Outpatient Management Research Articles

Exploring proposed recommendations for immediate-use seizure medication: Treating both cluster and prolonged seizures with diazepam nasal spray.

The Seizure Termination Project developed expert consensus recommendations for outpatient management of seizure clusters and prolonged seizures to prevent progression to a higher-level emergency. The consensus recommendations described therapeutic scenarios for seizure clusters (acute cluster treatment [ACT]) to prevent further seizures in a cluster and treatment to stop ongoing seizures that were expected to be prolonged (rapid and early seizure termination [REST]). Here, we review ACT and REST as categories and explore their practical application by examining patient-level data for diazepam nasal spray. ACT and REST criteria were examined using data from the long-term safety study that evaluated diazepam nasal spray for seizure clusters. To explore the effectiveness and duration of treatment for ACT, the proportion of seizure clusters for which second doses were administered within 24 h was used as a proxy. REST was investigated using the time from administration to seizure cluster termination; timing for the termination of prolonged seizures (5-15 min for the purposes of this analysis) in clusters also was examined. In the long-term safety study of diazepam nasal spray, a single dose demonstrated effectiveness at terminating a substantial majority of seizure clusters (3368/3853 [87.4%]) across 24 h, demonstrating its use as ACT. The majority of seizure clusters (2169/3225 [67.3%]) were recognized and treated quickly, within 5 min from onset, demonstrating its utility as REST. Notably, effectiveness was maintained in seizures treated after they had become prolonged. These findings from the large dataset of the long-term safety study of diazepam nasal spray demonstrate that it is of benefit in immediate use for both termination of an acute seizure and prolonged seizures within seizure clusters, thus supporting the recent expert consensus recommendations. Early use of a single rescue treatment can meet the need for ACT and REST, simplifying patient care. PLAIN LANGUAGE SUMMARY: An expert group defined 2 groups of seizure medicines for patients and caregivers to use. "ACT" medicines are for acute cluster treatment to prevent more seizures in a cluster. "REST" medicines for rapid and early seizure treatment stop prolonged seizures. Diazepam nasal spray for seizure clusters was looked at to see if it could fit in both categories. Study data showed that for most seizure clusters only 1 dose of diazepam nasal spray was used over 24 h (fitting ACT), and seizures were treated and ended quickly (fitting REST). One medicine for REST and ACT may make treatment simpler.

Cognitive Interviews With Emergency Physicians to Understand Disposition Decisions With People With Dementia With Borderline Cases.

People with dementia are often hospitalized from the emergency department (ED) for "borderline cases," where outpatient or inpatient management may be clinically reasonable. We sought to investigate how ED physicians make and communicate about decisions in borderline cases. Through cognitive interviews, we asked attending ED physicians from an academic hospital to share their approach to scenarios representing borderline cases with people with dementia and verbalize communication about ED disposition with patients and care partners. We deductively coded responses related to patient/care partner engagement and key features of communication and then elucidated themes related to content and phrasing of communication. Of 21 physicians, two-thirds stated they would offer the option of admission or discharge, but few explicitly communicated admission versus discharge as a choice. Shared decision-making is applicable to these situations and could provide a consistent structure to communication about disposition.

Promoting outpatient medication safety in Finland: A mid-term review of a national medication safety programme for community pharmacies (2021-2026).

Promoting outpatient medication safety in Finland: A mid-term review of a national medication safety programme for community pharmacies (2021-2026).

"I am not pain, I have pain": A pilot study examining iRest yoga nidra as a mind-body intervention for persistent pain.

"I am not pain, I have pain": A pilot study examining iRest yoga nidra as a mind-body intervention for persistent pain.

Improving Outpatient COPD Management: A Quality Improvement Initiative Using the New GOLD Classification System

Improving Outpatient COPD Management: A Quality Improvement Initiative Using the New GOLD Classification System

Identifying low-risk in patients with worsening heart failure with short hospital stay: A comparison of risk scores in predicting 30-day risk events.

Identifying low-risk in patients with worsening heart failure with short hospital stay: A comparison of risk scores in predicting 30-day risk events.

An outpatient TIA clinic works! Insights from the creation and the first year of Bordeaux TIA clinic.

