Referral Tool Research Articles

Abstract P1-10-06: High participation of African-American women veterans in high risk breast cancer screening pilot program

Abstract SPECIFIC AIMS: To assess breast cancer risk in Women Veterans. BACKGROUND/RATIONALE: Women are the fastest growing segment of patients numbering over 2 million and breast cancer incidence has more than tripled from 1995 to 2012 within the Veterans Health Administration (VHA). Preliminary data suggest that Women Veterans may be at an increased breast cancer risk based on unique service-related exposures (e.g., burn pits, depleted uranium) and Post Traumatic Stress Disorder (PTSD). Historically, breast cancer rates among African Americans (AA) are lower than those seen in the general population (8.2-13.3%). METHODS: A pilot study was conducted at Bronx, NY and Washington, DC Veterans Affairs Medical Centers. Participants were enrolled at their regular visit to Women's Health Clinics or at breast cancer education and awareness events. 5-year and lifetime risks of developing invasive breast cancer were calculated using the Gail Breast Cancer Risk Assessment Tool (BCRAT). Demographics, PTSD status, eligibility for chemoprevention and genetic counseling using the Breast Cancer Genetics Referral Screening Tool (B-RST), were also determined. ELIGIBILITY CRITERIA: Women Veterans age ≥ 35 years with no personal history of breast cancer. RESULTS: A total of 99 Women Veterans with an average age of 54 years participated between 2015 and 2018; 60% African American (AA); 13% Hispanic; 14% non-Hispanic White and 13% as other. In total, 35% (35/99) were considered high risk with a 5-year BCRAT of >1.66% and of these, 51% were AA; 14% Hispanic and 17 % were other. Prior breast biopsies were performed in only 22% (22/99) of our entire Veteran population; 57% (56/99) having a family history positive for breast cancer. Comparatively, in our high risk AA alone, 33% (6/18) had prior breast biopsies with 94% (17/18) having a positive family history. High risk patients were referred for chemoprevention; 5 (19%) accepted; and 13/35 (37%) patients were referred for genetic counseling. PTSD was present in 29% overall and in 31% of the high risk subgroup. IMPLICATIONS: The VHA, which leads the nation in mammogram compliance, is an untapped potential resource for the study of breast cancer. To our knowledge, this is the only study with 60% AA Women Veterans. High participation rates among AA in this pilot study have uncovered the potential for further inquiry into this population, which is otherwise dramatically under-represented in research. Over half (51%) of AA in this pilot study had a high risk score, likely linked to a high rate of prior breast biopsies and family history. Limitations of this study include the small sample size, exclusively urban population, geography and self-selection for screening due to a higher level of concern for breast cancer. If Women Veterans are at higher risk of breast cancer, it has been assumed that this would be related to service-related exposures, PTSD and other factors. However this pilot study, which was not designed or powered to do more than raise questions, suggests the additional possibility of an innate or genetic risk, especially in AAs. Future directions include the evaluation of genetic and molecular mutations in high risk AA Women Veterans, possibly even a role for PTSD epigenetic changes and tumorigenesis. Citation Format: Park Y-HA, Keller AT, Bidassie B, Venne VL, Heron BB, Hoffman-Hōgg L, Hawley DK, Hsu T-CM, Colonna SV, Aggarwal A. High participation of African-American women veterans in high risk breast cancer screening pilot program [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-10-06.

Utility of the Seattle Heart Failure Model for palliative care referral in advanced ambulatory heart failure

BackgroundPhysicians face uncertainty when predicting death in heart failure (HF) leading to underutilisation of palliative care. To facilitate decision-making, we assessed the Seattle Heart Failure Model (SHFM) as a referral...

Effect of a Palliative Screening Tool on Referrals: An Approach to Increase Access to Palliative Care Services.

