Patient Case Discussions Research Articles

Evaluation of a technology enhanced breast multidisciplinary cancer conference (MCC).

e23202 Background: Tumor board meetings have been a standard approach for managing complex cases. In 2020, a digital platform, navify® Tumor Board Solution (NTBS), was implemented at a comprehensive academic cancer center. The objectives of this study were to assess the impact of NTBS (1) on quality of patient information and case deliberation, (2) rate of change in care plans by the MCC, (3) compliance of care plans with national guidelines, and (4) concordance of treatment received with MCC recommendations. Methods: We conducted a prospective study from September 2020 to February 2022, before and after implementation of NTBS. We used a validated tool, “Metric for the Observation of Decision-Making", to assess the impact of the platform on the quality of breast MCC case presentation and discussion. We reviewed medical records to compare the rate of change in care plans, compliance with national guidelines, and concordance of treatment received with MCC recommendations. Results: There were 39 and 47 patient cases in the pre- and post-NTBS groups, respectively. We found that implementation of technology led to an improvement in the overall quality of the MCCs (mean composite scores: 56.4 vs 67.5; p < .001). Specific components that were significantly improved include case history, reason for presentation, radiology and pathology presentations, and medical oncology contribution to case discussions (mean scores: 3.4 vs 3.9; p < .001, 3.3 vs 3.9; p < .001, 2.7 vs 4.1; p < .001, 3.1 vs 4.2; p < .001 & 3.7 vs 4.1; p = .05). Pre- vs post-NTBS, rate of change in care plans decreased from 57.1% to 51.1%, compliance of MCC care plans with NCCN guidelines increased from 80.0% to 81.4%, and concordance of treatment received with MCC recommendations increased from 83.9% to 86.5%, though they were not statistically significant. Conclusions: Technology increases the quality of patient information presentation and case discussion at Breast MCCs, but in this small study we did not demonstrate an impact on MCC decision making. Areas for further development include assessment of improved efficiency of MCCs, opportunities for asynchronous MCC evaluation using this platform, establishment of automated case summaries, and technology-driven matching of detailed patient characteristics to established national guidelines.

(PM-09) PIONEERING SEXUAL HEALTH SERVICES IN NORTHEAST BRAZIL: AN EXPERIENTIAL ACCOUNT

Abstract Introduction Sexual dysfunctions remain inadequately addressed in medical education, despite their prevalence and adverse impact on quality of life. In Brazil, there are scarce university-affiliated healthcare centers that focus on sexual health. These services play a critical role in diagnosing and managing sexual disorders and can be pivotal in the training of healthcare professionals, as well as in the advancement of research and outreach in sexual medicine. Objective To describe the experience of establishing two sexual health centers in university-affiliated hospitals in Northeastern Brazil. Method This is an experiential report detailing the establishment of two distinct sexual health services. Results Both sexual health services started in different general hospitals in 2021, founded by a male and a female psychiatrists, authors of this paper. The initiative was prompted by the lack of dedicated sexual health services and the awareness of substantial patient distress stemming from sexual issues. Activities include patient consultations, case discussions, sexology seminars, and research project development, involving medical students and resident physicians, integrated into the psychiatry residency curriculum Referrals come mainly from other hospital specialties, but external referrals are also accepted. Collaboration with other healthcare professionals occurs through the analysis of clinical cases. Conclusion The establishment of sexual health services within university-affiliated hospitals has a positive impact on patient care and contributes to the study of sexual medicine, an area often overlooked in medical education. Improvements are needed in patient recruitment, counter-referral procedures, and the systematic incorporation of medical student rotations. While these services hold promise, they require greater integration with other healthcare services and a closer collaboration with undergraduate medical education. Financing No conflict.

