Medicine Consultation Research Articles

Recommendations of the Valencian Society of Digestive Pathology for the use of telemedicine and non-contact consultations

The COVID-19 pandemic has meant a qualitative change in the way patients are treated in outpatient clinics. The need to take measures of social isolation as prevention for contagion by the new coronavirus has forced the use of telematic and telephone consultations in most medical and surgical units. The specialty of digestive medicine, due to the characteristics of its patients and frequent support in complementary techniques for diagnosis, is especially suitable for the use of non-contact consultations. In this document a series of recommendations are proposed that can serve as a guide for the establishment or improvement of non-face-to-face digestive medicine consultations.

Effectiveness of Comanagement Model: Geriatric Medicine and Vascular Surgery.

Older surgical patients frequently develop postoperative complications due to their frailty and multiple comorbidities. Geriatric medicine consultation helps to optimize risk factors and improve outcomes in patients with hip fracture. This study aimed to evaluate patient outcomes before and after comanagement model implementation between geriatric medicine (Geriatric Surgical Service) and vascular surgery services. This was a case-control study involving emergency vascular surgical patients who were comanaged by vascular surgery, geriatric medicine, and geriatric nursing services. This study was conducted in a tertiary hospital in Singapore from 2015 to 2018 with acute vascular surgical patients aged older than 65years. A retrospective cohort of 135 patients from 2013 to 2014 (control group) who fulfilled the criteria for the comanagement model was compared with a prospective cohort of 348 patients who were comanaged by a geriatric surgical service from 2015 to 2018, and a further subgroup analysis of patients between 2015 and 2016 (n= 150) (early intervention group) and between 2017 and 2018 (n= 198) (late intervention group) was performed. Comanaged patients had a significantly shorter length of hospital stay (11.6 vs 20.8days, P=.001), reduced nosocomial infections (3% vs 12% for urinary tract infection, P= .003) and decreased 30-day readmission rates (22% vs 34%, P= .011). A trend of a decreased incidence of fluid overload was noted in patients comanaged with the geriatric surgical service (3% vs 7%, P= .073). Subgroup analysis showed progressive reductions in the length of stay (15.4 vs 11.6days, P= .001), 30-day readmission rate (35% vs 22%, P= .01), and nosocomial urinary tract infection (8% vs 3%, P= .003) between the early intervention group and the late intervention group. Although they were not statistically significant, reductions were also observed in the delirium rate (13% vs 11%) and other postoperative medical complications in the early intervention group and the late intervention group. Despite having increasing comorbidities, older vascular surgical inpatients had a significantly shorter length of stay, reduced nosocomial infections, and decreased 30-day readmission rates through a comanagement model with vascular surgery and geriatric medicine services. Improvements in outcomes were observed over time as the model of care evolved. Geriatric medicine intervention in the perioperative period improves the outcomes of older acute vascular surgical patients.

Primary care physicians' knowledge of travel vaccine and malaria chemoprophylaxis and associated predictors in Qatar.

In an era of globalization, travel-related illnesses have become a focus of public ‎health concern, especially in the Arab region where travel health services are insufficient and ‎not well-established. This study was conducted to assess travel vaccine and ‎malaria chemoprophylaxis knowledge and associated predictors among primary care physicians‎ (PCPs) in ‎Qatar. This was a cross-sectional study. A structured questionnaire was used to collect ‎data from all physicians working at all 27 primary healthcare centers from March 1st to May 31st 2020.‎ Knowledge scores were computed and a multivariable linear regression model was built to identify predictors of higher knowledge. A total of 364 PCPs participated (response rate of 89.2%). Participants' mean ‎age was 44.5 (±7.8) with 59.1% being males. Their overall mean knowledge score was 9.54/16 (±3.24). Significant predictors of higher knowledge included: aged 40-49 years ‎(1.072; 95% CI: 0.230, 1.915)‎, had medical degree from non-Arab countries ‏‎(0.748; 95% CI: 0.065, ‎‎1.432)‎‏,‏‎ had training in TM ‏ ‏‎(1.405; 95% CI: 0.407, ‎‎2.403), and provided ≥10 consultations/ month ‎(2.585; 95% CI:1.294, 3.876)‎. Online information was the main reported resource of travel medicine consultation. The overall PCPs' mean percentage knowledge score of travel medicine was 59.6% (±20.3). A high volume of pretravel consultation, prior training, middle age group, and medical degree from non-Arab countries were significant predictors of higher ‎knowledge. Continuing ‎education and training provided by recognised international institutions for all PCPs is highly ‎recommended to narrow the gap in travel medicine knowledge.

