On-site Specialist Research Articles

Towards 'Formalising' WhatsApp Teledermatology Practice in KZ-N District Hospitals: Key Informant Interviews.

District hospitals in KwaZulu-Natal Province, South Africa, do not have onsite specialist dermatology services. Doctors at these hospitals use WhatsApp instant messaging to informally seek advice from dermatologists and colleagues before possible referral. They have expressed the need to formalise WhatsApp teledermatology. To determine the views and perspectives of clinicians on the feasibility and practicality of formalising the current WhatsApp-based teledermatology activities within the KwaZulu-Natal Department of Health Dermatology Service. Key informant interviews with 12 purposively selected doctors at district hospitals and all 14 dermatologists in the KwaZulu-Natal dermatology service. Their views and perspectives on formalising the current informal use of WhatsApp for teledermatology were recorded, transcribed, and thematically analysed. Five primary themes (communication, usability, utility, process, and poor understanding of legal, regulatory, and ethical issues) and 22 sub-themes were identified. Clinicians wanted WhatsApp teledermatology to continue, be formalised, and be incorporated within the KwaZulu-Natal Department of Health, facilitated by the provision of practical guidelines addressing legal, regulatory, and ethical issues. These findings will be used to develop a policy brief, providing recommendations and proposed guidelines for formalising the teledermatology service. The findings and methods will be relevant to similar circumstances in other countries.

Inter-observer agreement among specialists in the diagnosis of oral potentially malignant disorders and oral cancer using store-and-forward technology.

Oral cancer is a leading cause of morbidity and mortality. Screening and mobile Health (mHealth)-based approach facilitates early detection remotely in a resource-limited settings. Recent advances in eHealth technology have enabled remote monitoring and triage to detect oral cancer in its early stages. Although studies have been conducted to evaluate the diagnostic efficacy of remote specialists, to our knowledge, no studies have been conducted to evaluate the consistency of remote specialists. The aim of this study was to evaluate interobserver agreement between specialists through telemedicine systems in real-world settings using store-and-forward technology. The two remote specialists independently diagnosed clinical images (n=822) from image archives. The onsite specialist diagnosed the same participants using conventional visual examination, which was tabulated. The diagnostic accuracy of two remote specialists was compared with that of the onsite specialist. Images that were confirmed histopathologically were compared with the onsite diagnoses and the two remote specialists. There was moderate agreement (k= 0.682) between two remote specialists and (k= 0.629) between the onsite specialist and two remote specialists in the diagnosis of oral lesions. The sensitivity and specificity of remote specialist 1 were 92.7% and 83.3%, respectively, and those of remote specialist 2 were 95.8% and 60%, respectively, each compared with histopathology. The diagnostic accuracy of the two remote specialists was optimal, suggesting that "store and forward" technology and telehealth can be an effective tool for triage and monitoring of patients. Telemedicine is a good tool for triage and enables faster patient care in real-world settings.

Service Level Characteristics of Rural Palliative Care for People with Chronic Disease.

Despite clear benefit from palliative care in end-stage chronic, non-malignant disease, access for rural patients is often limited due to workforce gaps and geographical barriers. This study aimed to understand existing rural service structures regarding the availability and provision of palliative care for people with chronic conditions. A cross-sectional online survey was distributed by email to rural health service leaders. Nominal and categorical data were analyzed descriptively, with free-text questions on barriers and facilitators in chronic disease analyzed using qualitative content analysis. Of 42 (61.7%) health services, most were public (88.1%) and operated in acute (19, 45.2%) or community (16, 38.1%) settings. A total of 17 (41.5%) reported an on-site specialist palliative care team, primarily nurses (19, 59.5%). Nearly all services (41, 95.3%) reported off-site specialist palliative care access, including: established external relationships (38, 92.7%); visiting consultancy (26, 63.4%); and telehealth (18, 43.9%). Perceived barriers in chronic disease included: lack of specific referral pathways (18; 62.1%); negative patient expectations (18; 62.1%); and availability of trained staff (17; 58.6%). Structures identified to support palliative care in chronic disease included: increased staff/funding (20, 75.0%); formalized referral pathways (n=18, 64.3%); professional development (16, 57.1%); and community health promotion (14, 50%). Palliative care service structure and capacity varies across rural areas, and relies on a complex, at times ad hoc, network of onsite and external supports. Services for people with chronic, non-malignant disease are sparse and largely unknown, with a call for the development of specific referral pathways to improve patient care.

