and 20 females, median age 66 years). Cancers included melanoma (n=17), renal (n=4), lung (n=5), and “other” (n=11). CPI therapies included dual anti-CTLA-4/PD-1/L1 (n=14), and anti-PD-1/L1 monotherapy (n=23). The mean time from referral to examination was shorter for Lumeneye (5 days, IQR 3-7) compared to lower GI endoscopy (21 days, IQR 14-26; p<0.001). The mean procedure time or Lumeneye was 6 (IQR 4-8) minutes. Lumeneye was associated with a lower MGCS score compared to lower GI endoscopy (2 -minimal discomfort vs 3-mild discomfort, p<0.001). Endoscopic findings revealed normal mucosa in 19 patients; the remainder showed varying degrees of oedema, erythema, and erosions (Figure 1). In 5 cases, views were suboptimal. Concordance between Lumeneye and standard endoscopy was observed in 10/13 patients (83%), with histological agreement in 11/13 (85%). In 11 cases, normal mucosal findings informed the rationale for rapid cs taper and administration of topical cs (Clipper). In 3 cases, Lumeneye expedited the diagnosis of severe CPI-colitis, leading to timely anti-TNFa escalation. In one case, suspected melanoma deposits in the rectum prompted investigation of metastatic disease. Conclusion Examination of patients with CPI-colitis in the physician’s office using Lumeneye was safe, well tolerated and reduced the burden on endoscopy services. Lumeneye streamlined the patient pathway by facilitating early, accurate diagnosis and allowing timely escalation or de-escalation of immunosuppressive therapy.

OP03 Redesigning the patient management pathway through prediction of flares in axial spondyloarthritis using a machine learning approach to improve care

Abstract Background and aims Treatment of axial spondyloarthritis (axSpA) involves the management of flares which can be unpredictable. ASAS developed a data-driven definition of flares/disease worsening as an increase in ASDAS-CRP of at least 0.9 points, for use in axSpA clinical trials (1). With the current pressures on clinic capacity, there is a challenge to see flare patients in a timely manner. Artificial intelligence (AI) and natural language processing (NLP) methods provide algorithms for learning systems to recognise disease-related terms and classify clinical phenotypes using large datasets, which may support early identification of patients with a risk of having a flare. In previous work, we presented an approach using NLP to identify patients who may have rheumatic disease with predictors to discriminate patients with diagnosed inflammatory arthritis from controls with non-inflammatory arthritis. With the same aim, we extended the panel of predictors by combining clinical and laboratory data to predict flares in axSpA. Methods 282 axSpA patients seen between January 2016 to May 2024 were included in the study. There are 100 flare and 182 non-flare patients studied. We utilised patient blood test results, demographic information, electronic patient-reported outcomes scores, comorbidity, weight and height. We developed a time series dataset and applied Long Short-Term Memory (LSTM) networks and neural networks (NN) to forecast the risk of flare before their future clinics. Results We conducted predictive modelling to forecast flare and non-flare events using data collected prior to patients upcoming clinic appointments. The dataset was split into training and testing sets based on observations taken 2 months before the clinic visit. Our LSTM model achieved 90.25% accuracy, 0.89 sensitivity, 0.96 specificity, 0.93 precision and 0.98 Area Under the Receiver Operating Characteristic Curve (AUROC) predicting flare and non-flare events 2 months before the clinics. The results are summarized in Table 1. OP03 Table 1.Performance of Long Short-Term Memory (LSTM) and neural networks (NN) on data from 2 months before the clinic visit.AVG ACCURACYAVG SENSITIVITYAVG SPECIFICITYAVG PRECISIONAVG AUROCLSTM (2 months before the next clinics)90.25%0.890.960.930.98NEURAL NETWORK (2 months before the next clinics)71.90%0.910.010.610.5 Conclusions The presented combination of clinical and laboratory data shows promising results for the prediction of flare in axSpA and may in the future assist clinicians in seeing the right patient in the right clinic. A study is planned not only to confirm the results but also to refine the machine learning (ML) models developed and specify disease attributes. In the service redesign, patients identified as at risk of flares will be booked and seen in routine clinics at the right time to prevent flares. This process in the long-term will reduce the reliance on flare and urgent clinics.