The Swiss Narcolepsy Network (SNaNe)

The Swiss Narcolepsy Network (SNaNe) was founded in 2017 as a non-profit organization with the vision of improving the care of patients with narcolepsy, central disorders of hypersomnolence (CDH), and rare sleep disorders. The SNaNe aims at maximizing the speed of diagnosis, minimizing difficulties stemming from the rare nature of these conditions, and providing patients with optimum health care throughout the course of their disease. In addition, the SNaNe promotes education, awareness, and research on CDH and rare sleep disorders. The article reports the current structure, organization, and the following main activities of the SNaNe: (1) the discussion of complex patient cases; (2) the organization of the Swiss Narcolepsy Days; (3) the coordination of multicenter research projects (e.g., SPHYNCS and iSPHYNCS studies); (4) the establishment of an anonymous Swiss registry for CDH patients (SNaNe Data Registry); (5) the collaboration with the national patients’ organization (SNAG); and (6) the collaboration with other national and international scientific, professional, and patients’ (eNAP) organizations.

Presternal Scrofuloderma in a HIV Infected Patient Case Report and Discussion of the Literature Data

Scrofuloderma is a cutaneous extension of Mycobacterium tuberculosis (and rarely Mycobacterium bovis or Calmette-Guerin bacillus) from a local focus. It is a rare form of extra-pulmonary tuberculosis, starting as a painless skin cold abscess that progresses to fistulisation and ulceration. This article presents a case of presternal scrofuloderma in a non-adherent to treatment HIV-infected patient with disseminated tuberculosis.

Advancing Team-Based Care for Spinal Muscular Atrophy: A Multi-State Project ECHO Initiative and National Education Strategy (S2.002)

<h3>Objective:</h3> N/A <h3>Background:</h3> An academic medical center, medical education provider, and faculty experts developed a comprehensive, multicomponent initiative, with Project ECHO® serving as the primary delivery platform. The goal was to help multidisciplinary, community-based teams across the US enhance care of their patients with spinal muscular atrophy (SMA). <h3>Design/Methods:</h3> We conducted monthly group tele-mentoring sessions using the proven Project ECHO model as our primary educational framework. Project ECHO creates collaborative learning networks led by expert interprofessional teams and includes de-identified patient case discussion, mentoring, and didactic presentations using a web-based videoconferencing platform to conduct virtual sessions with learners. Sessions were accredited for physicians and nurses. We assessed changes in knowledge, competency, and performance pre-/post-initiative and gathered participant feedback using online surveys and phone interviews. We also created an accredited, online activity for clinicians across the country; its content aligned with that of the live ECHO sessions. <h3>Results:</h3> Clinicians from 7 sites participated in the Project ECHO portion of the initiative. Sites included academic medical centers, community hospitals, and private practices. The online national educational activity launched April 27, 2022, with over 350 participants thus far. Learners for this initiative included neurologists, pediatricians, nurses, NPs, PAs, and other professionals who collectively care for approximately 1,000 patients with SMA on a regular basis. Outcomes data and feedback revealed positive effects on learning and performance with statistically significant increases in knowledge and competency. However, persistent learning gaps remained post-education related to appropriate use of available and emerging treatments, suggesting areas for continued education. <h3>Conclusions:</h3> This initiative’s high level of interactivity allowed for in-depth exploration of challenges clinicians face in SMA management, which is not easily accomplished within traditional educational frameworks. In the setting of SMA management, where clinicians may feel professionally isolated, the ECHO model proved critical in improving quality of patient care and cultivating communities of practice. <b>Disclosure:</b> Mrs. Gabriel has nothing to disclose. Ana Carolina Tesi Rocha, MD has nothing to disclose. Dr. Klotz has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Genentech Roche. Dr. Adewuya has nothing to disclose. Ms. Hack has nothing to disclose. Whitney Hess has nothing to disclose.

