On-site Consultation Research Articles

VISIT STROKE: non-inferiority of telemedicine-based neurological consultation for post-acute stroke patients – protocol of a prospective observational controlled multi-center study

BackgroundTelemedicine provides specialized medical expertise in underserved areas where neurological expertise is frequently not available on a daily basis for hospitalized stroke patients. While tele-consultations are well established in acute stroke assessment, the value of telemedicine-based ward-rounds in the subsequent in-patient stroke management is unknown.MethodsFour telemedicine stroke networks in Germany, implemented in eight out of 16 federal states, participate in this prospective observational multi-center study. We plan to enroll 523 patients hospitalized due to acute (suspected or confirmed) stroke or transient ischemic attack. Each recruited patient will receive both a tele-consultation and an on-site consultation at the same day within the first three days after hospital admission. We will test non-inferiority of telemedicine-based assessments in ward-rounds in terms of quality of medical assessment and recommendations for hospitalized stroke patients. The correctness of the medical assessment and recommendation is defined as positive evaluation (binary, correct vs. in-correct) of six out of six predefined quality indicators by at least two out of three blinded independent raters. The non-inferiority margin for the difference in proportions of correct assessments is set to 5%-points.DiscussionIf non-inferiority of telemedicine-based ward-rounds compared to on-site ward-rounds by a neurologist were demonstrated, telemedicine-based neurological consultation for post-acute stroke patients may contribute to deliver evidence-based high-quality stroke care more easily in underserved regions.Trial registrationDRKS - DRKS00028671 (https://drks.de/search/de/trial/DRKS00028671; registration date 09-27-2022).

Patient survey on the use of video consultation in the outpatient treatment of chronic pruritus

Analyses of patient evaluations and barriers to the implementation of teledermatology procedures are still rare. The aim of this study was to determine whether administrative processes have an influence on the patient evaluation of telephone and video consultations. With the help of apatient survey, assessments of the processes and organisation surrounding the outpatient appointment were asked. These were then compared to the assessment of whether the telephone or video consultation is an alternative to on-site consultation. In all, 1538 patients took part in the survey. Significant correlations were found between the evaluation of the telephone or video consultation and the distance between the place of residence and the outpatient clinic, whether the patient had already been seen several times or for the first time, as well as the evaluation of the waiting time for the appointment, the organisation before the appointment and the waiting time in the outpatient clinic. The study shows that even after the Coronavirus pandemic, telephone and video consultations remain an important tool for patients to contact their physician. However, patients' perceptions of the processes around the outpatient appointment have an influence on their willingness to participate in adigital consultation.

#2096 A randomized controlled study of telemonitoring in kidney transplantation: interim results of the Ap'TX trial

Abstract Background and Aims Telemedicine is a matter of growing interest in transplantation. However, its real added value is uncertain. In 2018, we have started to study the medico-economic impact of a less stringent on-site follow-up of our kidney transplant recipients (KTR) using Ap'Telecare®. We present here a preliminary report focusing on 500 KTR with a 2 years follow-up. Method The Ap'Tx study (NCT03750331) is a controlled randomized trial testing the hypothesis that monitoring stable KTR (at least 3 months after transplantation) with Ap'Telecare® is non inferior to a conventional follow-up in terms of the occurrence of graft dysfunction (defined as a decrease in eGFR of 20% or more). On-site consultation scheduling was 2 times less frequent for KTR followed by Ap'Telecare®. Secondary endpoints were the impact of a remote follow-up by Ap'Telecare® on medical workload, economic saving and quality of life. Results 688 KTR have been randomized so far with 500 of them having completed the 2 years follow-up. Among all KTR approached to participate in the study, 37% were not included mainly due to difficulties with accessing internet (44%) or to masterize the app (36%). After randomization, 27% of KTR were considered as non compliant in adequately using Ap'Telecare®. Over the 2 years study duration, graft dysfunction occurred in 16% and 18% of KTR in the Ap'telecare® and conventional arm, respectively (RR of 0.87 (0.56; 1.39), non-inferiority confirmed, superiority not significant). Medical time dedicated to handling daily lab results was decreased by a factor 3 for KTR using Ap'Telecare®. Rates of unplanned consultations and hospitalisations were reduced by 26% and 32% for patients using Ap'Telecare®, respectively (P < .05). Conclusion This preliminary report of Ap'Tx suggest that a partial and reasonable remote follow-up of selected KTR is feasible, safe and logistically beneficial. Determining the nature of factors associated with a wider implementation of Ap'Telecare® is underway.