Patients seeking stem cell therapies—a prospective qualitative analysis from a Regenerative Medicine Consult Service

Despite patient demand for stem cell therapies (SCTs) for musculoskeletal conditions, there remains limited research on why patients seek SCTs or their sources of information. We employ three questions into a consult intake form: (1) Why are you interested in stem cell treatment for your condition? (2) How did you find out about stem cell treatment for your condition? (3) Have you contacted a stem cell clinic? Responses analyzed, using a qualitative content analysis approach to identify themes reveal many patients seek SCTs to treat pain or delay surgery which may align with some current clinical evidence while other patients express motivations as expected outcomes (e.g., SCTs are better than standard of care or can regenerate tissue) which are not supported by current medical evidence. These differences suggests that patient-centered counseling may help patients by addressing misconceptions and increasing health literacy about expected outcomes of SCTs for treating musculoskeletal conditions.

Society for Maternal-Fetal Medicine Consult Series #61: Anticoagulation in pregnant patients with cardiac disease

Pregnancy in individuals with a mechanical heart valve has been classified as very high risk because of a substantially increased risk of maternal mortality or severe morbidity. Lifelong therapeutic anticoagulation is a principal component of the medical management of mechanical heart valves to prevent valve thrombosis. Anticoagulation regimens indicated outside of pregnancy for patients with mechanical valves should be continued during pregnancy with the possibility of modifications based on the type of valve, the trimester of pregnancy, individual risk tolerance, and circumstances around the time of delivery. The purpose of this document is to provide recommendations regarding the management of anticoagulation for common cardiac conditions complicating pregnancy, including mechanical heart valves, atrial fibrillation, systolic heart failure, and congenital heart disease.

Development of a research-based classification of approaches to paediatric palliative medicine service provision within children’s and young adults’ hospices: A mixed methods study

Background: Globally, pioneers in children’s palliative care influenced this speciality’s development through individual initiatives leading to diverse models of care. Children’s and young adults’ hospices have now been established around the world. However, service provision varies widely leading to inequities both within countries and internationally. Aim: To describe and classify existing approaches to paediatric palliative medicine in children’s and young adults’ hospices across the UK. Design: A mixed methods study conducted by telephone interview. Setting/participants: Thirty-one leaders of children’s hospice care, representing 28 services, 66% of UK children’s and young adults’ hospice organisations. Results: A geographic-specialist classification was developed through integration of findings, enabling hospices to be classified as Regional specialist, Regional non-specialist, Local specialist and Local non-specialist. Both qualitative and quantitative data demonstrated diversity and inequity in paediatric palliative medicine provision. Of 159 doctors (63.5% of whom were general practitioners) working in participating hospices only 27.5% had specialist training in paediatric palliative medicine. The majority of participating hospices (67.9%) did not have involvement from a paediatric palliative medicine consultant. Conclusions: Internationally, the integration of specialist children’s palliative care teams with existing services is a current challenge. Despite differing approaches to children’s palliative care world-wide, models of care which facilitate integration of specialist children’s palliative care could benefit a range of countries and contexts. The geographic-specialist classification could be used to inform recommendations for a networked approach to paediatric palliative medicine within children’s and young adults’ hospices to promote equity for children with life-limiting and life-threatening conditions.