P11.05.B Communication in neuro-oncology multidisciplinary team meetings (MDTM's)

Abstract Background The aim of MDTM’s is to ensure that all patients receive qualitative care from appropriately skilled professionals. However, empirical research shows that multidisciplinary team discussions do not always live up to their positive expectations. In discussions the team cycles through three main communicative phases: exploration, discussion and conclusion. The goal of this study is to gain insight in the structure of regional neuro-oncology MDTM’s and find an overarching reason why some discussions follow a different structure (or phase shifts) than others. Material and Methods We recorded 14 neuro-oncology MDTM’s in an non-academic Dutch Hospital by audio and video. All recordings were transcribed into time stamped sequences of verbal contributions. Every time stamped sequence was coded using a developed coding scheme. Results In total 14 regional Neuro-oncology MDMT’s were recorded, this resulted in 437 patient case reviews and 12512 coded verbal contributions. In each meeting the uniquely contributing members ranged from 12-21 members (M= 15.5, SD = 2.71) from 5 different institutions. The average of different disciplines was 7 disciplines (M=7.14, SD = 0.77). In 41% of the patient discussions there are two or three contributing disciplines in the decision making process. The maximum number of uniquely participating members in a patient discussion is 8 members. In only 28% of the case discussions 5 or more participants participated. Different categories for discussing a patient in an MTDM were found, these categories varied in specificity. From high to low specificity we found: justifying actions, pathology reviews, action-directed questions and open questions. We also found that in 20% of all patient case discussions the teams bypass the discussion phase. Conclusion MDTM’s are widely accepted and implemented. Therefore we should gain more insight in the structure and functioning of such teams. We found that there are different reasons for presenting a case which vary in their specificity. Our findings show that teams seem to deviate from the overall communication structure by bypassing the discussion phase in 20% of the cases. We also found that in 28% of patient discussions more than five participants contributed to the discussion. A future direction of organisation of MDTMs could be to clearly categorize on beforehand the patient questions in order to make the MDTM more efficient. Further analysis will include quality evaluation of MDTM’s, in neuro-oncology and other oncology domains. Support/Disclosure: this research is funded by WeCare (an collaboration between Tilburg University and Elisabeth-Tweesteden hospital).

Establishment of avirtual transborder tumor board for cancer patients in Central and Southeastern Europe : An initiative of the Central European Cooperative Oncology Group (CECOG).

PurposeTo establish a transborder virtual tumor board (VTB) fostering state-of-the-art management of cancer patients by exchanging knowledge and expertise among oncologists in Central and Southeastern Europe (CEE).MethodsWe established and implemented a VTB based on the WebEx platform. This allowed for password-protected and secure upload of patient cases to be presented and discussed among colleagues from various oncology centers scattered throughout CEE in order to arrive at a recommendation for further diagnoses and/or treatment.ResultsA total of 73 cases from 16 oncology centers located in 11 CEE countries were uploaded by 22 physicians; 71 were discussed over the course of 17 virtual meetings between June 2018 and May 2019 and 12 different kinds of malignant diseases were discussed with lung cancer (46.6%), melanoma (19.2%) and bladder cancer (13.6%) being the most commonly presented tumor entities. Of the discussed patients, 93.3% had stage IV disease at the time of presentation, 62.6% received chemotherapy or targeted treatment and 67.1% were treated with immune checkpoint inhibitors (ICPIs). The most common causes for presentation and discussion of patient cases were related to the use of ICPIs (80%).ConclusionWhen the need for expertise exceeds locally available resources, web-based VTBs provide a feasible way to discuss patient cases and arrive at conclusions regarding diagnoses and/or treatment across large geographic distances. Moreover, VTBs provide an innovative way for proper, state-of-the-art management of patients with malignant diseases in times of social distancing and the resulting need for restricted interaction during the current SARS-CoV‑2 (severe acute respiratory syndrome coronavirus type 2) pandemic.

Population Health Rounds: A Novel Vehicle for Training in Population Medicine and Clinical Preventive Medicine.

