Referral Criteria Research Articles

Behavioural economic interventions to embed palliative care in community oncology (BE-EPIC): study protocol for the BE-EPIC randomised controlled trial

IntroductionPalliative care (PC) is a medical specialty focusing on providing relief from the symptoms and stress of serious illnesses such as cancer. Early outpatient specialty PC concurrent with cancer-directed treatment...

Evaluation and outcomes of a 5-year assisted peritoneal dialysis program.

In 2016, Peritoneal Dialysis Assist (PDA) was implemented in British Columbia, Canada, as a pilot program to allow patients with physical, cognitive and social impairments to access an independent dialysis modality. This is a presentation of the usage and 5-year clinical outcomes of our provincial assisted peritoneal dialysis (PD) program. Patients who utilised long-term or respite PDA services in British Columbia, Canada, from 2016 to 2021 were included in this program evaluation. Incident and prevalent patient numbers were characterised annually as well as indications for PDA and patient demographics both annually and over time. Outcomes of interest included death, transfer to haemodialysis, transplantation and cessation of the PDA program but retention on PD. Three hundred twenty-two total patients received services through the PDA program. The percentage of PD patients supported by long-term PDA service has grown to 11.2% in the most recent year. Patients spend a median of 13.6 (95% CI: 11.0, 16.1) months on long-term PDA, prolonging overall patient duration on PD by a little over a year. Of the patients who exited the long-term PDA program, 73 (37.4%) were able to utilise the service until they died. PDA is an accessible, patient-centric service with clear and standardised referral criteria. Through the implementation of a local PDA program, patients have accessed PD and may have extended their PD life span, through avoidance of in-centre haemodialysis, by over 13 months during this 5-year study period. A significant proportion of patients on long-term PDA were able to use their preferred kidney replacement modality at home until they reached end of life.

Burn injury characteristics, referral pattern, treatment (costs), and outcome in burn patients admitted to a hospital with or without a specialized Burn Centre (BURN-Pro)

PurposeData on the epidemiology, treatment, and outcome of burn patients treated at non-burn centre hospitals are not available. The primary aim was to compare the burn characteristics of patients admitted to a hospital with or without a specialized burn centre.MethodsThis multicentre, prospective, cohort study enrolled patients with burns admitted to a hospital without a burn centre and patients with < 10% total body surface area (TBSA) burned admitted to the burn centre. Primary outcome measure was the burn-related injury characteristics. Secondary outcome measures were adherence to the Emergency Management of Severe Burns (EMSB) referral criteria, treatment (costs), quality of life, and scar quality.ResultsDuring the 2-year study period, 48 patients were admitted to a non-burn centre and 148 patients to the burn centre. In the non-burn centre group, age [44 (P25–P75 26–61) versus 30 (P25–P75 8–52) years; P = 0.007] and Injury Severity Score [2 (P25–P75 1–4) versus 1 (P25–P75 1–1); P < 0.001] were higher. In the burn centre group, the TBSA burned was significantly higher [4% (P25–P75 2–6) versus 2% (P25–P75 1–4); P = 0.001], and more surgical procedures were performed (in 54 versus 7 patients; P = 0.004). At 12 months, > 85% of the non-burn centre group and > 75% of the burn centre group reported no problems in quality of life. Scar quality score was < 1.5 in both groups, with significantly poorer scores in the burn centre group (P ≤ 0.007).ConclusionBoth groups differed in patient, burn, and treatment characteristics. At 12 months, quality of life and scar quality were good in both groups. Significantly poorer scar quality scores were found in the burn centre group. This might be related to their larger burns and more frequent surgery. The organization of burn care in the Netherlands seems to work adequately. Patients are treated locally when possible and are transferred when necessary.

