On-call Physician Research Articles

Patients Seeking Retreatment after Community Paramedic Assessment and Treatment: Piloting a Community Paramedic Unit Program in Southwest Finland

Community paramedic (CP) units are becoming more popular in enhancing a person’s access to the need for care assessment and treatment in acute but non-life-threatening health issues. Simultaneously CP units can reduce the strain on emergency departments (EDs) by treating patients effectively at home. The efficacy of CP units is proven in previous studies, but the details of conditions patients seek retreatment at the ED after a CP unit visit are largely unknown. This study aimed to categorize CP unit patients (n = 229) seeking retreatment after a CP unit visit and investigate links between CP unit actions and patients seeking retreatment. The study was based on a data set from a six-month CP unit pilot program in Finland. The main results show that 82% of the patients assessed and treated by the CP unit did not seek retreatment. Low back symptoms and nausea were the main problems patients presented to the ED within 96 h after the CP visit. On-call physician consultation (p = 0.335) or CP unit treatment time (p = 0.629) were not associated with the frequency of ED presentation. Further studies are needed in order to investigate which types of emergency medical missions are the most suitable for CP units. The findings of this study support the effectiveness of community paramedicine programs.

Case Report (Precis): Two Telemedicine Consultants Miss Foot Drop: When To See Patients in Person

Background: Telemedicine has been rapidly adopted due to COVID-19. In the earliest days, most screenings were performed by primary care/internal medicine consultants; referrals to subspecialists were minimized. Now, as the pandemic has evolved over 6 months, secondary telemedicine consultations should be limited, and earlier involvement of appropriate subspecialists should be reconsidered to optimize patient management.Case Description: An older individual spoke to an on-call general medical physician with the chief complaint of the acute onset of low back pain after moderately strenuous activity, with severe unilateral radiculopathy. The telemedicine physician recommended a non-steroidal. anti-inflammatory agent without any specific recommendations regarding follow-up. A few days later, with progression of unilateral pain and numbness, a second telemedicine medical consultation was performed; a Medrol dose pack and muscle relaxant were now recommended, again without any follow-up recommendations. Days later, with increased unilateral pain/ near anesthesia in the foot, the patient was seen by a spinal surgeon who found; unilateral SLR positive at 20 degrees, a 0/5 foot drop, loss of the Achilles Response, and decreased pin appreciation in the L5 distribution. The patient’s emergent lumbar MR showed a large unilateral disc herniation with inferior migration at the appropriate level, warranting surgical consideration.Conclusion: Here, we emphasized several points. First, telemedicine may be adequate for the initial screening, but further complaints would be better evaluated in person by either a medical or surgical subspecialist; here, both could have recognized the very clear unilateral foot drop. Second, the patient should have had a scheduled follow-up in-person consultation. Third, appropriate diagnostic studies should have been ordered at the time of the second telemedicine consultation to establish the correct diagnosis and direct treatment.

The economic value of an on-call neurosurgical resident physician.

The cost of training neurosurgical residents is especially high considering the duration of training and the technical nature of the specialty. Despite these costs, on-call residents are a source of significant economic value, through both indirectly and directly supervised activities. The authors sought to identify the economic value of on-call services provided by neurosurgical residents. A personal call log kept by a single junior neurosurgical resident over a 2-year period was used to obtain the total number of consultations, admissions, and procedures. Current Procedural Terminology (CPT) codes were used to estimate the resident's on-call economic value. A single on-call neurosurgical resident at the authors' institution produced 8172 work relative value units (wRVUs) over the study period from indirectly and directly supervised activities. Indirectly supervised procedures produced 7052 wRVUs, and directly supervised activities using the CPT modifier 80 yielded an additional 1120 wRVUs. Using the assistant surgeon billing rate for directly supervised activities and the Medical Group Management Association nationwide median neurosurgery reimbursement rate, the on-call activities of a single resident generated a theoretical billing value of $689,514 over the 2-year period, or $344,757 annually. As a program, the on-call residents collectively produced 39,550 wRVUs over the study period, or 19,775 wRVUs annually, which equates to potential reimbursements of $1,668,386 annually. Neurosurgery residents at the authors' institution theoretically produce enough economic value exclusively from on-call activities to far exceed the cost of their education. This information could be used to more precisely estimate the true overall cost of neurosurgical training and determine future graduate medical education funding.