Time is running out. No excuses to delay implementation of antimicrobial stewardship programmes: impact, sustainability, resilience and efficiency through an interrupted time series analysis (2017-2022).

The WHO declared antimicrobial resistance (AMR) a significant concern in 2014, sparking initiatives to ensure responsible antibiotic use. In human medicine, Antimicrobial Stewardship Programmes (ASPs) in hospitals play a pivotal role in combating AMR. Although evidence supports the effectiveness of ASPs in optimizing antimicrobial use, often the lack of resources becomes an excuse to limit their dissemination and use. This paper provides a comprehensive report on a 6-year analysis of an ASP implemented in a healthcare region in north-east Italy. A retrospective data collection was conducted to assess the programme's impact on antibiotic consumption expressed as DDDs/100 patient-days, its sustainability over time, resilience during the COVID-19 pandemic and the efficiency of the ASP (relationship between workload and human resources). A substantial overall reduction in antibiotic consumption (-14%), particularly in fluoroquinolones (-64%) and carbapenems (-68%), was demonstrated, showcasing the programme's impact. Sustainability was confirmed through enduring trends in antibiotic consumption and ecological analysis over time. The ASP demonstrates resilience by maintaining positive trends even amid the challenging COVID-19 pandemic. Efficiency was underscored by an increase in on-site consultations despite consistent human resources until 2021. This study offers insights into the prolonged success of a resource-efficient ASP, emphasizing the crucial role of long-term commitment in fostering responsible antibiotic use in the context of global health challenges such as AMR.

Acceptance, Satisfaction, and Preference With Telemedicine During the COVID-19 Pandemic in 2021-2022: Survey Among Patients With Chronic Pain.

The COVID-19 pandemic has forced many health care providers to make changes in their treatment, with telemedicine being expanded on a large scale. An earlier study investigated the acceptance of telephone calls but did not record satisfaction with treatment or patients' preferences. This warranted a follow-up study to investigate acceptance, satisfaction, and preferences regarding telemedicine, comprising of phone consultations, among health care recipients. The primary aim was to assess the acceptance and satisfaction of telemedicine during the subsequent months of 2021-2022, after the initial wave of the COVID-19 pandemic in Switzerland. Furthermore, we aimed to assess patients' preferences and whether these differed in patients who had already experienced telemedicine in the past, as well as correlations between acceptance and satisfaction, pain intensity, general condition, perception of telemedicine, and catastrophizing. Finally, we aimed to investigate whether more governmental restrictions were correlated with higher acceptance. An anonymous cross-sectional web-based survey was conducted between January 27, 2021, and February 4, 2022, enrolling patients undergoing outpatient pain therapy in a tertiary university clinic. We conducted a descriptive analysis of acceptance and satisfaction with telemedicine and investigated patients' preferences. Further, we conducted a descriptive and correlational analysis of the COVID-19 stringency index. Spearman correlation analysis and a chi-square test for categorical data were used with Cramer V statistic to assess effect sizes. Our survey was completed by 60 patients. Telemedicine acceptance and satisfaction were high, with an average score of 7.6 (SD 3.3; on an 11-point Numeric Rating Scale from 0=not at all to 10=completely), and 8.8 (SD 1.8), respectively. Respondents generally preferred on-site consultations to telemedicine (n=35, 58% vs n=24, 40%). A subgroup analysis revealed that respondents who already had received phone consultation, showed a higher preference for telemedicine (n/N=21/42, 50% vs n/N=3/18, 17%; χ22 [N=60]=7.5, P=.02, Cramer V=0.354), as well as those who had been treated for more than 3 months (n/N=17/31, 55% vs n/N=7/29, 24%; χ22 [N=60]=6.5, P=.04, Cramer V=0.329). Acceptance of telemedicine showed a moderate positive correlation with satisfaction (rs{58}=0.41, P<.05), but there were no correlations between the COVID-19 stringency index and the other variables. Despite high acceptance of and satisfaction with telemedicine, patients preferred on-site consultations. Preference for telemedicine was markedly higher in patients who had already received phone consultations or had been treated for longer than 3 months. This highlights the need to convey knowledge of eHealth services to patients and the value of building meaningful relationships with patients at the beginning of treatment. During the COVID-19 pandemic, the modality of patient care should be discussed individually.