Preventive medicine residents must train in population medicine (including analytics and population health) and clinical preventive medicine (including screening, behavioral counseling, and chemoprophylaxis). Yet, opportunities to perform both functions concurrently for the same population are scarce. Residents must also master the art of preventive medicine, but they often lack an established community of practice that provides a continuous forum to do so. This project explored Population Health Rounds as a novel vehicle to optimize preventive medicine residency training. Modeled after traditional medical rounds, Population Health Rounds consist of a 1-hour weekly meeting engaging preventive medicine residents and supervising attendings at Stony Brook Medicine in both population medicine and clinical preventive medicine concurrently, including patient case discussions and targeted population health analytics. Because of the pandemic, the rounds have predominantly focused on COVID-19 and its effects on the hospital employee population. In addition to providing direct patient care to COVID-19-positive and exposed employees, residents have analyzed data on this population and made recommendations to hospital leadership based on COVID-19's institutional epidemiology, including incidence, prevalence, and predictive factors. A formative qualitative survey of resident perceptions offers insights on the value and learning outcomes of this new model. Factors that may impact the implementation, sustainability, and feasibility of this model are discussed. The preventive medicine residency program is commissioned to address gaps in clinical preventive services for the patient-centered medical home tied to the sponsoring institution's family medicine practice. Additional plans are underway to expand the rounds to other clinical contexts, such as lifestyle medicine in the occupational setting, and for targeted populations, such as the underserved. Replication of the Population Health Rounds model is recommended to determine its effectiveness.

Health-system implementation of a collaborative core curriculum for advanced pharmacy experiential education during the COVID-19 pandemic.

PurposeA collaborative advanced pharmacy practice experience (APPE) education model established within a healthcare institution during the coronavirus disease 2019 (COVID-19) pandemic is described.SummaryThe COVID-19 pandemic caused a nationwide disruption of APPE pharmacy education. Healthcare institutions faced the challenge of educating APPE students while attempting to simultaneously de-densify work areas and reduce transmission risk for employees and patients. A pharmacist coordinator and pharmacist academic partners at a large teaching hospital created a collaborative common core curriculum model for resourceful implementation of APPE education. Healthcare network pharmacists, clinical pharmacist academic partners, and pharmacy residents delivered the curriculum to 35 pharmacy students over a 9-week time period. Main components of the curriculum included patient case discussions, topic discussions, journal club presentations, live continuing education (CE) webinars, and development of pharmacy technician CE programs. A majority of students reported positive experiences working with a variety of preceptors from different specialties (81%) and collaborating with students from other universities (62%).ConclusionA health system can leverage institutional, network-wide, and academic partner resources to implement a collaborative APPE curriculum during challenging times such as those experienced during the COVID-19 pandemic.

Navigating Early Careers in Heart Failure in the Era of Novel Coronavirus Disease-2019

Navigating Early Careers in Heart Failure in the Era of Novel Coronavirus Disease-2019

The Application of Mobile Telehealth System to Facilitate Patient Information Presentation and Case Discussion.

Background: Most secondary transmission of COVID-19 is occurring in a hospital setting. To decrease person-to-person contact, health care providers have built many isolation wards. However, out-of-hospital professionals cannot access patient information, which has greatly reduced the efficiency of treatment; it is inconvenient for health care professionals to issue a case discussion with professionals from other wards. This article mainly introduces a mobile telehealth system (MTS) applied to facilitate patient information presentation and case discussion. Materials and Methods: The MTS searches patient information, which is stored in hospital intranet, and uses five modules to display patient information. By a request/response module and a real-time interaction module, we successfully conducted case discussions. In addition, we took measures in three areas to prevent patient information leakage. Results: The system uses mobile collaboration technology to present patient information and support case discussion. MTS was officially launched for 37 days, during which it has been used 3,061 times. Conclusions: The building of the MTS not only provides convenience and benefit for health care professionals, but also reduces person-to-person contact.

Case-Based Teaching: Does the Addition of High-Fidelity Simulation Make a Difference in Medical Students' Clinical Reasoning Skills?

