Medical Unit Research Articles

Preparing Military Interprofessional Health Care Teams for Effective Collaboration

ABSTRACT Introduction Military Interprofessional Health care Teams (MIHTs) are the backbone of modern military medicine. However, these teams face distinct operational challenges, including frequent personnel rotation, diverse work environments, and the constant possibility of rapid deployment. Serving in dynamic teams that deploy for both military and humanitarian missions, MIHTs face the unique challenge of constant restructuring and reorganization. Consequently, preparing MIHT members to function effectively as a team presents a significant hurdle. This difficulty highlights the limited applicability of existing literature focused on training civilian interprofessional health care teams. To address this gap, we conducted interviews with MIHT members to understand specific training elements that equip MIHT members to effectively collaborate. By gaining a deeper understanding of their needs, we can improve training programs and ultimately optimize MIHT performance, readiness, and patient care. Methods We conducted individual semi-structured interviews with military health care professionals. We employed purposeful sampling to ensure a diverse range of perspectives from individuals with direct experience working in or leading MIHTs. The 30 participants interviewed represented a broad spectrum of MIHT professions. The data used for this study stems from a broader research program on MIHTs conducted between 2017 and 2019. We conducted a secondary analysis focusing specifically on interview data related to education and training. Using Braun and Clarke’s 6-step approach to Thematic Analysis, we identified themes from the data to build an understanding of MIHT perspectives on training effectiveness. Results The participants’ insights allowed us to identify 3 critical themes related to the training elements they considered most beneficial for fostering collaboration within MIHTs: (1) MIHT members rely on their own predeployment readiness; (2) MIHT contexts require unique, adaptive communication skills; and (3) MIHT training is an ongoing endeavor. Discussion We need our MIHTs to be ready to deploy and effectively collaborate, which involves being clinically, emotionally, physically, and operationally ready. MIHT members describe 3 aspects of specific training elements as having significant potential to equip them to effectively collaborate: (1) MIHT members rely on their own predeployment readiness; (2) MIHT contexts require unique, adaptive communication skills; and (3) MIHT training is an ongoing endeavor at both the individual and team levels. By investing in tailored training programs that address these areas, we can empower MIHTs to continuously adapt, excel, and ultimately, positively impact patient outcomes in diverse military health care settings.

Combat-Relevant Anesthesia Fellowships Help Sustain the Army’s Multidomain Medical Force

ABSTRACT In the community of Army Nurse Anesthetists, there is an underutilized potential for Combat-Relevant Fellowship training that, if enthusiastically encouraged and taken advantage of, would proffer many benefits to the Military Health System and the beneficiaries of its care. Most importantly, increased access to and encouragement for participation in these fellowships for Nurse Anesthetists would act as a tool for skill sustainment, denying any potential for skill degradation or readiness gaps in preparation for the next-generation war. These fellowships would also augment the already robust breadth, quality, and safety of Army Nurse Anesthetists’ combat and noncombat anesthesia care, potentially increase Return-To-Duty rates, potentially expedite casualty clearance of the battlefield, increase the often-limited access to advanced pain management care for chronic pain patients in Military Treatment Facilities, increase the retention rates of Nurse Anesthetists, augment the military anesthesia community’s knowledge-base, and help to advance the art of anesthesia as a whole. To triumph against the anticipated rigors of the future war’s multidomain operational environment, we are duty bound to continually improve and strive to be the best versions of ourselves as soldiers, as professionals, and as communities. This paper will explore the untapped utility of Combat-Relevant Fellowships for Army Nurse Anesthetists.

The Application of Trauma-Informed Care to Health Care for Military-Connected Individuals.

Military families face unique stressors beyond civilian life, such as deployments, frequent relocations, and the potential for combat, all of which can significantly impact well-being. A trauma-informed care (TIC) approach to military medicine is paramount; however, a critical gap exists, with no published curricula to guide practitioners in employing TIC in the care of military-connected individuals. We delivered a 50-minute interactive and virtual session to second-year medical students at the Uniformed Services University (USU) that reviewed the neurobiology of adversity and the relevance of TIC in caring for military-connected populations. Participants completed a 14-question pre- and posttest on perceived knowledge, attitudes, practice, and confidence, as well as posttest questions evaluating session quality. The USU Institutional Review Board approved this evaluation. One hundred sixty medical students participated in the session, with 78 matched pre- and posttest responses. We observed a statistically significant pre-post improvement (p ≤ .05) in all category scores, with the largest changes in knowledge (1.33) and confidence (1.33). On a 5-point Likert scale, with 5 being best, mean scores for overall quality of the session and relevance of the material to participants' learning and future practice were 3.95 and 4.20, respectively. By equipping health care providers with knowledge and confidence to apply TIC in military medicine, we can improve the well-being of service members and their families across both military and civilian health care settings. Broader implementation of this program has potential to improve patient outcomes and overall health care delivery for this population.