The aim of this study was to develop and trial a screening tool to increase palliative care referrals for hospitalized patients with chronic obstructive pulmonary disease (COPD) at a community hospital. Baseline data were collected retrospectively to determine the palliative care referral rate of patients with COPD at a high risk for readmission using the LACE index. A palliative care referral tool was developed to screen the patients who were at a high risk for readmission for palliative care referral. A 3-month pilot project prospectively evaluated the palliative care referral rate after educating staff on the use of the screening tool and implementing its use. During the baseline study, 2 palliative care referrals were placed out of 19 patients who were deemed appropriate by the screening tool (10.5%). During the pilot project, 16 palliative care referrals were placed out of 45 patients who were deemed appropriate by the screening tool (35.6%). Emergency room visits and readmissions were not significantly different between those with palliative referrals and those without. Barriers to palliative care referral were explored. The improvement in palliative care referrals, which occurred after the introduction of the consensus-driven screening process for patients with COPD, suggests the possibility of improved patient care using this model.

External validation of the Rapid Assessment Prioritisation and Referral Tool for multidisciplinary teams in medical assessment and planning units.

The Rapid Assessment Prioritisation and Referral Tool (RAPaRT) was developed for identifying appropriate referrals to allied members of the multidisciplinary team in hospital medical assessment and planning units (MAPUs). This study examined the performance of the RAPaRT for identifying appropriate referrals as well as predicting requirement for admission to hospital and length of stay. A prospective cohort study was conducted. The RAPaRT, inclusive of seven mandatory items, was completed by nurses for 195 patients presenting to a hospital ED and assessed in a MAPU external to the instrument development site. Members of the multidisciplinary team (dietetics, occupational therapy, physiotherapy, social work and speech pathology) assessed participants to determine whether a referral to their profession was warranted and this was compared to RAPaRT responses. All health professionals reviewed n = 175/195 (90%) participants, with n = 117/195 (60%) considered appropriate for referral to an allied health professional. At least one positive response to the RAPaRT items was recorded for n = 123 (63%) participants. Patterns of sensitivity and specificity for each item, and the instrument as a whole were consistent with the development study. The RAPaRT also predicted which patients required admission to an acute hospital ward (odds ratio = 1.22; 95% CI 1.01, 1.47) and their length of stay in hospital (coefficient = 0.18; 95% CI 0.14, 0.22). Findings supported the external validation of the RAPaRT. In addition, this investigation made a novel contribution in demonstrating that positive RAPaRT responses were associated with requirement for admission to an acute hospital ward and length of stay.

An Assessment of the Wind Power Generation Potential of Built Environment Wind Turbine (BEWT) Systems in Fort Beaufort, South Africa

The physical and economic sustainability of using built environment wind turbine (BEWT) systems depends on the wind resource potential of the candidate site. Therefore, it is crucial to carry out a wind resource assessment prior to the deployment of the BEWT. The assessment results can be used as a referral tool for predicting the performance and lifespan of the BEWT in the given built environment. To date, there is limited research output on BEWTs in South Africa, with available literature showing a bias towards utility-scale or conventional ground-based wind energy systems. This study aimed to assess the wind power generation potential of BEWT systems in Fort Beaufort using the Weibull distribution function. The results show that Fort Beaufort wind patterns can be classified as fairly good and that BEWTs can best be deployed at 15 m for a fairer power output as roof height wind speeds require BEWTs of very low cut-in speeds of at most 1.2 ms − 1 .

Implementation of an electronic referral smoking cessation tool into clinical practice across cancer clinics of different disease sites and institutions.

112 Background: Cancer Care Ontario, the government's cancer management agency, mandated routine collection of smoking data province wide (catchment of > 13 million individuals), but did not mandate specifics of a smoking cessation program for cancer patients, despite known benefits. Referral rates to smoking cessation clinics for cancer patients are low. In 2014, Princess Margaret Cancer Centre developed an electronic, patient-driven e-referral tool shown to improve referral rates, known as the smoking Cessation E-referrAl SystEm (CEASE). The objective of this study is to assess the feasibility for expanding this program through adoption and implementation of the CEASE tool to 5 additional clinics across 3 different Cancer Centres. Methods: The Canadian Institute of Health Research’s Knowledge-to- Action (CHIR KTA) framework guided the assessment. Feasibility was addressed through situational assessments, pilot implementation, and clinic/patient feedback in at least two cycles, with procedural changes made at the conclusion of each cycle. Clinics were selected to cover a wide range of hospital, clinic styles, and disease sites. Results: Pilot implementation occurred over 21 clinic days (Jun 2017- Aug 2017); 123 patients were enrolled in the pilot studies in breast, gastrointestinal, head and neck, and thoracic sites. Feasibility assessment in each clinic identified similarities and differences in resource availability, access to authority figures, and patient flow patterns. After the feasibility assessment, a pilot implementation identified English as a second language and the lack of patient's tablet/technological experience as the main barriers for implementation in 4 of 5 clinics. The use of volunteers assisting patients with the survey helped address these barriers. Strong internet connection, short survey length and staff engagement were seen as universal common facilitators to implementation in all 5 clinics. Conclusions: Despite different outpatient environments, common barriers and potential solutions were identified, which will help with scalable future widespread implementation of CEASE across the province of Ontario.