Situativity theory posits that learning and the development of clinical reasoning skills are grounded in context. In case-based teaching, this context comes from recreating the clinical environment, through emulation, as with manikins, or description. In this study, we sought to understand the difference in student clinical reasoning abilities after facilitated patient case scenarios with or without a manikin. Fourth-year medical students in an internship readiness course were randomized into patient case scenarios without manikin (control group) and with manikin (intervention group) for a chest pain session. The control and intervention groups had identical student-led case progression and faculty debriefing objectives. Clinical reasoning skills were assessed after the session using a 64-question script concordance test (SCT). The test was developed and piloted prior to administration. Hospitalist and emergency medicine faculty responses on the test items served as the expert standard for scoring. Ninety-six students were randomized to case-based sessions with (n = 48) or without (n = 48) manikin. Ninety students completed the SCT (with manikin n = 45, without manikin n = 45). A statistically significant mean difference on test performance between the two groups was found (t = 3.059, df = 88, p = .003), with the manikin group achieving higher SCT scores. Use of a manikin in simulated patient case discussion significantly improves students' clinical reasoning skills, as measured by SCT. These results suggest that using a manikin to simulate a patient scenario situates learning, thereby enhancing skill development.

295. South Carolina Hepatitis C Telehealth Initiative (SCHTI): Increasing Access to HCV Care

BackgroundLack of access to specialists is often a deterrent to comprehensive health care, especially in rural areas. Chronic Hepatitis C (CHC) affects 1% of the US population, and with the availability of highly efficacious treatment, it is imperative innovative steps are taken to screen and treat these patients. The South Carolina Hepatitis C Telehealth Initiative (SCHTI) is designed to provide Infectious Diseases (ID) consultation to rural providers caring for HCV-infected individuals across the Southeast. SCHTI is an interdisciplinary collaboration incorporating physicians, pharmacists, nurses and case managers from USC, MUSC, and Vanderbilt University.MethodsSCHTI tele-consultation sessions were initiated in 2016, are held weekly, and provide a short didactic followed by discussion of patient cases with real-time feedback to the presenting providers. In addition, the program provides 1-hour continuing education certification for physicians, pharmacists and nurses. The South Carolina Department of Health and Human Services has approved SCHTI as an alternative to in-office expert consultation.ResultsFrom July 2016 through December 2018, 63 sessions were conducted, with 43 unique providers presenting cases and over 160 clinical attendees. Participating providers include Infectious Diseases, Family Medicine and Internal Medicine, amongst others. 259 cases have been reviewed, with a mean of 4.11 cases/session. Genotype 1a predominated and 44% of cases had advanced liver fibrosis. An increasing number of cases are young patients outside the high-prevalence birth cohort, and these individuals have a history of intravenous drug use. Overall, 13% of HCV cases were co-infected with HIV.ConclusionSCHTI provides multidisciplinary HCV teleconsultation to providers across the Southeast and is improving access to specialists and high-quality health care for patients across rural areas within the Southeast. Future outcomes to be assessed include sustained virologic response rates, relapse rates and impact on hepatic and extra hepatic morbidity and mortality from CHC. Disclosures All authors: No reported disclosures.

Finding the Sweet Spot: An Interactive Workshop on Diabetes Management in Older Adults.