An outpatient TIA clinic works! Insights from the creation and the first year of Bordeaux TIA clinic.

Pharmacist-led intervention reduced drug-related problems in the management of type 2 diabetes mellitus patients

This pre- and post-quasi-experimental study was undertaken to analyze the impact of pharmacist-led intervention (PI) on the reduction of DRPs in the management of type 2 diabetes mellitus outpatients (n = 106) for six months admitted to Prof. Dr. Chairuddin P. Lubis Hospital, Medan, Indonesia. The required data of patients in the control group (CG) and PI groups were extracted from medical records. DRPs were analyzed by applying PCNE version 9.1. The significance of PI on DRPs was analyzed using a paired t-test. The mean age of the patients was 58.61 ± 8.89 (years). Most (54.72%) of them were female. The total incidences of DRPs in CG and PI groups were 263 and 205, respectively, (p = 0.001). The relative risk of PI on DRPs was 0.93 and the absolute risk reduction was 6.6%. This study indicated that PI through patient counseling reduced the incidence of DRPs in the management of T2DM outpatients.

High-Frequency Utilization of the Outpatient Messaging System in a Specialized Outpatient Catatonia Clinic for Individuals with Autism Spectrum Disorder.

Purpose: Catatonia is a highly morbid psychomotor disorder that impacts autistic adults and children. There is very little literature that describes outpatient catatonia management practices, none of which discusses the use of the electronic health record (EHR). Thus, we conducted this study to analyze patient messages in a specialized catatonia clinic. Methods: We conducted a retrospective analysis of messaging practices in the EHR for patients in a specialized clinic with autism and catatonia from July 1, 2021, to May 31, 2024. Catatonic symptom severity was recorded via the Bush Francis Catatonia Rating Scale (BFCRS), Kanner Catatonia Severity Scale (KCS), and Kanner Catatonia Examination (KCE). We conducted Spearman and Pearson correlation coefficients to determine whether a relationship exists between the frequency of patient messages, catatonic symptoms, and length of follow-up. Results: A total of 12,972 messages were sent to the health system or received by the patient or their family. Of those, 6375 (49.1%) messages were sent from the family to the health system. Relationships between message frequency to the health system and all baseline catatonia severity scores (BFCRS, KCS, KCE) were not statistically significant, although message frequency was strongly associated with length of follow-up (r = 0.65, p < 0.001). A total of 5555 (42.8%) messages were sent directly to or received from providers in the catatonia specialty clinic. The rate of messages to providers in the catatonia clinic was 2.9 messages/day. Conclusion: The frequency of patient messaging was high in this catatonia specialty clinic. Health systems should consider this possibility when planning for similar service lines.

Oncology for the "On-Call"-ogist: a Canadian Curriculum to Improve the Quality of Acute Oncology Education for General Medicine Trainees.

General internal medicine (GIM) trainees manage many hospitalized cancer patients with complex care needs; however, most oncology educational resources focus on outpatient management. We aimed to develop and evaluate a novel and practical curriculum to improve the quality of oncology education to help GIM trainees care for cancer patients in the acute inpatient setting. A multi-specialty team of GIM trainees and medical oncology and palliative care physicians collaborated to develop a case-based, interactive curriculum built upon trainee input, involving three sessions focusing on respective domains of competency (DoC): (1) cancer diagnosis and staging, (2) oncological emergencies, and (3) end-of-life care. This curriculum was delivered to GIM trainees during their clinical rotations at Mount Sinai Hospital (Toronto, Canada) and was evaluated using anonymized pre- and post-course surveys. Twenty-nine residents and medical students participated in this curriculum from August to December 2023. Upon completion of the course, trainees' satisfaction with their oncology knowledge for the purpose of inpatient care improved, and their comfort level improved in overall DoC 1, overall DoC 2, and two of five competencies within DoC 3. The efficacy of this curriculum demonstrates the feasibility of teaching specialized oncology principles to a generalist audience using a novel educational approach.

Outpatient management of prelabour rupture of membranes (PROM) at term-a re-evaluation and contribution to the current debate.