Pharmacy diabetes screening trial (PDST): Outcomes of a national clustered RCT comparing three screening methods for undiagnosed type 2 diabetes (T2DM) in community pharmacy

AimsTo compare the effectiveness of three pharmacy-based screening methods for type 2 diabetes (T2DM): (1) risk assessment (AUSDRISK) alone (Group A); AUSDRISK followed by a point of care test if AUSDRISK ≥12; either (2) HbA1c (Group B); or (3) small capillary blood glucose test (Group C). MethodsA cluster RCT with a nationally representative sample of Australian pharmacies was implemented with random allocation of eligible pharmacies to Groups A, B or C. GP referral was based on prespecified cut offs. Diagnoses were considered positive if confirmed by a GP, pathology laboratory, or national diabetes register. ResultsOf the 14,093 people screened in 339 pharmacies, 3059 participants met group-specific referral criteria: 1775 (45%) (Group A); 893 (17%) (Group B); and 391 (8%) (Group C). For the total screened population rates of T2DM diagnoses were significantly higher in Group B (1.5%), compared with Groups A (< 0.8%) and C (< 0.6%) with the odds of detection in Group B compared with Group A (1.8 [1.0;3.0]), and no difference between Groups A and C. ConclusionsIn community pharmacy, the most effective method to uncover undiagnosed T2DM was a stepwise approach; initial risk assessment; and if appropriate an HbA1C POC test and referral.

Risk Factors for Obstetric Emergencies With Referral Implementation at the Palembang Health Center

Obstetric emergencies are potentially life-threatening conditions that can occur in pregnant women and even during delivery. The main causes of obstetric emergencies (APGO, AGO and AGDO) are due to bleeding during childbirth, septic infection, hypertension, preeclampsia or eclampsia, and dystocia. One of the effective management efforts in obstetric emergencies is the implementation of appropriate and planned referrals that can save mothers and newborns. The purpose of this study was to determine the risk factors for obstetric emergencies with referrals at the Palembang Health Center. Methods: Quantitative research using a cross sectional approach. The population is all pregnant women who carry out examinations at the Palembang Health Center with a total sample of 128 pregnant women. The results showed that the highest frequency of cases in the APGO risk factor group was pregnant women aged ≥ 35 years (35.9%), in the AGO group it was serotonin (43%), in the AGDO group it was severe preeclampsia/eclampsia (13.3%) , the highest scoring group was High Risk Pregnancy (KRT) (11.7%) and the most referral criteria were planned referrals (91.4%). In conclusion, there was no significant difference in the risk factors for obstetric emergencies in the APGO variable p=0.727 and AGO p=0.328 between planned referrals and late referrals (p&gt;0.05), but there were significant differences in the risk factors for obstetric emergencies in the AGDO variable between planned referrals and referrals late p=0.011 (p&lt;0.05)

Chronic kidney disease: the canary in the coal mine

Chronic kidney disease is a common condition that is costly to manage. Most of the costs are linked with advanced kidney disease and the associated cardiovascular disease. Fortunately, there are now several treatments that can not only slow the progression of chronic kidney disease but also reduce the burden of cardiovascular morbidity and mortality. To do this effectively, patients need to be diagnosed as early as possible, as only then can optimal preventative measures, both lifestyle and pharmaceutical, be deployed. With the scale and complexity of chronic kidney disease, timely access to specialist care is increasingly required. Referral criteria have changed, with more focus on the 5-year risk of developing end-stage renal disease by using the four variable kidney failure risk equation. One of the major limitations to the effective treatment of people living with chronic kidney disease is hyperkalaemia. The appropriate frequency of testing, assessment and management of hyperkalaemia helps not only reduce the risk of dying from the condition, but also from chronic kidney disease and heart failure, as too often sub-optimal treatment with renin-angiotensin-aldosterone system inhibitors impairs optimal care. Chronic kidney disease is commonly seen in primary care. Patrick Holmes looks at identification and optimal management of the condition

Digital morphology and complete remote reporting capabilities by scientists and haematologists – a review

Aim: To establish a workflow for full remote reporting of blood films by laboratory haematologists. Methods: A review of a fully digital morphology workflow by a scientist and haematologist was undertaken as an audit to determine the ability of digital morphology to be utilised as a complete workflow process without the aid of a glass slide to assist with authorising referred cases requiring haematologists review. Over 100 slides were first reviewed by a haematology scientist and referred for haematologist examination on the basis of established laboratory referral criteria. These referred films were first analysed by a haematologist via the digital morphology platform. All cases were then analysed by traditional microscopy from the glass slide. Cases were assessed for reliability and concordance of the digital morphology platform to standard glass slide analysis. Cases not concordant between the digital platform and glass slide review were reassessed by an extended scan function of the digital morphology platform and concordance and reliability were again assessed and recorded. Results: One hundred and nineteen cases were assessed by both methods. There was concordance for 102 cases. The discrepant cases were discordant due to missing platelet clumping in two cases, one case missed low number myelocytes on film and the remainder of the cases were discordant due to discrepancies in assessing red cell morphology. Following the review of the extended scan file for each discordant case all 17 discordant cases were able to be assigned as concordant. Conclusion: A digital morphology workflow is a feasible alternative to standard glass slide review for FBC film cases requiring a haematologist review. The addition of the extended scan function allowed all cases to be assigned as concordant between digital morphology platform and glass slide review. This is a promising technology which will allow quicker remote authorisation of cases requiring haematologist intervention for blood film review. This approach provides flexibility in work arrangements and also offers increased access for rural and remote laboratories to centralised specialist expertise in a timely manner.