Intensive glucose lowering in older adults with diabetes leads to increased risks with minimal benefits. Surveys indicate that clinician confidence for individualizing glycemic goals and regimens remains low. We created an interactive workshop and clinical tool kit to improve clinician knowledge of safe diabetes management in older adults. Finding the Sweet Spot was a 1-hour workshop taught by pharmacists to medical and pharmacy learners that introduced a five-step framework for diabetes management in older adults. The interactive presentation included cases and a clinical tool kit based on current recommendations from the American Diabetes Association and American Geriatrics Society. Pilot workshops were held for 6 months, allowing for real-time revisions based on feedback; final implementation occurred for 6 months thereafter. We evaluated learner self-efficacy (via a 5-point Likert scale) and knowledge (via multiple-choice questions) of diabetes management in older adults before and after the workshop. Thirty learners participated in Finding the Sweet Spot (70% medicine, 30% pharmacy). The percentage of confident learners increased from 55% to 97% (p < .05) after the workshop. All learners demonstrated improvements in knowledge, with the mean score on the knowledge assessment increasing from 61% to 80% (p < .05). Via open-ended feedback, learners expressed satisfaction and found the clinical tool kit especially helpful. Our Finding the Sweet Spot workshop demonstrated statistically significant changes in self-efficacy and knowledge among learners, indicating that this interactive workshop improves medical and pharmacy provider confidence and skills in caring for older adults with diabetes.

Collaborating to care for a standardized patient in the outpatient setting: An interprofessional learning activity for dental and pharmacy students

Abstract A small group standardized patient interview and case discussion with both online and classroom components was developed for second-year pharmacy students and fourth-year dental students. Student objectives for this experience were to learn about the dental or pharmacy profession, to collaborate interprofessionally to develop a care plan for a medically complex patient in the outpatient setting and to document a patient care plan for a patient. This format was chosen to allow the students multiple opportunities to interact with interprofessional peers and to simulate clinical patient care. Students completed the Jefferson Scale of Attitudes Toward Interprofessional Collaboration (JeffSATIC) and a “Roles and Responsibilities” quiz (RR quiz) before and after the activities. Students used an online tool to discuss roles/responsibilities of their professions with their team members prior to the IPLE (Interprofessional Learning Experience). During the IPLE, student teams interviewed a medically complex standardized patient presenting with acute dental pain and collaboratively discussed therapeutic options and developed a treatment plan. A paired t-test for students in both professions on the JeffSATIC and pre- and post-RR quiz resulted in no significant differences in attitude or knowledge due to the IPLE. This experience could be implemented as one part of a comprehensive IPE curriculum. Students reported the experience was valuable. The interprofessional collaboration resulted in a novel experience using active learning and mutually relevant content. Future offerings of this IPLE should include assessment of specific interprofessional outcomes such as collaboration. Materials required are available from the authors.

Development, implementation and perceived benefits of student pharmacist learning experiences in transitions of care

BackgroundExperiential education designed around transitions of care (TOC) offers student pharmacists a variety of educational activities to build their skills and confidence related to direct patient care, communication, and practice management. The purpose of this paper is to describe the development, implementation, and student perceptions of introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs) that emphasize TOC. Educational activitySixty students (22 IPPE and 38 APPE) completed the learning experience with the oversight of two faculty members in two, separate, large community hospitals providing pharmacy led TOC services. Each educational activity was mapped to the Pharmacists' Patient Care Process, which includes guided electronic medical record review, patient case discussions, and direct patient care (i.e. medication history collection, patient education). Other aspects of the learning experience include the use of layered learning, intention/reflection dialogues, and topic discussions. Evaluation of the learning experience occurred through review of student performance data and feedback. Critical analysis of the educational activityStudent performance data demonstrated an increase in the mean score between midpoint and final evaluation of all TOC specific competencies. Students expressed a positive learning experience as demonstrated by an approximately 3.8 overall rating of the learning experience on a 4-point scale for both IPPEs and APPEs. Analysis of open comments from students demonstrated the most beneficial aspects of the learning experience as interprofessional communication, patient communication, and a variety of patient care opportunities.