A Clinical Trial to Increase the Identification, Genetic Counseling Referral and Genetic Testing of Women at risk for Hereditary Breast and/or Ovarian Cancer

Background: Approximately 1/300 individuals in the general population are at risk for hereditary breast and ovarian cancer due to an inherited mutation in the BRCA1/BRCA2 genes. BRCA mutations are associated with dramatically increased risks for breast cancer, especially at younger ages, in addition to ovarian cancer. Enhanced screening and risk reduction strategies can significantly reduce associated morbidity and mortality. The United States Preventive Services Task Force (USPSTF) recommends identifying women at-risk for BRCA mutations for receipt of genetic counseling and if appropriate, testing. The Breast Cancer Genetics Referral Screening Tool (B-RST) is a validated screen endorsed by USPSTF to facilitate this process. This implementation study seeks to evaluate the most effective means of follow-up for screen-positive women to maximize the number who are referred to, and receive, cancer genetic counseling (CGC) services.

PHIRST Trial – pharmacist consults: prioritization of HIV-patients with a referral screening tool

ABSTRACTThe role of pharmacists in HIV outpatient clinics has greatly increased in the past decades. Given the limited resources of the health system, the prioritization of pharmacist consults is now a main concern. This study aimed to create a scoring system allowing for standardized prioritization of pharmacist consults for patients living with HIV. Data was retrospectively collected from 200 HIV patients attending the Chronic Viral Illness Service at the McGill University Health Center. An expert panel consisting of four pharmacists working in the field of HIV prioritized each patient individually, after which a consensus was established and was considered as the gold standard. In order to create a scoring system, two different methods (Delphi, statistical) were used to assign a weight to each characteristic considered to be important in patient prioritization. A third method (equal weight to each characteristic) was also evaluated. The total score per patient for each method was then compared to the expert consensus in order to establish the score cut-offs to indicate the appropriate categories of delay in which to see the patient. All three systems failed to accurately prioritize patients into urgency categories (“less than 48 h”, “less than 1 month”, “less than 3 months”, “no consult required”) according to expert pharmacist consensus. The presence of high level interactions between patient characteristics, the limited number of patients and the low prevalence of some characteristics were hypothesized as the main causes for the results. Creating a prioritization tool for pharmacy consults in HIV outpatient clinics is a complex task and developing a decision tree algorithm may be a more appropriate approach in the future to take into account the importance of combinations of patient characteristic.

Prospective Evaluation of the Relationship Between Mechanical Stability and Response to Palliative Radiotherapy for Symptomatic Spinal Metastases

A substantial number of patients with spinal metastases experience no treatment effect from palliative radiotherapy. Mechanical spinal instability, due to metastatic disease, could be associated with failed pain control following radiotherapy. This study investigates the relationship between the degree of spinal instability, as defined by the Spinal Instability Neoplastic Score (SINS), and response to radiotherapy in patients with symptomatic spinal metastases in a multi-institutional cohort. The SINS of 155 patients with painful thoracic, lumbar, or lumbosacral metastases from two tertiary hospitals was calculated using images from radiotherapy planning CT scans. Patient-reported pain response, available for 124 patients, was prospectively assessed. Pain response was categorized, according to international guidelines, as complete, partial, indeterminate, or progression of pain. The association between SINS and pain response was estimated by multivariable logistic regression analysis, correcting for predetermined clinical variables. Of the 124 patients, 16 patients experienced a complete response and 65 patients experienced a partial response. Spinal Instability Neoplastic Score was associated with a complete pain response (adjusted odds-radio [ORadj] 0.78; 95% confidence interval [CI] 0.62-0.98), but not with an overall pain response (ORadj 0.94; 95% CI 0.81-1.10). A lower SINS, indicating spinal stability, is associated with a complete pain response to radiotherapy. This supports the hypothesis that pain resulting from mechanical spinal instability responds less well to radiotherapy compared with pain from local tumor activity. No association could be determined between SINS and an overall pain response, which might indicate that this referral tool is not yet optimal for prediction of treatment outcome. Patients with stable painful spinal metastases, as indicated by a Spinal Instability Neoplastic Score (SINS) of 6 or lower, can effectively be treated with palliative external beam radiotherapy. The majority of patients with (impending) spinal instability, as indicated by a SINS score of 7 or higher, will achieve a (partial) response after palliative radiotherapy; however, some patients might require surgical intervention. Therefore, it is recommended to refer patients with a SINS score of 7 or higher to a spine surgeon to evaluate the need for surgical intervention.