Oncoguía de cuidados paliativos 2023

Palliative care in oncology focuses on improving patients' quality of life with advanced cancer by controlling physical, psychological, and spiritual symptoms during their illness. It can be started as soon as advanced neoplasia is diagnosed, combined with disease-modifying therapies. This approach also includes the accompaniment of the family members by guiding the patient's care and providing psychological support to relatives of patients. The integration of palliative care in oncology must be flexible according to the type of oncological care provided and adapted to the level of care where it is necessary. In these guidelines, we describe the implementation of palliative medicine at Instituto Nacional de Cancerología (INCan). This gradual process began with the care of patients at the end of life. It is being integrated early into advanced cancer care and psychological attention and adapted to the patient's needs as we did during COVID-19. In the INCan model, the palliative cancer team works with the medical oncologist, surgical oncologist, radio-oncologist, and hemato-oncologist at all levels of care. Oncoguía de cuidados paliativos 2023 also incorporates the experiences and recommendations of teams from different hospitals that care for pediatric, young adults, and geriatric cancer patients in the Mexican Health System. Likewise, referral criteria and pharmacological resources are also included. Its objective is to provide an essential guide and contribute to the standardization of criteria.

A Clinical Workflow for Cost-Saving High-Rate Diagnosis of Genetic Kidney Diseases.

To optimize the diagnosis of genetic kidney disorders in a cost-effective manner, we developed a workflow based on referral criteria for in-person evaluation at a tertiary center, whole-exome sequencing, reverse phenotyping, and multidisciplinary board analysis. This workflow reached a diagnostic rate of 67%, with 48% confirming and 19% modifying the suspected clinical diagnosis. We obtained a genetic diagnosis in 64% of children and 70% of adults. A modeled cost analysis demonstrated that early genetic testing saves 20% of costs per patient. Real cost analysis on a representative sample of 66 patients demonstrated an actual cost reduction of 41%. This workflow demonstrates feasibility, performance, and economic effect for the diagnosis of genetic kidney diseases in a real-world setting. Whole-exome sequencing (WES) increases the diagnostic rate of genetic kidney disorders, but accessibility, interpretation of results, and costs limit use in daily practice. Univariable analysis of a historical cohort of 392 patients who underwent WES for kidney diseases showed that resistance to treatments, familial history of kidney disease, extrarenal involvement, congenital abnormalities of the kidney and urinary tract and CKD stage ≥G2, two or more cysts per kidney on ultrasound, persistent hyperechoic kidneys or nephrocalcinosis on ultrasound, and persistent metabolic abnormalities were most predictive for genetic diagnosis. We prospectively applied these criteria to select patients in a network of nephrology centers, followed by centralized genetic diagnosis by WES, reverse phenotyping, and multidisciplinary board discussion. We applied this multistep workflow to 476 patients with eight clinical categories (podocytopathies, collagenopathies, CKD of unknown origin, tubulopathies, ciliopathies, congenital anomalies of the kidney and urinary tract, syndromic CKD, metabolic kidney disorders), obtaining genetic diagnosis for 319 of 476 patients (67.0%) (95% in 21 patients with disease onset during the fetal period or at birth, 64% in 298 pediatric patients, and 70% in 156 adult patients). The suspected clinical diagnosis was confirmed in 48% of the 476 patients and modified in 19%. A modeled cost analysis showed that application of this workflow saved 20% of costs per patient when performed at the beginning of the diagnostic process. Real cost analysis of 66 patients randomly selected from all categories showed actual cost reduction of 41%. A diagnostic workflow for genetic kidney diseases that includes WES is cost-saving, especially if implemented early, and is feasible in a real-world setting.