Shared Loneliness During COVID-19.

Shared Loneliness During COVID-19.

A Glimpse Into the Future.

The novel coronavirus will forever change the world in ways we have yet to realize What will our lives look like when the crisis abates? Will we still shake hands? Will my Italian relatives still kiss me on both cheeks (or just give air kisses)? When this is over there may be fewer elderly, more guns, less movie theaters and greater paranoia in America but perhaps more generosity and kindness as well Most of what will change after the pandemic is beyond my ability to guess However, I see more clearly the changes that will come to Emergency Medicine once the Hot Zone has cooled Let's pull back the curtain of time and glimpse into the future for our specialty after the Time of COVID

Turning a new “page”: ways to decrease the number of pages after hours without compromising patient care

Pages to house staff after hours, especially overnight, lead to interrupted sleep and fatigue the next day. Although some pages are urgent, others may not need an immediate response. In this study we aimed to identify unwarranted pages and to establish ways to reduce them. Over 2 months, all pages to the Department of Pediatric Urology at the Hospital for Sick Children in Toronto, Canada, during call hours were documented, including the assessment of the responding physicians of their medical necessity. After analyzing the reasons for inappropriate pages, we took several steps to try to reduce them without impairing patient care. One year later, pages were tracked again to evaluate the efficacy of our interventions. In the initial measurement period, no calls from parents and approximately 50% of the in-hospital pages (15 of 36 pages from the wards, 27 of 49 pages from the emergency department, 17 of 31 pages requesting consultations, and 8 of 8 pages from the inhouse pharmacy and outside pharmacies) were considered medically urgent. The reasons for unwarranted pages were inconsistent parent teaching, lack of adequate triaging and prioritizing on the ward and lack of awareness of the structure of the on-call provisions among different services in the hospital. Several steps were taken to streamline the teaching of parents and nurses, standardize information, provide alternative means of communication within the hospital and restrict parents’ access by phone to the urologist on call. One year later, the number of pages had decreased by 70%. Although physician coverage throughout the day and night is necessary for high-quality and safe patient care, communication with on-call physicians should be only for appropriate reasons. The provision of consistent teaching and alternative communication channels can improve patient care as well as decrease the number of after-hour pages.

Hospitalization of children after ENT surgery in Germany

Morbidity following tonsil surgery is widely determined by pain, odynophagia, and bleeding. Detailed information about postoperative care in pediatric patients in Germany in the context of otolaryngologic interventions is currently lacking. Aquestionnaire including eight questions to clarify trends and traditions in hospitalization strategies for pediatric patients was sent via email on January14, 2019, to all heads of ENT departments who were also members of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNO). The electronic survey was designed by the Pediatric Working Group of the DGHNO. The response rate was 72.9% (120/166), one response was excluded because it was not provided via the online tool. Children are currently transferred to pediatric clinics after surgery in 64 of 120 otorhinolaryngology departments, atradition in existence for at least 5years in 48 of the 64departments. In the remaining 56institutions, children remained in the otorhinolaryngology department despite 30 having specialized pediatric clinics or clinics for pediatric surgery. This strategy is expected to be discontinued in 5 of the 56hospitals in due course. Aseparate pediatric ENT clinic within the same institution is uncommon (27/120). The average travel time of on-call physicians in cases of postoperative bleeding is 3.4 min; transportation of the child to the emergency operation room takes 5.4 min on average. The nursing staff is predominantly responsible for transportation of pediatric emergency patients (109/120). The wards and operation rooms are commonly located in the same building, but on different floors (83/120). There is currently no uniform hospitalization strategy for postoperative care of children who undergo typical otorhinolaryngologic interventions in Germany.