Clinic-Level Predictors of Psychotherapy Dosage in the Military Health System.

This study aimed to describe the demand for, supply of, and clinic processes associated with behavioral health care delivery in the Military Health System and to examine the clinic-level factors associated with receipt of a minimally adequate dosage of psychotherapy. This retrospective study used administrative behavioral health data from eight military treatment facilities (N=25,433 patients; N=241,028 encounters) that were participating in a larger implementation study of evidence-based psychotherapy for posttraumatic stress disorder. Minimally adequate dosage of psychotherapy was defined in two ways: at least three sessions within a 90-day period and at least six sessions within a 90-day period. The authors then used a path model to examine clinic-level factors hypothesized to predict psychotherapy dosage, including care demand, supply, and processes. Patients had an average of 2.5 psychotherapy appointments per quarter. Wait times for intake, between intake and the first psychotherapy session, and between follow-up sessions all averaged 17 days or longer. Path modeling showed that a higher patient-to-encounter ratio was associated with a longer wait time between follow-up psychotherapy appointments. In turn, a longer wait time between appointments was associated with a lower probability of receiving an adequate dosage of psychotherapy. However, a greater proportion of care delivered in groups was associated with a greater probability of receiving at least six sessions of psychotherapy. Receipt of a minimally adequate dosage of psychotherapy in the Military Health System is hindered by clinic staffing and workflows that increase wait times between follow-up psychotherapy appointments.

Transmission of highly virulent CXCR4 tropic HIV-1 through the mucosal route in an individual with a wild-type CCR5 genotype

BackgroundNearly all transmitted/founder (T/F) HIV-1 are CCR5 (R5)-tropic. While previous evidence suggested that CXCR4 (X4)-tropic HIV-1 are transmissible, virus detection and characterization were not at the earliest stages of acute infection. MethodsWe identified an X4-tropic T/F HIV-1 in a participant (40700) in the RV217 acute infection cohort. Coreceptor usage was determined in TZM-bl cell line, NP-2 cell lines, and primary CD4+ T cells using pseudovirus and infectious molecular clones. CD4 subset dynamics were analyzed using flow cytometry. Viral load in each CD4 subset was quantified using cell-associated HIV RNA assay and total and integrated HIV DNA assay. FindingsParticipant 40700 was infected by an X4 tropic HIV-1 without CCR5 using ability. This participant experienced significantly faster CD4 depletion compared to R5 virus infected individuals in the same cohort. Naïve and central memory (CM) CD4 subsets declined faster than effector memory (EM) and transitional memory (TM) subsets. All CD4 subsets, including the naïve, were productively infected. Increased CD4+ T cell activation was observed over time. This X4-tropic T/F virus is resistant to broadly neutralizing antibodies (bNAbs) targeting V1/V2 and V3 regions, while most of the R5 T/F viruses in the same cohort are sensitive to the same panel of bNAbs. InterpretationsX4-tropic HIV-1 is transmissible through mucosal route in people with wild-type CCR5 genotype. The CD4 subset tropism of HIV-1 may be an important determinant for transmissibility and virulence. FundingInstitute of Human Virology, National Institutes of Health, Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.

Mapping the diagnostic odyssey of congenital disorders of glycosylation (CDG): insights from the community

BackgroundCongenital disorders of glycosylation (CDG) are a group of rare metabolic diseases with heterogeneous presentations, leading to substantial diagnostic challenges, which are poorly understood. Therefore, this study aims to elucidate this diagnostic journey by examining families’ and professionals’ experiences.Results and discussionA questionnaire was designed for CDG families and professionals, garnering 160 and 35 responses, respectively. Analysis revealed the lack of seizures as a distinctive feature between PMM2-CDG (11.2%) with Other CDG (57.7%) at symptom onset. Hypotonia and developmental disability were prevalent symptoms across all studied CDG. Feeding problems were identified as an early onset symptom in PMM2-CDG (Cramer’s V (V) = 0.30, False Discovery Rate (FDR) = 3.8 × 10− 9), and hypotonia in all studied CDG (V = 0.34, FDR = 7.0 × 10− 3). The average time to diagnosis has decreased in recent years (now ~ 3.9 years), due to advancements namely the increased use of whole genome and exome sequencing. However, misdiagnoses remain prevalent (PMM2-CDG – 44.9%, non-PMM2-CDG – 64.8%). To address these challenges, we propose adapting medical training to increase awareness of CDG and other rare diseases, ongoing education for physicians, the development of educational resources for relevant medical units, and empowerment of families through patient organizations and support networks.ConclusionThis study emphasizes the crucial role of community-centered research, and the insights families can offer to enhance CDG management. By pinpointing existing gaps and needs, our findings can inform targeted interventions and support systems to improve the lives of those impacted by CDG.

