On-call Physician Research Articles

A protocol to determine the acceptability and feasibility of a pilot intervention emergency department virtual observation unit fall prevention program

BackgroundAs a third of all community dwellers aged 65+ fall each year, falls are common reasons for older adults to present to an Emergency Department (ED). Although EDs should assess patients’ multifactorial fall risks to prevent future fall-related injuries, this frequently does not occur. We describe our protocol to determine the feasibility, acceptability, and safety of a pilot ED Virtual Observation Unit (VOU) Falls program.MethodsTo ensure standardized conduct and reporting, the Standard Protocol Items for Intervention Trials (SPIRIT) guidelines will be used. The VOU is a program where patients are sent home from the ED but are part of a virtual observation unit in that they can call on-call ED physicians while they are being treated for conditions such as cellulitis, congestive heart failure, or pneumonia. A paramedic conducts daily visits with the patient and facilitates a telemedicine consult with an ED physician. VOU nursing staff conduct daily assessments of patients via telemedicine. The ED VOU Falls program is one of the VOU pathways and is a multi-component fall prevention program for fall patients who present after an ED visit. The paramedic conducts a home safety evaluation, a Timed Up and Go Test (TUG). During the VOU visit, the ED physician conducts a telemedicine visit, while the paramedic is visiting the home, to review patients' fall-risk-increasing drugs and their TUG test. We will determine feasibility by calculating rates of patient enrollment refusal, and adherence to fall-risk prevention recommendations using information from 3-month follow-up telephone calls, as well as qualitative interviews with the paramedics. We will determine the acceptability of the ED VOU Falls program based on patient and provider surveys using a Likert scale. We will ask VOU nursing staff to report any safety issues encountered while the patient is in the ED VOU Falls program (e.g., tripping hazards). We will use the chi-square test or Fisher’s exact test for categorical variables, Student’s t-test for continuous variables, and Mann-Whitney for nonparametric data. We will review interview transcripts and generate codes. Codes will then be extracted and organized into concepts to generate an overall theme following grounded theory methods. This is a pilot study; hence, results cannot be extrapolated. However, a definite trial would be the next step in the future to determine if such a program could be implemented as part of fall prevention interventions.DiscussionThis study will provide insights into the feasibility and acceptability of a novel ED VOU Falls program with the aim of ultimately decreasing falls. In the future, such a program could be implemented as part of fall prevention interventions.

Drepadom - a Homecare Protocol for Vaso-Occlusive Crisis for Sickle Cell Disease Patients

INTRODUCTION Vaso-occlusive crisis (VOC) is first cause of emergency room (ER) admissions and hospitalizations for sickle-cell disease (SCD) patients. Acute chest syndrome (ACS) is a complication that can occur during VOC and prolong hospitalization, and is the main cause of death in SCD patients. The PRESEV score (Bartolucci - eBioMed 2016), established by our team, allows physicians to evaluate the risk of developing ACS and is calculated upon arrival to the ER and has been validated by an international multicenter study in five different countries (PRESEV 2 - ASH 2020). During the Covid-19 pandemic, we set up a temporary system to monitor VOC patients at home using a telephone hotline and homecare services. The success of this system led to the establishment of DREPADOM, a home-care protocol for VOC management for patients with low risk of developing ACS, or who can be discharged early from the hospital, as standard care (DREPADOM - ASH 2021). Since 2021, Drepadom has been successfully running in seven hospitals in the Parisian region. DESCRIPTION OF SETTING Drepadom has two inclusion modes: 1/ Patients arriving at the ER for VOC with a PRESEV score ≤ 6 and not presenting any exclusion criteria; 2/ patients that are discharged early following hospitalization for VOC and/or ACS (after at least 3 days of hospitalization for patients with PRESEV > 6 upon ER arrival). The Drepadom homecare protocol is activated by a coordinator, who coordinates delivery of PO opioids and parenteral treatments, and a home oxygen concentrator, to the patients' home within four hours. Drepadom uses an online platform and mobile app (Link4Life), where the patient's medical record is shared to the homecare nurse who will perform house calls twice a day. During each visit, the nurse enters the patient's vitals into the app, which are monitored by an on-call SCD expert physician. The online platform also hosts a secure messaging service where nurses, doctors and coordinators can communicate in real-time regarding patient status and care, as well as an automatic alert system that is triggered when vitals fall outside of a predetermined range set by SCD experts. Patient safety is further ensured with a daily calls to the patient using a decision-making algorithm supervised by SCD experts, who arbitrate according to the evolution of the situation (stopping/continuing outpatient follow-up vs. rehospitalization). RESULTS Over a 30-month period we had 209 inclusions for 170 patients into DREPADOM. Of these, 105 were inclusions from the ER and 104 were early discharges (ED). SCD genotype distribution was 83.2% SS, 10.5% SC, and 5.8% S-bThalassemia and female to male ratio was 128:81. In both ER and ED groups, median age was 31 [27-40], 74% of patients were under hydroxyurea treatment and median homecare follow-up duration was 3 [2-4] days. No significant differences in population characteristics were found between the ER and ED groups. In the ER group, 96/105 patients (91.4%) were included with PRESEV ≤ 6. 9/105 (8.6%) patients were included with a PRESEV score >6 only in 2021 during the Covid-19 pandemic, when the ER was saturated. In the PRESEV ≤ 6 group, 9/96 (9.4%) patients were rehospitalized: 1 for ACS (PRESEV = 4), 4 for uncontrolled VOC pain, 2 for chest pain, 2 for fever/infection unrelated to VOC. In the PRESEV >6 group, 3/9 (33%) were hospitalized, one for ACS (PRESEV = 8), one for uncontrolled VOC pain and one for issues with veinous access. In the ED group, patients were hospitalized for a median of 4.5 [3-7] days before being discharged. 27 patients (26%) were included in a post-ACS context. 48/104 (46.2%) had a PRESEV ≤6, of which only 2/48 (4.2%) were rehospitalized for uncontrolled VOC pain. Of the 56/104 (53.8%) patients included with a PRESEV > 6, 8/56 (14.3%) were rehospitalized: 1 for ACS, 3 for uncontrolled VOC pain, 1 for chest pain, 1 for fever/infection unrelated to VOC, 1 for issues with veinous access, and 1 for morphine withdrawal symptoms. For both ER and ED groups, a total of 22/209 patients (11%) required rehospitalization (Figure 1), and no deaths or ICU were reported in either group. PERSPECTIVES Our results confirm that Drepadom is a successful and safe tool to reduce hospital stay for SCD patients.