Emergency Care to the Sound of Music

Introduction:There are known higher rates of drug and alcohol consumption in music festival attendees. Patterns of MDMA use had been changing over a number of years however the festival season (Sept 2018 - May 2019) in NSW saw a dramatic rise in drug related mortality and morbidity which had not been seen in other states in Australia although similar instances had been noted overseas.With over 70 music festivals in NSW in this period, five deaths in four months and 29 severely unwell patrons transported to NSW hospitals, the impact was significant.To support both the festival site and NSW hospitals a Health Response Team (HRT) deployment model was implementedMethod:The planning and intervention strategies included provision of onsite specialist critical care teams to complement existing event management and paid healthcare providers. Disaster management principles, although documented, had not previously been used in the music festival setting. To deploy such a team, guidance on equipment, pharmaceutical and physical requirements were scarce. Our team developed processes and protocols for all aspects of this unique deployment.Operational procedures included specific equipment, medications, documentation processes, and clinical protocols were developed and reviewed and refined after each festival.Results:The effectiveness of the teams was evidenced through the early recognition and management of severe drug toxicity seen at the five festivals to which WSLHD deployed HRTs. This management resulted in good outcomes with minimal morbidity and no deaths of the 29 festival patrons treated by the HRT noting 25 required intensive care admission.Conclusion:Innovative processes and collaborative arrangements enabled effective deployment to NSW music festivals. Expert HRTs were key in preventing drug related morbidity and mortality through early recognition and management of complications. Team members gained unique and invaluable experience as a result of their deployments and patients transported to hospital were managed more effectively.

Daily practices of advanced practice nurses within a multi-professional primary care practice in Switzerland: a qualitative analysis

BackgroundThe rising global population of older persons with chronic conditions demands new primary care models. Advanced practice nurses (APNs) can help meet that need. In Switzerland, APNs have only recently been introduced in primary care and little is known about their daily practice. This study aims to describe APNs’ activities and general roles at four sites with multi-professional primary care practices in the Swiss cantons of Bern and Solothurn.MethodsTo study the practices of APNs at the study sites, we adopted a social constructivist perspective, lending methods from ethnographic field research. We interviewed, observed and accompanied participants over five months, generating rich data on their daily practices. The analysis followed Braun and Clarke’s six-step thematic analysis process.ResultsThe APNs’ daily practices cover three main themes. Their core activities are working with expanded clinical skills and being on-site specialists for patients and their relatives. These practices are surrounded by net activities, i.e., taking care of patients in tandem with the physicians and regular visits in residential long-term care facilities. The outer activity layer consists of cohesive activities, with which APNs anchor and facilitate their role and catalyze further development of the care model. APNs tailor their expanded medical knowledge and nursing practice to maximize the value they provide in patient care.ConclusionsThis study extends our knowledge of APNs’ daily practice within a Swiss multi-professional primary care practice. Our results indicate competencies that need to be integrated in APN education and point out the high potential of APN integration in such primary care practices.

Novel Approach to Improving Specialist Access in Underserved Populations with Suspicious Oral Lesions.