Spinal Injuries and Spine Care in the US Military Health System (2001-Present).

Literature Review. The goal of this study was to provide a comprehensive outline of spinal injuries that may transpire over the course of military service from traumatic to repetitive stress injuries and chronic sequalae. We considered studies that assessed spinal injuries in the combat and non-combat settings as reported in the literature over the last 15-20 years. Military service places servicemembers under substantial physical demands, while also exposing them to dangerous, unpredictable environments. As a result, servicemembers are at an increased risk of spinal injuries from combat-related trauma and other causes. They may have different care needs and recovery profiles when compared to civilians with spinal disorders. We performed a review of the available literature on spinal injuries and spinal care in the Military Health System from 2001-present. The studies discussed in this review were primarily focused on the conflicts in both Iraq and Afghanistan from over ten years ago and do not fully capture the present-day advancements in military technology that may have an impact on the potential for spinal injuries. The long-term effects of sustained military service and the relative influence of high demand versus sedentary military occupations on the development of spinal disorders remains poorly understood. Given the changing nature of military service, both with respect to the demographic in uniform and the ever-evolving nature of modern combat, we believe that only a long-term prospective observational study dedicated to the surveillance of spinal problems could effectively answer these questions. Further research into the present-day characterization of spinal injuries is warranted given the advancements in both military technology and spine care that have occurred over the last ten years.

Radiology during a war - experience in Ukraine.

Military radiology, an integral part of military medicine, plays a pivotal role in medical triage, diagnosis, and treatment. Its significance lies in providing timely and accurate assessments in challenging situations.The utilization of contemporary sonographic techniques enables rapid identification of life-threatening conditions, ensuring prompt medical aid and facilitating regional anesthesia. Computed tomography emerges as a critical tool for assessing injury extent, planning surgeries, monitoring postoperative phases, and conducting retrospective evaluations, especially when anatomical dissection is complex.Battlefield radiology not only enhances the understanding of injury mechanisms and battlefield traumas but also contributes significantly to the overall improvement of diagnostic and treatment approaches. Ukrainian doctors actively engaged in diverse stages of patient care accumulate a wealth of knowledge, substantially elevating the survival rates of wounded individuals. This experience serves as the foundation for ongoing enhancements and the advancement of military radiology, even during periods of peace. · Military radiology is essential in medical triage, diagnosis, and treatment within military contexts.. · Modern sonographic methods enable swift identification of life-threatening conditions.. · Computed tomography is indispensable for assessing injuries, planning surgeries, and conducting retrospective evaluations.. · Ukrainian doctors actively contribute to the knowledge base, improving diagnostic and treatment practices.. · The acquired experience serves as a foundation for ongoing advancements in military radiology, extending its impact beyond wartime scenarios.. · Nehria N, Nehria Y, Bukharin T. Radiology during a war - experience in Ukraine. Fortschr Röntgenstr 2024; DOI 10.1055/a-2326-7724.

Do Fellowship-educated Military Orthopaedic Oncologists Who Practice in Military Settings Treat a Sufficient Volume of Patients to Maintain Their Oncologic Expertise?