Impact of an addiction medicine consult team intervention in a Canadian inner city hospital on acute care utilization: a pragmatic quasi-experimental study

BackgroundInner city patients have a higher illness burden and need for care, but experience more unmet care needs. Hospital Addiction Medicine Consult Teams (AMCTs) are a promising emerging intervention. The objective of this study was to assess the impact of a Canadian AMCT-like intervention for inner city patients on reduction in high emergency department (ED) use, hospital admission, and inpatient length of stay.MethodsUsing a community-engaged, two-arm, pre-post, longitudinal quasi-experimental study design, 572 patients reporting active substance use, unstable housing, unstable income, or a combination thereof (302 at intervention site, 270 at control sites) were enrolled. Survey and administrative health service data were collected at baseline, six months post-enrolment, and 12 months post-enrolment. Multivariable regression models tested the intervention effect, adjusting for clinically important covariables (inpatient status at enrolment, medical complexity, age, gender, Indigenous identity, shelter use, opioid use).ResultsInitial bivariable analyses demonstrated an intervention effect on reduction in admissions and length of stay, however, this effect was no longer significant after adjusting for covariables. There was no evidence of reduction in high ED use on either bivariable or subsequent multivariable analysis.ConclusionsAfter adjusting for covariables, no AMCT intervention effect was detected for reduction in high ED use, inpatient admission, or hospital length of stay. Further research is recommended to assess other patient-oriented intervention outcomes.

814 GENERAL INTERNAL MEDICINE AND THE GERIATRIC MEDICINE WORKFORCE: RESULTS: OF THE RCP CENSUS AND WELLBEING SURVEY

Abstract Background In the UK, most geriatric medicine consultants also contribute to general internal medicine (‘acute take’) services. However, impact on workforce was unclear. Methods We used anonymised data available from the Royal College of Physicians (RCP) 2019 census, and the RCP wellbeing snapshot survey conducted in early 2020. We used multivariable analysis of covariance (adjusting for age, gender, nation, NHS academic or other contract type, contribution to general or acute medicine services, and less than full-time working) to assess for differences in mean excess Programmed Activities (PAs) worked above contracted PAs between geriatric medicine and other physician specialties. We used binary logistic regression analysis to assess for satisfaction in own specialty and general medicine (adjusting for variables above), and in perceived excess workload and excess hours (adjusting for age, gender, and nation). Results The RCP census included 16,746 consultant physicians, including 1,677 (10%) geriatricians. The wellbeing survey included 2,670 respondents, including 343 (12.8%) geriatricians. Geriatricians reported working excess programmed activities, but fewer than other specialties (adjusted means: 0.74, CI 0.59–0.89 vs. 0.95, CI 0.82–1.07; p < 0.001). Geriatricians were also less likely to report always or often working excess hours (OR 0.61, CI 0.47–0.78; p < 0.001) or having an excess workload (OR 0.60, CI 0.47–0.78; p < 0.001). There were no differences in satisfaction with their own specialty, but geriatricians were more likely to report increased satisfaction with general medicine (OR 1.65, CI 1.30–2.09; p < 0.001). Conclusion Physicians, in the UK, frequently report working excess hours beyond their contracted job plans. However, geriatricians report fewer excess hours than other specialties. Geriatricians also report greater perceived satisfaction working in general medicine than other physician specialties.

The impact of physical medicine and rehabilitation consultation on clinical outcomes in the surgical intensive care unit: A prospective observational cohort study.

The impact of a physical medicine and rehabilitation (PM&R) consultation on clinical outcomes in critically ill surgical patients remains unclear. The aim of this study is to examine whether the patients who received PM&R consultation will demonstrate better clinical outcomes in terms of the differences in clinical outcomes including muscle mass and strength, intensive care unit (ICU) length of stay (LOS) and functional outcomes between the PM&R consultation and no PM&R consultation and between early PM&R consultation and late PM&R consultation in critically ill surgical patients.A prospective observational cohort study was undergone in 65-year-old or older patients who were admitted > 24 hours in the surgical intensive care unit (SICU) in a tertiary care hospital. Data collection included patients’ characteristic, muscle mass and muscle strength, and clinical outcomes.Ninety surgical patients were enrolled and PM&R was consulted in 37 patients (36.7%). There was no significant difference in muscle mass and function between consulted and no consulted groups. PM&R consulted group showed worse in clinical outcomes including functional outcomes at hospital discharge, longer duration of mechanical ventilation, ICU, and hospital LOS as compared with no PM&R consulted group. The median time of rehabilitation consultation was 6 days and there were no significant differences in clinical outcomes between early (≤ 6 days) and late (> 6 days) consultation.PM&R consultation did not improve muscle mass, functional outcomes at hospital discharge, and ICU LOS in critically ill surgical patients. The key to success might include the PM&R consultation with both intensified physical therapy and early start of mobilization or the rigid mobilization protocol.