The Value of Using a Quality Assurance Follow-Up Team to Address Incidental Findings After Emergency Department or Urgent Care Discharge: A Cost Analysis

BackgroundIncidental finding (IF) follow-up is of critical importance for patient safety and is a source of malpractice risk. Laboratory, imaging, or other types of IFs are often uncovered incidentally and are missed, not addressed, or only result after hospital discharge. Despite a growing IF notification literature, a need remains to study cost-effective non–electronic health record (EHR)–specific solutions that can be used across different types of IFs and EHRs. ObjectiveThe objective of this study was to evaluate the utility and cost-effectiveness of an EHR-independent emergency medicine–based quality assurance (QA) follow-up program in which an experienced nurse reviewed laboratory and imaging studies and ensured appropriate follow-up of results. MethodsA QA nurse reviewed preceding-day abnormal studies from a tertiary care hospital, a community hospital, and an urgent care center. Laboratory values outside preset parameters or radiology over-reads resulting in clinically actionable changes triggered contact with an on-call emergency physician to determine an appropriate intervention and its implementation. ResultsOf 104,125 visits with 1,351,212 laboratory studies and 95,000 imaging studies, 6530 visits had IFs, including 2659 laboratory and 4004 imaging results. The most common intervention was contacting a primary care physician (5783 cases [88.6%]). Twenty-one cases resulted in a patient returning to the ED, at an average cost of $28,000 per potential life-/limb-saving intervention. ConclusionsAlthough abnormalities in laboratory results and imaging are often incidental to patient care, a dedicated emergency department QA follow-up program resulted in the identification and communication of numerous laboratory and imaging abnormalities and may result in changes to patients’ subsequent clinical course, potentially increasing patient safety.

Survival Outcomes in Palliative Sedation Based on Referring Versus On-Call Physician Prescription.

This study sought to determine the survival duration of patients who underwent palliative sedation, comparing those who received prescriptions from referring physicians versus on-call physicians. It included all patients over 18 years old who died in the Palliative Care, Internal Medicine, and Oncology units at the Hospital Universitario of Jerez de la Frontera between 1 January 2019, and 31 December 2019. Various factors were analyzed, including age, gender, oncological or non-oncological disease, type of primary tumor and refractory symptoms. Statistical analysis was employed to compare survival times between patients who received palliative sedation from referring physicians and those prescribed by on-call physicians, while accounting for other potential confounding variables. This study revealed that the median survival time after the initiation of palliative sedation was 25 h, with an interquartile range of 8 to 48 h. Notably, if the sedation was prescribed by referring physicians, the median survival time was 30 h, while it decreased to 17 h when prescribed by on-call physicians (RR 0.357; 95% CI 0.146-0.873; p = 0.024). Furthermore, dyspnea as a refractory symptom was associated with a shorter survival time (RR 0.307; 95% CI 0.095-0.985; p = 0.047). The findings suggest that the on-call physician often administered palliative sedation to rapidly deteriorating patients, particularly those experiencing dyspnea, which likely contributed to the shorter survival time following sedation initiation. This study underscores the importance of careful patient selection and prompt initiation of palliative sedation to alleviate suffering.