Satisfaction with Teleophthalmology Services: Insights from Remote Areas of Taiwan.

During and after the COVID-19 pandemic, teleophthalmology provided access to eye care for rural populations. This study aimed to assess the efficacy of and satisfaction with an integrated real-time videoconferencing module. This project incorporated ophthalmic instruments and telecommunication devices and provided on-site consultations via videoconferencing. Both patients and healthcare providers completed satisfaction questionnaires. From May 2020 to May 2021, this project provided eye care services to 395 patients (aged 6-90 years). The most frequent eye condition was chronic conjunctivitis (n = 197), followed by senile cataract (n = 163), dry eye (n = 103), and refractive error (n = 95). Among them, 40 (10.1%) patients were referred to secondary or tertiary hospitals for further evaluation or treatment. In total, 181 recruited respondents provided good satisfaction scores in all dimensions, including quality of medical care (4.50 of 5.00), financial aspects of care (4.48), supportive attitude toward the project (4.47), quality of service (4.40), and quality of telecommunication (4.40). Women had a substantially more supportive attitude toward the project, and 25 healthcare providers provided low ratings in areas representing the quality of telecommunication (4.04) and user-friendliness of the instrument (4.00). This teleophthalmology system provided efficient and satisfactory eye care to participants in remote communities. However, better internet access and training in instrument use can reduce obstacles to the future implementation of the project.

Preliminary Exploration of On-Site Consultation and Analysis of Consultation Aspects- From the Perspective of a SHEAP Consultant

&lt;p&gt;本文以輔導委員的角度從SHEAP環境安全諮詢計畫輔導的架構及內容重點切入，分別介紹「緊急應變計畫」、「演練與訓練」、「建築與設備」及「管理機制」四大面向之輔導重點，並統整輔導過程中發現機構常見的問題。最後與讀者分享從國外專家委員身上學習到的寶貴經驗，期待能鼓勵更多醫院重視環境安全與火災風險管理，並透過本計畫給予醫院更適切的改善策略。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;This article examines the framework and key content of the Safe Healthcare Environment Advisory Program (SHEAP) from the perspective of a consultant by highlighting the focal points of consultation in four major aspects, namely emergency response planning, drills and training, construction and equipment, and management mechanisms. It also organizes common issues identified in institutions during the consultation process. Finally, the article shares valuable experience provided by international experts and consultants, hoping to encourage more hospitals to stress environmental safety and fire risk management. Through SHEAP, this article provides strategies for hospitals to improve their healthcare services.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Making decisions for follow-up chemotherapy based on digital patient reported outcomes data in patients with multiple myeloma and other M protein diseases – A mixed method study

ObjectivesTo test if Patient Reported Outcomes (PRO) data can replace physical on-site consultation in determining if patients with multiple myeloma, AL amyloidosis, or plasma cell leukemia are ready for their next bortezomib treatment without dose reduction. MethodsWe developed an online questionnaire addressing common side effects to bortezomib and an algorithm stratifying patients according to their responses and asked them to complete the questionnaire the day before attending the clinic. Applying a mixed-method study design of PRO data, time registrations, and interviews with patients and healthcare professionals, we tested the usability of electronic PRO data forming the basis of decision-making on whether patients are physically fit for the next treatment with an unchanged dose. ResultsThe questionnaire and the associated algorithm were able to identify patients who were physically fit for treatment without need for further consultation, with a positive predictive value of 98 %. The method proved to be feasible for all groups of patients regardless of age and educational level. Patients and healthcare professionals found the online questionnaire to be advantageous and flexible. ConclusionThe use of PRO data to evaluate patients prior to bortezomib treatment is safe and feasible. Patients prefer to report their side effects themselves as it provides them with more freedom during their treatment.