Late detection and specialist referral result in poor oral cancer outcomes globally. High-risk LRMU populations usually do not have access to oral medicine specialists, a specialty of dentistry, whose expertise includes the identification, treatment, and management of oral cancers. To overcome this access barrier, there is an urgent need for novel, low-cost tele-health approaches to expand specialist access to low-resource, remote and underserved individuals. The goal of this study was to compare the diagnostic accuracy of remote versus in-person specialist visits using a novel, low-cost telehealth platform consisting of a smartphone-based, remote intraoral camera and custom software application. A total of 189 subjects with suspicious oral lesions requiring biopsy (per the standard of care) were recruited and consented. Each subject was examined, and risk factors were recorded twice: once by an on-site specialist, and again by an offsite specialist. A novel, low-cost, smartphone-based intraoral camera paired with a custom software application were utilized to perform synchronous remote video/still imaging and risk factor assessment by the off-site specialist. Biopsies were performed at a later date following specialist recommendations. The study's results indicated that on-site specialist diagnosis showed high sensitivity (94%) and moderate specificity (72%) when compared to histological diagnosis, which did not significantly differ from the accuracy of remote specialist telediagnosis (sensitivity: 95%; specificity: 84%). These preliminary findings suggest that remote specialist visits utilizing a novel, low-cost, smartphone-based telehealth tool may improve specialist access for low-resource, remote and underserved individuals with suspicious oral lesions.

Evaluation of antenatal point-of-care ultrasound training workshops for rural/remote healthcare clinicians: a prospective single cohort study

BackgroundThere is limited access to life-saving antenatal ultrasound in low-resource rural and remote settings worldwide, including Australia, mainly due to shortages in skilled staff. Point-of-care ultrasound (PoCUS) offers a viable solution to this service deficit, however, rural clinicians face many barriers accessing training and professional development critical to advancing their clinical practice. Standards for PoCUS training and competency assessment are unclear. Regulation is lacking globally, allowing untrained and inexperienced clinicians to practice PoCUS clinically.MethodsThis prospective single cohort study aimed to evaluate antenatal PoCUS training workshops for General Practitioners (GPs) and Midwives/Nurses (M/Ns) from rural/remote Australia, assessing the impact of the training on trainees’ knowledge, confidence and translation of PoCUS into clinical practice. Two-day antenatal ultrasound workshops were delivered at the University of South Australia (UniSA) in 2018 and 2019 to 41 rural/remote clinicians . The training was designed and evaluated using the New world Kirkpatrick Evaluation Framework. Sixteen GPs and 25 M/Ns with mixed prior ultrasound experience were funded to attend. The course consisted of lectures interspaced with hands-on training sessions using high-fidelity simulators and live pregnant models. Pre- and post-knowledge assessments were performed. Post-workshop evaluation and follow-up surveys (3- and 6-month post-training) assessed the workshops and changes to trainees’ clinical practice. A 2-day follow-up training session was conducted 12 months after the workshops for 9 trainees.ResultsPre/post knowledge testing demonstrated a 22% mean score improvement (95% CI 17.1 to 27.8, P < 0.0001). At 6 months, 62% of trainees were performing PoCUS that had assisted in patient management and clinical diagnosis, and 46% reported earlier diagnosis and changes to patient management. 74% of trainees had increased scanning frequency and 93% reported improved scanning confidence.ConclusionThis study demonstrated intensive 2-day workshops can equip clinicians with valuable antenatal PoCUS skills, offering a viable solution to assist in the assessment and management of pregnant women in the rural/resource-poor setting where access to ultrasound services is limited or non-existent. Geographical isolation and lack of onsite specialist supervision poses an ongoing challenge to the continuing professional development of remote trainees and the implementation of PoCUS.