Our study aims to underpin the safety of ambulatory management for 24 h after PROM at term. Patient data from 2021 were compared with data from 2010 to 2013, when ambulatory management was first introduced at the Women's Clinic of the University Hospital of Basel. In this retrospective study with historical control groups, we compared a cohort of women who underwent outpatient management of PROM at term in 2021, n=78 with two previous cohorts with inpatient management in 2010-2012, n=202 and outpatient management in 2013, n=37, respectively. The maternal and foetal outcomes of our cohort were comparable to those of the previous cohorts. The expected difference in shorter hospital stay was confirmed. The study confirms the safety of an outpatient approach in the management of PROM at term. Further studies, especially RCTs, are needed for a definitive evaluation.

The Clinical Impact of a Multidisciplinary Strategy: Diagnostic and Therapeutic Flow-Chart for Vertebral Metastases with Spinal Cord Compression

Introduction: Metastatic spinal cord compression (MSCC) is a life-threatening complication caused by the involvement of the spinal cord or nerve roots. It can result in severe neurological deficits, including paralysis, sensory loss, and bladder or bowel dysfunction, significantly affecting patients’ quality of life. Prompt diagnosis and intervention are critical to minimizing these outcomes and improving neurological recovery. This study evaluates the efficacy of a diagnostic and therapeutic protocol introduced at our institution in 2022, designed to enhance early detection, optimize management, and improve outcomes for patients with MSCC. Materials and Methods: The protocol was developed through a multidisciplinary collaboration involving emergency physicians, oncologists, spine surgeons, neuroradiologists, and radiation oncologists. Each specialty contributed its expertise to create a streamlined approach emphasizing early symptom recognition, rapid diagnostic imaging, and timely therapeutic interventions, such as surgical decompression and radiotherapy. To assess the protocol’s effectiveness, a retrospective analysis was conducted. Clinical data from the pre-implementation period (years 2019–2021) were compared to the post-implementation period (2022–2024). Results: The implementation of the algorithm significantly improved MSCC management, increasing outpatient consultations from 671 to 828 (+23%). Comparing the pre- to post-implementation periods, emergency consultations rose from 14% to 23%, while intrahospital consultations decreased from 20% to 16%. Surgical procedures increased slightly, from 60 to 66 (+10%), including 26 emergency surgeries (+4%) and 40 elective delayed surgeries (+14%). Conclusions: The introduction of a multidisciplinary diagnostic and therapeutic protocol significantly improved outpatient management of patients with metastatic spine disease, demonstrated by a significant increase in urgent outpatient consultations and a reduction in intrahospital consultations. The number of surgical interventions for metastatic spinal cord compression slightly increased after the protocol’s adoption, although the proportion of elective surgeries remained unchanged. Neurological presentation at the time of surgery did not show a statistically significant difference between the pre- and post-implementation periods. These findings highlight the protocol’s effectiveness in optimizing patient flow and triaging, while further research is needed to evaluate its long-term clinical impact.

Leveraging Online Booking for Outpatient Chronic Condition Management: A 5-Year Analysis of Diabetes Care in Shanghai

Leveraging Online Booking for Outpatient Chronic Condition Management: A 5-Year Analysis of Diabetes Care in Shanghai

Outpatient Management of Bispecific Related Toxicities: An Observational Study of Safety Outcomes and Resource Utilization.

Cytokine release syndrome (CRS) of any grade occurs in 56%-80% of bispecific antibodies (BsAbs) used in multiple myeloma (MM). Risk mitigation strategies are required to expedite escalation of care if toxicities develop. The rarity of grade 3 or 4 CRS compels protocolized outpatient management of BsAbs as outpatient practice may avoid hospital admissions and costly resource utilization without compromising safety. Patients with MM who received BsAb step-up dosing (SUD) from August 23, 2023, to March 29, 2024, were enrolled. Baseline demographics, patient outcomes, and CRS management were reviewed to assess the safety of outpatient practice. Resource utilization was also analyzed. In this study, 34 patients received outpatient SUD of BsAbs (teclistamab n = 17, talequetamab n = 17) with 16 remaining outpatient throughout the entire SUD period. CRS occurred in seven patients who did not require hospitalization, demonstrating the safety of outpatient management of BsAb toxicity, regardless of low-grade CRS. CRS was observed in 24 patients (maximum grade 2) and immune effector cell-associated neurotoxicity syndrome in four patients (maximum grade 3). All patients with CRS received steroids, including 12 patients at home when instructed. Tocilizumab was given to 13 patients, accounting for 18 doses. If all doses of BsAbs and tocilizumab were given outpatient, the medication margin would be $115,004 in US dollars (USD). An outpatient-based practice for BsAb administration demonstrated safety and cost savings. The description of our practice and results of this study provide valuable insights into the safety, feasibility, and resource stewardship of outpatient management of BsAbs. Future research should attempt to predict and stratify CRS risk to deliver a tailored supportive strategy and continued increase of outpatient management.