Fellowship-trained orthopaedic oncologists in the US military provide routine clinical care and also must maintain readiness to provide combat casualty care. However, low oncologic procedure volume may hinder the ability of these surgeons to maintain relevant surgical expertise. Other low-volume specialties within the Military Health System (MHS) have established partnerships with neighboring civilian centers to increase procedure volume, but the need for similar partnerships for orthopaedic oncologists has not been examined. The purpose of this study was to characterize the practice patterns of US military fellowship-trained orthopaedic oncologists. We asked the following questions: (1) What are the diagnoses treated by US military fellowship-trained orthopaedic oncologists? (2) What are the procedures performed by US military fellowship-trained orthopaedic oncologists? We queried the Military Data Repository, a centralized repository for healthcare data for all healthcare beneficiaries (active duty, dependents, and retirees) within the Defense Health Agency using the MHS's Management and Reporting Tool for all international common procedure taxonomy (CPT) codes and ICD-9 and ICD-10 codes associated with National Provider Identifier (NPI) numbers of active duty, military fellowship-trained orthopaedic oncologists. Fellowship-trained orthopaedic oncologists were identified by military specialty leaders. Then, we identified all procedures performed by the orthopaedic oncologist based on NPI numbers for fiscal years 2013 to 2022. We stratified the CPT codes by top orthopaedic procedure categories (such as amputation [performed for oncologic and nononcologic reasons], fracture, arthroplasty, oncologic) based on associated ICD codes. These were then tabulated by the most common diagnoses treated. Thirteen percent (796 of 5996) of the diagnoses were oncologic, of which 45% (357 of 796) were malignant. Forty-four percent (158 of 357) of the malignancies were primary and 56% (199 of 357) were secondary; this translates to an average of 2 patients with primary and 2.5 patients with secondary malignancies treated per surgeon per year. During the study period, nine orthopaedic oncologists performed 5996 orthopaedic procedures, or 74 procedures per surgeon per year. Twenty-one percent (1252 of 5996) of the procedures were oncologic; the remaining procedures included 897 arthroplasties, 502 fracture-related, 275 amputations for a nononcologic indication, 204 infections, 142 arthroscopic, and 2724 other procedures. Although military orthopaedic oncologists possess expert skills that are directly translatable to combat casualty care and operational readiness, within MHS hospitals they treat relatively few patients with oncologic diagnoses, and less than one-half of those involve malignancies. Despite postgraduation procedure volume raining stable over the last decade, it is unknown how many new patient visits for oncologic diagnoses and how many corresponding tumor procedures are necessary to maintain competence or build confidence after musculoskeletal oncology fellowship training. It is important to note that there are no military orthopaedic oncology fellowships, and all active duty orthopaedic oncologists undergo training at civilian institutions. Military-civilian partnerships with high-volume cancer centers may enable military orthopaedic oncologists to work at civilian cancer centers to increase their oncologic volume to ensure sustainment of operationally relevant knowledge, skills, and abilities and improve patient care and outcomes.

Specific features of bilateral otolith manifestations in patients with vestibular balance disorder

Bilateral asymmetry in the function of the semicircular canals underlies dizziness and vestibular balance disorders. According to the traditional view, otolith dysfunction does not have a significant effect on the clinical picture in individuals with peripheral vestibular disorders. In recent years, interest in studying the contribution of vestibular function to the control of posture and movements has increased. However, we have not identified any studies addressing the reactivity of otolith organs in vestibular balance disorders in the available literature.Aim: To study bilateral otolith reactions in patients with vestibular balance disorders using the method of cervical vestibular evoked myogenic potentials (cVEMP) in patients with episodic and chronic vestibular disorders.Material and Methods. A clinical examination was carried out in 63 patients complaining of dizziness and balance problems. They were hospitalized on an emergency and planned basis in the neurological departments of the clinics of the Siberian State Medical University and the Medical and Sanitary Unit No 2 in Tomsk. From the total group, 28 patients (8 men and 20 women aged from 22 to 84 years) were selected for assessment of vestibular function; the average age was 63.87 ± 11.52 years and 57.2 ± 18.5 years for men and women respectively. They had chronic and episodic vestibular dysfunction unrelated to acute or progressive neurological disease and inflammatory pathology of the inner ear.Results. 27 patients (96.4%) complained of dizziness. Systemic dizziness, characterized by a feeling of objects rotating around the subject, was detected in 29.63% of patients; non-systemic dizziness, including a feeling of “failing” – in 81.48%. Both types of complaints appeared in 10.71% of those examined, which made it possible to identify 2 groups of patients: Group A – with chronic vestibular disorders (7 patients) and Group B – with episodic vestibular disorders (21 patients). During the study of the groups of patients, differences were found in the amplitudes of cVEMP latency P13 and the coefficient of vestibular asymmetry between Groups A and B, as well as the absence of a difference in amplitudes in Group A and the presence of a difference in Group B on the right.Conclusion. Despite the fact that patients presented with predominantly one complaint of dizziness, clinical and instrumental tests of vestibular dysfunction showed the presence of damage to both the semicircular canals and otolithic organs; asymmetry of vestibular reflexes and/or bilateral damage to the vestibular organs. The results of the study allow us to consider the cVEMP method as one of the methods for objectively assessing the condition of the otolithic apparatus in patients with impaired vestibular function. In this regard, it is recommended to use this method in routine neurological practice.