Referral Systems to Integrate Health and Economic Strengthening Services for People with HIV: A Qualitative Assessment in Malawi

Supporting the diverse needs of people living with HIV (PLHIV) can help reduce the individual and structural barriers they face in adhering to antiretroviral treatment (ART). The Livelihoods and Food Security Technical Assistance II (LIFT) project sought to improve adherence in Malawi by establishing 2 referral systems linking community-based economic strengthening and livelihoods services to clinical health facilities. One referral system in Balaka district, started in October 2013, connected clients to more than 20 types of services while the other simplified approach in Kasungu and Lilongwe districts, started in July 2014, connected PLHIV attending HIV and nutrition support facilities directly to community savings groups. From June to July 2015, LIFT visited referral sites in Balaka, Kasungu, and Lilongwe districts to collect qualitative data on referral utility, the perceived association of referrals with client and household health and vulnerability, and the added value of the referral system as perceived by network member providers. We interviewed a random sample of 152 adult clients (60 from Balaka, 57 from Kasungu, and 35 from Lilongwe) who had completed their referral. We also conducted 2 focus group discussions per district with network providers. Clients in all 3 districts indicated their ability to save money had improved after receiving a referral, although the percentage was higher among clients in the simplified Kasungu and Lilongwe model than the more complex Balaka model (85.6% vs. 56.0%, respectively). Nearly 70% of all clients interviewed had HIV infection; 72.7% of PLHIV in Balaka and 95.7% of PLHIV in Kasungu and Lilongwe credited referrals for helping them stay on their ART. After the referral, 76.0% of clients in Balaka and 92.3% of clients in Kasungu and Lilongwe indicated they would be willing to spend their savings on health costs. The more diverse referral network and use of an mHealth app to manage data in Balaka hindered provider uptake of the system, while the simpler system in Kasungu and Lilongwe, which included only 2 referral options and use of a paper-based referral tool, seemed simpler for the providers to manage. Participation in the referral systems was perceived positively by clients and providers in both models, but more so in Kasungu and Lilongwe where the referral process was simpler. Future referral networks should consider limiting the number of service options included in the network and simplify referral tools to the extent possible to facilitate uptake among network providers.

Assessment of primary rehabilitation needs in neurological rehabilitation: translation, adaptation and face validity of the Danish version of Rehabilitation Complexity Scale-Extended.

BackgroundAssessing primary rehabilitation needs in patients with acquired brain injury is a challenge due to case complexity and the heterogeneity of symptoms after brain injury. The Rehabilitation Complexity Scale-Extended (RCS-E) is an instrument used in assessment of rehabilitation complexity in patients with severe brain injury. The aim of the present study was to translate and test the face validity of the RCS-E as a referral tool for primary rehabilitation. Face validity was tested in a sample of patients with acquired brain injury.MethodsTen clinicians and records from 299 patients with acquired brain injury were used in the translation, cross-cultural adaptation and face validation study of the RCS-E. RCS-E was translated into Danish by a standardized forward-backward translation by experts in the field. Face validity was assessed by a multi-professional team assessing 299 patients. The team was asked their opinion on whether the RCS-E presents a sufficient description of the patients.ResultsThe RCS-E was translated according to international guidelines and tested by health professionals; some adaptations were required due to linguistic problems and differences in the national health system structures.The patients in the study had a mean age of 63.9 years (SD 14.7); 61 % were male.We found an excellent face validity with a mean score of 8.2 (SD 0.34) assessed on a 0–10 scale.ConclusionsThe RCS-E demonstrated to be a valid assessment of primary rehabilitation needs in patients with acquired brain injury. Excellent face validity indicates that the RCS-E is feasible for assessing primary rehabilitation needs and the present study suggests its applicability to the Danish health care system.Electronic supplementary materialThe online version of this article (doi:10.1186/s12883-016-0728-7) contains supplementary material, which is available to authorized users.