Determinants of default from outpatient management of severe acute malnutrition among caregivers of children aged 6–59 months at Fortportal regional referral hospital, Southwestern Uganda: a mixed methods study

BackgroundSuccessful outpatient management of severe acute malnutrition (SAM) significantly lowers the morbidity and mortality of patients. However, 29.5% of children under five years of age default from outpatient management of SAM in the Tooro subregion in southwestern Uganda, and little is known about the associated factors. This study assessed the determinants of default from the outpatient management of SAM among caregivers of children aged 6–59 months. It explored their experiences and perceptions of SAM and its management at Fort Portal Regional Referral Hospital in the Tooro subregion, Uganda.MethodsA mixed methods study was conducted among caregivers of children who received outpatient management between January 2018 and August 2022. Cases were selected purposively, whereas controls were randomly selected. Data was collected using a structured questionnaire and exported to STATA 14 for analysis. Logistic regression was used to identify the determinants of default from the outpatient management of SAM. Fourteen caregivers and five health workers were purposively selected and interviewed, with informed consent. The interviews were audio recorded, transcribed verbatim, and analysed using Atlas. Ti 9 software. Ethical approval was sought from the Makerere School of Public Health Research & Ethics Committee (Protocol ID: 087).ResultsA total of 88 cases and 111 controls were recruited. Several factors, including being Protestant (AOR = 2.60; 95% CI: 1.12–5.90), being Orthodox/Seventh-day Adventist (AOR = 3.65; 95% CI: 1.47–9.10), high transport costs (AOR = 3.30; 95% CI: 1.59–6.80), lacking perceived susceptibility to other illnesses (AOR = 3.90; 95% CI: 1.84–8.30), lacking health education (AOR = 3.97; 95% CI: 1.1–14.30) and lacking self-efficacy (AOR = 0.33; 95% CI: 0.16–0.66), were significantly associated with default from the outpatient management of SAM. Most caregivers reported being afraid of the possible consequences of default and agreed that SAM management was beneficial. However, their confidence in adhering to management was undermined by several factors, including transport costs, distance to the health facility, and discrimination.ConclusionBeing Protestant, Orthodox/Seventh-day Adventist, high transport costs, lack of perceived susceptibility to other illnesses, lack of health education, and lack of self-efficacy were essential determinants of default from outpatient management of SAM. To reduce the default rate, stakeholders must strengthen peripheral sites and community health workers to bring SAM management services closer to the community. Additionally, a closer examination of the role of religious beliefs in default from the outpatient management of SAM is needed.

What do readers need? Qualitative requirements of medical discharge summaries from the recipients’ perspective

BackgroundDischarge summaries (DSs) are the primary communication tools in clinical medicine. The transfer of information and plans is essential to ensure consistent patient safety and continuity of care. Therefore, DSs play a key role in population health. However, the overall quality of DSs is considered deficient, and there is a notable lack of scientific knowledge and research in this field, particularly regarding the needs of physicians as the primary recipients of DSs and key providers of ongoing patient care. The purpose of this study was to explore their requirements concerning the content, structure, and processing of DSs.MethodsA total of 159 outpatient primary care physicians (general practitioners, GPs) and specialists who refer patients to hospitals for various conditions were contacted across Germany using mixed sampling methods combining convenience, quota, and theory-driven sampling. Of these, 106 (66.67%) participated in telephone interviews. The interviews included nine open-ended questions, analyzed using Mayring’s qualitative content analysis, and a 43-item questionnaire, evaluated quantitatively with descriptive statistical methods to assess DS characteristics.ResultsQuantitative analysis revealed that recipients rated the prompt arrival of DSs, a clear treatment and diagnostic plan, and a coherent rationale as the most important requirements. The least important elements were newsletter-style content, patient contact information, patient ethnicity, and hospital logos or awards. Both quantitative and qualitative analyses identified similar priorities and challenges in DS content and structure. Sending a diagnosis list was considered a top priority by all physicians. While GPs placed high importance on diagnoses, treatment plans, and medication changes, specialists prioritized a logical line of reasoning.ConclusionThis recipient-focused study highlighted specific areas for improvement in the content, structure, and delivery of DSs. Tailoring DS formats to the distinct needs of GPs and specialists has the potential to enhance their overall quality and utility. Ultimately, optimizing DSs may strengthen population health outcomes by improving care transitions, reducing adverse events, and supporting effective outpatient management across the healthcare system.

