Significant Increase In Referrals Research Articles

The Impact of COVID-19 on Bicycle-Related Injuries Managed at a Level 1 Major Trauma Center in London, United Kingdom.

Introduction The COVID-19 pandemic changed peoples' travel behaviors; an uptake in cycling was observed in the United Kingdom. The aim of this study was to assess the cycling-related orthopedic injuries presented to a major trauma center (MTC) before and during the COVID-19 pandemic. Method This retrospective observational single-center study analyzed referrals to the orthopedic department during a matched two-month period in 2019 and 2020. Data were collated on cycling-related injuries including demographic variables, mechanism of injury, anatomical area of injury, and the management of injury. The data were compared and statistical analysis was performed using the Pearson Chi-squared test to assess for significance. Results A total of 2409 patients were referred to the orthopedic department with injuries. A 35.6% decrease in total referrals was made during the COVID-19 pandemic. Analysis of cycling-specific injuries demonstrated a statistically significant increase in referrals to the orthopedic department during the COVID-19 pandemic. A statistically significant difference in upper limb trauma was also observed during the COVID-19 pandemic. Patterns of management, namely operative vs. non-operative management, did not demonstrate a difference in the two time periods. Discussion This study highlights that during the COVID-19 pandemic, cycling behavior changed with more patients suffering orthopedic injuries as a result. Orthopedic departments may need to plan for this change in behaviors with more capacity being created to manage the demand. Conclusion Cycling-related injuries referred to the orthopedic department increased during the pandemic.

Utilizing electronic medical records alert to improve documentation of neonatal acute kidney injury

BackgroundNeonatal acute kidney injury (AKI) is a common yet underdiagnosed condition in neonates with significant implications for long-term kidney health. Lack of timely recognition and documentation of AKI contributes to missed opportunities for nephrology consultation and follow-up, potentially leading to adverse outcomes.MethodsWe conducted a quality improvement (QI) project to address this by incorporating an automated real-time electronic medical record (EMR)-AKI alert system in the Neonatal Intensive Care Unit (NICU) at Le Bonheur Children’s Hospital. Our primary objective was to improve documentation of neonatal AKI (defined as serum creatinine (SCr) > 1.5 mg/dL) by 25% compared to baseline levels. The secondary goal was to increase nephrology consultations and referrals to the neonatal nephrology clinic. We designed an EMR-AKI alert system to trigger for neonates with SCr > 1.5 mg/dL, automatically adding AKI diagnosis to the problem list. This prompted physicians to consult nephrology, refer neonates to the nephrology clinic, and consider medication adjustments.ResultsOur results demonstrated a significant improvement in AKI documentation after implementing the EMR-AKI alert, reaching 100% compared with 7% at baseline (p < 0.001) for neonates with SCr > 1.5 mg/dL. Although the increase in nephrology consultations was not statistically significant (p = 0.5), there was a significant increase in referrals to neonatal nephrology clinics (p = 0.005).ConclusionsIntegration of an EMR alert system with automated documentation offers an efficient and economical solution for improving neonatal AKI diagnosis and documentation. This approach enhances healthcare provider engagement, streamlines workflows, and supports QI. Widespread adoption of similar approaches can lead to improved patient outcomes and documentation accuracy in neonatal AKI care.Graphical A higher resolution version of the Graphical abstract is available as Supplementary information

The role of an integrated referral program for patients with liver disease: A network between hub and spoke centers.