Improving Traumatic Brain Injury Outcomes: The Development of an Evaluation and Referral Tool at Groote Schuur Hospital

The Western Cape Province of South Africa has a great shortage of diagnostic expertise, rehabilitative infrastructure, and support services for patients with traumatic brain injury (TBI). The neurosurgical outpatient setting is busy and often chaotic, and patients are frequently lost to follow-up. This study sought to continue with the design and development of a comprehensive, yet brief tool to aid patient referrals and ensure that no consequence of TBI is left unidentified and unaddressed. There were 47 patients with TBI (mean age, 35 years; range, 18-75 years) assessed. The study was designed in 3 distinct phases, each representing a different stage in the tool's development. The Groote Schuur Traumatic Brain Injury Evaluation was shortened and simplified. Overall, 81% of the participants indicated cognitive dysfunction. There was a high prevalence of psychological/psychiatric sequelae, with 85% of participants reporting at least 1 such problem. The findings further highlight the prevalence of the cognitive, behavioral, and psychological consequences of TBI and shed additional light on the particular types of problems that patients with TBI face. Following the identified changes, the questionnaire and algorithm combination are now ready to be validated in the neurosurgical clinical setting.

Depression screening and referral in cardiac wards: A 12-month patient trajectory.

Depression is common among patients with coronary heart disease (CHD) and has a major impact on their quality of life, morbidity and mortality. The aim of this study was to map the 12-month psychosocial outcomes of patients with CHD who were screened positive for depression in an acute cardiac ward. A prospective cohort study was conducted of the psychosocial trajectory (depression, anxiety, wellbeing, social support, mental health service access) of 212 patients with CHD who were screened for depression after being admitted to acute cardiac wards of a major metropolitan hospital. Outcomes were assessed before hospital discharge and at one, three, six and 12 months post-discharge. Linear mixed models identified that those patients screened at 'moderate to high' risk of depression at baseline had higher levels of depression ( F(1,173)=53.93, p<0.0001) and anxiety ( F(1,180)=67.01, p<0.001), and lower levels of wellbeing ( F(1,186)=42.47, p<0.001) and social support ( F(1,177)=25.40, p<0.0001), compared to those at 'no to low' risk of depression. Levels of depression and wellbeing remained fairly constant over the 12-month trajectory. Surgical and medical treatment groups were of similar psychological composition over the 12-month period. These findings attest to the effectiveness and predictive validity of a simple nurse-administered screening tool designed to identify depression in hospital patients with CHD and also indicate that a screening and referral tool alone is not sufficient to achieve optimal disease management. A collaborative care model involving family members and integrated pathways to primary care is recommended.

Validation of an Efficient Screening Tool to Identify Low-Income Women at High Risk for Hereditary Breast Cancer

Background/Aims: We compared the 6-Point Scale, a screening tool to identify low-income women for referral to genetic counseling, with genetic counselors' (GCs') recommendation and the Referral Screening Tool (RST). Methods: RST and 6-Point Scale scores were computed for 2 samples: (1) S1, public hospital mammography clinic patients in 2006-2010 (n = 744), classified by GCs as high risk (meriting referral to counseling) or not high risk, and (2) S2, primary care patients enrolled in an education intervention study in 2011-2012 (n = 1,425). Sensitivity, specificity, and area under the ROC curve (AUROC) were computed for the 6-Point Scale score versus GC and RST classification as high risk. Results: The 6-Point Scale had low sensitivity (0.27, 95% confidence interval [CI] 0.21-0.34) but high specificity (0.97, 95% CI 0.95-0.99) and AUROC (0.85, 95% CI 0.81-0.90) versus GC classification, and high sensitivity (S1: 0.90, 95% CI 0.79-1.00; S2: 0.94, 95% CI 0.87-0.97), specificity (S1: 0.95, 95% CI 0.93-0.97; S2: 0.94, 95% CI 0.93-0.96), and AUROC (S1: 0.98, 95% CI 0.96-0.99; S2: 0.98, 95% CI 0.98-0.99) versus the RST. Conclusion: The 6-Point Scale compared favorably with the RST, a validated instrument, and is potentially useful as a simple tool for administration in a safety net setting, requiring minimal time investment by primary care physicians and their staff and no financial investment in tablet computers or software.