Moderate-to-Severe Polyhydramnios: Cutoffs for Deepest Vertical Pocket Corresponding to Amniotic Fluid Index.

Society for Maternal-fetal medicine Consult Series (#46) states "antenatal fetal surveillance is not required for mild idiopathic" polyhydramnios defined as amniotic fluid index (AFI) of 24 cm or a deepest vertical pocket (DVP) between 8 and 11 cm. The objective of this study was to determine the cutoff for DVP which correlates with AFI ≥ 30 cm. This retrospective study of singleton third trimester ultrasounds included a study group randomly divided into test and validation. In the test group, DVP cutoffs correlating with AFI ≥ 30 cm which was used to define moderate-severe polyhydramnios were calculated in two ways, rounded to the nearest whole number: 1) a receiver operating curve and Youden's J statistic (DVP-Youden) and 2) calculation of the DVP percentile that corresponded with AFI of 30 cm (DVP-Percentile). Using the validation group, diagnostic characteristics were DVP-Youden and DVP-Percentile for diagnosis of AFI ≥ 30 cm and were compared against SMFM cutoffs (DVP-SMFM). Seventy one thousand eight hundred and ninety three ultrasound exams in the 3rd trimester had assessment of AFI and DVP. Moderate-severe polyhydramnios occurred in 286 (1.2%) in test group and 571 (1.2%) in validation group. AFI of 30 cm corresponded to the 98.9th percentile, which in turn correlated to a DVP of 10 cm (DVP-Percentile). The calculated cutoff for moderate-severe polyhydramnios was 8cm for DVP-Youden. Using 8.0 cm rather than 12.0 cm increased the detection of moderate-severe polyhydramnios to 100% with a false positive rate under 5%. For those utilizing DVP for amniotic fluid evaluation, identification of a DVP ≥ 8.0 cm should prompt further evaluation with complete AFI.

Strength, Weakness, Opportunities, and Threats (SWOT) Analysis of Virtual Outpatient Department Under Telemedicine Department During the COVID-19 Pandemic.

BackgroundCOVID-19 pandemic has challenged all current management tools used for patient care. This study aims to determine strength, weakness, opportunities and threats (SWOT) to virtual OPD and consultants' perceptions of teleconsultation virtual OPD during the COVID-19 pandemic, adapting to newer technologies for successfully handling this situation.Material and methodsA facility-based cross-sectional study was conducted at the Virtual OPD of All India Institute of Medical Sciences Rishikesh among patients availing Telemedicine consultation during the COVID-19 pandemic. All patients availing services from April 2020 to October 2020 were included in this study. Method for SWOT analysis: A checklist was prepared, and investigators assessed SWOT. An external evaluator was invited to evaluate the SWOT analysis conducted by the investigators. For numeric variables, the mean ± SD was used, and for categorical variables, percentages and proportions were used.Results Around 22% of the patients who approached virtual OPDs were ≥ 60 years of age. More than half (55.3%) of the patients or their attendants who consulted Telemedicine OPD were from Uttarakhand, followed by Uttar Pradesh (42.6%). The proportions of male patients were 54.4%. Around 17.6% of teleconsultations were performed for radiotherapy. General medicine and cardiology consultations were (15.2%) and (12.8%), respectively.ConclusionTelemedicine can be effective if certain requirements had been provided. Maintaining privacy of the patient's data was a challenge.