Access to Liver transplantation (LT) can be affected by several barriers, resulting in delayed referral and increased risk of mortality due to complications of the underlying liver disease. To assess the clinical characteristics and outcomes of patients with acute or chronic liver disease referred using an integrated referral program. An integrated referral program was developed in 1 October 2017 based on email addresses and a 24/7 telephone availability. All consecutive adult patients with liver disease referred for the first time using this referral program were prospectively collected until 1 October 2021. Characteristics and outcomes of inpatients were compared with a historical cohort of patients referred without using the integrated referral program (1 October 2015-1 October 2017). Patients were further divided according to pre- and post-Covid-19 pandemic. Two hundred eighty-one referred patients were considered. End stage liver disease was the most common underlying condition (79.3%), 50.5% of patients were referred as inpatients and 74.7% were referred for LT evaluation. When inpatient referrals (n=142) were compared with the historical cohort (n=86), a significant increase in acute liver injury due to drugs/herbals and supplements was seen (p=0.01) as well as an increase in End stage liver disease due to alcohol-related liver disease and NASH, although not statistically significant. A significant increase in referrals for evaluation for Trans-jugular intrahepatic portosystemic shunt placement was seen over time (5.6% vs. 1%; p=0.01) as well as for LT evaluation (84.5% vs. 81%; p=0.01). Transplant-free survival was similar between the study and control groups (p=0.3). The Covid-19 pandemic did not affect trends of referrals and patient survival. The development of an integrated referral program for patients with liver disease can represent the first step to standardize already existing referral networks between hub and spoke centers. Future studies should focus on the timing of referral according to different etiologies to optimize treatment options and outcomes.

A hub-and-spoke model for cardiac ablations: utilising satellite units to tackle the challenges from the pandemic and beyond

Abstract Background Since setting up the cardiac electrophysiology (EP) service at our tertiary centre (UH) in 2010, there has been a significant increase in referrals for EP procedures. We currently serve a large catchment area (&amp;gt;1.6 million people) and the increasing demand coupled with limited resources in a publicly funded health system has led to a huge supply-demand mismatch in our EP waiting list. This mismatch was compounded by the COVID-19 pandemic. Aim To share our experience of how we set up a hub-and-spoke model to mitigate the EP waiting list pressures before and during the pandemic by utilising satellite EP laboratory units. Methods Single shot cryoballoon pulmonary vein isolation (PVI) became the initial ablation strategy for all paroxysmal and persistent atrial fibrillation (AF) patients undergoing catheter ablation (due to shorter procedure times/standardised workflow). Almost all EP cases were performed under local anaesthesia. We transitioned from overnight-stay to same-day EP cases (all standard ablation and some complex ablation procedures) and demonstrated its safety and cost-effectiveness. We increased our EP laboratory capacity by developing a hub-and-spoke model in collaboration with 2 regional secondary care centres (WH &amp; StX). During the pandemic, 3 national lockdowns were declared (Figure 1) and national healthcare services were restructured. Urgent inpatient cardiac EP cases were still performed at UH but elective EP procedures across all three sites (UH, WH &amp; StX) were cancelled during the first lockdown. One of the steps taken to mitigate the impact of the pandemic on our EP waiting list was to collaborate with the private sector (MH) which functioned as a ‘clean’ site for elective EP procedures. Cryoballoon PVI and other EP cases resumed at our centre within 2 months of the first lockdown. Data from every EP case performed were routinely entered into an electronic database. Data was extracted from the 01/01/2018 (pre-pandemic) to 31/12/2022 (post-pandemic). UH was labelled as ‘tertiary unit’ while WH, StX and MH were pooled together (labelled as ‘satellite units’). Graphpad Prism was used for analysis (Chi-squared test for categorical variables and t-test for continuous variables). Results 3695 EP cases were performed over 5 years. Satellite units performed predominantly standard ablation and cryoballoon PVI cases (Table 1). The implementation of three national lockdowns led to a transient decrease in the number of EP procedures (Figure 1). However, the ‘clean’ patient pathway that we rapidly established at our satellite unit (MH) facilitated the sustained delivery of our cardiac EP service throughout the pandemic from 2020 to 2021. The higher complication rates in the tertiary unit likely reflected the higher proportion of complex ablation cases. Conclusion Our hub-and-spoke model is a safe and novel system in tackling the EP waiting list even throughout the pandemic.Figure 1Table 1

If You Build It, Will They Come? Patient and Provider Use of a Novel Hybrid Telehealth Care Pathway for Low Back Pain.