1060-P: After-Hours Nurse Line Utilization Decreased Call Burden in an Academic Pediatric Endocrinology Practice

Background: Optimal management of childhood diabetes benefits from access to a 24-hour support line. If staffed by on-call physicians, repeated interruptions to sleep can lead to physician burn out. Utilization, and outcomes of an after-hours nurse call service in a pediatric endocrinology practice have not been previously reported. Methods: Barton Schmitt guidelines, which are widely accepted as the standard for telephone triage care, were modified to include our institution specific diabetes management protocols. We analyzed demographics, reasons for call, clinical presentation to the emergency room, and clinical disposition of the callers. Results: After we instituted our after-hours nurse triage service (September 2019), the call burden to the on-call physicians decreased by 70%. Patients who called the after-hours line before coming to the emergency room were less sick (higher pH and lower glucose) and were more likely to be discharged home. We cannot infer causality from our data. Nevertheless, given that <10% of patients called first, encouraging earlier and more consistent utilization of the nurse line seems like a low-cost intervention that might reduce hospital admissions for diabetic ketoacidosis. After-hours service was utilized well by our patients of all races and insurance statuses. We noted that language was a barrier in utilization which is an opportunity for improvement. Disclosure A.Choudhary: None.

The New York City Pediatric Disaster Coalition Pediatric Intensive-Care Response Team (PIRT)

Introduction:Children represent 25% of the population, have special needs, and are often over-represented in disasters. The New York City Pediatric Disaster Coalition (NYC PDC) is funded by the NYC Department of Health and Mental Hygiene (DOHMH) to improve pediatric disaster preparedness and response. PDC worked with a network of pediatric intensivists to create the Pediatric Intensive-Care Response Team (PIRT). PIRT consists of volunteer pediatric intensivists that currently practice in New York City.Method:Secondary transport may be requested by hospitals due to a mismatch of resources to needs for patients requiring critical and/or subspecialty care. The team is activated when a disaster involves a significant number of pediatric patients. In the proposed plan, the PIRT physician on-call will triage/prioritize the patients based on acuity and need for services and relay the necessary information to the transport agency. PIRT is designated to provide subject matter expertise and resources during real-world events. PIRT maintains a 24/7 on-call schedule with backup. The PIRT system was tested in four call-down communications drills and a tabletop exercise for prioritization of pediatric mass casualty victims.Results:The call-down drills demonstrated the ability to contact the on-call and backup physicians by email or text within 20 minutes and others within one hour. In the tabletop, PIRT members were given 15 patient profiles based on a scenario and asked to prioritize patients based on their injuries/medical needs. This was accomplished in less than 30 minutes, followed by a review and discussion of the rank order. A number of lessons learned were identified and will be presented.Conclusion:The NYCPDC has developed and tested a PIRT that is available 24/7 to prioritize patients for secondary transport and offer subject matter expertise during pediatric mass casualty events. This model can be utilized to enhance pediatric disaster preparedness.

Involuntary admissions to the emergency department: a retrospective observational study.

The main objective of this study was to describe patients who were involuntarily admitted to the emergency department of Lausanne University Hospital on involuntary admission in 2018 in terms of age, gender, emergency department length of stay, the motive for involuntary admission, use of psychoactive substances, diagnosis, and destination at emergency department discharge, with or without discontinuation of involuntary admission. This retrospective, observational, and monocentric study included patients 18 years and older admitted to the emergency department of Lausanne University Hospital on involuntary admission from January 1, 2018, to December 31, 2018. Patients were identified by the Cantonal Medical Office of Vaud. The emergency department length of stay and patient destination on discharge from the emergency department were extracted from the patient flow database, and discharge letters and involuntary admission were extracted from the electronic archiving software. Descriptive statistics were processed by using means and standard deviations for quantitative variables with a normal distribution and median and interquartile range for non-normally distributed data. During the study period, 83 patients were admitted on involuntary admission to the emergency department. The majority of the patients were male (58%) with a mean age of 55 (±20) years. The median emergency department length of stay of patients with an involuntary admission was between 9 and 16 hours, depending on whether the involuntary admission was confirmed or discontinued after patient assessment in the emergency department. In comparison, the median emergency department length of stay was 6 hours for patients overall. The two principal diagnoses described were psychiatric (schizophrenia) and mental and behavioural disorders due to psychoactive substance use. Half of the patients on involuntary admission consumed psychoactive substances, primarily alcohol, and had a mean ethanolaemia of 53 (±32) mmol/l. Only a third of patients admitted on involuntary admission saw this measure confirmed after their assessment in the emergency department. Involuntary admissions with admission to the emergency department is used to force patients to be examined by an emergency physician or even a psychiatrist. On-call and primary care physicians seemed to lack the time or resources to set up alternatives to emergency department admissions on involuntary admission, especially in situations in which the involuntary admission was discontinued after an emergency department assessment. This demonstrates the inappropriate use of this measure because a patient cannot be involuntarily hospitalised in an emergency department.