Care workers’ view on factors leading to unplanned hospitalizations of nursing home residents: A cross-sectional multicenter study

Nursing home residents have a high risk of adverse events during hospitalizations. Since up to two-thirds of hospitalizations of nursing home residents are rated as potentially preventable, this study aimed to describe factors related to unplanned hospitalizations and to describe rates of unplanned hospitalizations, comparing differences between high- and low-hospitalization nursing homes. This cross-sectional multicenter study was conducted in 19 Swiss nursing homes and used questionnaire surveys of ward supervisors (n = 33) and nursing staff (n = 146) and retrospectively assessed hospitalization data.The study revealed several issues regarding unplanned hospitalizations, mostly concerning limitations regarding physicians’ availability, lack of acquaintance of on-call physicians with the residents, and health professionals’ lack of knowledge about the residents’ wishes concerning therapeutic decisions. Our findings suggest that standardizing advance care planning processes and better physician availability might further reduce hospitalizations and improve quality of care in nursing homes.

Prospective Validation of the Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults.

The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults (Scandinavian guidelines) are the first to incorporate serum measurement of the S100 astroglial calcium-binding protein B (S100B) to emergency department (ED) triage of patients with head injury (HI). This prospective validation study was conducted in the ED of the Tampere University Hospital, Finland, between November 2015 and November 2016. All consecutive adult patients with HI presenting to the ED within 24 h from injury were eligible for inclusion. Venous blood for S100B sampling was drawn from all patients, and the result was available at the ED. Computed tomography (CT) scans of the head were performed according to the on-call physician's evaluation. Only the samples collected within 6 h after injury were used. A one-week follow-up was conducted to identify possible HI-related complications. A total of 295 patients (median age, 67.0 years, range, 18-100; women, 48.8%) were enrolled. Of those, 196 (66.4%) underwent scanning. Acute traumatic lesions were detected on 31 (15.8%) of the scans. Two of the CT-positive patients were scanned without a guidelines-based indication. These lesions did not require any specific treatment or repeated imaging. The guidelines-based sensitivity was 0.94 (95% confidence interval [CI], 0.77-0.99) and specificity 0.19 (95% CI, 0.13-0.26) for predicting traumatic intracranial CT abnormalities. The positive and negative predictive value for positive head CT was 0.18 (95% CI, 0.12-0.25) and 0.94 (95% CI, 0.78-0.99), respectively. In the mild-low risk group, no false negative S100B values were recorded. Thirteen patients (4.4%) were re-admitted to the ED, and two patients (0.7%) died one week after the primary HI. The deaths were unrelated to the injury. None of these adverse events were directly caused by a primarily undiagnosed intracranial injury. The Scandinavian guidelines incorporated with S100B are a valid means of screening clinically significant acute traumatic lesions after HI and have the potential to reduce unnecessary CT scanning.

Clinical Approach to the Patient in Critical State Following Immunotherapy and/or Stem Cell Transplantation: Guideline for the On-Call Physician.

The initial management of the hematology patient in a critical state is crucial and poses a great challenge both for the hematologist and the intensive care unit (ICU) physician. After years of clinical practice, there is still a delay in the proper recognition and treatment of critical situations, which leads to late admission to the ICU. There is a much-needed systematic ABC (Airway, Breathing, Circulation) approach for the patients being treated on the wards as well as in the high dependency units because the underlying hematological disorder, as well as disease-related complications, have an increasing frequency. Focusing on score-based decision-making on the wards (Modified Early Warning Score (MEWS), together with Quick Sofa score), active sepsis screening with inflammation markers (C-reactive protein, procalcitonin, and presepsin), and assessment of microcirculation, organ perfusion, and oxygen supply by using paraclinical parameters from the ICU setting (lactate, central venous oxygen saturation (ScVO2), and venous-to-arterial carbon dioxide difference), hematologists can manage the immediate critical patient and improve the overall outcome.