The purpose of this study was to describe the referrals and use of a hybrid care model for low back pain that includes on-site care by physical therapists, physical activity training, and psychologically informed practice (PiP) delivered by telehealth in the Improving Veteran Access to Integrated Management of Low Back Pain (AIM-Back) trial. Data were collected from November 2020 through February 2023 from 5 Veteran Health Administration clinics participating in AIM-Back, a multisite, cluster-randomized embedded pragmatic trial. The authors extracted data from the Veteran Health Administration Corporate Data Warehouse to describe referral and enrollment metrics, telehealth use (eg, distribution of physical activity and PiP calls), and treatments used by physical therapists and telehealth providers. Seven hundred one veterans were referred to the AIM-Back trial with 422 enrolling in the program (consult-to-enrollment rate = 60.2%). After travel restrictions were lifted, site visits resulted in a significant increase in referrals and a number of new referring providers. At initial evaluation by on-site physical therapists, 92.2% of veterans received pain modulation (eg, transcutaneous electrical nerve stimulation, manual therapy). Over 81% of enrollees completed at least 1 telehealth physical activity call, with a mean of 2.8 (SD = 2.0) calls out of 6. Of the 167 veterans who screened as medium to high risk of persistent disability, 74.9% completed at least 1 PiP call, with a mean of 2.5 (SD = 2.0) calls out of 6. Of those who completed at least 1 PiP call (n = 125), 100% received communication strategies, 97.6% received pain coping skills training, 89.6% received activity-based treatments, and 99.2% received education in a home program. In implementing a hybrid care pathway for low back pain, the authors observed consistency in the delivery of core components (ie, pain modulation, use of physical activity training, and risk stratification to PiP), notable variability in telehealth calls, high use of PiP components, and increased referrals with tailored provider engagement. These findings describe variability occurring within a hybrid care pathway and can inform future implementation efforts.

Improving access to vision rehabilitation care: implementation of the South East Ontario Vision Rehabilitation Service

ObjectiveTo investigate the effect of the South East Ontario Vision Rehabilitation Service (SOVRS), a centrally administered, regionally delivered vision rehabilitation service, on access to vision rehabilitation care. DesignPre-implementation (n = 1196) and post-implementation (n = 414) observational study. ParticipantsPatients referred for low-vision assessment at the hospital-based Kingston Health Sciences Centre Vision Rehabilitation Clinic and community-based Southeastern Vision Loss Rehabilitation Ontario clinics from 2014 to 2019. MethodsMarkers for access to care (e.g., patient rurality, diversity of referral source, distance and time travelled, and wait times) were compared before and after SOVRS implementation. ResultsAfter SOVRS implementation, there was a significant increase (p < 0.001) in the number of rural patients seen in the community. After SOVRS implementation, the hospital-based Vision Rehabilitation Clinic site experienced a significant increase in referrals from outside of Kingston (p < 0.001) and non-eye-care clinicians (p < 0.001), a significant reduction in patient time and distance travelled (p < 0.001), a 6% decrease in median wait time for low-vision assessments, and a significant reduction in wait time between referral and first available appointment (p = 0.011). ConclusionSOVRS, a novel service-delivery model for vision rehabilitation care, improved the delivery of and access to vision rehabilitation care in southeast Ontario through the integration of regional resources and services.