Burnout syndrome in paediatricians working in paediatric emergency care settings. Prevalence and associated factors: a multilevel analysis

IntroductionThe aim of our study was to describe the prevalence of burnout syndrome (BOS) in paediatricians working in paediatric emergency care settings and to analyse its association with potential risk factors. Material and MethodsMulticentre cross-sectional study through a survey of paediatricians working in paediatric emergency care settings in hospitals affiliated to the Research Network of the Spanish Society of Paediatric Emergency Medicine (SEUP) between September 2019 and January 2020. We analysed the association between social/family-related, demographic, occupational and satisfaction factors and the presence of BOS by means of multivariate and multilevel mixed-effects logistic regression models. ResultsThe estimated prevalence of BOS was 36.5% (95% confidence interval [CI], 31.7 %–41.2%). In the multivariate analysis, lacking a stable group of friends (OR, 2.57; 95% CI, 1.10−5.97), problems in and out of the work setting (OR, 3.06; 95% CI, 1.60−5.88) and a work experience of 9 years or less (OR, 2.31; 95% CI, 1.37−3.90) were identified as individual factors that increased the risk of SBO, while feeling acknowledged by coworkers (OR, 0.48; 95% CI, 0.30−0.79) and acknowledged by one’s supervisor (OR, 0.62; 95% CI, 0.41−0.93) were protective factors. In relation to the hospital, the paediatric emergency unit being a subdepartment of the Department of Paediatrics (OR, 3.81; 95% CI, 1.85−7.85), the presence of an on-call emergency medicine specialist around the clock (OR, 3.53; 95% CI,1.62−7.73) and a volume of 28 or more paediatric emergency encounters a day to be managed per on-call physician (OR, 2.05; 95% CI, 1.01−4.16) were identified as independent risk factors for SBO. There was no variability in the prevalence of BOS attributable to differences between hospitals and autonomous communities, save for the described situations. ConclusionsThe prevalence of SBO among these providers is high. There are modifiable factors that we can intervene on to address BOS, independently of the hospital or region.

Empijem pleure kao komplikacija Kovid 19 pneumonije kod pacijenta sa destroyed lung sindromom

Introduction. Destroyed lung syndrome is a severe destruction of the pleural parenchyma due to lung infection, mostly caused by tuberculosis. Besides tuberculosis, necrotizing pneumonia may also lead to this disease complication. Pleural empyema is a frequent consequence of the destroyed lung syndrome. Pleural empyema may occur during the COVID-19 infection and is negatively correlated with a favorable disease outcome. Case report. A male 50 y/o showed up during the on-call shift during the winter COVID-19 wave with a medical report from the Internal medicine clinic. His personal history is significant for his pneumonectomy in 2016. In the past two months, he had been treated for pneumonia and COVID-19 infection with antibiotics and corticosteroid therapy. Due to prolonged malaise and tachycardia his GP referred him to yet another chest X-ray and lab work. The chest X-ray showed pleural effusion, so he was promptly referred to an on-call hospital. The on-call physician, after looking into the hospital reports, consulted an internal medicine doctor and it was decided to refer the patient to a thoracic surgeon. He was hospitalized for pleural empyema and treated with thoracic drainage using the system of active aspiration. A year later, he feels well, and he regained his appetite, and body mass, with occasional leaking from the thoracic fistule. Conclusion. This case report shows a recurrence of pleural empyema in a patient with pneumonectomy due to necrotizing pneumonia and destroyed lung syndrome, complicated by COVID-19 infection. We aimed to draw the attention of GPs to diseases and disease complications that are rarely met in GP practice and are not otherwise treated on the primary healthcare level.

Allocating Blood Products During a Time of Remarkable Shortage

Abstract The COVID-19 Pandemic adversely impacted the nation’s blood supply such that blood suppliers could not fill standing orders. To address the dwindling blood supply, the American Red Cross (ARC) implemented daily thresholds, which distributed red blood cells (RBCs) based on clients’ historical blood orders and the ARC’s inventory. The threshold system left the blood bank to devise a process to judiciously allocate the reduced RBC supply across our institution. Herein, we describe an internal RBC utilization audit, the data from which we used to devise an algorithm to predict our ability to meet transfusion requirements for operating room (OR) procedures. An OR adjudication committee used our report to prioritize elective surgical cases taking places the following day. Thirty-one non-consecutive days of blood inventory release slips were reviewed across three months of recent transfusions. Weekdays were disproportionally investigated to predict the blood utilization for days with scheduled OR procedures. For all RBCs released, the blood type requested and the final disposition (transfused vs returned to blood bank) of the units were recorded. Average use was calculated as well as interquartile range (IQR) to account for transfusion variability. Utilization data was then used to develop a worksheet-based tool to predict ability to meet RBC requirements. Overall, the hospital transfused an average of 80 RBC units each weekday (IQR: 64-92 units). Approximately 40% of all requested RBC units were released to the OR. In turn, the OR transfused only 39% of the RBCs released to them, which represented 20% of transfusions hospital-wide. The OR requested an average of 41 RBC units each weekday (IQR: 25-57 units). The OR transfused an average of 16 units of RBCs each weekday (IQR: 9-21 units). The outpatient cancer center infusion clinic used less than 15% of total RBCs. The biggest user of RBCs were inpatients, who were transfused 65% of RBCs during the week and 82% of transfusions during the weekend. These percentages and the average-to-third-quartile range were used to devise a blood allocation algorithm to inform the OR if the blood bank could support anticipated use. The data was also used to devise a blood allocation worksheet for the on-call transfusion medicine physicians to predict our ability to provide adequate blood for emergent, non-elective procedures that require transfusion support such as liver transplants and aortic repairs. The audit of RBC disposition informed blood inventory management practices during a time of remarkable shortage. Within the confines of the threshold system, the transfusion medicine service allocated the expected number of units based on historical request and transfusion data to predict whether inventory levels could support scheduled and nonscheduled OR procedures.