Impact of Infectious Diseases Consultation in Patients With Candidemia at a Multisite Health Care System With Established Antimicrobial Stewardship and Telemedicine Services.

Infectious diseases consultation improves outcomes in patients with candidemia, although some facilities lack access to consultation. This multisite health care system study compared in-hospital mortality in patients with candidemia across 3 groups-those who received on-site consultation, telemedicine consultation, or no consultation. All patients were reviewed by an antimicrobial stewardship pharmacist. A retrospective observational cohort study was performed of adult hospitalized patients with candidemia from January 2018 to October 2021. The primary outcome was in-hospital mortality. Secondary outcomes included receipt and duration of antifungals, removal of central venous lines if present, ophthalmologic examination, echocardiography, and determination of infection source. A total of 265 patients were evaluated: 187 in the on-site consultation group, 49 in the telemedicine consultation group, and 29 in the nonconsultation group. Although in-hospital mortality did not differ significantly between the on-site and nonconsultation groups, it was significantly lower in the telemedicine group when compared with the nonconsultation group (10.2% vs 34.5%, P = .009). Patients who received on-site or telemedicine consultation had significantly more antifungal therapy initiated, appropriate therapy duration, central lines removed, and echocardiography performed, as well as fewer unknown candidemia sources, vs those in the nonconsultation group. This is the first study of a multisite health care system providing telemedicine services to evaluate the impact of infectious diseases consultation on candidemia mortality. These findings suggest that when on-site consultation is unavailable, infectious diseases telemedicine consultation and antimicrobial stewardship can improve outcomes and should be considered for all patients with candidemia at resource-limited sites.

Cardiac screening: physician-led or a score based approach?

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Research innovation and development trust Beating Hearts Malta. Introduction Sudden cardiac death (SCD) is an important cause of morbidity in young individuals. Cardiac screening may help identify high risk subjects and enable physicians to implement various early preventive strategies. However, geographical limitations and physician related expenses hinder the feasibility of widespread screening. Objective The objective of this study was to compare a physician-led assessment with a score-based approach. Methodology Students attending Form 5 (2017/2018 scholastic year) were invited to undergo cardiac screening. The screening protocol consisted of a questionnaire, ECG and an onsite consultation with a physician (Approach 1). The questionnaire included symptomatology, family history and athletic ability. Subjects were referred based on symptoms or red flags in the family history or ECG. Questions from the validated Sports Cardiology British Columbia (SCBC) questionnaire were also included in the questionnaire.[1] The SCBC score was calculated retrospectively and a score ≥7 would have required physician referral. Those with red flags in the family history or ECG would also have been referred (Approach 2). The referral, diagnostic rates and costs were compared for both approaches. Results 2672 students gave consent to undergo cardiac screening (mean 15.0±0.3 years, 50.4% female, 95.85 Caucasian). Patients who were under follow-up for known heart disease were excluded (n=9). 9 subjects were diagnosed with a condition linked to SCD (n=5 WPW, n=2 coronary anomalies, n=1 HCM, n=1 LQTS). A physician led screening method (Approach 1) led to 109 (4.1%) referrals. The commonest reason for referral was an abnormal ECG (n=99, 3.7%) in isolation or in combination with symptoms/family history (Pie Chart). ECG was far more sensitive (88.9% [95% CI, 50.7% to 99.4%]) compared to symptoms (22.2% [95% CI, 3.9% to 59.8%]). Symptoms and ECG had comparable specificity (99.3% [95% CI, 98.9% to 99.5%] vs 96.5% [95% CI 95.7% 97.2%]). Approach 2 would have led to more referrals (14.3% (n=382), p&amp;lt;0.001)) compared to a physician-led approach. 294 (n=11.0%) had a SCBC questionnaire score of ≥7, most (n=277, 10.4%) did not have other red flags (family history or ECG). The sensitivity of this approach was however comparable to ECG (88.9% [95% CI, 50.7% to 99.4%]). Specificity was also high (89.4% [95% CI, 88.2% to 90.5%]). One individual would have been missed, resulting in a lower diagnostic yield (2.2% vs 8.3%, p=0.005). Having a two-tier approach (SCBC and ECG initially) led to a 49.4% cost reduction. The total cost of the screening program would drop to €70,079.95, equivalent to €26.32/individual screened. The cost per cardiac diagnosis linked to SCD would drop to €7,786.66 per cardiac diagnosis. Conclusion A two-tier approach leads to substantial reductions in cost, with no negative impact on sensitivity and specificity. The impact of score-based questionnaires should be evaluated in larger cohorts.