A hub-and-spoke model: the role of satellite cardiac electrophysiology laboratory units in mitigating the waiting list pressures for catheter ablation for atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Since setting up the cardiac electrophysiology (EP) service at our tertiary centre (UH) in 2010, there has been a significant increase in referrals for EP procedures especially catheter ablation for atrial fibrillation (AF). UH serves a catchment area of above 1 million people and the increasing demand coupled with limited resources in a publicly funded health system has led to a huge supply-demand mismatch in our AF ablation waiting list. This mismatch was compounded by the COVID-19 pandemic. Aim To share our experience of how we attempted to mitigate the waiting list pressures on our AF ablation procedures before and during the pandemic by utilising satellite cardiac EP laboratory units. Methods Firstly, we made cryoballoon pulmonary vein isolation (PVI) the initial ablation strategy for all of our paroxysmal and persistent AF patients undergoing catheter ablation (due to shorter procedure times and standardised workflow). All cryoballoon PVI cases were performed under local anaesthesia. In 2016, we transitioned from overnight-stay to same-day AF ablation and demonstrated its safety and cost-effectiveness. Finally, we increased our EP laboratory capacity by developing a hub-and-spoke model in collaboration with 2 secondary care centres regionally (WH &amp; StX). From May 2019, cryoballoon PVI cases were performed at 3 sites: UH (hub) and 2 satellite units (WH &amp; StX). During the pandemic, 3 national lockdowns were declared (23/3/20, 5/11/20, 6/1/21) and national healthcare services were restructured. Urgent inpatient cardiac EP cases were still performed at UH but elective EP procedures across all three sites (UH, WH &amp; StX) were cancelled during the first national lockdown. One of the steps taken to mitigate the impact of the pandemic on our increasing AF ablation waiting list was to collaborate with the private sector (MH) which functioned as a ‘clean’ site for elective EP procedures. Cryoballoon PVI cases resumed within 2 months of the first national lockdown. From September 2020, all 3 sites [UH and its two satellite units (WH &amp; MH)] were performing cryoballoon PVI. Data from every EP case performed in all centres was entered into an electronic database. Data was extracted from the 1st January 2019 (pre-pandemic) to the 31st December 2021 (post-pandemic). UH was labeled as ‘tertiary unit’ while WH, StX and MH were pooled together and labeled as ‘satellite units’. Results The implementation of three national lockdowns led to a transient decrease in the number of electrophysiology procedures (Figure 1). However, the ‘clean’ patient pathway that we rapidly established at our satellite unit (MH) facilitated the sustained delivery of our cardiac electrophysiology service throughout the pandemic from 2020 to 2021. There were no deaths or differences in complication rates between the 2 units (Table 1). Conclusion Our hub-and-spoke model is a safe and practical system in tackling the AF ablation waiting list even throughout the pandemic.

Social disparities in pain management provision in stage IV lung cancer: A national registry analysis

A strong association exists between pain and lung cancer (LC). Focusing on the disparities in pain referral in LC patients, we are aiming to characterize the prevalence and patterns of referrals to pain management (PM) in Stage IV non-small-cell LC (NSLC) and small-cell LC (SCLC). We sampled the National Cancer Database for de novo stage IV LC (2004-2016). We analyzed trends of pain referral using the Cochran-Armitage test. Chi-squared statistics were used to identify the sociodemographic and clinico-pathologic determinants of referral to PM, and significant variables (P < .05) were included in one multivariable regression model predicting the likelihood of pain referral. A total N = 17,620 (3.1%) of NSLC and N = 4305 (2.9%) SCLC patients were referred to PM. A significant increase in referrals was observed between 2004 and 2016 (NSLC: 1.7%-4.1%, P < .001; SCLC: 1.6%-4.2%, P < .001). Patient and disease factors played a significant role in likelihood of referral in both groups. Demographic factors such as gender, age, and facility type played a role in the likelihood of pain referrals, highlighting the gap and need for multidisciplinary PM in patients with LC. Despite an increase in the proportion of referrals to PM issued for terminal stage LC, the overall proportion remains low. To ensure better of quality of life for patients, oncologists need to be made aware of existent disparities and implicit biases.

Tracheal complications of mechanical ventilation for COVID-19: a plot twist for survivors.

Tracheal complications should be suspected in mechanically ventilated COVID-19 survivors with respiratory symptoms. Treatment requires a multimodal approach of interventional bronchoscopy and surgery with tight follow-up due to a high rate of restenosis. https://bit.ly/3iw05xQ.

Adherence to NCCN screening guidelines for germline testing of patients with pancreatic cancer at a large academic medical center: A retrospective chart review.