Guidelines for peri-discharge management and follow-up of acute exacerbations of chronic obstructive pulmonary disease(2024 edition)

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are important events in the course of chronic obstructive pulmonary disease(COPD), and its diagnosis, treatment and prevention are the focus of disease management. Optimizing the peri-discharge management of AECOPD will help to improve continuity of care, prevent recurrence of acute events in the short time, and improve long-term prognosis. In recent years, evidence on the peri-discharge period and the cluster management of AECOPD has accumulated, and confirming the benefit of early follow-up and management after discharge. By reviewing the available evidence, this guideline aims to standardize discharge management and follow-up pathways for AECOPD patients. This guideline is intended for physicians and nursing staff involved in the clinical practice of COPD.

Multidisciplinary management of gastroesophageal reflux disease: an italian retrospective study

Abstract Background Millions of individuals are affected by gastroesophageal reflux disease (GERD) that causes significant discomfort negatively affecting patients’ overall quality of life. For a collaborative approach of continuous improvement in public health we wanted to know the real-world perspectives in the multidisciplinary and multimodal management pathway. Methods We aimed to interview a sample of gastroenterologists (GE), primary care physicians (GP), and otolaryngologists (ENT) to investigate the management of the intake and treatment of patients reporting symptoms of GERD. Symptoms were divided into typical and extraesophageal, and their severity and impact on quality of life was explored with the GERD Impact Scale (GSI) and Reflux Symptom Index (RSI). Results A total of 6211 patients were analyzed of whom with typical symptoms were 53.5%, while those with extraesophageal symptoms were 46.5%. The latter were more frequently reported by ENT patients (53.6%, p < 0.0001). GSI was highest in patients followed by GE (9 points) and GP (9 points) than ENT specialists (8 points), while the RSI was higher in the ENT group (14.3 ± 6.93) than in the groups of GP and GE, respectively (10.36 ± 6.36 and 10.81 ± 7.30, p < 0.0001). Chest pain had the greatest negative impact on quality of life (p < 0.0001). Of the 3,025 patients who used (proton pump inhibitors) PPIs, non-responders had a lower GSI when treated with a combination of adjunctive drug treatments and bioadhesive compounds, compared with single-component drugs. Conclusions The multidisciplinary and multimodal approach to the management pathway of GERD patients reveals variations in patient profiles by physician specialty, directing toward more appropriate and targeted treatments. In addition, the combination of adjunctive drug treatments and bioadhesive compounds appears to be effective in the management of patients refractory to PPIs. Key messages • The presentation of GERD symptoms is different in accordance with the physician’s speciality: the patients with GERD referred to a gastroenterologist had more severe disease and poorer quality of life. • The combination of adjunctive pharmacological treatments and bioadhesive compounds seems to be effective in the management of PPI refractory patients.

Implications of the Updated Lyon Consensus 2.0 in Clinical Practice

Over the past few decades, efforts have been made to refine the characterization of gastroesophageal reflux disease (GERD) and delineate accurate diagnostic criteria. The original Lyon Consensus published in 2018 defined conclusive diagnostic criteria for GERD, and its subsequent iteration, Lyon Consensus 2.0, provides an updated assessment for actionable GERD. We aim to review the modifications made to the updated consensus, review the supporting literature for said changes, and highlight how these changes may alter clinical practice. The key revisions in the updated consensus are the recommendations to discontinue antisecretory therapy before endoscopic grading, the modifications to endoscopic criteria for proven GERD, the incorporation of wireless pH testing parameters, and the establishment of the threshold for pH-impedance monitoring on antisecretory therapy. Apart from enhancing diagnostic reliability using conclusive and inconclusive thresholds for defining GERD, Lyon Consensus 2.0 provides medical and surgical clinicians the guidance they need to provide clear management pathways for patients with GERD symptoms.