Antibiotic therapy completion for injection drug use-associated infective endocarditis at a center with routine addiction medicine consultation: a retrospective cohort study

BackgroundAddiction medicine consultation and medications for opioid use disorder are shown to improve outcomes for patients hospitalized with infective endocarditis associated with injection drug use. Existing studies describe settings where addiction medicine consultation and initiation of medications for opioid use disorder are not commonplace, and rates of antibiotic therapy completion are infrequently reported. This retrospective study sought to quantify antibiotic completion outcomes in a setting where these interventions are routinely implemented.MethodsMedical records of patients hospitalized with a diagnosis of bacteremia or infective endocarditis at an urban hospital between October 1, 2015 and December 31, 2017 were screened for active injection drug use within 6 months of hospitalization and infective endocarditis. Demographic and clinical parameters, receipt of antibiotics and medications for opioid use disorder, and details of re-hospitalizations within 1 year of discharge were recorded.ResultsOf 567 subjects screened for inclusion, 47 had infective endocarditis and active injection drug use. Addiction medicine consultation was completed for 41 patients (87.2%) and 23 (48.9%) received medications for opioid use disorder for the entire index admission. Forty-three patients (91.5%) survived to discharge, of which 28 (59.6%) completed antibiotic therapy. Twenty-nine survivors (67.4%) were re-hospitalized within 1 year due to infectious complications of injection drug use.ConclusionsAmong patients admitted to a center with routine addiction medicine consultation and initiation of medications for opioid use disorder, early truncation of antibiotic therapy and re-hospitalization were commonly observed.

Knowledge and attitudes amongst internal medicine clinicians in referring valvular heart disease patients : a multi-centre survey study

Abstract Funding Acknowledgements Type of funding sources: None. Background With advancement in valvular interventions, outcomes of valvular heart disease (VHD) patients have improved dramatically. However, very little is known regarding levels of knowledge and attitudes amongst non-cardiology clinicians in managing VHD. Purpose To determine the knowledge and attitudes towards VHD management, pertaining specifically to referrals to cardiology services for consideration for intervention, amongst internal medicine clinicians in Malaysia. Methods We conducted a multi-centre survey study. A 20-item survey was distributed amongst internal medicine clinicians within three different institutions. Results A total of 75 responses was obtained (response rate of 35.7%). The mean age of responders was 36.6 years (S.D. 7.9). 57.3% were male. Respondents include medical officers (50.6%), internal medicine consultants (31.9%) and internal medicine specialist (i.e. pre-consultant) (17.5%). Majority had more than 10 years of experience working as medical doctors (46.7%). 69.3% admit to managing patients with VHD regularly (defined as at least one VHD patient per week). Respondents were comfortable using online resources, both formal (95.0%) and informal (75.0%) sources. A large proportion felt that they had ‘insufficient’ or ‘very insufficient’ knowledge and experience managing VHD patients on their own (28.0% and 8.0% respectively) and less than half felt that management of VHD patients within their institutions was ‘adequate’ or ‘very adequate’ (46.7% and 2.7% respectively). However, it is reassuring that most respondents felt comfortable discussing cases of VHD with their senior colleagues or their local cardiology services. Although many were felt to be over-zealous in wanting too frequent an echocardiography monitoring for cases of mild VHD (majority felt that the patient would require it every 1 year (25.3%) or 1-2 years (29.3%)), nevertheless attitudes in referrals to cardiology services for consult and intervention were felt appropriate (majority felt that cardiology consult would be indicated if valvular lesion was at least moderate in severity (56.0%), when there were changes to the heart function or structure (52.0%), when patients became symptomatic (45.3%) or when there were two or more valvular lesions simultaneously (45.3%). However, within a Malaysian context, there may be a need to shift attitudes towards referring much earlier, consistent with changes in recent international guidelines on managing VHD, as valvular surgery waiting times are extremely long. Conclusion The survey highlights the need for education amongst internal medicine clinician to tackle both the over-zealous attitude in monitoring patients with mild valvular disease on one extreme, and in improving early referrals for VHD indicated for intervention in the other. Abstract Figure. Survey items on echocardiography Abstract Figure. Survey items on cardiology referrals

Knowledge and attitudes amongst internal medicine clinicians in referring valvular heart disease patients : a multi-centre survey study