Síndrome de burnout en pediatras con actividad asistencial en urgencias. Prevalencia y factores asociados. Análisis multinivel

IntroductionThe aim of our study was to describe the prevalence of burnout syndrome (BOS) in paediatricians working in paediatric emergency care settings and to analyse its association with potential risk factors. Material and methodsMulticentre cross-sectional study through a survey of paediatricians working in paediatric emergency care settings in hospitals affiliated to the Research Network of the Spanish Society of Paediatric Emergency Medicine (SEUP) between September 2019 and January 2020. We analysed the association between social/family-related, demographic, occupational and satisfaction factors and the presence of BOS by means of multivariate and multilevel mixed-effects logistic regression models. ResultsThe estimated prevalence of BOS was 36.5% (95% confidence interval [CI]: 31.7%-41.2%). In the multivariate analysis, lacking a stable group of friends (OR: 2.57; 95%CI: 1.10-5.97), problems in and out of the work setting (OR: 3.06; 95%CI: 1.60-5.88) and a work experience of 9years or less (OR: 2.31; 95%CI: 1.37-3.90) were identified as individual factors that increased the risk of SBO, while feeling acknowledged by coworkers (OR: 0.48; 95%CI: 0.30-0.79) and acknowledged by one's supervisor (OR: 0.62; 95%CI: 0.41-0.93) were protective factors. In relation to the hospital, the paediatric emergency unit being a subdepartment of the Department of Paediatrics (OR: 3.81; 95%CI: 1.85-7.85), the presence of an on-call emergency medicine specialist around the clock (OR: 3.53; 95%CI: 1.62-7.73) and a volume of 28 or more paediatric emergency encounters a day to be managed per on-call physician (OR: 2.05; 95%CI: 1.01-4.16) were identified as independent risk factors for SBO. There was no variability in the prevalence of BOS attributable to differences between hospitals and autonomous communities, save for the described situations. ConclusionsThe prevalence of SBO among these providers is high. There are modifiable factors that we can intervene on to address BOS, independently of the hospital or region.

Developing and sustaining advanced practice provider services: A decade of lessons learned.

Developing and sustaining advanced practice provider services: A decade of lessons learned.

Acute medical missions by helicopter medical service (HEMS) to municipalities with different approach for primary care physicians.

BackgroundThe prehospital emergency system in Norway involves out-of-hours (OOH) services with on-call physicians. Helicopter emergency medical service (HEMS) are used in cases of severe illness or trauma that require rapid transport and/or an anesthesiologist’s services. In recent years, on-call primary care physicians have been less available for call-outs in Norway, and HEMS may be requested for missions that could be adequately handled by on-call physicians. Here, we investigated how different availability of an on-call physician to attend emergency patients at site (call-out) impacted requests and use of HEMS.MethodsOur analysis included all acute medical missions in an urban and nearby rural OOH district, which had different approach regarding physician call-outs from the OOH service. For this prospective observational study, we used data from both HEMS and the OOH service from November 1st 2017 until November 30th 2018. Standard descriptive statistical analyses were used.ResultsThe rates of acute medical missions in the urban and rural OOH districts were similar (30 and 29 per 1000 inhabitants per year, respectively). The rate of HEMS requests was significantly higher in the rural OOH district than in the urban district (2.4 vs. 1.7 per 1000 inhabitants per year, respectively). Cardiac arrest and trauma were the major symptom categories in more than one half of the HEMS-attended patients, in both districts. Chest pain was the most frequent reason for an OOH call-out in the rural OOH district (21.1%). An estimated NACA score of 5–7 was found in 47.7% of HEMS patients from the urban district, in 40.0% of HEMS patients from the rural OOH district (p = 0.44), and 12.8% of patients attended by an on-call physician in the rural OOH district (p < 0.001). Advanced interventions were provided by an anesthesiologist to one-third of the patients attended by HEMS, of whom a majority had an NACA score of ≥ 5.ConclusionsHEMS use did not differ between the two compared areas, but the rate of HEMS requests was significantly higher in the rural OOH district. The threshold for HEMS use seems to be independent of on-call primary care physician involvement.