164 OLDER PATIENTS AT THE PREOPERATIVE ASSESSMENT CLINIC: CHANGING THE FOCUS FROM FIT FOR SURGERY TO OPTIMISATION FOR SURGERY

Abstract Background The Pre-operative Assessment Clinic (PAC) is run by the Anaesthetic Department and assesses older patients undergoing elective orthopaedic surgery. The aim of this study was to examine how PAC currently assesses older patients and how effective it is in assessing for likelihood of postoperative complications and requirement for rehabilitation. Methods A single-centre, retrospective study that received approval from the local ethics committee. Data were collected on all patients post elective orthopaedic surgery admitted to the on-site specialist rehabilitation unit for older persons, between 1st May 2020 and 31st December 2021. Data were collected from hospital Information Technology platform, Bluespiers. Results Seventy-six patients (58 female; median age: 80 years) were included. Median time from PAC to surgery was 95 days. Functional assessment was completed in 63.16% of cases, formal cognitive assessment was done in 13% of cases. Number of falls in the preceding year was recorded in 31% of patients. Baseline mobility was recorded in 93% of cases. Whilst smoking and alcohol history was recorded in 96% of cases, number of units was not calculated. 45% (n=34) of patients were correctly identified as likely to require post-operative inpatient rehabilitation. PAC did not record sarcopaenia, polypharmacy or delirium risk factors. From our dataset, at least 13% had sarcopaenia, 80% had polypharmacy and 23% required opiate medications. Post-operatively, 16% of patients developed a delirium and 12% had an acute kidney injury. Conclusion In its current format, PAC fails to optimally risk stratify frail, older patients. Attention concentrates on fitness for surgery rather than optimisation of patients. Failure to record frailty, sarcopenia, cognitive impairment and risk factors for delirium is leading to missed opportunities in terms of delirium prevention, and peri-operative optimisation of older patients as well as discharge planning before surgery. Collaboration with specialist geriatric services at PAC should improve patient outcomes.

248 BENEFITS OF POST-OPERATIVE SPECIALIST GERIATRIC CARE FOR OLDER PATIENTS UNDERGOING ELECTIVE ORTHOPAEDIC SURGERY

Abstract Background The Covid-19 pandemic changed work practices across many different healthcare institutions. The difficulties with cross-site transfers created an opportunity in our institution to provide on-site post-operative rehabilitation for older patients undergoing elective orthopaedic surgery. The aim of this study is to assess the impact of post-operative specialist geriatric care on older patients. Methods This is a single-centre, retrospective study that received approval from the local hospital ethics committee. Data were collected on all patients admitted to the on-site specialist rehabilitation unit post-elective orthopaedic surgery between 1st May 2020 and 31st December 2021. Two patients in this group were excluded as they had not attended a pre-operative assessment clinic. Data were collected from hospital Information Technology platform, Bluespiers. Results 76 patients, 18 males and 58 females, were included in this study. The median age was 80 years. In the specialist rehabilitation unit, evidence of cognitive impairment was established in 40.79% of cases, there were 3 cases of newly diagnosed dementia, a history of falls was identified in 32.89% of patients and 13.16% of patients were found to have sarcopaenia. The median length of stay in the rehabilitation unit was 25 days. 51.32% of patients were discharged home independently, 23.68% of patients went home with a new Home-Care Package (HCP), 15.79% of patients were discharged home with an existing HCP, 6.58% of patients were transferred for further treatment and 2.63% patients were discharged to residential care units. Conclusion This data demonstrates a clear role for specialist geriatric care in elective rehabilitation, with a significant proportion of patients being discharged home independently. The benefits of a comprehensive geriatric assessment in the peri-operative setting include increased identification of cognitive impairment allowing appropriate implementation of brain health as well as identification of a history of falls, enabling falls risk assessment and management including bone health assessment.

Field validation of deep learning based Point-of-Care device for early detection of oral malignant and potentially malignant disorders