Abstract Funding Acknowledgements Type of funding sources: None. Background With advancement in valvular interventions, outcomes of valvular heart disease (VHD) patients have improved dramatically. However, very little is known regarding levels of knowledge and attitudes amongst non-cardiology clinicians in managing VHD. Purpose To determine the knowledge and attitudes towards VHD management, pertaining specifically to referrals to cardiology services for consideration for intervention, amongst internal medicine clinicians in Malaysia. Methods We conducted a multi-centre survey study. A 20-item survey was distributed amongst internal medicine clinicians within three different institutions. Results A total of 75 responses was obtained (response rate of 35.7%). The mean age of responders was 36.6 years (S.D. 7.9). 57.3% were male. Respondents include medical officers (50.6%), internal medicine consultants (31.9%) and internal medicine specialist (i.e. pre-consultant) (17.5%). Majority had more than 10 years of experience working as medical doctors (46.7%). 69.3% admit to managing patients with VHD regularly (defined as at least one VHD patient per week). Respondents were comfortable using online resources, both formal (95.0%) and informal (75.0%) sources. A large proportion felt that they had ‘insufficient’ or ‘very insufficient’ knowledge and experience managing VHD patients on their own (28.0% and 8.0% respectively) and less than half felt that management of VHD patients within their institutions was ‘adequate’ or ‘very adequate’ (46.7% and 2.7% respectively). However, it is reassuring that most respondents felt comfortable discussing cases of VHD with their senior colleagues or their local cardiology services. Although many were felt to be over-zealous in wanting too frequent an echocardiography monitoring for cases of mild VHD (majority felt that the patient would require it every 1 year (25.3%) or 1-2 years (29.3%)), nevertheless attitudes in referrals to cardiology services for consult and intervention were felt appropriate (majority felt that cardiology consult would be indicated if valvular lesion was at least moderate in severity (56.0%), when there were changes to the heart function or structure (52.0%), when patients became symptomatic (45.3%) or when there were two or more valvular lesions simultaneously (45.3%). However, within a Malaysian context, there may be a need to shift attitudes towards referring much earlier, consistent with changes in recent international guidelines on managing VHD, as valvular surgery waiting times are extremely long. Conclusion The survey highlights the need for education amongst internal medicine clinician to tackle both the over-zealous attitude in monitoring patients with mild valvular disease on one extreme, and in improving early referrals for VHD indicated for intervention in the other. Abstract Figure. Survey item on echocardiography Abstract Figure. Survey item on cardiology referrals

Treatment of tibial shaft nonunion with a retained nail in morbidly obese patients.

Morbid obesity is a rising worldwide health problem. Tibial shaft nonunion with retained intramedullary nail (IMN) in the morbidly obese is a challenging orthopaedic problem. Prolonged immobilization carries a significant risk of complications. This study aimed to investigate whether decortication and cancellous bone grafting with the application of a circular external fixator (CEF) over the preexisting IMN can achieve fracture union and avoid serious complications. We retrospectively reviewed 27 consecutive morbidly obese patients treated for tibial diaphysis aseptic nonunion after failed IMN. All cases were treated with osteoperiosteal decortication, cancellous bone grafting, and fixation with CEF over the IMN. Peri-operative multidisciplinary patient evaluation included internal medicine, cardiology, chest, vascular surgery, and anesthesia consultations. The union rate, bone results, functional results, and complications were recorded. The mean age of the patients was 37.9years. The mean BMI was 45.8. Sixteen cases (59.3%) were treated for hypertrophic nonunion, while 11 cases (40.7%) were treated for atrophic nonunion. Seven cases (25.9%) had open initial injury, 14 cases (51.9%) had associated comorbidities, and seven cases (25.9%) were smokers. Twenty-six cases united. The mean time to union was 5.2months. Bone results and functional results were good to excellent in 96.3% of the cases. We recorded 25 complications in 21 patients. However, most of the complications were minor. Decortication and cancellous bone grafting with the application of CEF over the preexisting nail is a safe and reliable treatment method for aseptic tibial shaft nonunion with retained IMN in morbidly obese patients.