Periprocedural Management and Multidisciplinary Care Pathways for Patients With Cardiac Implantable Electronic Devices: A Scientific Statement From the American Heart Association.

The rapid technological advancements in cardiac implantable electronic devices such as pacemakers, implantable cardioverter defibrillators, and loop recorders, coupled with a rise in the number of patients with these devices, necessitate an updated clinical framework for periprocedural management. The introduction of leadless pacemakers, subcutaneous and extravascular defibrillators, and novel device communication protocols underscores the imperative for clinical updates. This scientific statement provides an inclusive framework for the periprocedural management of patients with these devices, encompassing the planning phase, procedure, and subsequent care coordinated with the primary device managing clinic. Expert contributions from anesthesiologists, cardiac electrophysiologists, and cardiac nurses are consolidated to appraise current evidence, offer patient and health system management strategies, and highlight key areas for future research. The statement, pertinent to a wide range of health care professionals, underscores the importance of quality care pathways for patient safety, optimal device function, and minimization of hemodynamic disturbances or arrhythmias during procedures. Our primary objective is to deliver quality care to the expanding patient cohort with cardiac implanted electronic devices, offering direction in the era of evolving technologies and laying a foundation for sustained education and practice enhancement.

Engagement personas in patients living with atrial fibrillation and multimorbidity, and their caregivers: results from the AFFIRMO international online survey

Abstract Introduction Patients with atrial fibrillation (AF) often experience concomitant long-term health conditions. Their level of engagement, defined as their active role in the management of their condition, is crucial in identifying strategies to improve their care and self-management; similarly, the engagement level of their caregivers is also important. Purpose The AFFIRMO study aims to examine ways of optimising care and self-management for AF patients with multimorbidity by identifying characteristics of engagement personas for patients and their caregivers. Methods An online survey, distributed between June 2022 and January 2023, open to AF patients and their caregivers in five countries (UK, Italy, Denmark, Romania and Spain) collected data related to patients and caregivers’ engagement in the healthcare process using the Patient Health Engagement Scale® (PHE-s), the Altarum Consumer Engagement (ACE), and the Caregiver Health Engagement Scale® (CHE-s). Patients and caregivers were grouped into ‘high’ and ‘low’ engagement groups, based on scale-specific cut-off values, and compared by age group, sex, level of education and country of recruitment, using Chi-square tests (p<0.05). Results 659 patients (311 (47.2%) male, 70.9 (10.2) years), and 201 caregivers (54 (26.9%) male, 58.3 (15.2) years) participated. Based on the PHE-s®, 428 (64.9%) were classified as ‘high’ engagement level. Patients in the high engagement group were significantly more likely to be male, aged <75 years, have secondary level education or above, and have <3 co-morbidities; no differences in engagement level based on country of recruitment. Based on the ACE scale, 369 (56.0%) were categorised as ‘high’ engagement level. Those with ‘high’ engagement were significantly more likely to be <65 years old, living in Northern Europe, educated to degree level or above, and had <3 co-morbidities, with no sex differences in engagement level. One hundred thirty-eight (68.7%) caregivers reported ‘high’ engagement. However, there were no significant differences between sex, age group, region of recruitment, or level of education between high and low engagement in caregivers. Conclusions Identification of engagement personas of patients and their caregivers could help to develop better management pathways for AF patients with multimorbidity.Table 1.Level of engagement

Pitfalls, patience and patients: developing a physiotherapy-led balance clinic.