Early detection of oral cancer in low-resource settings necessitates a Point-of-Care screening tool that empowers Frontline-Health-Workers (FHW). This study was conducted to validate the accuracy of Convolutional-Neural-Network (CNN) enabled m(mobile)-Health device deployed with FHWs for delineation of suspicious oral lesions (malignant/potentially-malignant disorders). The effectiveness of the device was tested in tertiary-care hospitals and low-resource settings in India. The subjects were screened independently, either by FHWs alone or along with specialists. All the subjects were also remotely evaluated by oral cancer specialist/s. The program screened 5025 subjects (Images: 32,128) with 95% (n = 4728) having telediagnosis. Among the 16% (n = 752) assessed by onsite specialists, 20% (n = 102) underwent biopsy. Simple and complex CNN were integrated into the mobile phone and cloud respectively. The onsite specialist diagnosis showed a high sensitivity (94%), when compared to histology, while telediagnosis showed high accuracy in comparison with onsite specialists (sensitivity: 95%; specificity: 84%). FHWs, however, when compared with telediagnosis, identified suspicious lesions with less sensitivity (60%). Phone integrated, CNN (MobileNet) accurately delineated lesions (n = 1416; sensitivity: 82%) and Cloud-based CNN (VGG19) had higher accuracy (sensitivity: 87%) with tele-diagnosis as reference standard. The results of the study suggest that an automated mHealth-enabled, dual-image system is a useful triaging tool and empowers FHWs for oral cancer screening in low-resource settings.

Hepatitis C diagnosis and treatment in people who use drugs: mind the gap in the linkage to care.

The objective of this study is to identify a simplified rapid screening and linkage-to-care model for HCV among PWUD. The study stems from a collaborative project bringing together two local Italian Centers for Drug Addiction and the Hepatology-Infectious Diseases Department of Lazzaro Spallanzani. A research physician analyzed the available medical records seeking to identify HCV and HIV infected patients in care in the addiction centers. Between March 2018 and January 2020 subjects were selected from among a cohort of 720 PWUD in the two Centers' care. The study comprises three steps: first, screening for HCVAb; second, the linkage to care; third, clinical assessment to treatment. The research physician recruited patients for the first two steps directly in their local addiction center. The third step was conducted in the Spallanzani. The characteristics of those subjects who adhered to the three-step study program were then compared to those of the non-adhering PWUD. 194 were known HCVAb positive patients. Of the 505 PWUD in the care of the two Centers eligible for screening, 364 were enrolled in the study. 144 resulted HCVAb positive. 269 were tested for HCVRNA. 101 underwent a full assessment. 96 patients started antiviral therapy with DAA. Patients who refused first step screening were older patients and mainly heroin users; in the second step, almost all the HIV/HCV co-infected patients agreed to a viremia test; in the third step all the HIV/HCV co-infected patients refused HCV treatment. The study suggests an on-site specialist approach conducted directly in the addiction centers themselves starting from screening; it can bring the goal of HCV PWUD microelimination closer.

Study of the Intelligent Control and Modes of the Arctic-Adopted Wind–Diesel Hybrid System

For energy supply in the Arctic regions, hybrid systems should be designed and equipped to ensure a high level of renewable energy penetration. Energy systems located in remote Arctic areas may experience many peculiar challenges, for example, due to the limited transport options throughout the year and the lack of qualified on-site maintenance specialists. Reliable operation of such systems in harsh climatic conditions requires not only a standard control system but also an advanced system based on predictions concerning weather, wind, and ice accretion on the blades. To satisfy these requirements, the current work presents an advanced intelligent automatic control system. In the developed control system, the transformation, control, and distribution of energy are based on dynamic power redistribution, dynamic control of dump loads, and a bi-directional current transducer. The article shows the architecture of the advanced control system, presents the results of field studies under the standard control approach, and models the performance of the system under different operating modes. Additionally, the effect of using turbine control to reduce the effects of icing is examined. It is shown that the advanced control approach can reduce fuel consumption in field tests by 22%. Moreover, the proposed turbine control scheme has the potential to reduce icing effects by 2% to 5%.