Telemedical Consultations in Palliative Care: Benefits through Knowledge Exchange and Intercollegiate Collaboration-Findings from the German oVID Project.

(1) Background: As the number of people receiving specialized palliative care (PC) continues to rise, there is a need to ensure the transfer of this expertise from university-based PC departments to primary care hospitals without such in-house access. The present study examines the potential of telemedicine to bridge these gaps. (2) Methods: This is a prospective multi-center feasibility trial. All physicians were appropriately pre-equipped and instructed to conduct telemedical consultations (TCs), which took place within fixed meetings or on-call appointments either related or unrelated to individual patients (allowing TCs also for educational and knowledge exchange purposes). (3) Results: An inquiry for participation was submitted to 11 hospitals, with 5 external hospitals actively cooperating. In the first study section, a total of 57 patient cases were included within 95 patient-related TCs during 80 meetings. Other university disciplines were involved in 21 meetings (26.2%). Therapy adjustments resulted following 25 of 71 affected TCs (35.2%). In 20 cases (21.1%), an on-site consultation at the university hospital was avoided, and in 12 cases (12.6%), a transfer was avoided. Overall, TCs were considered helpful in resolving issues for 97.9% of the cases (n = 93). Yet, technical problems arose in about one-third of all meetings for at least one physician (36.2%; n = 29). Besides, in the second study section, we also conducted 43 meetings between physicians for education and knowledge exchange only. (4) Conclusions: Telemedicine has the potential to transfer university expertise to external hospitals through simple means. It improves collaboration among physicians, may prevent unnecessary transfers or outpatient presentations, and is thus likely to lower costs.

Quality comparison of remote anesthetic consultation versus on-site consultation in children with sedation for a magnetic resonance imaging examination-A randomized controlled trial.

In the course of the corona pandemic, digital media has increasingly been used in many areas of medical practice to reduce personal contact. As it is of interest whether this can be practiced in the context of anesthesia consultations without loss of quality, we interviewed parents whose children received a cardiac or neuro magnetic resonance imaging (MRI) under sedation. Parents either received an on-site or a remote consultation conducted by an anesthesiologist. Both parents and anesthesiologist were asked to indicate their satisfaction with the respective consultation procedure in a questionnaire. The aim of this study was to investigate if remote pre-anesthesia consultation, supported by an online video, for parents whose children are receiving MRI examinations under sedation can replace the commonly performed on-site consultation, without decreasing its quality. In this randomized trial, a total of 200 patients were included, one half received pre-anesthesia consultation on-site and the other half was given a link to a video and pre-anesthesia consultation was conducted by phone. As a primary analysis, we compared the level of satisfaction for the general procedure, the quality of the pre-anesthesia consultation and the contact to the anesthesiologists (or parents). We further investigated the frequency of complications and the preference for a possible next informed consent. Both groups showed high levels of satisfaction. Some anesthesiologists and parents were less satisfied with the quality of on-site pre-anesthesia consultation than with the remote. In our patient cohort, there was no evidence for higher risk of complications when information was provided by telephone. Further, parents as well as anesthesiologists clearly favored the combined form of telephone information and online video. Overall, 61.2% of parents and 64% of anesthesiologists would choose this form of pre-anesthesia consultation for repeat anesthesia. We did not observe that combined telephone and video decreased the quality of pre-anesthesia consultation. A remote version seems feasible for simple procedures such as sedation for MRI. Further research on this topic in other areas of anesthesia would be beneficial.