Waiting Time for Specialist Consultation and Visit Requested in the Emergency Department; a Cross-Sectional Study.

Introduction:Waiting time in the hospital directly affects the quality of healthcare providing centers. One of the waiting times in hospital is the time spent waiting for receiving various consultations and visits requested by emergency medicine specialists from specialist services. Objective:The present study was designed and performed to assess the waiting times for receiving specialist visits and consultations requested in the emergency department based on the corresponding service in a referral hospital in Isfahan, Iran. Method:In the present cross-sectional study, patients presenting to emergency department of Dr. Shariati Hospital, Isfahan, Iran, from October 2017 to March 2018, who were in need of visit or consultation from other specialist services based on the opinion of the emergency medicine specialist, were studied. By attending the patients’ bedside, the researcher filled out a checklist consisting of demographic data and waiting time of the patients and other probable related factors. Finally, raw data were entered to the computer and after correction of errors were statistically analyzed via SPSS software.Results:Overall, 400 patients with the mean age of 53.3 ± 24.3 years were included in the study, 58.8% of which were male. Mean waiting time for receiving a visit or consultation among the studied patients was 242.0 ± 202.4 (min: 5 and max: 1200) minutes. Mean waiting time for a visit or consultation did not significantly correlate with the corresponding physician being resident or on-call. However, it showed a statistically significant correlation with triage level (p = 0.013), work shift (p = 0.000), type of service requested/the specialist service asked for a consultation or visit (p = 0.049), and the consultation or visit being emergent or non-emergent (p = 0.000). In addition, emergent visits or consultations by on-call physicians had been performed significantly faster than those by resident physicians; while non-emergent visits or consultations by resident physicians had been performed significantly faster than those by on-call physicians (p = 0.001).Conclusion:The results of the present study showed that patients with triage level 2, emergent visit of consultation and a visit or consultation request in the morning or evening shift wait a shorter time for receiving the visit or consultation. In addition, neurosurgery, nephrology, and pediatrics services had the shortest waiting times, while gastroenterology, gynecology, and infectious disease services had the longest waiting times for giving the visit or consultation requested from them.

Healthcare Professionals and In-Flight Medical Emergencies: Resources, Responsibilities, Goals, and Legalities as a Good Samaritan.

Common in-flight emergencies include syncope, respiratory symptoms, nausea/vomiting, cardiac symptoms, and seizures. Flight conditions, such as changes in air pressure and humidity, can exacerbate existing chronic medical conditions. In 2017, US airlines carried 849.3 million passengers. Undoubtedly, there were many requests for in-flight medical assistance. Whenever a medical event occurs, it is standard procedure that an announcement be made by a flight attendant, requesting medical personnel to identify themselves. The 1998 Aviation Medical Assistance Act provides liability protection for a healthcare professional (HCP) acting as a good Samaritan. Nevertheless, HCPs may initially experience trepidation providing care in an aircraft. They may be unaware that a first aid kit, a emergency medical kit, and an automatic external defibrillator are on every plane. Flight crews have been trained in cardiopulmonary resuscitation, and a support system, including a ground-based consultation service, is available to provide radio assistance from an on-call physician. When multiple HCPs volunteer, the most experienced should assume leadership of care. After evaluating the ill passenger, the HCP communicates the assessment to the crew and, when necessary, to the ground-based physician. The goal of in-flight care is to medically stabilize the ill passenger and facilitate the individual's arrival at the scheduled destination for continued medical care. When unable to stabilize the passenger's condition, the decision to divert the plane rests with the flight's captain. Our article helps HCPs to best understand their resources, structured support, liability, and role during an in-flight medical event. With this knowledge of resources, a good Samaritan can confidently attend to an ill airline passenger in flight.