Antibiotic Stewardship Implementation at Hospitals Without On-Site Infectious Disease Specialists: A Mixed-Methods Study

Background: Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist. In this study, we sought to understand ASP implementation at hospitals within the Veterans’ Health Administration (VHA) that lack on-site ID support. Methods: Using a mandatory 2016 VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. For each hospital, antibiotic use (2018–2019) was quantified as days of therapy (DOT) per 1,000 days present, based on NHSN methodology for tracking all antibacterial agents. From July 2019 through April 2020, we conducted semistructured interviews with personnel involved in or affected by ASP activities at 7 qualifying hospitals. All interview transcripts were analyzed using thematic content analysis. Results: Of the 7 acute-care hospitals, 6 (86%) had a long-term care unit; 3 (43%) had an intensive care unit; and 2 (29%) had full-time employment equivalents dedicated to stewardship. Sites averaged 1,075 (SD, ±654) and 148 (SD, ±96) admissions per year in acute-care and long-term care, respectively. At the site-level, mean antibiotic use was 486 DOT (SD, ±98) per 1,000 days-present in acute-care and 207 DOT (SD, ±74) per 1,000 days present in long-term care. We interviewed 42 personnel across the 7 sites. Although sites reported using similar interventions to promote antibiotic stewardship, the shape of these interventions varied. The following 4 common themes were identified: (1) The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. (2) The pharmacist champions were more successful at gaining buy-in for stewardship initiatives when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. (3) Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers to stewardship and improving the acceptance of their stewardship interventions. (4) In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals. Conclusions: In this study of 7 hospitals without local ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.Funding: NoDisclosures: None

Readiness to Provide Medications for Addiction Treatment in HIV Clinics: A Multisite Mixed-Methods Formative Evaluation.

We sought to characterize readiness, barriers to, and facilitators of providing medications for addiction treatment (MAT) in HIV clinics. Four HIV clinics in the northeastern United States. Mixed-methods formative evaluation conducted June 2017-February 2019. Surveys assessed readiness [visual analog scale, less ready (0-<7) vs. more ready (≥7-10)]; evidence and context ratings for MAT provision; and preferred addiction treatment model. A subset (n = 37) participated in focus groups. Among 71 survey respondents (48% prescribers), the proportion more ready to provide addiction treatment medications varied across substances [tobacco (76%), opioid (61%), and alcohol (49%) treatment medications (P values < 0.05)]. Evidence subscale scores were higher for those more ready to provide tobacco [median (interquartile range) = 4.0 (4.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.008] treatment medications, but not significantly different for opioid [5.0 (4.0, 5.0) vs. 4.0 (4.0, 5.0), P = 0.11] and alcohol [4.0 (3.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.42] treatment medications. Median context subscale scores ranged from 3.3 to 4.0 and generally did not vary by readiness status (P values > 0.05). Most favored integrating MAT into HIV care but preferred models differed across substances. Barriers to MAT included identification of treatment-eligible patients, variable experiences with MAT and perceived medication complexity, perceived need for robust behavioral services, and inconsistent availability of on-site specialists. Facilitators included knowledge of adverse health consequences of opioid and tobacco use, local champions, focus on quality improvement, and multidisciplinary teamwork. Efforts to implement MAT in HIV clinics should address both gaps in perspectives regarding the evidence for MAT and contextual factors and may require substance-specific models.