Balance dysfunction and vestibular conditions are major problems requiring significant resources. There is significant national and international variation in management pathways for such patients. This paper outlines a collaborative project run by the ENT department and two vestibular rehabilitation trained physiotherapists to establish a clinic to manage patients referred to ENT with vestibular and/or balance complaints. As part of a six-month pilot, two physiotherapy-led balance clinics were provided per week. A total of 159 new patients were seen, with only 15 needing ENT consultant input. This led to the successful creation of substantive posts; the clinic has seen 698 patients in its first two years. Patient outcomes and experience have been positive, and accompanied by reduced waiting and in-service times. The authors discuss some of the pitfalls, challenges and opportunities of developing this type of clinic.

Long-Term Adherence to Continuous Positive Airway Pressure in Patients with Obstructive Sleep Apnoea Set Up in a Complete Remote Pathway: A Single-Centre Service Evaluation Project.

Background: Continuous positive airway pressure (CPAP) is the first-line treatment for obstructive sleep apnoea (OSA). Maintaining adherence to CPAP in the long term is a clinical problem, and numerous factors have been identified that impact adherence. Although fully remote diagnostic and CPAP services were frequently utilised during the COVID-19 pandemic for patients with OSA, long-term adherence data have not been published. The aim of this service evaluation project was to describe the long-term adherence to CPAP. We also analysed factors that are associated with it. Methods: two-hundred and eighty patients diagnosed with OSA and set up on CPAP remotely during the first wave of the COVID-19 pandemic as part of routine clinical practice were analysed. Results: One-hundred and seven patients (38%) were fully adherent to CPAP at 24 months, determined by at least 4 h of usage on at least 70% of the days. Of the factors analysed, body mass index, disease severity, driving status and the presence of depression were related to long-term adherence (all p < 0.05). Conclusions: with the likelihood of future pandemics similar to COVID-19, our data provide evidence that fully remote pathways for management of patients with OSA can be designed and be sustainable with good long-term adherence.

Optimizing the care management pathway of patients with ischemia and non-obstructive coronary arteries

Ischemia with non-obstructive coronary arteries (INOCA) is defined by the coexistence of anginal symptoms and demonstrable ischemia, with no evidence of obstructive coronary arteries. The underlying mechanism of INOCA is coronary microvascular dysfunction with or without associated vasospasm. INOCA patients have recurrent symptoms, functional limitations, repeated access to the emergency department, impaired quality of life and a higher incidence of cardiovascular events than the general population. Although well described in chronic coronary syndrome guidelines, INOCA remains underdiagnosed in clinical practice because of insufficient awareness, lack of accurate diagnostic tools, and poorly standardized and consistent definitions to diagnose, both invasively and non-invasively, coronary microvascular dysfunction.To disseminate current scientific evidence on INOCA as a distinct clinical entity, during 2022 we conducted at 30 cardiology units all over the country a clinical practice improvement initiative, with the aim of developing uniform and shared management pathways for INOCA patients across different operational settings. The present document highlights the outcomes of this multidisciplinary initiative.

Dental core training in community dental services.

Community dental services (CDS) provide dental treatment for patients who cannot gain access or have treatment with their general dental practitioner. This includes groups of patients who are dentally phobic, medically compromised, or with physical or learning disabilities.This paper provides insight into the experience and the challenges of working in CDS as a dental core trainee (DCT). The post involves an equal split in the management of paediatric and special care dental patients.Patients seen in CDS can be split into cohorts such as paediatric, special care adults, dental anxious and others. Case discussions throughout the paper will illustrate commonly seen scenarios and exemplify patient management pathways though the service.NHS England Education provide training for DCTs through study days which focus on dental disciplines specific to their post.