Health emergencies in media context. Bibliometric review in scopus (2002-2022)

Within the framework of the research project "Information coverage of the Coronavirus in the Colombian digital press", this work was developed to know the state of the art on health emergencies, such as COVID-19, in the context of the media (traditional and digital). This work was developed to know state of the art on health emergencies, such as COVID-19, in the context of the media (both traditional and digital). The search for information was carried out in the Scopus database, using a search strategy through the title or title/abstract. Keywords were obtained from the literature already published on "Health emergencies in media context", using search strings with Boolean AND/OR operators (health AND emergencies AND media). Information retrieval was performed on August 22, 2022. A total of 5,967 studies met the referral criteria for "Healt emergencies in media context". Data were also exported in RIS format for analysis in VOSviewer 1.6.8 software. Although media coverage of health emergencies has been taken as a starting point, this research has gone further, not only because relationships have been found between health emergencies and other platforms, such as social networks, but also because scientific evidence has been detected on the potential that the media can have to curb and even prevent diseases. It was found that scientific production on health emergencies in the context of the media has evolved in the last ten years (2002-2022), with a peak in 2020. It is concluded that the scientific approach to health emergencies in the context of the media demands multidisciplinary work. When the authors' keyword co-occurrence analysis was carried out, four clusters were identified in which the term "human" stood out with close relationships with the words "emergency room", "masculine", "feminine", "elderly", cohort analysis, and hospitalization.

Effectiveness of the Spot Vision Screener using updated 2021 AAPOS guidelines

To evaluate the Spot Vision Screener according to updated 2021 AAPOS Vision Screening Committee guidelines for instrument-based pediatric vision screen validation. As part of an IRB-approved ongoing prospective study, children were screened with the Spot prior to a complete examination. Spot screening was successful in 1,036 of 1,090 children (95%). Forty-eight percent of participants were referred for further screening using the Spot manufacturer guidelines, and 40% of all children were found to have a 2021 amblyopia risk factor or visually significant refractive error by gold standard examination. The Spot recommendation compared reasonably well to the 2021 criteria, with an overall sensitivity of 0.88 and a specificity of 0.78. Applying updated guidelines to the Spot for hyperopia, anisometropia, and astigmatism yielded moderate-to-poor sensitivity (0.27-0.77) but excellent specificity (>0.9). The area under the curve of the receiver operating characteristic analysis demonstrates overall good prediction performance for the Spot for each diagnosis-myopia, hyperopia, astigmatism, anisometropia (range, 0.87-0.97). Results of our study suggest increasing the instrument referral criterion for astigmatism from 1.5 D (manufacturer thresholds of the screener used in this study) to 2 D in older children. Decreasing the anisometropia cut-off from 1 D to 0.75 D would improve sensitivity from 0.59 to >0.8. In our study population, the overall predictive ability of the Spot is good, with a sensitivity of 0.88 and a specificity of 0.78. We recommend specific device refractive referral criteria to maximize screening effectiveness using the updated AAPOS guidelines.

Integrating Palliative Care into Burn Care: A Retrospective Application of Criteria for Appropriate Referral.

Burn injuries often require complex interdisciplinary care. Despite potential benefits, consultation with specialist palliative care typically occurs in 2% of burn admissions, due largely to lack of availability and misconceptions concerning palliative care. Criteria to guide consultation with specialist palliative care have been developed at this institution. The purpose of this study was to quantify the sensitivity and specificity of these criteria, and then optimize them. Retrospective examination of 388 admissions over 15 months at this adult and pediatric Burn Center were conducted. Chi-square or Fisher's exact test for categorical variables and Wilcoxon Rank Sum test for continuous variables were used to test for between-group differences in demographic and clinical characteristics. Logistic regression model was built to determine modified Baux cut-off score using Youden index (J) value. Criteria were sensitive (0.96) and specific (0.90), though with a low positive predictive value (0.43). Persons with lengths of stay greater than one week, advanced directives, Allow Natural Death orders, and/or deterioration events were significantly more likely to have had palliative care consulted. There were significant between-group differences (with/without palliative care consultation) based on burn surface area, modified Baux score, and mortality risk. Potential criteria revisions are proposed. Prospective adherence to revised criteria could provide useful guidance to providers and benefit to patients and families.