Impact of a primary care based intervention on breast cancer knowledge, risk perception and concern: A randomized, controlled trial

PurposeTo estimate the effects of a tablet-based, breast cancer risk education intervention for use in primary care settings (BreastCARE) on patients' breast cancer knowledge, risk perception and concern. MethodsFrom June 2011–August 2012, we enrolled women from two clinics, aged 40–74 years with no personal breast cancer history, and randomized them to the BreastCARE intervention group or to the control group. All patients completed a baseline telephone survey and risk assessment (via telephone for controls, via tablet computer in clinic waiting room prior to visit for intervention). All women were categorized as high or average risk based on the Referral Screening Tool, the Gail model or the Breast Cancer Surveillance Consortium model. Intervention patients and their physicians received an individualized risk report to discuss during the visit. All women completed a follow-up telephone survey 1–2 weeks after risk assessment. Post-test comparisons estimated differences at follow-up in breast cancer knowledge, risk perception and concern. Results580 intervention and 655 control women completed follow-up interviews. Mean age was 56 years (SD = 9). At follow-up, 73% of controls and 71% of intervention women correctly perceived their breast cancer risk and 22% of controls and 24% of intervention women were very concerned about breast cancer. Intervention patients had greater knowledge (≥75% correct answers) of breast cancer risk factors at follow-up (24% vs. 16%; p = 0.002). In multivariable analysis, there were no differences in correct risk perception or concern, but intervention patients had greater knowledge ([OR] = 1.62; 95% [CI] = 1.19–2.23). ConclusionsA simple, practical intervention involving physicians at the point of care can improve knowledge of breast cancer without increasing concern.Trial Registration: ClinicalTrials.gov identifier NCT01830933.

Think Stoma Nurse: a tool to trigger referral to specialist care.

This article describes the initial development and subsequent evolution of a simple referral assessment tool for stoma care. The first author's personal experience identified that there was widespread inconsistency in perceptions of local multidisciplinary teams as to when it was appropriate to refer to specific specialist nursing teams. This resulted in both inappropriate and delayed referrals. A 'Think Specialist Nurse' initiative was developed across the author's trust, building on the traffic light template from the 'ThinkGlucose' tool, to facilitate referrals to clinical nurse specialists. The stoma-care specific tool, 'Think Stoma Nurse', has subsequently evolved beyond its initial audience, and has been adapted into materials aimed at patients and carers.

Using patient engagement in the design and rationale of a trial for women with depression in obstetrics and gynecology practices

IntroductionSignificant health disparities exist among socioeconomically disadvantaged women, who experience elevated rates of depression and increased risk for poor depression treatment engagement and outcomes. We aimed to use stakeholder input to develop innovative methods for a comparative effectiveness trial to address the needs of socioeconomically disadvantaged women with depression in women's health practices. MethodsUsing a community advisory board, focus groups, and individual patient input, we determined the feasibility and acceptability of an electronic psychosocial screening and referral tool; developed and finalized a prioritization tool for women with depression; and piloted the prioritization tool. Two intervention approaches, enhanced screening and referral using an electronic psychosocial screening, and mentoring using the prioritization tool, were developed as intervention options for socioeconomically disadvantaged women attending women's health practices. We describe the developmental steps and the final design for the comparative effectiveness trial evaluating both intervention approaches. ConclusionsStakeholder input allowed us to develop an acceptable clinical trial of two patient-centered interventions with patient-driven outcomes.