Competencies for on-call physicians for home medical care: A qualitative study of home care providers' experiences in Japan's super-aged society.

BackgroundIn Japan, many older people hope to receive end‐of‐life care at home. In such situations, team‐based home medical care with the support of on‐call physicians is needed. However, to date, necessary competencies for the on‐call physicians have yet to be clarified. We aim to reveal the competencies for on‐call physicians in home medical care settings.MethodThis was a qualitative study of semi‐structured interviews concerning competencies for on‐call physicians in home medical care. We evaluated digitally recorded interviews with eight home care professionals in seven home care facilities (three clinics, one hospital, and three nursing agencies) in A City, Japan. The transcribed data were analyzed by three researchers using thematic analysis.ResultsThe competencies for on‐call physicians were divided into the following six categories: clinical skills for frequent complaints, collecting patients' information in advance, understanding purposes of home care, understanding general roles of home care health professionals, thoughtfulness toward patients' families, and an attitude of humility.ConclusionThese competencies were classified into disease‐specific and interpersonal (collaborative) skills in home medical care. The competencies revealed by the study could contribute to the development of effective learning and preparation for on‐call physicians who support home medical care.

Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) study protocol: a stepped wedge randomised trial of stroke screening using the National Institutes of Health Stroke Scale in the ambulance

BackgroundLess than 50% of stroke patients in Norway reach hospital within 4 h of symptom onset. Early prehospital identification of stroke and triage to the right level of care may result in more patients receiving acute treatment. Quality of communication between paramedics and the stroke centre directly affects prehospital on-scene time, emphasising this as a key factor to reduce prehospital delay. Prehospital stroke scales are developed for quick and easy identification of stroke, but have poor sensitivity and specificity compared to an in-hospital assessment with the National Institutes of Health Stroke Scale (NIHSS). The aim of the Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) is to assess whether a structured learning program, prehospital NIHSS and a mobile application facilitating communication with the stroke physician may improve triage of acute stroke patients.MethodsA stepped wedge cluster randomised controlled intervention design will be used in this trial in Oslo, Norway. Paramedics at five ambulance stations will enrol adult patients with suspected stroke within 24 h of symptom onset. All paramedics will begin in a control phase with standard procedures. Through an e-learning program and practical training, a random and sequential switch to the intervention phase takes place. A mobile application for NIHSS scoring, including vital patient information for treatment decisions, transferring data from paramedics to the on-call stroke physician at the Stroke Unit at Oslo University Hospital, will be provided for the intervention.The primary outcome measure is positive predictive value (PPV) for prehospital identification of patients with acute stroke defined as the proportion of patients accepted for stroke evaluation and discharged with a final stroke diagnosis. One thousand three hundred patients provide a 50% surplus to the 808 patients needed for 80% power to detect a 10% increase in PPV.DiscussionStructured and digital communication using a common scale like NIHSS may result in increased probability for better identification of stroke patients and less stroke mimics delivered to a stroke team for acute diagnostics and treatment in our population.Trial registrationClinicalTrials.govNCT04137874. Registered on October 24, 2019.

Standardized Evaluation of Cord Gases in Neonates at Risk for Hypoxic Ischemic Encephalopathy.

Umbilical-cord acidemia may indicate perinatal asphyxia and places a neonate at increased risk for hypoxic ischemic encephalopathy (HIE). Our specific aim was to develop a standardized clinical care pathway, ensuring timely identification and evaluation of neonates with umbilical-cord acidemia at risk for HIE. A standardized clinical care pathway to screen inborn neonates ≥36 weeks with abnormal cord blood gases (a pH of ≤7.0 or base deficit of ≥10) for HIE was implemented in January 2016. Abnormal cord blood gases resulted in a direct notification from the laboratory to an on-call physician. Evaluation included a modified Sarnat examination, postnatal blood gas, and standardized documentation. The percentage of neonates in which physician notification, documented Sarnat examination, and postnatal blood gas occurred was examined for 6 months before and 35 months after implementation. Of 203 neonates with abnormal cord gases in the post-quality improvement (QI) period, physician notification occurred in 92%. In the post-QI period, 94% had a documented Sarnat examination, and 94% had postnatal blood gas, compared with 16% and 11%, respectively, of 87 neonates in the pre-QI period. In the post-QI period, of those evaluated, >96% were documented within 4 hours of birth. In the post-QI period, 15 (7.4%) neonates were cooled; 13 were in the NICU at time of identification, but 2 were identified in the newborn nursery and redirected to the NICU for cooling. A standardized screening pathway in neonates with umbilical-cord acidemia led to timely identification and evaluation of neonates at risk for HIE.