Use of Telepsychiatry in Pediatric Emergency Room to Decrease Length of Stay for Psychiatric Patients, Improve Resident On-Call Burden, and Reduce Factors Related to Physician Burnout

Background: Our study aims to demonstrate through implementation of telepsychiatry for child psychiatry patients evaluated in the pediatric emergency room (PedsER); we can reduce length of stay (LOS) and reduce factors contributing to physician burnout through reduction of on-call travel burden. Introduction: Telepsychiatry has increased access to health care using real-time interactive videoconferencing, allowing clinicians and patients in separate locations to have a meaningful clinical encounter. Use has increased over the past several years given cost reduction and need for psychiatric specialty services in under-resourced systems. Materials and Methods: We evaluated data regarding child psychiatry fellow use of telepsychiatry through a prospective real-time questionnaire filled out by the on-call clinician from July 1, 2017 to December 23, 2017 (study period). LOS was measured from the patient's registration time through time of discharge. Results: Telepsychiatry significantly reduced the total monthly LOS for nonhospitalized patients in the PedsER during the study period compared to all prior months (285-193 h; p = 0.032) and compared to a similar prior seasonal time frame (329-193 h; p = 0.017). Telepsychiatry use reduced travel for face-to-face evaluations by 75% and saved 2.22 h per call day. Discussion: Unique in this study is enhancing on-site psychiatric consultation in the emergency room, rather than solving a systems issue of referring out for psychiatric consultation. Moreover, this study uniquely demonstrated a noted improvement in on-call physician travel burden by reducing travel time with telepsychiatry. Physician burnout is notably high during residency training. Factors such as telepsychiatry can improve work efficiency and lend time to activities outside of work, mitigating the onset of this challenging issue. Conclusions: Telepsychiatry was shown to be effective in reducing dwell time and improving on-call burden. This study also showed promise in our system for improving access to other forms of specialized care consultation in PedsER settings.

Supporting the on-call primary care physician with community paramedicine.

Prior to being referred to the emergency department (ED), patients such as the frail elderly often call their primary care physician. However, the on-call primary care physician or covering provider does not always have the tools to make an accurate and safe assessment over the phone or to treat patients remotely. This often results in preventable transport to an ED, avoidable admissions and iatrogenic events. An opportunity exists to reduce unnecessary ED referrals by enhancing the capabilities of the on-call primary care physician. In this communication, we describe the development of a community paramedicine programme that supports on-call primary care providers managing a high-risk patient population with the goal of reducing avoidable ED referrals.

Physician alert: the legal risks associated with ‘on-call’ duties in the USA

On-call physicians encounter a diverse aggregate of interfaces with sundry persons concerning patient care that may surface potential legal peril. The duties and obligations of an on-call physician, who must...

MP34: Evaluation of real-time virtual support for rural emergency care

Introduction: In many rural and remote communities in BC, family physicians who are providing excellent primary and emergency care would like to access useful, timely, and collegial support to ensure the highest quality of health services for their patients. We undertook a real-time virtual support project in Robson Valley, located in northern BC, to evaluate the use of digital technologies such as videoconferencing for on demand consultation between family physicians at rural sites and emergency physicians at a regional site. Telehealth consults also occurred between rural sites with nurses at community emergency rooms consulting with local on-call physicians. Our aim was to use telehealth to facilitate timely access to high quality, comprehensive, coordinated team-based care. An evaluation framework, based on the Triple Aim sought to: 1) Identify telehealth use cases and assess impact on patient outcomes, patient and health professional experience, and cost of health care delivery; and 2) Assess the role of relationships among care team members in progressing from uptake to normalization of telehealth into routine usage. Methods: Using a participatory approach, all members of the pilot project were involved in shaping the pilot including the co-development of the evaluation itself. Evaluation was used iteratively throughout implementation for ongoing quality improvement via regular team meetings, sharing and reflecting on findings, and adjusting processes as required. Mixed methods were used including: interviews with family physicians, nurses, and patients at rural sites, and emergency physicians at regional site; review of records such as technology use statistics; and stakeholder focus groups. Results: From November 2016 to July 2017, 26 cases of telehealth use were captured and evaluated. Findings indicate that telehealth has positively impacted care team, patients, and health system. Benefits for care team at the rural sites included confidence in diagnoses through timely access to advice and support, while emergency physicians at the regional site gained deeper understanding of the practice settings of rural colleagues. Nevertheless, telehealth has complicated the emergency department work flow and increased physician workload. Findings demonstrated efficiencies for the health system, including reducing the need for patient transfer. Patients expressed confidence in the physicians and telehealth system; by receiving care closer to home, they experienced personal cost savings. Implementation saw a move away from scheduled telehealth visits to real use of technology for timely access. Conclusion: Evidence of the benefits of telehealth in emergency settings is needed to support stakeholder engagement to address issues of workflow and capacity. This pilot has early indications of significant local impact and will inform the expansion of emergency telehealth in all emergency settings in BC.