Implementation of Medical Hospitalist Care at a Korean Tertiary Hospital: A Retrospective Cross-Sectional Study

Background/Objectives: In March 2018, a tertiary teaching hospital launched a medical hospitalist team. This study presents the clinical characteristics and outcomes of medical hospitalist care and reveals the relationship between them. Methods: This study included 4003 patients first admitted to the hospitalist team via emergency room and then discharged from the hospitalist team between March 2018 and November 2022. The patients were admitted either to the teaching admitter hospitalist team or the hospitalist-led acute medical unit (AMU). Afterward, the patients were either discharged, if possible, within a few days or transferred to ward hospitalists if assigned wards for hospitalist care were available. Results: The patients’ mean Charlson Comorbidity Index score was 3.5 and the mean National Early Warning Score was 3.4. Of the admissions, 44.2% of the patients were admitted to the AMU, and 26.8% received an early consultation with a subspecialist. Each hospitalist managed 12.8 patients per month on average. The patients’ mean LOS was 14.52 days, 10.5% of patients died during hospitalization, and 13.0% of patients had unscheduled readmission within 1 month. The patients’ mean total cost per hospital stay was 572,836 won per day. Admission to the AMU was associated with a lower total cost per hospital stay, but the relationships with mortality, readmission, and LOS were not significant. Conclusions: The study reports on the outcomes of implementing a medical hospitalist care system that combines short-term admission wards with integrated care models to manage complex cases. These findings provide insights into optimizing hospitalist systems for improved patient outcomes.

Machine Learning Models for Tracking Blood Loss and Resuscitation in a Hemorrhagic Shock Swine Injury Model

Hemorrhage leading to life-threatening shock is a common and critical problem in both civilian and military medicine. Due to complex physiological compensatory mechanisms, traditional vital signs may fail to detect patients’ impending hemorrhagic shock in a timely manner when life-saving interventions are still viable. To address this shortcoming of traditional vital signs in detecting hemorrhagic shock, we have attempted to identify metrics that can predict blood loss. We have previously combined feature extraction and machine learning methodologies applied to arterial waveform analysis to develop advanced metrics that have enabled the early and accurate detection of impending shock in a canine model of hemorrhage, including metrics that estimate blood loss such as the Blood Loss Volume Metric, the Percent Estimated Blood Loss metric, and the Hemorrhage Area metric. Importantly, these metrics were able to identify impending shock well before traditional vital signs, such as blood pressure, were altered enough to identify shock. Here, we apply these advanced metrics developed using data from a canine model to data collected from a swine model of controlled hemorrhage as an interim step towards showing their relevance to human medicine. Based on the performance of these advanced metrics, we conclude that the framework for developing these metrics in the previous canine model remains applicable when applied to a swine model and results in accurate performance in these advanced metrics. The success of these advanced metrics in swine, which share physiological similarities to humans, shows promise in developing advanced blood loss metrics for humans, which would result in increased positive casualty outcomes due to hemorrhage in civilian and military medicine.

First experience of endovascular balloon occlusion of the aorta in the wounded with hemorrhagic shock during the war in Ukraine

Background. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used worldwide to stop bleeding in trauma and wounds in patients with hemorrhagic shock. REBOA allows for the hemodynamic stabilization, patient transportation and final bleeding control. The study aims to demonstrate the capabilities of REBOA as a method of bleeding control in the wounded with hemorrhagic shock in the context of war in Ukraine. Materials and methods. Five AFU servicemen who sustained mine-blast wounds in the Eastern Ukraine as a result of shelling by Russian troops were delivered with signs of internal bleeding and hemorrhagic shock to the primary and secondary levels of medical care (Role 1, 2). The REBOA balloon catheter was inserted and inflated by surgeons working in stabilization centers or advanced surgical teams. Upon admission, all patients underwent chest and abdominal ultrasound according to the FAST protocol. We used COBRA-OS 4 Fr and ER-REBOA 7 Fr balloon catheters. The positioning of the balloon in the aorta was performed according to external anatomical landmarks (3 cases) and ultrasound (2 cases). In all clinical cases, the balloon catheter was placed in zone I. In one case, the balloon was moved from zone I to zone III (control of the source of bleeding). The duration of aortic occlusion ranged from 15 to 50 minutes. Immediately after removal of the introducer, manual compression of the puncture site was used (3 cases) or suturing of the arteriotomy (2 cases). Results. The sources of bleeding in our clinical cases were injuries of the iliac vessels (2 cases), the renal artery (1 case), and injuries of the inferior vena cava and liver (2 cases). Four patients were evacuated to a higher level of medical care after the REBOA was installed. In one case, there were complications from vascular access (femoral artery thrombosis). We were unable to save one wounded soldier, most likely due to the delay in evacuation from the previous stage, the severity of injury, and massive blood loss. Conclusions. As our observations have shown, the use of REBOA in combat conditions allows not only to stabilize hemodynamics in the wounded with severe combined trauma and bleeding but also to conduct a successful evacuation to a higher level of medical care to stop bleeding ultimately. REBOA can be successfully used at the prehospital stage. This requires clearly defined indications for the technique’s use, training of medical personnel, and provision of balloon catheters to medical units of the Armed Forces of Ukraine.