An evaluation of an innovative screening program based on risk criteria for early diagnosis of head and neck cancers.

Head and neck cancer represents 3% of all cancers and is the cause of 5% of the deaths caused by cancer. The purpose of this study is to evaluate the implementation of a screening program to diagnose the early phase of the head and neck oncological processes. We have studied 324 asymptomatic patients who had at least one major risk factor (habitual consumption of tobacco or alcohol) or two minor risk factors: family history of head and neck cancer of the upper aerodigestive tract, occupational exposure, poor oral hygiene and history of Human Papillomavirus or chronic inflammatory processes of the aerodigestive tract. Family and personal head and neck oncological medical history, ENT exploration, performance of CT scans or biopsies and program procedures were analyzed. The most usual referral criteria for being sent to a specialist was being a smoker (98.1%). 10.5% reported family histories of head and neck cancer, 9.9% reported occupational exposure, 7.1% were referred due to poor oral hygiene and 5.9% were referred for gastroesophageal reflux disease. Although being asymptomatic was a requirement for inclusion, we verified that, after the anamnesis, 9.6% of the patients had some symptom to which they did not give importance to 119 patients (36.7%) presented a lesion that potentially could become malignant, located in the larynx and hypopharynx (25%) and in the oral cavity and oropharynx (10.8%). Eighteen patients (5.56%) presented more than one lesion. The detection rate of neoplasia was 1.2% and the detection rate of pre-neoplastic lesions was 4.6%. There did exist a statistically significant ratio between the detection of pre-neoplastic lesions and occupational exposure to carcinogenic agents (p = 0.006), poor oral hygiene (p = 0.01) and gastroesophageal reflux disease (p = 0.007). Samples were taken for a pathological anatomy study in 30 patients (9.25%). In order to follow up the patients, 22.8% were controlled at hospital medical consultations, 11.1% were examined at outpatient consultation and 66% were given appointments for follow-up visits. The use of this screening program could be a tool for the early diagnosis of malignant head and neck tumors and to foster healthy habits for cancer prevention.

Hospitalisations for heart failure: increased palliative care referrals − a veterans affairs hospital initiative

ObjectivesHeart failure (HF) portends significant morbidity and mortality. Integrating palliative care (PC) with HF management improves quality of life and preparedness planning. At a Veterans Affairs hospital, PC was used...

Palliative Care in Patients With Hematological Malignancies. We Have a Long Way to Go….

Background: Patients with hematological malignancies have significant and diverse palliative care needs but are not usually referred to specialist palliative care services in a timely manner, if at all. Objective: To identify the characteristics of patients with hematological malignancies referred to the palliative care service in a tertiary hospital in Mexico City. Patients: Retrospective study including consecutive patients with hematological malignancies referred to palliative care services at Mexico's National Cancer Institute. Results: Between 2011 and 2019, 5,017 patients with hematological malignancies were evaluated for first time at Mexico's National Cancer Institute. Of these, 9.1% (n = 457) were referred to palliative care. Most were male (53.4%), with a median age of 58years. The most frequent diagnosis was non-Hodgkin lymphoma (54.9%). The primary indication for referral to palliative care was for cases wherein chemotherapy was no longer an option (disease refractory to treatment, 42.8%). The median time of referral to the palliative care service occurred 11.2months after the first evaluation at the National Cancer Institute and death occurred on median 1.1months after the first palliative care evaluation. Conclusion: Patients with hematological neoplasms are infrequently referred to Palliative Care at the Institute (9.1%). We found no clear referral criteria for Palliative Care referral and note that hematologists' optimism regarding a cure can delay referrals. Clearly, we have a long way to go in improving the number of patients referred, and we still saw frequent referrals near the end of life, but the high rate of outpatient referrals is encouraging.