Stage of presentation and survival rates of head and neck cancer in Western Cape, South Africa

Background: The Western Cape province in South Africa has a high age-standardised mortality from cancer. Most literature reports significantly poorer access to healthcare, more advanced cancers and worse survival for rural and remote populations. This study investigates if significant disparities exist with regard to stage at presentation and overall survival of patients with head and neck cancer (HNC) between geographical areas within the Western Cape province in South Africa.Methods: A retrospective chart review was conducted on all patients managed at the Combined ENT Head and Neck Oncology clinic at Groote Schuur from January 2010 to December 2014. Ethics approval was granted by the University of Cape Town Human Research Ethics Committee (HREC, 351-2017).Results: Although we observed no significant difference in TNM clinical stages or overall survival between metropolitan and remote patients, there were statistically and clinically significant differences in terms of both stages of HNC and overall survival between some individual metropolitan and remote areas. The remote area of Eden had a median overall survival of more than 6 months less than that of the Southern subdistrict of the City of Cape Town.Conclusion: Differences in HNC stages and overall survivals between some subdistricts of the City of Cape Town and remote areas are not only statistically significant but also clinically relevant.Contribution: This article highlights the need to improve on diagnostic and referral pathways for management of patients with HNC in the Western Cape.

The role of Doppler ultrasound in the evaluation of penile haemodynamics—A sonographer's guide to the documentation of vasculogenic erectile dysfunction

AbstractVasculogenic erectile dysfunction (ED) is the most common form of ED affecting the male population. Once the first line investigation for erectile dysfunction, penile Doppler ultrasound examinations have reduced in number following the introduction of oral phosphodiesterase inhibitors as a treatment method. As such, skilled professionals versed in the performance of these examinations are dwindling. This skill deficit is compounded by the lack of standardisation that exists in the performance and interpretation of penile haemodynamics relative to impotence of vascular origin. Despite the success of pharmacological agents in the treatment of vasculogenic dysfunction, penile Doppler examinations are still relevant in the assessment of ED in non‐responders, and those patients in which pelvic surgery or trauma has altered the normal erectile mechanism. Growing evidence in the literature also suggests that vasculogenic ED may be an early indicator of systemic vascular disease and therefore prognostic of future cardiovascular events. Considering this, the relevance of Doppler assessment of penile haemodynamics with ultrasound should not be underestimated. This article will introduce the sonographer to advanced vascular anatomy of the penis, pathophysiology of erectile function and the principles of normal and pathological penile haemodynamic patterns. It also aims to suggest a standardised protocol for the performance of penile Doppler ultrasound relative to primary vasculogenic ED and reduce the amount of variability that exits between operators. As such the sonographer can make a significant contribution to patient management pathways.

General practitioners' representation of early-stage CKD is a barrier to adequate management and patient empowerment: a phenomenological study.

In high-income countries, chronic kidney disease (CKD) affects over 10% of the population. Identifying these patients early is a priority, especially as new treatments are available to reduce the risk of cardiovascular and renal morbidity. We aimed at understanding the management and care pathway of patients with early-to-moderate CKD defined as an estimated glomerular filtration rate (eGFR) ≥ 45mL/min/1.73m2 (CKD-EPI), by analyzing the experience of general practitioners in a region in France. This qualitative semiopragmatic phenomenological study analyzed in-depth interviews held with a purposive sample (age, gender, training, type of practice, rural/urban context) of 24 general practitioners, with triangulation of research until data saturation. From diagnostic, etiological and prognostic viewpoints, the general practitioners enrolledin our study perceived CKD as a complex, poorly-defined clinical entity in asymptomatic and multimorbid patients. They distinguished it from a rare condition they considered as 'mainly renal'. The fact that they did not perceive early-stage CKD as a disease was a hindrance to patient care, which should protect the kidneys with a preventive approach. Indeed, general practitioners perceived CKD patient management as a pathway requiring a personalized, integrative model, common to all chronic diseases, without necessarily involving a nephrologist, at least in the early stages. This study shows how the general practitioners' representations influence their attitudes and interventions. Clarifying the concept of early-stage CKD by taking factors like age and etiology into account would facilitate personalized management of this heterogeneous, often multimorbid, population. Finally, organizational models to support patient empowerment in an integrative care pathway must be established andvalidated.

Mastitis and Mammary Abscess Management Audit (MAMMA) in the UK and Ireland.