Missed nursing care and associated factors among nurses at University of Gondar Comprehensive Specialized Hospital, Ethiopia, 2022

The issue of missed nursing care is a problem that affects the overall quality of nursing care in hospitals around the world. However, there is limited research about it in Ethiopia. This study assessed missed nursing care and factors among nurses. An institutional-based cross-sectional study was conducted among 485 nurses at the University of Gondar Specialized Hospital. The data were collected from May 15 to June 15, 2022 using a self-administered questionnaire. A simple random sampling technique was used to select study participants. The data was entered to EPI DATA version 4.6 and exported to SPSS version 23 for analysis. Descriptive statistics were computed, and a summative score of missed nursing care was calculated. Then, multiple linear regression analysis was used to identify the factors. A P-value of 0.05 was used to declare significant level. In this study, missed nursing care was 62.5% (95% CI 60.98–64.02). Documentation, vital signs assessment, intravenous care, and assessment as per hospital policy and patient education were the most frequently missed nursing care. Being single in marital status (B = −4.609, P = 0.004), adequacy of nursing staff (B = −2.458, P = 0.003), satisfaction with income (B = −8.753, P = 0.007), working in medical unit (B = −5.708, P = 0.002) and working in both day and night shift (B = 1.731, P = 0.027) were statistically associated factors. More than half of the participants missed basic nursing care. Most of the identified factors correlated with missed nursing care negatively. Efforts should be done to enhance communication between health team members, assign a manageable number of patients per nurse, and adjust shifts and units.

A Cross-Sectional Study of the Perception of Individualized Nursing Care Among Nurses in Acute Medical and Perioperative Settings

Background/Objectives: Individualized nursing care allows for systematic assessment and intervention; considers a patient’s preferences, values, and context; and contributes to a positive care trajectory. However, its operationalization has proven to be challenging. This research aimed to evaluate nurses’ perceptions of individualized care and analyze their relationship with sociodemographic variables. Methods: A cross-sectional study was conducted on 122 eligible and registered nurses at a Hospital Center, in the Ophthalmology (operating room and inpatient ward) service, the Cardiology service, the Internal Medicine service, and the Medical Emergency Unit, for adults/older adults in Portugal. The nursing version of the Individualized Care Scale (ICS-Nurse) was used for the assessment, including three sub-dimensions: clinical situation, personal life situation, and decisional control over care-related decisions. Cronbach’s alpha and principal component analysis were used for the data analysis. The STROBE checklist was used to report this study. Results: No statistically significant differences were found based on the age, gender, level of education, or years of professional experience of the nurses within the sub-dimensions of individualization. The nurses overall had a good perception of the importance of individualized care (4.06 ± 0.46 ICS-A-NURSE) but faced difficulties in its implementation during the last shift they worked (3.97 ± 0.49 ICS-B-NURSE). Conclusions: The items considered to be of greatest importance were the response to the physical and emotional needs arising from illness and assistance in decision-making through educational instructions. Aspects related to the personal lives of patients, such as family inclusion in an individual’s care plan, everyday habits, and previous experiences of hospitalization, received the lowest scores. Recognizing priority areas for improvement in the individualization of nursing care can contribute to developing training programs and policies that promote a holistic approach. Future studies should consider patient outcomes related to their needs for individualization.

Comparative Analysis of Treatment Patterns in DoD Beneficiaries With Malignant Central Nervous System Tumors: A Focus on Care Setting.