The role of liver transplant for intrahepatic cholangiocarcinoma: the UK NHSBT liver advisory group pilot programme

Aim: Liver transplantation (LT) offers a potential curative treatment for non-metastatic intrahepatic cholangiocarcinoma (iCCA) in patients with chronic liver disease who are not amenable to liver resection (LR). Recent evidence suggests that cirrhotic patients with “very early” iCCA (single tumour, ≤ 2 cm) might benefit the most from LT, with a 5-year survival as high as 73%. In view of these developments, NHS Blood and Transplant’s Liver Advisory Group (LAG) established a Fixed Term Working Group (FTWG) to determine whether iCCA in patients with background cirrhosis should be considered for LT in the United Kingdom. Methods: The FTWG included cholangiocarcinoma/LT patient representatives, experts in cholangiocarcinoma surgery/oncology, LT surgery, hepatology, hepatobiliary radiology, hepatobiliary pathology, nuclear medicine, and representation from various national hepatobiliary/oncology and transplant professional bodies. The objective was to make recommendations on appropriate indications, patient selection criteria, referral criteria, radiological assessment, transplant listing pathways, data management, and overall quality assurance. Results: The FTWG recommended LT for very early iCCA in cirrhotics, who are otherwise not suitable for LR. In this paper, we summarise the selection criteria, patient pathways, referral framework, pre-transplant assessment criteria, outcome measures, and dissemination strategy for implementing this new indication for LT in the UK. Conclusion: The introduction and evaluation of this pilot programme is an important breakthrough for iCCA patients in the UK, marking a significant stride in the field of transplant oncology. The results of this service evaluation will describe the role of LT in iCCA and guide future programmes to optimise patient selection, management, and outcomes.

A Quality Improvement Study to Improve the Utilization of Occupational Therapy and Physiotherapy Services in a Level 4 Neonatal Intensive Care Unit and Neurodevelopmental Follow-Up Clinics

Background: Neonates admitted to the neonatal intensive care unit (NICU) are at risk of neuromotor and behavioral impairments, and therapy services can optimize their neurodevelopment. Physiotherapy (PT) and Occupational therapy (OT) services are available in the NICU of Women’s Wellness and Research Center, and as per the guidelines, physicians should refer the neonates for appropriate services. Baseline analysis of 1-month data revealed that 25%, 36%, 62%, and 10% of eligible neonates were not referred to (1) inpatient OT, (2) inpatient PT, (3) baby therapy, and (4) neonatal neurodevelopmental clinic, respectively. The study’s objective is to increase the number of babies being referred, by reducing the number of eligible neonates not being referred to 4 available therapy services to 50% of the baseline data after 1 month of implementation. Methods: A Plan-Do-Study-Act cycle guided the interventions. The 1st phase identified stakeholders’ challenges for not referring the babies to appropriate services. Based on their feedback, the referral criteria were revised. The 2nd phase involved implementing the revised criteria. Steps included (a) stakeholders’ education on the revised criteria and making it available all the time, (b) daily triage and huddle to inform stakeholders of the needed referrals, and (c) establishing communication pathways. Results: Exceeding the targets, all eligible and 75% of the eligible neonates for neonatal neurodevelopmental and baby therapy clinics, respectively, were referred. For inpatient OT and PT services, 22% (targeted 12.5%) and 20% (targeted 18%) of the eligible neonates were missed. Conclusion: Within 1 month, we decreased the number of nonreferrals to all 4 therapy services. Inpatient PT and OT referrals need more focus.

Knowledge of diagnosis and management of selected oral mucosal lesions among dentists in The Netherlands.

Knowledge of oral mucosal lesions (OMLs) among dentists is relevant in diagnosing potentially malignant diseases and oral cancer at an early stage. The aim of this survey was to explore dentists' knowledge about OMLs. Respondents to a web-based questionnaire, containing 11 clinical vignettes representing patients with various OMLs, provided a (differential) diagnosis and management for each. Information about demographics and clinical experience of the participants was acquired as well. Descriptive statistics were performed and T-tests were used to test for significant (p<0.05) differences in mean scores for correct diagnosis and management between subgroups based on demographic variables. Forty-four of 500 invited dentists completed the questionnaire. For (potentially) malignant OMLs, the number of correct diagnoses ranged from 14 to 93%, whilst the number of correct management decisions ranged from 43 to 86%. For benign OMLs, the number of correct diagnoses and management decisions ranged from 32 to 100% and 9 to 48%, respectively. For 11 clinical vignettes, mean scores for correct diagnosis, correct management and correct diagnosis and management were respectively 7.2 (±1.8), 5.7 (±1.5), and 3.8 (±1.7). The results show that dentists in the Netherlands do not have sufficient knowledge to accurately diagnose some OMLs and to select a correct management. This may result in over-referral of benign OMLs and under-referral for (potentially) malignant OMLs. Clinical guidelines, that include standardized criteria for referral, and continuing education, may improve dentists' ability to correctly diagnose and accurately manage OMLs.