DEVELOPMENT OF COMPLEX INTERVENTION IN EMERGENCY CARE OF FALLS FOR EVALUATION:IMPLEMENTATION OF THE MRC GUIDANCE

BackgroundThe Medical Research Council (MRC) guidance for the development and evaluation of complex interventions describes such an intervention as one which has several interacting components; the MRC recommends that complex interventions are developed through literature identification, modelling of processes and theory development. We describe the utilisation of this guidance to develop the SAFER 2 (Support and Assessment for Fall Emergency Referrals) study intervention—a multi-centre randomised controlled trial (RCT) looking to improve the care Ambulance Services provide to elderly patients who fall.MethodsLiterature was identified using MedLine and through applicant's previous work in this field. Two pilot studies were undertaken in two UK ambulance services; an economic evaluation was identified. A workshop, incorporating stakeholders from ambulance services, acute trusts and primary care, allowed further development and finalisation of the intervention. Specialist sub-groups were set-up to develop specific components of the interventionResultsLiterature review identified previous RCTs and a recent systematic review, highlighting the need for a comprehensive evaluation of the ability of paramedics to safely make decisions to not convey elderly patients who fall to hospital and the effect of direct referral to multi-factorial community interventions on such patients. Pilot studies reinforced the need for an intervention that improves paramedic's decision making. The workshop resulted in the amalgamation of all evidence and agreement of the final intervention by all stakeholders.The final definition of the intervention comprised of paramedic training, patient assessment tool, referral tool, process of referral, clinical support and Falls Prevention Service make-up and response.DiscussionThorough intervention development and effective implementation are vital to the success of SAFER 2 and other studies in this field. In order to produce generalisable evidence about clinical and cost effectiveness that is reproducible, the intervention needs to be clearly defined with input and agreement from study stakeholders.

Louisiana State University Health Sciences Center Katrina Inspired Disaster Screenings (KIDS): Psychometric Testing of the National Child Traumatic Stress Network Hurricane Assessment and Referral Tool

Post disaster psychosocial surveillance procedures are important for guiding effective and efficient recovery. The Louisiana State University Health Sciences Center Katrina Inspired Disaster Screenings (KIDS) is a model designed with the goal of assisting recovering communities in understanding the needs of and targeting services toward children and adolescents. As a critical, yet understudied, component to the KIDS model, the objective of this study is to test the psychometric properties of the National Child Traumatic Stress Network Hurricane Assessment and Referral Tool for Children and Adolescents. Exploratory factor analysis (EFA) was used to investigate the factor structure of the NCTSN Hurricane Assessment and Referral Tool. The convenience sample included 7530, 9–18 years old students who completed the school initiated screener in Southeastern Louisiana schools from December 2005 to December 2006. On a small treatment seeking population (N = 62), associations among the referral tool and the PTSD Reaction Index were also explored. EFA of the referral tool revealed a two factor solution, anxious and depressive reactions, that accounted for 45.8 % of model variance. Internal consistency was high and symptom scores were moderately associated with the PTSD Reaction Index. The cutoff score was also confirmed with scores ≥4 suggesting the need for referral. This study allows for the recommendation of the NCTSN Hurricane Assessment and Referral Tool as a reliable and valid part of the KIDS model; together they provide an initial step toward addressing the needs of child and adolescent disaster survivors.

Factors Influencing Outpatient Cardiac Rehabilitation Attendance.

In the current health climate, the length of stay of cardiac patients in hospital has been decreasing, and this has significantly reduced the time nurses and colleagues have for providing inpatient cardiac rehabilitation (CR). The purpose of this research was to determine if inpatient CR has an influence on outpatient cardiac rehabilitation attendance for women, Māori, and older people. An audit of patients discharged from hospital between November 2011 and July 2012 with a diagnosis of acute coronary syndrome were sent a postal questionnaire. The survey was completed by 143 people: 46% female, 12% Māori, and 70% > 65 years. Only 38% attended outpatient CR on discharge. Reasons for not attending included lack of referral to CR, and 61% understood only some/none of the information given to them while in hospital. The Cardiac Rehabilitation Coordinator most consistently recommended attendance, but this invitation was extended after discharge from hospital. Attendance at outpatient CR is low and may increase with an improved individualized plan of care including greater cultural considerations and attention to discharge planning. An automatic referral tool as well as following evidence-based guidelines for inpatient care may increase participation rates for CR. Nursing staff have the majority of contact with patients and it appears that very few nurses are discussing CR programs with their patients. The information to attend CR should be offered by all of the health professionals patients meet during their stay in hospital.