Analyse du cadre réglementaire des certificats médicaux demandés par une municipalité en 2019

Medical certificates have a regular place in general medicine consultation. Since 2011, the french law has highlighted the absence of regulatory support of certain certificates, in particular of public services. The objective of this study was to find out which regulatory texts were based on the medical certificates required by a municipal administration, 8 years after the 2011 rationalization circular? Material and methodQualitative study by observation and critical analysis of certificates by literature reviews according to the main PRISMA quality criteria (Preferred Reporting Items for Systematic Reviews and Meta-Analyzes). The first step consisted of the exhaustive collection of the medical certificates provided by the municipality, for the citizens or the employees of the city. The origin of one of the municipal services was the only criterion for inclusion. The second stage consisted in analyzing the certificates according to the law by using databases classified depending on their level, taking their regulatory value into account as a priority. The research equations were constructed with an inductive process as the certificates were collected. ResultsForty-two certificates were collected and analyzed. Twenty-seven had regulatory support, two of which (not concerned in general medicine) complied with its content. No regulatory support was found for the 15 other certificates. The regulatory vagueness around sports accidents, or even the abuse of authority, are explanations for these certificates without existing or respected regulatory support. ConclusionThe general practitioner is put in a difficult and ambivalent position. A major institutional commitment should be considered for the rationalization of medical certificates, in particular through medical education, health education for users and law enforcement.

A certified child life specialist influences the emotional response during polysomnography setup

ObjectivesTo examine if the presence of a certified child life specialist (CCLS) had a positive impact on patient emotion at the time of polysomnography setup and to determine the optimal timing of CCLS intervention prior to polysomnography (PSG) in our sleep center. MethodsWe implemented a study which measured the impact of a CCLS on the emotional manifestation score (EMS) of pediatric patients (4 months–17 years, median 7 years) during PSG setup. CCLS intervention was either at the time of sleep medicine consultation (daytime) or during PSG setup (evening). We used Emotional Manifestations Scores (EMS) as well as patient/caregiver satisfaction data to measure the impact of a CCLS and inform decision-making regarding ongoing employment of a CCLS in our sleep lab. ResultsHigh EMS scores were noted during PSG setup in all groups indicating the emotional distress of children undergoing PSG. The EMS improved more when CCLS was present at the time of PSG setup. Statistically significant improvements occurred in level of cooperation, pain/discomfort, and child coping. Based on the results of the study, we hired a CCLS to work in our sleep center at the time of PSG setup 2 evenings per week. ConclusionsPSG is emotionally stressful for pediatric patients as seen on EMS. A CCLS present in the evening at our sleep lab led to an improvement in EMS in children being prepared for PSG set-up. After implementation of a CCLS two nights per week in our sleep lab, parents/caregiver satisfaction scores were higher on nights a CCLS was present at setup.

Inpatient Addiction Medicine Consultation Service Impact on Post-discharge Patient Mortality: a Propensity-Matched Analysis.

Inpatient addiction medicine consultation services (AMCS) have grown rapidly, but there is limited research of their impact on patient outcomes. To examine whether AMCS is associated with all-cause mortality and hospital utilization post-discharge. This was a propensity-score-matchedcase-control study from 2018 to 2020. The intervention group included patients referred to the AMCS from October 2018 to March 2020. Matched control participants included patients hospitalized from October 2017 to September 2018 at an urban academic hospital with a large suburban and rural catchment area. The effect of treatment was estimated as the difference between the proportion of subjects experiencing the event (7-day and 30-day readmission, emergency department visits, and mortality within 90 days) for each group in the matched sample. There were 711 patients in the intervention group and 2172 patients in the control group. The most common substance use disorders among the intervention group were primary alcohol use disorder (n=181; 25.5%) and primaryopioid use disorder (n=175, 24.6%) with over a third with polysubstance use (n=257, 36.1%). Intervention patients showed a reduction in 90-day mortality post-hospital discharge (average treatment effect [ATE]: -2.35%, 95% CI: -3.57, -1.13; p-value <0.001) compared to propensity-matched controls. We found a statistically significant reduction in 7-day hospital readmission by 2.15% (95% CI: -3.65, -0.65; p=0.005) and a nonsignificant reduction in 30-day readmission (ATE: -2.38%, 95% CI: -5.20, 0.45; p=0.099). There was a statistically significant increase in 30-day emergency department visits (ATE: 5.32%, 95% CI: 2.19, 8.46; 0.001) compared to matched controls. There was a reduction in 90-day all-cause mortality for the AMCS intervention group compared to matched controls, although the impact on hospital utilization was mixed. AMCS are systems interventions that are effective tools to improve patient health and reduce all-cause mortality.