Safety, Feasibility and Healthcare Cost Differences between Inpatient and Outpatient Mobilization Chemotherapy for Autologous Hematopoietic Stem Cell Transplantation in Multiple Myeloma: A Single Center Experience

IntroductionThe standard of care for patients with multiple myeloma (MM) involves autologous hematopoietic stem cell transplantation (ASCT). Pre-ASCT mobilization chemotherapy for MM, vinorelbine and high dose cyclophosphamide (VC), has been historically given in the inpatient (IP) setting. Due to rising bed occupancy rates and patients' preferences for treatment in the ambulatory setting, our team has offered eligible patients an option to receive VC outpatient (OP) since 2018. Our study aims to audit the feasibility and safety of this initiative, and review potential healthcare-related cost savings.MethodsEligibility criteria for OP chemotherapy were developed by a multidisciplinary team based on patients' age, functional status, medical comorbidities and social factors (Figure 1). The chemotherapy regimen was modified for an OP setting (Figure 2), of which the main alteration involved changing the route of administration of intravenous (IV) mesna to a combination of IV and oral. A retrospective review was conducted for 35 MM patients (18 IP and 17 OP) who received VC for mobilisation at our center from 2018 to 2019. The patient characteristics were similar between the two groups (Table 1). Patient data were analyzed from the day of admission for VC (IP) or day 1 of VC (OP), to the day before admission for stem cell harvesting. Clinical charts were reviewed for unexpected complications and unplanned admissions. Costs incurred were calculated using the value-driven-outcome (VDO) informatics analysis of the hospital.ResultsThere were no unexpected clinical complications or unplanned admissions in both groups . The median length of hospital stay for the IP cohort was 3 days, amounting to a saving of 51 hospital days over 2 years in the OP cohort. Median costs were 73% lower in the OP cohort (Figure 3). The difference was mainly due to certain costs not incurred in the OP setting. These included room charges and daily treatment fees (which accounted for an average of 46% and 19% of IP charges respectively). Investigation costs were also 55% lower in the OP cohort, which could be attributed to more investigations being performed in the IP setting such as screening for methicillin-resistant Staphylococcus aureus and nonurgent radiographs ordered after hours by the on-call physician upon admission.ConclusionsOur findings show that OP mobilization chemotherapy for MM is safe, feasible and associated with improved bed utilization and cost savings. Other components of the stem cell transplantation process are also increasingly being transitioned from the IP to OP setting in our center as part of an ongoing paradigm shift in right-siting treatment services, which has been accelerated by the COVID-19 pandemic's strain on inpatient capacity. These results provide an affirmation of our efforts to optimize the utilization of healthcare resources. [Display omitted] DisclosuresChng: Takeda: Consultancy; GlaxoSmithKline: Consultancy; Johnson & Johnson: Consultancy, Research Funding; Aslan: Research Funding; Antengene: Consultancy; Abbvie: Consultancy; Pfizer: Consultancy; Novartis: Research Funding; Sanofi: Consultancy; Amgen: Consultancy; BMS/Celgene: Consultancy, Research Funding.

“House Calls” by Mobile Integrated Health Paramedics for Patients with Heart Failure: A Feasibility Study

Background: Early readmissions following hospital discharge for heart failure (HF) remain a major concern. Among the various strategies designed to reduce readmissions, home evaluations have been observed to have a favorable impact. We assessed the feasibility of integrating community paramedics into the outpatient management of HF patients. Methods: Selected paramedics completed an educational HF curriculum. These Mobile Integrated Health Paramedics (MIHP) performed scheduled home visits 2- and 15-days post-discharge for patients with Stage C HF (Phase I) and patients with Stage D HF (Phase II). Facilitated by a Call Center, a process was created for performing urgent MIHP house calls within 60 minutes of a medical provider’s request. A HF specialist, with an on-call emergency department command physician, could order an intravenous diuretic during home visits. During each phase of the study the incidence of 30-day HF readmissions, 30-day all-cause readmissions, emergency room evaluations, unplanned office encounters, as well as any adverse events were prospectively documented. Results: Collaborative relationships between our hospital network and local EMS organizations were created. There were 82 MIHP home visits. Eight patients received urgent home evaluations within 60-minutes post-request, one requiring transport to an ED. The incidence of all-cause 30-day readmissions in 20 Stage C and 20 Stage D patients was 15% and 40%, respectively. There were no adverse events attributable to the MIHP house calls. Conclusions: It is feasible to integrate MIHPs into the outpatient management of HF. Signals of effectiveness for reducing early readmissions were observed. Obstacles to creating an effective paramedic “House Calls” program were identified. A randomized trial is required to assess the value of this care process and its impact on early readmissions in patients with Stage C and Stage D HF.

Retrospective review of enquiries to the Québec diving medicine call centre: 2004 through 2018.