Malignant brain and other central nervous system tumors (MBT) are deadly and disproportionately affect younger men and women in the age range of most active-duty service members. Timely and appropriate treatment is important to both survival and quality of life of patients. Information on treatment factors across direct care (DC) and private sector care (PSC) networks may be important for provider training and staffing for the DoD. The aim of this study was to analyze treatment patterns for patients with MBT within the DoD's universal access Military Health System (MHS), comparing DC and PSC networks. The Military Cancer Epidemiology database was used to identify patients 18 years and older who were diagnosed with an MBT between 1999 and 2014 who received primary treatment. Differences in first treatment type and time from diagnosis to initial treatment between DC and PSC were assessed using chi-square and Wilcoxon-Mann-Whitney tests, respectively. Frequency of treatment initiation beyond the 28-day TRICARE Prime access standard for Specialty Care was also compared between care settings using chi-square and Fisher's exact tests. Then logistic regression models generated odds of treatment initiation beyond 28 days and 95% confidence intervals (CIs) associated with care setting. Kaplan-Meier survival curves and log-rank tests compared survival between DC and PSC. The study included 857 patients, with n = 540 treated in DC and n = 317 treated in PSC. The proportion of patients receiving each initial treatment type did not differ by care setting (P = .622). Median time from diagnosis to initial treatment (interquartile range) varied significantly between DC at 6 (0 to 25) days and PSC at 12 (0 to 37) days for all treatment types combined (P < .001). For all years combined, treatment was initiated beyond 28 days for 21% of patients using DC compared to 31% of patients using PSC (P = .001). The odds of treatment initiation beyond 28 days for a patient treated in PSC were 1.61 (95% CI, 1.11 to 2.33, P = .012) compared to patients treated in DC when controlling for demographic, military, tumor, and patient variables. Survival did not differ by care setting (P = 1.000). Based on the available data between 1999 and 2014, care setting was associated with differences in time to initial treatment and odds of treatment initiation beyond 28 days among DoD beneficiaries with MBT receiving care in the MHS. Information on these differences may help inform MHS leadership decisions on the most appropriate location for military provider training and staffing.

Strategic Aeromedical Evacuations of the French Armed Forces in French Guiana From 2018 to 2020.

The French Armed Forces are deployed in French Guiana (FG) to protect national territory and ensure the security of strategically important sites. Military health support (MHS) provides medical support for missions in this tropical environment, which is hazardous and where confrontations are possible. MHS must organize tactical and strategic evacuations (Strat-AEs), so that an optimal level of care can be delivered. Overall, Strat-AE activity has been described previously but no specific data related to FG has been reported. The main objective of this study was to provide an overview of military Strat-AEs from FG. We conducted a retrospective cohort study from January 01, 2018 through 31 December, 2020. All patients who required a military Strat-AE were included, and we collected sociodemographic characteristics, medical information, service-related injuries and illnesses, and the reason for and conditions of evacuation. We analyzed 210 patients and 199 were included. Most were noncommissioned members (63.3%) and belonged to the Army (75.4%) and the Gendarmerie (15.6%). Injury or illness was duty-related in 66.2% of patients. The main cause for evacuation was nonbattle injury (63.3%), followed by illness (27.1%). Battle stress and injury accounted for 9.5%. The main reasons for evacuation were surgical conditions (58.3%), particularly orthopedic (47.2%). Medical (22.1%), psychiatric (18.6%), and dental (1.0%) disorders followed. Most patients were categorized by the flight surgeon as P3 (98.5%), the lowest level of priority, and D4 (82.9%), the lowest level of dependency. The escort used during evacuation was identical to that recommended by the requester in 83.5% of cases. The final destination was mainly a hospital (89.9%). The time lag between injury or onset of illness and the request for evacuation was significantly longer when local health resources were insufficient. The particularity of FG is a local health care system that provided initial care before the evacuation. To reduce the number of Strat-AEs in FG, the risk of nonbattle injury must be lessened and improvements must be made to the local health care system and to the partnership between civilian and military health services.

Efficient and Fair Healthcare Rationing

The rationing of healthcare resources has emerged as an important issue, which has been discussed by medical experts, policy-makers, and the general public. We consider a rationing problem where medical units are to be allocated to patients. Each unit is reserved for one of several categories, and each category has a priority ranking over the patients. We present a class of allocation rules that respect the priorities, comply with the eligibility requirements, allocate the largest feasible number of units, and do not penalize agents for rising in the priority ranking of a category. The rules characterize all possible allocations that satisfy the first three properties and are polynomial-time computable.