The impact of a digital solution on case discussion time at tumor boards.

e18028 Background: A multidisciplinary tumor board (MTB) provides an interdisciplinary approach for decision-making in cancer care. Information factors such as, multiple data sources, incomplete or missing information and teleconferencing failures, have been identified as issues contributing to variability in MTB conduction and impact. Little is known about how digital tumor board solutions can optimize MTB meeting conduction. Methods: A prospective IRB approved cohort study was undertaken to evaluate the time for patient case discussions,before and after the implementation of the NAVIFY Tumor Board (NTB) solution, at University of Missouri Health Care. Data was collected using a digital time-tracking application. The NTB manual version was implemented via a phased roll-out (Breast May 18, 2018; Gastrointestinal (GI) Jul 11, 2018; ENT Oct 30, 2018 – no manual version phase). Subsequently, the integrated version was introduced (Oct 4, 2018) whereby automated electronic medical record (EMR) data extraction was enabled. Results: Patient case discussion time was recorded at 138 MTBs (1109 patient cases) during 2018 (Breast 40 MTB; 236cases / GI 49 MTB; 389 cases / ENT 49 MTBs; 484 cases). Case discussion time significantly reduced at the Breast MTB (6.6mins to 5.3 mins; p-value = 0.01). Case discussion time at ENT MTB and GI MTB showed no significant change (Table 1). Time variance in case discussions significantly decreased post-NTB implementation at the Breast MTB (p-value = 0.008). For the GI &amp; ENT MTBs, there was no significant difference post-NTB implementation (GI p-value =0.199; ENT p-value = 0.511), however, variance was already sma Conclusions: Introduction of the NTB reduced the time spent discussing cases for the Breast MTB, but showed no change forGI MTB and ENT MTB. Interestingly, case discussion times converged to between 5.5 - 6.5 minutesirrespective of the MTB type. Furthermore, variance decreased or was already small, for all MTB types. Both observations suggest that NTB standardized the case discussion process, perhaps because it created a common format for case presentation. A common workflow tool for MTB meeting conduction could ensure availability of all required data, increase efficiency of therapy decision-making, and lead to higher throughput of cases resulting in shorter time-to-treatment.

Integrated IT Platform for Coordination of Diagnosis, Treatment, and Aftercare of Prosthetic Joint Infections.

Prosthetic joint infections (PJI) are difficult to diagnose and treat. For a correct diagnosis, an array of information has to be processed and weighted. Successful treatment depends on the diagnosis, timing, and surgical strategy paired with treatment of the infectious agent. The complexity and interdisciplinarity needed cause difficulties concerning decision-making, the communication between disciplines, and the execution of a treatment strategy. The aim of this study was to develop a software platform to enhance the collection of information for the diagnosis of PJI, the interdisciplinary decision-making process, the communication between team members, and continuous evaluation of treatment. In regular planning sessions with an information technology (IT) specialist, a concept for an IT solution was chosen and the tool was designed in an interdisciplinary approach. The tool has been used as a trial version since June 2017. It consists of 14 user interfaces with 431 items. A total of 117 patients with 118 infections have been entered and the strategy decided upon and communicated using 298 infection board documents outlining the treatment. The tool is now being used to organize the infections board agenda, schedule patient case discussions, document the relevant data and treatment plan, as well as communicate with the other teams involved in the treatment. Using the developed tool enables the infections team to work collaboratively and under division of labor on each case, rendering the work flow more efficient for each team member.

Experiences of community-based Clinical Nurse Specialists in supporting the delivery of integrated diabetes care: A qualitative study