MO351CENTRE VARIATION IN MORTALITY FOLLOWING HOSPITAL-ACQUIRED ACUTE KIDNEY INJURY IN ENGLAND

Abstract Background and Aims Routine monitoring of outcomes for patients with Acute Kidney Injury (AKI) is necessary to drive quality improvement in AKI care. In this study, we describe development of a case-mix adjusted 30-day mortality indicator for patients with hospital acquired AKI (H-AKI), to facilitate identification of unwarranted variation in outcomes across hospitals in England. Method We utilised a routinely collected national dataset of biochemically defined AKI cases, linked with hospitals administrative and mortality data. 250,504 H-AKI episodes were studied in total, across 103 hospitals between January 2017 - December 2018. Standardised mortality ratios were calculated for each hospital using logistic regression; adjusting for age, sex, primary diagnosis, comorbidity score, AKI severity, month of AKI, and admission method. Results Mean 30-day mortality rate was high at 28.6% and varied considerably between hospitals (22.3%-35.5%), with 23/103 trusts classed as outliers (95% control limits). Patients with H-AKI had mortality rates more than 5 times higher than the overall hospitalized population in 90/136 diagnosis groups and over 10 times higher in 60/136 groups. Increasing age, male sex, deprivation, higher comorbidity burden, more severe AKI stage at detection, emergency admission and admission during winter months were all associated with a higher risk of death Presentation at hospitals with on-site specialist nephrology services and Asian or Black ethnicity, however, were linked to a lower risk of death. Conclusion This is the largest multi-centre analysis of mortality for patients with biochemically ascertained H-AKI to date, once again highlighting development of AKI as an important patient safety concern across hospital settings. Centres identified as having poor outcomes will need to carefully interrogate their AKI care pathways to understand and explore reasons underlying the observed variation to guide future quality improvement interventions.

Antibiotic stewardship implementation at hospitals without on-site infectious disease specialists: A qualitative study.

Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist. In this study, we sought to understand ASP implementation at hospitals that lack on-site ID support within the Veterans' Health Administration (VHA). Using a mandatory VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. We conducted semistructured interviews with personnel involved in ASP activities. The study was conducted across 7 VHA hospitals. In total, 42 hospital personnel were enrolled in the study. The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. The pharmacist champions were more successful at gaining buy-in when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers and improving the acceptance of their stewardship recommendations. In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals. In this study of 7 hospitals without on-site ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.

97 What Are the Main Delays to Surgery After A Patient Presents with An Acute Type A Aortic Dissection?

Abstract Introduction Acute-aortic-dissection (AAD) represents a serious cardiovascular emergency, with an associated mortality of 1-2% per hour after symptom onset. It is known that the relative infrequency of AAD and plausible differentials can negatively impact on a timely diagnosis. Female sex, absence of typical features and high-risk examination findings (hypotension/pulse deficits) shown to delay diagnosis. In UK, services for AAD are centralised, working on established volume/outcome relationships. However, this has the potential to introduce delays in rapidly diagnosing patients without on-site specialist support and in the logistics of transferring patients across large distances. This study aims to report on time taken for patients to receive surgery after first presentation at local hospital and identify points that contribute to maximal delay. Method Retrospective analysis of all operated type-A-aortic-dissections at our hospital in 2019. Hospital database used to identify patients, and local/referring hospital documentation reviewed to establish times. Results Mean time from A&amp;E presentation to surgery is 8-hours-and-30 minutes (4:16–13:43). Largest contributor to delay is time from A&amp;E admission to CT scan. Conclusions Our findings suggest greatest impact on improving times from presentation to surgery is to increase awareness of AAD in regional, non-specialist hospitals and to encourage rapid imaging.

Skin cancer screening using total body photography and digital dermoscopy: A pilot study among Florida firefighters

To the Editor: Firefighters have an increased risk of developing melanomas than the general population, with these melanomas occurring at significantly younger ages.1 Early detection of skin cancer is associated with reduced morbidity, mortality, and financial costs.2 Currently, early detection is based on self-detection and opportunistic full-body skin exam (FBSE) by trained medical providers.3 However, performing FBSE becomes challenging in settings without on-site specialists or with social distancing policies.

MHealth-Based&amp;nbsp;Point-Of-Care Diagnostic Tool for Early Detection of Oral Cancer and Pre-Cancer Lesions in a Low-Resource Setting