The Definition of Non-Urgent Visits to the Emergency Department and Validation of Criteria for Referrals

Background: The centers of disease control and prevention define a non-urgent Emergency Department (NU-ED) visit as a medical condition requiring treatment within more than 24 hours. These visits constitute one of the main reasons for emergency department (ED) overcrowding, which greatly affects healthcare workers’ wellbeing, health costs, patients’ satisfaction and treatment outcomes. Currently, there is no solid definition of non-urgent emergency visits, which is the first step towards dealing and potentially solving this issue. Having that, the aim of the current study is to define and validate the criteria for NU-ED visits in Israel. Methods: This qualitative study included twelve senior physicians and nurses working in Emergency Department and/or Health Maintenance Organizations (HMOs) across Israel. The study was performed using in-depth, semi-structured, open-ended interviews. Qualitative data analysis was performed by conventional content analysis. Results: The urgency of medical visits was defined based on these two questions: 1) Does the medical condition require an immediate treatment? 2) Is the emergency department the only place that can provide the required treatment at a certain timepoint? We found that non-urgent visits mostly occur during the nights and weekends, when medical treatments are not available in the HMOs. Visitors for non-urgent cases mostly complained about minor injuries or chronic conditions, fever, abdominal or chest pain. Most visits occurred based on referral from the family physician or the nurse from the call center. Participants reported a lack of awareness and knowledge about the roles of the EDs and the available options in the HMOs, which seem unable to provide patients with appropriate treatments. The usage of triage scales seems to ensure that patients are being treated based on the clinical urgency of their condition. Medical cases that score above 3 can be defined as non-urgent visits. Therefore, implementation of these scales in the community and their use in decision making of referrals to emergency department might greatly reduce non-urgent visits. Conclusions: Participants defined urgent ED visits as medical situations that need to be treated immediately, while there are no available treatment options in the HMOs. Participants identified many reasons behind NU referrals to the ED, mainly, low awareness about the role of ED, low availability of certain tests in the HMOs, and inability to provide adequate treatment in the community.

A Preliminary Study on Two-technology Neonatal Hearing Screening

Abstract Introduction: Newborn hearing screening is essential for the early identification of hearing loss, which can lead to timely intervention and improved outcomes for affected infants. Two commonly used screening methods are distortion product otoacoustic emissions (DPOAEs) and automated auditory brainstem response (AABR). While both methods are effective, there is still ongoing research to determine which method is more efficient and accurate. The aim is to compare the referral rates of DPOAE and AABR in neonatal hearing screening and to evaluate the efficacy of the two technologies in identifying hearing loss in high-risk and well-born neonates by adhering to the new 1–3-month timeline (Joint Committee on Infant Hearing, 2019). Methods: This was a prospective cross-sectional study conducted on 404 neonates (808 ears) in a multispecialty hospital in Tamil Nadu, India. Neonates with referral criteria for either DPOAE or AABR in the first step were rescreened immediately with the preferred technology. Obtained data were subjected to statistical analysis. Results: Among 404 (100%) neonates screened, 364 (90.14%) were well-born and 40 (9.90%) were high-risk babies. The total referral rate for DPOAE was 70 (8.6%) among which 54 (7.5%) were well-born babies and 16 (20%) were high-risk infants. The total referral rate in AABR was 68 (8.4%) among which 52 (7.2%) were well-born and 16 (20%) were high-risk infants. All the infants enrolled were screened by 1 month and no referrals were obtained for a detailed audiological diagnostic for reaching the 2-month benchmark and intervention by 3 months. Statistical analysis revealed no significant difference between the groups (P &gt; .01). Conclusion: AABR had similar referral rates with DPOAE in neonatal hearing screening. The two-technology screening protocol was effective in identifying hearing loss in high-risk and well-born neonates. The inclusion of AABR in the screening protocol proves utility in detecting retrocochlear pathologies such as auditory neuropathy spectrum disorder (ANSD).