07 Partnering with patients with living and lived experience of eating disorders to improve inpatient care on an acute paediatric medicine unit

Abstract Background Since the COVID-19 pandemic, hospitals nationally are seeing a growing number of adolescent patients with eating disorders requiring acute medical stabilization, which is often a time of crisis in the trajectory of this ego-syntonic disorder. The complexity of these admissions often lead to safety events for patients and moral distress for clinicians. Medical admissions can also be an opportunity to engage youth and families. Patient partners are a pillar in healthcare quality improvement, but historically we have not engaged adolescent patient partners in improving acute eating disorder treatment. We gathered the experience of patients and families with living and lived experience of eating disorder treatment to improve their quality of care in an acute paediatric medicine unit. Objectives We aimed to describe the experience of patients and families with living and lived experience of eating disorder treatment, specifically acute medical stabilization, through a quality improvement patient engagement project. Design/Methods We used a mixed-methods design of semi-structured interviews and a focus group with adolescents with eating disorders and their caregivers in an acute medical unit at a tertiary paediatric hospital in British Columbia. We employed opportunity sampling by distributing recruitment flyers through patient experience councils, outpatient clinics, other non-acute units, and to all patients admitted with a medically unstable eating disorder at our hospital during the study period. The interviews consisted of open-ended questions, yes/no questions, and Likert scales related to four categories: admission process, inpatient experience, team communication, and discharge process. Two reviewers analyzed the qualitative data using thematic analysis, and the quantitative data was analyzed descriptively. Quality improvement projects are exempt from Research Ethics Board approval. However, we utilized the "A Project Ethics Community Consensus Initiative" (ARECCI) Ethics Guideline and Screening Tool and presented our proposal at the hospital's quality improvement and research oversight committees. Results We completed 8 interviews with patients with current living experience admitted to our acute medical unit. We also completed 1 interview with a patient with past lived experience and 1 focus group with patients and caregivers. Primary themes identified included uncertainty about their overall treatment journey and stress due to the sudden new expectations on the inpatient unit, such as activity restriction, meal plans by the hospital, and bathroom access after meal times. Patients identified the importance of relational care, inclusion in treatment planning, acknowledgement of the demanding nature of eating disorders, and individualized care. Due to variability in training, resource allocation, and gaps in communication, these patient-identified priorities are not always met. While 100% of participants stated they understood the reasons and goals for admission, participants averaged 3.7 on a 1 (lowest) to 5 (highest) Likert scale when asked to rate their satisfaction with the information they received. Five out of eight adolescents felt that there was consistency in communication within the team. Conclusion We demonstrate the complex needs of patients with eating disorders who require acute medical stabilization. Targeted knowledge mobilization initiatives through admission orientation documents and family-centered rounds could better meet those needs. We are currently developing an admission pamphlet and journal for patients admitted with a new eating disorder to our medical unit. Patient partners exhibited a high willingness to participate in our study and readily acknowledged the importance their contributions could hold for other patients.

Exploring the influence of music on cognitive performance in female assembly line workers at a medical device manufacturing unit.

The significance of enhancing working conditions for the physical health and performance of workers, particularly female workers, underscores the need for research in this domain and the examination of interventions such as music. Previous studies have yielded diverse outcomes regarding the influence of music on individuals' performance; hence, further research in this area appears imperative. The aim of this study is to explore the impact of music on the cognitive and task performance of female assembly operation operators. This study is an interventional (quasi-experimental) study that involved 81 participants from the female workforce of the medical equipment assembly unit in Isfahan, Iran. The evaluation encompassed task performance, working memory using N-Back test, sustained attention using continues performance test (CPT), degree of sleepiness, and mental fatigue using Flicker Fusion test, along with physiological parameters such as heart rate and blood oxygen level. Participants underwent testing both in the presence of classical music and in a condition without music playback. The provision of background music enhanced the workers' sustained attention and working memory. It led to improved task performance and a reduction in drowsiness. Concerning physiological parameters, it resulted in a slight decrease in heart rate at the end of the work shift and a marginal increase in participants' blood oxygen levels. Background music enhanced working memory (p-value = 0.001), sustained attention (p-value = 0.001), and improved the task performance of workers(p-value = 0.005). Additionally, likely due to increased relaxation, it led to a decrease in heart rate (p-value = 0.001) and an increase in blood oxygen levels (p-value = 0.016). Music also played a role in reducing participants' sleepiness (p-value = 0.001).