The aim of this multicentre prospective audit was to describe the current practice in the management of mastitis and breast abscesses in the UK and Ireland, with a specific focus on rates of surgical intervention. This audit was conducted in two phases from August 2020 to August 2021; a phase 1 practice survey and a phase 2 prospective audit. Primary outcome measurements for phase 2 included patient management pathway characteristics and treatment type (medical/radiological/surgical). A total of 69 hospitals participated in phase 2 (1312 patients). The key findings were a high overall rate of incision and drainage (21.0 per cent) and a lower than anticipated proportion of ultrasound-guided aspiration of breast abscesses (61.0 per cent). Significant variations were observed regarding the rate of incision and drainage (range 0-100 per cent; P < 0.001) and the rate of needle aspiration (range 12.5-100 per cent; P < 0.001) between individual units. Overall, 22.5 per cent of patients were admitted for inpatient treatment, out of whom which 72.9 per cent were commenced on intravenous antibiotics. The odds of undergoing incision and drainage for a breast abscess or being admitted for inpatient treatment were significantly higher if patients presented at the weekend compared with a weekday (P ≤ 0.023). Breast specialists reviewed 40.9 per cent of all patients directly, despite the majority of patients (74.2 per cent) presenting within working hours on weekdays. Variation in practice exists in the management of mastitis and breast abscesses, with high rates of incision and drainage in certain regions of the UK. There is an urgent need for a national best-practice toolbox to minimize practice variation and standardize patient care.

A Review on the Use of Imaging Biomarkers in Oncology Clinical Trials: Quality Assurance Strategies for Technical Validation.

Imaging biomarkers (IBs) have been proposed in medical literature that exploit images in a quantitative way, going beyond the visual assessment by an imaging physician. These IBs can be used in the diagnosis, prognosis, and response assessment of several pathologies and are very often used for patient management pathways. In this respect, IBs to be used in clinical practice and clinical trials have a requirement to be precise, accurate, and reproducible. Due to limitations in imaging technology, an error can be associated with their value when considering the entire imaging chain, from data acquisition to data reconstruction and subsequent analysis. From this point of view, the use of IBs in clinical trials requires a broadening of the concept of quality assurance and this can be a challenge for the responsible medical physics experts (MPEs). Within this manuscript, we describe the concept of an IB, examine some examples of IBs currently employed in clinical practice/clinical trials and analyze the procedure that should be carried out to achieve better accuracy and reproducibility in their use. We anticipate that this narrative review, written by the components of the EFOMP working group on "the role of the MPEs in clinical trials"-imaging sub-group, can represent a valid reference material for MPEs approaching the subject.

The effects of a multidisciplinary pathway for perioperative management of patients with hip fracture

ABSTRACT Objectives To determine if a multidisciplinary pathway focused on non-opioid pain management, delirium assessment, and resource utilization improved outcomes in geriatric hip fracture patients. The goal was to reduce opioid usage, consultation not congruent with guidelines, and increase use of regional anesthesia to reduce delirium and improve outcomes. Methods An observational study was performed on hip fracture patients before and after the intervention. Hospitalists were educated on indications for preoperative cardiac consultation and specialized preoperative cardiac testing according to evidence-based guidelines with the inpatient cardiology service. Additional education on multimodal analgesia, limiting opioids, and peripheral nerve blocks was provided by the acute pain service. Pre-intervention outcomes from 1 July 20171 July 2017 to 31 May 201831 May 2018 (N = 92) were compared to post-intervention outcomes from 1 July 20181 July 2018 to 31 May 201931 May 2019 (N = 98) and included delirium, length of stay, 30-day readmission rate, time from arrival to procedure start time, time to first physical therapy session, and completion of cardiology consult time. We examined adherence, use of nerve blocks, and pre- and post-operative pain scores and opioid use. Results Delirium was reduced from 50.0% (N = 46/92) to 28.6% (N = 28/98); p = 0.002. Postoperative opioid use (IV morphine milligram equivalents) decreased from an average of 57.2 mg (±67.7) to 42.6 mg (±58.2),P < .0001. There was a significant decrease in mean pre-operative (5.4 ± 4.14 to 5.05 ± 2.8, P < .0001) and post-operative pain scores (4.3 ± 5.2 to 3.2 ± 2.2, P < .0001). There was a significant reduction in time to cardiology consultation from 18 h] to 12 h ; p < .001). Conclusions A multidisciplinary collaboration between hospitalists, anesthesiologists, and cardiologists for hip fracture patients was associated with a reduction in pain and delirium and time to cardiologist evaluation. Prospective studies focusing on additional patient-centered outcomes are warranted.