Effect of Inpatient Integrative Medicine Consultation on 30-Day Readmission Rates: A Retrospective Observational Study at a Major U.S. Academic Hospital.

Objectives: The prevalence of inpatient integrative medicine (IM) consult services is increasing among academic health care institutions. The diversity of services between institutions, as well as the novel nature of such interventions, makes it challenging for health care administrators to determine the cost/benefit of adding such a program to their institution. The main purpose of this study was to examine the performance of the new University of California, Los Angeles (UCLA) East-West (EW) consult service as measured by 30-day readmission rates and lengths of stay. Design: This is a retrospective observational case-control study with participants matched to themselves. Setting: UCLA Santa Monica Hospital, a 281-bed academic tertiary care hospital near Los Angeles, California. Subjects: Patients who had received an EW consultation during the inaugural 20 months of the program (2018-2020), and who had been hospitalized in the prior 2 years from the date of their first EW consult. Intervention: Inpatient East-West consultation, which may include counseling, acupuncture and/or trigger point injections depending on medical necessity. Outcome Measures: Thirty-day readmission rates and lengths of hospital admission were compared between the hospitalization that included an EW consult (which included the use of acupuncture and/or trigger point injections when appropriate) and any prior admissions during the 2 years before that EW consult. Secondary outcomes included quantitative analysis of average number of treatments and qualitative assessment of integrative treatment(s) received, conditions treated, and reasons that EW treatment may have been deferred during a consult. Results: One hundred sixty-five unique patients met the study criteria. The EW consultation was associated with clinically relevant, statistically significant decreased 30-day readmission rates (33.0% vs. 4.6%, p < 0.001, odds ratio [OR] 0.10, 95% confidence interval [CI] 0.06-0.17). This effect was similar when limiting the analysis to pain-related admissions (32.3% vs. 3.4%, p < 0.001, OR = 0.07, 95% CI 0.03-0.16). Hospital admissions with EW consults were found to have a statistically significant increased length of stay (7.03 days vs. 5.40 days, p < 0.001). Conclusion: The EW medicine, an example of IM, correlates with a reduced risk of 30-day readmission and with modestly increased lengths of stay.

Patients With Serious Injection Drug Use-Related Infections who Experience Patient-Directed Discharges on Oral Antibiotics Have High Rates of Antibiotic Adherence but Require Multidisciplinary Outpatient Support for Retention in Care.

BackgroundPersons who inject drugs (PWID) are frequently admitted for serious injection-related infections (SIRIs). Outcomes and adherence to oral antibiotics for PWID with patient-directed discharge (PDD) remain understudied.MethodsWe conducted a prospective multicenter bundled quality improvement project of PWID with SIRI at 3 hospitals in Missouri. All PWID with SIRI were offered multidisciplinary care while inpatient, including the option of addiction medicine consultation and medications for opioid use disorder (MOUD). All patients were offered oral antibiotics in the event of a PDD either at discharge or immediately after discharge through an infectious diseases telemedicine clinic. Additional support services included health coaches, a therapist, a case manager, free clinic follow-up, and medications in an outpatient bridge program. Patient demographics, comorbidities, 90-day readmissions, and substance use disorder clinic follow-up were compared between PWID with PDD on oral antibiotics and those who completed intravenous (IV) antibiotics using an as-treated approach.ResultsOf 166 PWID with SIRI, 61 completed IV antibiotics inpatient (37%), while 105 had a PDD on oral antibiotics (63%). There was no significant difference in 90-day readmission rates between groups (P = .819). For PWID with a PDD on oral antibiotics, 7.6% had documented nonadherence to antibiotics, 67% had documented adherence, and 23% were lost to follow-up. Factors protective against readmission included antibiotic and MOUD adherence, engagement with support team, and clinic follow-up.ConclusionsPWID with SIRI who experience a PDD should be provided with oral antibiotics. Multidisciplinary outpatient support services are needed for PWID with PDD on oral antibiotics.