Refugee Minors from Ukraine and their Families - First Experiences from an Intercultural Practice for Child and Adolescents Psychiatry and an Outpatient Clinic for Refugees/Hamburg

Due to the Russian invasion in Ukraine, many families were forced to flee to Germany, often having to leave relatives behind.The outpatient clinic for refugees at Universitätsklinikum Eppendorf coordinates the psychosocial and psychotherapeutic care for refugee minors from Ukraine in Hamburg. The intercultural practice for child and adolescents psychiatry offers on-site consultations for children and adolescents in camps in order to provide a low-threshold access to counseling and diagnostics. Diagnostic and therapeutic experiences to this point indicate the contribution of multifactorial stress to the development of symptoms in Ukrainian minors.The threat of war and displacement seems to be only one of many factors. Although there are some remarkable resilience factors for Ukrainian refugee children and adolescents in comparison to refugees from other countries of origin, the forced adaptation to living and studying conditions in Hamburg bears challenges for many. Additionally due to war experiences psychotherapeutic and psychiatric care is frequently needed. On Germany's side, there is a need for action to ameliorate the accessibility to the health care system for refugees and migrants. Support of therapists in this complex working field is thereby as important as advocacy for the needs of minor refugees in German society.

Efficacy, Efficiency, and Acceptability of Telemedicine for Inflammatory Bowel Disease Patients’ Follow-Up Care during the COVID-19 Pandemic

Background: During the COVID-19 pandemic, ambulatory clinic visits were replaced by the implementation of telehealth modalities in most inflammatory bowel disease (IBD) units. Aims: The aim of this study was to assess the efficacy, efficiency, patient satisfaction, and acceptability of using telephone consultation in an IBD unit. Methods: A prospective cohort study was performed in IBD patients who underwent telephone consultation during COVID-19 lockdown (between 16th March and 13th April 2020). To assess the efficacy of this telephone consultation (lockdown visit), nonscheduled visits, emergency consultation, hospital admission, and surgery from lockdown visit to the next scheduled consultation (post-lockdown) were checked. To evaluate efficiency, the time between lockdown visit and post-lockdown consultation was compared with previous consultation (pre-lockdown), and the total number of visits 12 months before and after lockdown visit was checked. A telephone survey was designed to rate perception for a telephone consultation. Results: Out of a total of 274 patients, 220 patients (52.2% male; mean age 49 ± 16 years; Crohn’s disease, n = 126; ulcerative colitis, n = 83; indeterminate colitis, n = 11) were included. Only one patient was consulted at the emergency department, 11 patients needed to rearrange the visit, and none patient underwent surgery before the scheduled post-lockdown visit. The interval to post-lockdown visit compared to pre-lockdown visit increased in 37.7% of patients. The satisfaction survey (n = 185) revealed that 94.6% perceived it was effective. However, 44.4% of patients rather prefer on-site consultation for follow-up. Conclusions: Telemedicine during the COVID-19 pandemic was shown to be effective and efficient to care for IBD patients. In addition, telephone consultation is well accepted by patients in non-extended follow-up periods.

Sentinel monitoring of COVID-related daily activity in primary care practices of the canton of Vaud