Systematic extraction of diagnostic data items for common high-risk pregnancies using Delphi technique

Introduction
 The quality of clinical decisions being made every day by on-call physicians are totally based on the quality of medical information they receive during telephone consultations with residents. Some basic factors such as the right selection of medical items, type and format, and also the volume of such information may highly affect the quality of remote consultations. Therefore, developing a trusted standard model for such clinical communication seems vital. In this research, we used Delphi technique to develop a set of information items in form of clinical decision archetypes to standardize teleconsultation in high-risk pregnancies.
 Methods
 A multi-stage cross-sectional study was conducted to exploit the diagnostic items for the most common high-risk pregnancies in three obstetrics and gynecology department of educational hospitals, Mashhad, Iran. 
 Results
 Our study revealed eclampsia/preeclampsia, hemorrhage, PROM, pre-term and post-term delivery as the most common high-risk pregnancies in the hospitals being studied. 189 clinically-important items were extracted from scientific references and then hand-filtered to 128 items by the participating gynecology and obstetrics experts. The final items were categorized into five classes including general information, chief complaint / current problem, medical history, clinical examination, and paraclinic tests.
 Conclusion
 In this study, a set of clinical decision archetype was developed to improve the decisions being made in high risk pregnancies.

Which Physicians' Behaviors on Death Pronouncement Affect Family-Perceived Physician Compassion? A Randomized, Scripted, Video-Vignette Study

ContextAlthough the death of a loved one is a devastating family event, little is known about which behaviors positively affect families' perceptions on death pronouncements. ObjectivesThe objective of this study was to evaluate the effect of a compassionate death pronouncement on participant-perceived physician compassion, trust in physicians, and emotions. MethodsIn this randomized, video-vignette study, 92 people (≥50 years) in Tokyo metropolitan area viewed two videos of death pronouncements by an on-call physician with or without compassion-enhanced behaviors, including five components: waiting until the families calm themselves down, explaining that the physician has received a sign-out about information of the patient's condition, performing examination respectfully, ascertaining the time of death with a wristwatch (vs. smartphone), and reassuring the families that the patient did not experience pain. Main outcomes were physician compassion score, trust in physician, and emotions. ResultsAfter viewing the video with compassion-enhanced behaviors compared with the video without them, participants assigned significantly lower compassion scores (reflecting higher physician compassion) (mean 26.2 vs. 36.4, F = 33.1, P < 0.001); higher trust in physician (5.10 vs. 3.00, F = 39.7, P < 0.001); and lower scores for anger (2.49 vs. 3.78, F = 18.0, P < 0.001), sadness (3.42 vs. 3.85, F = 11.8, P = 0.001), fear (1.93 vs. 2.55, F = 15.8, P < 0.001), and disgust (2.45 vs. 3.71, F = 19.4, P < 0.001). ConclusionTo convey compassion on death pronouncement, we recommend that physicians initiate prompt examination, explain that the physician has received a sign-out, perform examination respectfully, ascertain the time of death with a wristwatch, and reassure the families that the patient did not experience pain.