The Centre de Médecine de Plongée du Québec (CMPQ) established a bilingual 24-hour dive emergency call line and diving medicine information service in 2004. The toll-free number (888-835-7121) works throughout Canada. Calls and emails (cmpq.cisssca@ssss.gouv.qc.ca) are answered by a CMPQ coordinator or on-call hyperbaric physicians and other consultants as needed. We reviewed 15 years of activity. Details of phone calls and email enquiries to the centre were reviewed individually and compiled into a database. Data were analysed to characterise contact volume and issues addressed. Contacts were categorised into five groups: information only (INF); medical opinion required (MOP); medical issue after the critical period of urgency had passed (PUR); current urgent but not immediate life-threatening issue (NLT); and immediate life- or health-threatening issue (ILT). Data presented as mean (standard deviation) or percentage. A total of 3,232 contacts were made from May 2004 through December 2018: 19 (SD 8) per month [215 (70) per year]. Primary issues of concern were: emergency planning (20%); technical (not medical/physiology) questions (16%); otorhinolaryngological (12%); and decompression sickness-related (7%). Categorisation was 52% INF, 28% MOP, 13% PUR, 7% NLT, and 0.1% ILT, with 0.2% lacking sufficient detail to categorise. The nature of the diving activity of interest was determined in 67% of cases: 48% (n = 1,039) professional; 46% (n = 1,008) recreational; and 1% (n = 11) breath-hold. The call centre serves as a resource to the community, providing information on health and safety for diving in addition to being available to assist with emergent needs.

Re-Presentation to Medical Care Due to Adverse Effects of Intravenous Immunoglobulin Therapy in Pediatric Immune Thrombocytopenia Patients

Background : Immune Thrombocytopenia (ITP) is one of the most common acquired bleeding disorders affecting children, with an incidence rate of approximately 5-10 per 100,000 children per year. Intravenous immunoglobulin (IVIG) is an effective and widely employed frontline therapy for ITP; but is associated with substantial adverse effects, most commonly including headaches (~40%) and nausea/vomiting (5-26%). These may occur immediately following infusion or up to 72 hours later, often resulting in re-presentation to medical care. Additional diagnostic testing is often performed, including computed tomography (CT) imaging of the head, given concern for intracranial hemorrhage in these severely thrombocytopenic patients who have not yet responded to IVIG.Objective : To identify rates of re-presentation to medical care due to IVIG-associated adverse effects within a cohort of treated pediatric ITP patients, and to identify the impact of this re-presentation to care on patient safety, health-related quality of life (HRQoL), and healthcare-related costs.Methods : We completed a retrospective chart review, inclusive of all pediatric ITP patients receiving IVIG therapy at a large pediatric referral center within a 6-year timeframe from 2010 - 2016. Included patients were between the ages of 0 and 18 years, receiving IVIG for the primary indication of ITP at a dose of 1 g/kg/dose, and receiving the commercial IVIG product Gamunex-C® 10% (Grifols). All patients not meeting these criteria were excluded in order to maximize homogeneity of evaluated patients. Pre-medication with acetaminophen and diphenhydramine is the standard of practice for IVIG administration within the institution.Results : Among the 473 ITP patients who received Gamunex-C® at Texas Children's Hospital from 2010 - 2016, 133 (28%) experienced documented headache, nausea/vomiting, or both following IVIG infusion, consistent with published incidences. Among these patients, 101 (76%) sought medical care due to these symptoms. Of the 81 patients who had already been discharged, 54 (67%) re-presented for Urgent or Emergency Care services; while 27 (33%) called for medical advice or to obtain supportive prescriptions. Of the 20 patients remaining hospitalized, 100% presented as calls to the on-call physician, resulting in additional medical evaluation, often including laboratory or imaging evaluation. Among all patients re-presenting to medical care, 60 (59%) underwent additional laboratory testing, and 36 (36%) underwent CT imaging to evaluate for life-threatening intracranial bleeding. No CT evaluations revealed evidence of intracranial bleeding, and for all 101 patients re-presenting to medical care, symptoms fully resolved with supportive management.Conclusions : Nearly 1/3 of treated patients in our cohort experienced headache and/or nausea/vomiting, consistent with published incidences for Gamunex-C®. Of these, 76% sought further medical care. Subsequent medical management ranged from supportive care only (41%) to full evaluation with repeat laboratory studies (59%) + CT imaging in many cases (36%). These findings implicate substantially increased healthcare-related costs in the form of laboratory, CT imaging, and emergency service expenses; as well as increased risk to these patients' health and safety, in the form of additional radiation exposure, infection risk, and potential exposure to unnecessary therapies. Formal evaluation of downstream HRQoL and costs is ongoing. Additionally, we believe that a standardized prophylactic post-medication strategy could prevent or significantly reduce re-presentation to medical care due to IVIG-associated headache and/or nausea/vomiting, thereby improving HRQoL and cost impact in this patient population; and a formal prospective trial of this strategy is planned. [Display omitted] DisclosuresLambert:AstraZeneca: Research Funding; Educational Concepts in Medicine: Honoraria; Novartis: Honoraria. Despotovic:Sanofi: Consultancy; Schell Cooley LLP: Other: Expert witness.