Abstract Introduction During the COVID pandemic, COVID-related data collected in family medicine were scarce. We aimed to monitor cantonal trends of COVID-related activity in family medicine and paediatric practices during the year 2021. Methods Family physicians and paediatricians established in the canton of Vaud were invited to join an ad hoc sentinel surveillance system. Online data collection was based on daily activity reports and monthly questionnaires. In particular, participants categorized daily counts of consultations and phone calls into predefined COVID-related categories. Results Thirty-seven practices contributed regularly to the system between March 20th and December 31st 2021. Out of 81'407 medical consultations, 4'950 (6.1%) were related to new COVID suspicions as defined by the Federal Office of Public Health, and 5'252 (6.4%) otherwise related to COVID. Depending on the week and the practice, between 5.6% and 26.5% of face-to-face consultations were COVID-related. In paediatrics, COVID-related activity corresponded mostly to new COVID suspicions (11.2% of on-site consultations), whereas among family physicians other COVID topics predominated (9.8% of face-to-face consultations), mainly questions about vaccination. Consultations for persisting COVID-related symptoms were stable at a low level throughout the year, and constituted less than 1% of all consultations. Most practices swabbed patients for SARS-CoV-2 tests, and an increasing proportion performed rapid antigenic tests over the year. In paediatrics, COVID-suspicions were not systematically tested. Conclusions Throughout 2021, COVID-related consultations constituted an important part of family medicine and paediatric practices’ activity in the canton of Vaud. Monitoring COVID-related activity in primary care during a pandemic documents how physicians translate recommendations into practice and provides health authorities with valuable information to guide public health action. Key messages • Throughout 2021, COVID-related consultations constituted an important part of family medicine and paediatric practices’ activity in the canton of Vaud. • Monitoring COVID-related activity in primary care during a pandemic documents how physicians translate recommendations into daily practice.

A National Survey to Guide Pediatric Curricula for Hospice and Palliative Medicine Fellows.

The pediatric hospice and palliative medicine (pHPM) workforce caring for an increasing population of medically fragile children is small due to a lack of both pHPM training opportunities and pediatric palliative care (PPC) community resources.1–10 Of the 159 HPM fellowship programs in the U.S., only 13 are dedicated pHPM programs with 17 training spots annually.11,12 A majority of pHPM specialists go on to practice within hospital-based programs, most of which are located in urban areas and prioritize on-site consultation.

Pandemic response gaps: Infection prevention and control lessons learned during coronavirus disease 2019 (COVID-19) outbreaks in skilled nursing facilities in Detroit, Michigan.

Hospitalizations among skilled nursing facility (SNF) residents in Detroit increased in mid-March 2020 due to the coronavirus disease 2019 (COVID-19) pandemic. Outbreak response teams were deployed from local healthcare systems, the Centers for Disease Control and Prevention (CDC), and the Detroit Health Department (DHD) to understand the infection prevention and control (IPC) gaps in SNFs that may have accelerated the outbreak. We conducted 2 point-prevalence surveys (PPS-1 and PPS-2) at 13 Detroit SNFs from April 8 to May 8, 2020. The DHD and partners conducted facility-wide severe acute respiratory coronavirus virus 2 (SARS-CoV-2) testing of all residents and staff and collected information regarding resident cohorting, staff cohorting, and personnel protective equipment (PPE) utilized during that time. Resident cohorting had been implemented in 7 of 13 (58.3%) SNFs prior to point-prevalence survey 1 (PPS-1), and other facilities initiated cohorting after obtaining PPS-1 results. Cohorting protocols of healthcare practitioners and environmental service staff were not established in 4 (31%) of 13 facilities, and in 3 facilities (23.1%) the ancillary staff were not assigned to cohorts. Also, 2 SNFs (15%) had an observation unit prior to PPS-1, 2 (15%) had an observation unit after PPS-1, 4 (31%) could not establish an observation unit due to inadequate space, and 5 (38.4%) created an observation unit after PPS-2. On-site consultations identified gaps in IPC knowledge and cohorting that may have contributed to ongoing transmission of SARS-CoV-2 among SNF residents despite aggressive testing measures. Infection preventionists (IPs) are critical in guiding ongoing IPC practices in SNFs to reduce spread of COVID-19 through response and prevention.

Effect of On-site Consultation and Education on Infection Control in Nursing Homes in Korea

Effect of On-site Consultation and Education on Infection Control in Nursing Homes in Korea

Effectiveness of a Conversational Chatbot (Dejal@bot) for the Adult Population to Quit Smoking: Pragmatic, Multicenter, Controlled, Randomized Clinical Trial in Primary Care.