Background: Early detection of oral cancer in low-resource settings necessitates a robust, Point-of-Care screening tool that can empower Frontline-Health-Workers (FHW) for triaging high-risk populations. This study was conducted to validate the accuracy of Artificial-Neural-Network (ANN) enabled m(mobile)-Health device deployed with FHWs. Methods: The dual-imaging device enables white-light as well as auto-fluorescence imaging with both a wide and focused view. The effectiveness of the device was tested in tertiary-care/dental hospitals and low-resource settings of South/North-East India. Demographics and clinical details were documented in the device, and the subjects were screened independently, either by FHWs or along with specialists, in addition to a remote evaluation by oral cancer specialists. Simple and complex ANN were built using the images for classification of oral-potentially-malignant/malignant lesions and integrated into the mobile phone/cloud. The specialist diagnoses were compared with the histopathology, FHW, and ANN-based diagnosis to evaluate the efficacy of the oral cancer detection program. Findings: The program screened 5025 subjects with 95% (n=4728) having tele-diagnosis. Among the 16% (n=752) assessed by onsite specialists, biopsy was advised for 515, out of which 20% (n=102) underwent biopsy. The onsite specialist diagnosis showed high sensitivity (94%) and moderate specificity (72%) when compared to histology diagnosis, while tele-diagnosis showed high accuracy when compared with onsite specialists (sensitivity: 95%; specificity: 84%). FHWs, when compared with tele-diagnosis, identified suspicious lesions with less sensitivity (60%). Further, the efficacy of the FHWs in delineating suspicious lesions correlated (r= 0·80) with their prior experience in the project. The ANN (MobileNet) integrated with the phone for a real-time diagnosis could accurately delineate lesions (n=1416; sensitivity: 82%), while the cloud-based ANN (VGG19) had higher accuracy (sensitivity: 87%) when compared to tele-diagnosis. Interpretation: This study suggests that an automated mHealth-enabled dual-image system could prove a useful triaging tool, empowering FHWs towards accurate screening in low-resource settings. Clinical Trial: The study protocol was registered in the Clinical Trial Registry of the Indian Council of Medical Research (CTRI/2019/11/022167). Funding: This study is primarily funded by the National Institutes of Health (NIH), USA grants (UH2EB022623, UH3CA239682). This work is also supported by LAMMP NIH/NIBIB P41EB05890, Arnold and Mabel Beckman Foundation, California Tobacco-Related Diseases Program: T31IR1825. Declaration of Interest: We declare no competing interests. Ethical Approval: Institutional Ethics Committee approvals were obtained from the three nodal centers- The KLE Society’s Institute of Dental Sciences (KLE; ECR/887/Inst/KA/2016), Bengaluru, India, Christian Institute of Health Sciences and Research (CIHSR; EC/NEW/INST/2020/782), Dimapur, Nagaland, India, and Mazumdar Shaw Medical Center (MSMC; NNH/MEC-CL-2016-394), Bengaluru, India prior to the initiation of the clinical trial.

잠수기어선에서 조업하는 선원의 안전사고 분석

The diving apparatus fishery is a fishing industry in which divers catch settled shellfish by installing a diving apparatus on powered fishing vessel. We conducted to serve as a basic data for improving the healthy and safe working environment of fisher using fishermen’s occupational accidents of the national federation of fisheries cooperative (NFFC) from 2016 to 2018 and the questionnaire survey by the onsite specialist, such as a fishing master, diver and fisher in diving apparatus fishing vessel from June to October 2018. The average occurrence rate of victim in this fishery was 4.55% in all industries 8.4 times the rate of that. In addition, average fatality rate was found to have a very serious level management to 22.75‱ in all industries fatality of 20.3 times. In the 4M analysis by safety accident factor during fishing work, the mechanical factors were decrepit equipments or poor maintenance 33 cases (40.7%) and systemic error of fishing equipments 16 cases (19.8%). The environmental factors were poor environment such as deep water etc. 37 cases (46.8%) and unexpressiveness by noise and vibration 24 cases (30.4%). The human factors were personal’s carelessness 36 cases(40.0%) and unskillfulness of operating net and haulers 15 cases (16.7%). The management factors are work practice of poor safety precautions 37 cases (42.0%) and inadequacy of education on hazard factor 15 cases (17.0%). The results are expected to contribute to the creation of a safe operating environment for diving apparatus fishery, such as a fisher and diver boarding a apparatus fishing vessel, enabling the analysis of major causes of working safety accidents by cause.