080 SLOW LOW-EFFICIENCY DIALYSIS IN INTENSIVE CARE UNIT

Category: Nursing Issues (education, training, care delivery) Presenter: Mrs HELEN BLACKMAN Keywords: SLED, ICU, dialysis Sustained low-efficiency dialysis (SLED), in which conventional haemodialysis machines are used to provide extended duration RRT (8 - 12 h vs 3-4 h with intermittent haemodialysis), has emerged as an alternative to CRRT for patients with hemodynamic instability. Whereas CRRT often necessitates some form of anticoagulation to prevent filter clotting, SLED may be readily performed with no anticoagulation. A session of SLED, especially if performed during the overnight hours, may be scheduled around tests and procedures and is thus less likely to be interrupted. Observational studies have suggested comparable clinical outcomes, and in some cases lower costs, in patients treated with SLED as compared to CRRT In City Hospital Sunderland a training program for Intensive care unit (ICU) nursing staff was undertaken. Over the last 30 years AKI renal replacement therapy treatment in ICU were performed by dialysis nursing staff. Using a nurse educator and multiple Plan do study act (PDSA) cycles a frame work for educating ICU nursing staff was created. In conjunction with this an electronic prescribing and administrating tool was developed. A SLED nurse champion from ICU was part of the first 12 senior ICU nurses trained. One week induction program in the main renal unit. A competency based assessment was developed with national UK ICU competency frame work. Theory and supervision taught by 1:1 by senior nurse from the main renal unit. Every learning opportunity logged and reflected on as a learning outcome. All dialysis was still prescribed by the on-call renal physician via an electronic prescription in collaboration with the ICU team. Anti-coagulation of the dialysis circuit used for SLED ranged from saline flushes to standard heparin and citrate concentrate. ACT testing for heparin administration. Electrolyte management with different dialysis concentrates. Management of common scenarios such as hypotension, bleeding and anaphylaxis in simulation environment. Vascular access for RRT was standardised and lessons learnt regarding vascular catheter placement and length of catheter for ICU doctors. Regular education meetings and a joint email to share questions, information, reflect and feed back on cases. Senior leadership to maintain the momentum of the program and adopt a culture of change was vital. A total of 4 ICU nurses have been trained to date as independent dialysers with 12 in the pipeline for the future. Mentor-ship is being developed. We continue to learn as further refinement is being made to the electronic prescription and training program.

An innovative algorithm for planning and scheduling healthcare units with the aim of reducing the length of stay for patients (Case study: Cardiac SurgeryWard of Razavi Hospital of Mashhad)

One of the key applications of operational research in health systems management is to improve the mechanism of resource allocation and program planning in order to increase the system efficiency. This study seeks to offer an innovative method for the planning and scheduling of health service units with the aim of reducing the patients' Length of Stay (LOS) in the Cardiac Surgery Ward of Razavi Hospital of Mashhad. Also, to estimate the patients' LOS, two methods have been applied: multiple One of the key applications of operational research in health systems management is to improve the mechanism of resource allocation and program planning in order to increase the system efficiency. This study seeks to offer an innovative method for the planning and scheduling of health service units with the aim of reducing the patients' Length of Stay (LOS) in the Cardiac Surgery Ward of Razavi Hospital of Mashhad. Also, to estimate the patients' LOS, two methods have been applied: multiple linear regression models and Bayesian networks. The introduced method takes into account all treatment processes of patients in an integrated system and by eliminating any undue waiting time, the length of stay can be reduced to a significant extent. Also, the system efficiency is considerably improved by resolving the current conflicts in the workflow of on-call physicians and optimum allocation of resources, gaining satisfaction of health sector officials and patients. linear regression models and Bayesian networks. The introduced method takes into account all treatment processes of patients in an integrated system and by eliminating any undue waiting time, the length of stay can be reduced to a significant extent. Also, the system efficiency is considerably improved by resolving the current conflicts in the workflow of on-call physicians and optimum allocation of resources, gaining satisfaction of health sector officials and patients.