BackgroundTobacco addiction is the leading cause of preventable morbidity and mortality worldwide, but only 1 in 20 cessation attempts is supervised by a health professional. The potential advantages of mobile health (mHealth) can circumvent this problem and facilitate tobacco cessation interventions for public health systems. Given its easy scalability to large populations and great potential, chatbots are a potentially useful complement to usual treatment.ObjectiveThis study aims to assess the effectiveness of an evidence-based intervention to quit smoking via a chatbot in smartphones compared with usual clinical practice in primary care.MethodsThis is a pragmatic, multicenter, controlled, and randomized clinical trial involving 34 primary health care centers within the Madrid Health Service (Spain). Smokers over the age of 18 years who attended on-site consultation and accepted help to quit tobacco were recruited by their doctor or nurse and randomly allocated to receive usual care (control group [CG]) or an evidence-based chatbot intervention (intervention group [IG]). The interventions in both arms were based on the 5A’s (ie, Ask, Advise, Assess, Assist, and Arrange) in the US Clinical Practice Guideline, which combines behavioral and pharmacological treatments and is structured in several follow-up appointments. The primary outcome was continuous abstinence from smoking that was biochemically validated after 6 months by the collaborators. The outcome analysis was blinded to allocation of patients, although participants were unblinded to group assignment. An intention-to-treat analysis, using the baseline-observation-carried-forward approach for missing data, and logistic regression models with robust estimators were employed for assessing the primary outcomes.ResultsThe trial was conducted between October 1, 2018, and March 31, 2019. The sample included 513 patients (242 in the IG and 271 in the CG), with an average age of 49.8 (SD 10.82) years and gender ratio of 59.3% (304/513) women and 40.7% (209/513) men. Of them, 232 patients (45.2%) completed the follow-up, 104/242 (42.9%) in the IG and 128/271 (47.2%) in the CG. In the intention-to-treat analysis, the biochemically validated abstinence rate at 6 months was higher in the IG (63/242, 26%) compared with that in the CG (51/271, 18.8%; odds ratio 1.52, 95% CI 1.00-2.31; P=.05). After adjusting for basal CO-oximetry and bupropion intake, no substantial changes were observed (odds ratio 1.52, 95% CI 0.99-2.33; P=.05; pseudo-R2=0.045). In the IG, 61.2% (148/242) of users accessed the chatbot, average chatbot-patient interaction time was 121 (95% CI 121.1-140.0) minutes, and average number of contacts was 45.56 (SD 36.32).ConclusionsA treatment including a chatbot for helping with tobacco cessation was more effective than usual clinical practice in primary care. However, this outcome was at the limit of statistical significance, and therefore these promising results must be interpreted with caution.Trial RegistrationClinicaltrials.gov NCT 03445507; https://tinyurl.com/mrnfcmtdInternational Registered Report Identifier (IRRID)RR2-10.1186/s12911-019-0972-z

COVID-19 Response Among US Hospitals with Emerging Special Pathogen Programs.

In February 2015, the US Department of Health and Human Services developed a tiered hospital network to deliver safe and effective care to patients with Ebola virus disease (EVD) and other special pathogens. The tiered network consisted of regional special pathogen treatment centers, state- or jurisdiction-designated treatment centers, assessment hospitals able to safely isolate a patient until a diagnosis of EVD was confirmed and transfer the patient, and frontline healthcare facilities able to identify and isolate patients with EVD and facilitate transport to higher-tier facilities. The National Emerging Special Pathogens Training and Education Center (NETEC) was established in tandem to support the development of healthcare facility special pathogen management capabilities. In August 2020, 20 hospitals that previously received an onsite readiness consultation by NETEC were surveyed to assess how special pathogen programs were leveraged for COVID-19 response. All surveyed facilities indicated their programs were leveraged for COVID-19 response in at least 1 of the following ways: NETEC-sponsored resources and training, utilization of patient isolation spaces, specially trained staff, and supplies. Personal protective equipment shortages were experienced by 95% of facilities, with 80% of facilities reporting that special pathogens program personal protective equipment was used to support facility response to COVID-19 admissions. More than half of facilities (63%) reported leveraging biocontainment unit staff to provide training and education to frontline staff during initial response to COVID-19. These findings have implications for planning and investments to avoid the panic-then-forget cycle that hinders sustained preparedness for future special pathogens.