Introduction: In Ireland, more Diabetes Nurse Specialists DNS have been introduced into the community as part of a national programme to standardise and improve diabetes care. DNS support the delivery of a new model of care whereby uncomplicated type 2 diabetes T2DM is managed in primary care, and complicated T2DM is managed between primary and secondary care. Historically diabetes care in Ireland has often been delivered in an unstructured way, with a lack of integration between primary and secondary care. Given this context we wanted to understand the experiences of community-based DNS in supporting the delivery of integrated care. Methods: We purposively sampled DNS from community-based respondents to a national survey n=25, according to four administrative regions of the National Health Service. We conducted focus groups and interviews using a semi-structured topic guide. Interviews were digitally recorded and transcribed into NVivo V.11 for coding and analysis. Coding was data-driven, with a focus on DNS actions or behaviours, the causes and conditions, and any consequences of those actions. Results: Nineteen DNS participated in two focus groups n=8, and 11 individual interviews. Lacking guidance on their role, DNS felt setting up their service was a case of ‘sink or swim’; they used initiative to establish the service. DNS adapted to working with a ‘whole different MDT’ in the community. They lacked the ‘safety net’ of the hospital team to check things with and ‘bounce ideas off’. As a result they worked more autonomously and perceived themselves to be ‘practicing at a higher level’, which some felt was ‘daunting’. For some, this highlighted the importance of maintaining their expertise and specialist skills. DNS needed to ‘blend in’ with how things were done in GP practices; being flexible and responsive to the practice’s experience in diabetes. The lack of a shared record between settings meant patient information from hospital appointments was not readily accessible by DNS at practices and vice versa, making patient follow-up and case discussion difficult. DNS often acted as an information link, sometimes ‘the only link, [or] bit of integration between the hospital and GP’. DNS felt managers and consultants did not understand their role, creating difficulty when negotiating certain aspects, including flexible working hours. One community DNS found integrating care difficult when not seen as part of the team. DNS needed to explain their role which required ‘quite good interpersonal skills’ and initiative on their part. Discussions: Community-based DNS used initiative to respond to challenges presented by the healthcare context. Conclusions: Challenges included how the role was introduced, understanding by management and colleagues, and characteristics of the health system e.g. ICT infrastructure. Lessons learned: DNS may need to be better supported to deliver their role to ensure effective delivery of integrated diabetes care. Limitations: This study is limited to DNS in Ireland; the findings may not reflect experiences of DNS in other countries working in a health service with different characteristics. Suggestions for future research: Future work should evaluate ongoing changes to DNS support.

Interactive Case-based Postgraduate Medical Education with Bone Health TeleECHO

Background Bone Health TeleECHO is a non-profit collaborative medical educational project developed at ECHO Institute at the University of New Mexico Health Sciences Center in association with the Osteoporosis Foundation of New Mexico. It uses videoconferencing technology to link healthcare professionals interested in achieving an advanced level of knowledge about the evaluation and treatment of osteoporosis and metabolic bone diseases. Weekly online sessions have been held since October 2015. Participants use videoconferencing technology with a computer or smartphone for discussion of real de-identified patient cases, with brief didactic presentations on topics of interest. Bone Health TeleECHO has been shown to improve self-confidence of healthcare professionals treating patients with osteoporosis. The ECHO model of learning aims to improve the care of patients with osteoporosis and reduce the osteoporosis treatment gap. Methods Online registration captures the demographics of Bone Health TeleECHO participants. Attendance is tracked for each session. Electronic queries record anticipated changes in the clinical practice. A self-efficacy assessment questionnaire retrospectively evaluated the effect of the intervention on confidence in managing patients with osteoporosis. Results During the first 24 months of weekly Bone Health TeleECHO, 224 individuals attended at least 1 online session. Of those who attended at least once, 115 (51.3%) were classified as physicians (MD, DO, DC), 53 (23.7%), advanced practice providers (PA, CNP, RN, CNM), 43 (19.2%), other (PT, OT, PhD), and 13 (5.8%) unknown. Number of Bone Health TeleECHO clinics attended ranged from 1 to 79, with a mean of 10.2. There were 36 learners (excluding faculty) who attended more than 20 TeleECHO clinics and 29 who attended more than 30. Attendees were located in 37 US states plus 8 other countries. Two additional TeleECHO programs devoted to skeletal health, based in Michigan and Washington, DC, were established in 2017. Summary Bone Health TeleECHO educates healthcare professionals to provide better care, closer to home, with greater convenience, and lower cost than referral to a specialty center. It relieves professional isolation that may occur in urban as well as rural settings. Bone Health TeleECHO can be scaled to any level through replication in other US states and other countries.