Outpatient models of care for pregnant women with hyperemesis gravidarum: a scoping review

Background/Aims Hyperemesis gravidarum can significantly impact physical and mental health and adversely affect quality of life. The aim of this review was to describe current literature regarding outpatient services for women experiencing hyperemesis gravidarum. Methods This scoping review searched a range of databases for studies conducted between January 2010 and October 2024. Results Overall, 18 papers were included. Descriptions of investigations, treatments and medications varied and were poorly reported. Outpatient care decreased inpatient admissions and length of stay without negatively impacting women's health. Women receiving outpatient care were as satisfied as those receiving inpatient care. Conclusions There is significant variation in outpatient models of care for hyperemesis gravidarum. Further research is needed to address the large evidence gaps in optimising models of care. Implications for practice Outpatient services should be considered as an alternative to inpatient care. Development of standardised, evidence-based protocols for outpatient management is required including consistent approaches to investigations, treatments and education.

A stepped wedge cluster randomized implementation trial to increase outpatient management of low-risk pulmonary embolism from the emergency department – the MEDIC ALERT PE study

BackgroundHome-based care for patients diagnosed in emergency departments (EDs) with low-risk pulmonary embolism (PE) is an evidence-based, guideline-recommended practice that is not widely adopted in the US. Few studies demonstrate how this care pathway can be implemented effectively or test whether implementation strategies can address known barriers. Further, prior studies have lacked diversity in population and health system type and did not integrate theory-informed implementation frameworks. Although essential for establishing the evidence base for safe home management of low-risk acute PE, these studies have thus fallen short of guiding broad dissemination and equitable implementation. To bridge this gap, we are conducting a pragmatic multi-site implementation trial, guided by implementation science theory and frameworks, across twelve diverse hospital settings to assess the effectiveness of new care pathways for patients with low-risk PE presenting to EDs.Methods/designThe study uses a cluster-randomized stepped wedge trial design to investigate a set of implementation strategies to support establishing low-risk PE pathways in 12 EDs. Clusters of three hospitals were randomly assigned to one of four start dates, staggered over a 12-month period. During an initial three-month pre-implementation period, we will work with site champions to identify key site personnel and understand site barriers and facilitators. We will then tailor the care pathway to local needs and capabilities. During the six-month active implementation period, we will provide coaching to help sites implement a multi-component intervention informed by behavioral economics intended to address multi-level (site, provider, patient) barriers and integrate the new care pathway for discharging low-risk PE patients. Sites are then followed for a minimum of 12 months post-implementation. Our primary aim is to assess the change in discharge rates of patients with acute PE pre- and post-implementation. Secondary and exploratory aims will assess change in patient safety outcomes along with other key implementation outcomes guided by the RE-AIM framework.DiscussionThis study expands upon prior effectiveness research to tailor, implement, and robustly evaluate a multi-component implementation intervention for diverse health systems aiming to increase guideline-based outpatient management of low-risk PE. Broad-scale implementation in the US could avert up to 100,000 hospitalizations annually.Trial registrationClinicaltrials.gov (NCT06312332), registered on March 13, 2024.

Low-Risk Febrile Neutropenia Management: An Audit of Practice in a UK Cancer Center.

Low-Risk Febrile Neutropenia Management: An Audit of Practice in a UK Cancer Center.

Potentially preventable hospitalizations among American Indian and Alaska Native adults, 2016-2021.

Potentially preventable hospitalizations among American Indian and Alaska Native adults, 2016-2021.