1038-P: Evaluation of an Outpatient Pathway for Management of Pediatric Patients with New-Onset Diabetes

Background: Education and management for new onset diabetes (NOD) does not always require hospitalization. A pathway for outpatient management of pediatric NOD patients after initial evaluation and long-acting insulin dose in the emergency department was developed at a tertiary academic medical center. Methods: A multidisciplinary team identified key initial eligibility criteria for outpatient NOD management including absence of DKA, age ≥3 years, and beta-hydroxybutyrate (BOHB) &amp;lt;1 mmol/L. Data tracking, chart review, and endocrine provider surveys determined reasons for exclusion or non-participation. Control charts tracked and analyzed monthly utilization. Refinement of the pathway occurred through iterative PDSA cycles. Results: The pathway launched in September 2020. To date, 58 eligible children (33%) have completed the pathway (monthly median 33%). One patient was hospitalized after newly identified social concerns. Increase of BOHB cut-off to 1.5 mmol/L and option of rapid-acting insulin bolus for borderline BOHB resulted in significant shift in utilization from mean 23% to 41%. Barriers to participation include limited space availability, weekend presentation, and patient/family refusal. Conclusion: Data suggest that outpatient management is feasible for select patients with NOD but requires flexible resources and supportive patient messaging regarding outpatient education. Disclosure S.Azova: None. E.Rhodes: None. C.Baskaran: None. S.Einis: None. J.A.Fortin: None. M.Silva: None. K.Aamodt: None. B.G.Ethier: None. S.Nanavati: None. K.Garvey: None.

Postoperative complications and disposition for vascular surgery.

Among all surgical specialties, vascular surgery has the greatest proportion of patients with unplanned admissions to the intensive care unit postoperatively. Therefore, current clinical pathways for the postoperative management of vascular surgery patients may need to be revised. We aimed to compare the prevalence of postoperative deterioration in the high and standard risk cohorts of patients through several markers: medical emergency team activations and unplanned intensive care unit admissions. This was a single-centre, retrospective cohort study of all vascular surgical patients, emergency and elective, between 1 January and 31 December 2020 at Fiona Stanley Hospital, a tertiary hospital located in Perth, Western Australia. Patients (n = 680) were risk stratified using the surgical outcome risk tool into standard-risk (30-day mortality risk <5%; n = 475, 69.9%) and high-risk (30-day mortality risk ≥5%; n = 205, 30.1%). There were 43 unplanned intensive care unit admissions (6.3%) in total. Furthermore, surgical outcome risk tool 5% or greater risk patients were approximately eight times more likely to experience an unplanned intensive care unit admission compared with their surgical outcome risk tool less than 5% risk counterparts (relative risk 7.65, 95% confidence interval 3.84-15.21). There were 87 medical emergency team calls (12.8%) in total. In addition, surgical outcome risk tool 5% or greater risk patients were approximately five times more likely to experience a medical emergency team activation than their surgical outcome risk tool less than 5% risk counterparts (relative risk 5.15, 95% confidence interval 3.37-7.86). Our findings highlight the need for a revision of the inpatient journey for surgical outcome risk tool 5% or greater risk vascular patients, given their increased rates of unfavourable postoperative outcomes such as unplanned intensive care unit admission and medical emergency team activation. Ideally this can be addressed through appropriate postoperative triage, thus allowing this vulnerable population group early access to higher acuity care.