342 Background: Pancreatic ductal adenocarcinoma (PDAC) carries a poor prognosis with an overall 5-year survival rate of 10%. Depending on geographic region, 10-20% of cases are hereditary, with mutations in BRCA1 and BRCA2 being the most common. Contrary to popular belief, clinical risk factors such as family history of cancer and young age of onset are not reliable predictors for which patients may carry one of these predisposing mutations. In 2018, the National Comprehensive Cancer Network (NCCN) recommended that all pancreatic cancer patients should receive germline testing, regardless of family history. In a compliance analysis, we hypothesized that patients diagnosed after the NCCN guideline changes were more likely to be referred for genetic testing than those diagnosed beforehand. Methods: We conducted a retrospective chart review to compare trends in genetic testing of PDAC patients diagnosed from 02/17 - 07/18 versus 08/18 - 01/20, pre- and post-changes to NCCN guidelines, respectively.Family and personal cancer history, referral patterns and results of genetic counseling (GC) were recorded. Data were compared using Chi-square, Fisher’s Exact, and multivariate analyses. Results: There were 268 patients treated for PDAC (128 pre-, 140 post-) at a large academic institution. Demographics across both groups were comparable. A total of 175 were seen by our institution’s medical oncologist (84 pre-, 91 post-). Overall, 52 were referred to GC, 32 attended, 12 at our institution. More PDAC patients were referred to GC following the guideline changes (21% vs. 47%, p= 0.0005, Table). Patients with a family history of cancer were more likely to be referred to genetic testing (51% vs. 19%, p = 0.0002). This was the case for both pre- (odds ratio (OR) = 15.217 (95% CI, 2.725, 286.663)) and post- (OR = 3.353, (95% CI 1.263, 9.435)) eras, but the effect was not statistically significant when compared between eras ( p= 0.2034). Of all patients who underwent genetic testing, 27% were found to have a deleterious germline mutation related to hereditary PDAC. Conclusions: Despite a significant increase in referrals of PDAC patients for genetic testing following the guideline changes, adherence remains inconsistent with more than half of patients still not being referred. As a limitation of this study, we were not able to capture if patients were referred for GC outside of our network. Historically, the medical oncologist places the referral. However, as a possible solution to improve guideline adherence, referral for genetic testing could be initiated after initial diagnosis of PDAC by any provider, regardless of their role on the healthcare team.[Table: see text]

Developing an effective triaging algorithm for breast referrals

Background: Nationally, a significant increase in referrals has created unsustainable pressure on breast services. Radiology shortages have compounded this, reducing availability of triple assessment appointments. Despite revising our regional 2WW referral form, increasing primary care education and improving access to online advice and guidance, demand continued to outstrip supply. We developed a triaging algorithm to identify patients at higher risk of breast cancer based on a retrospective analysis of referrals. High risk patients were directed to a one stop hot clinic. The remaining patients attended cold clinic for clinical assessment and delayed imaging was requested as required. All referrals were seen within two weeks and their outcomes analysed.

Improve data classification performance in diagnosing diabetes using the Binary Exchange Market Algorithm

Today's lifestyle has led to a significant increase in referrals to medical centers to diagnose various diseases. To this end, over the past few years, researchers have turned to new diagnostic methods, including data mining and artificial intelligence, intending to facilitate the detection process and increase reliability. The high volume of data available in medical centers can be considered one of the main problems in using these methods. The optimal selection of essential and influential features reduces the maximum dimension for better diagnosis with more reliability of results. In this paper, a new approach uses a Binary Exchange Market Algorithm (BEMA) to identify essential and practical features in the diabetes dataset and determine the best algorithm binary function (type of sigmoid function) to improve the performance of the EMA algorithm is presented. For validation and efficiency of the proposed BEMA algorithm, several SVM, KNN, and NB classification models have been used to train and test the final model. The results obtained from the evaluations show that the proposed BEMA-SVM combined method has a better performance than the previous methods to improve accuracy and offer an effect equivalent to 98.502%. Also, to provide better results and more reliability than the proposed method, researchers can use a combination of several classes with the proposed method, which is outside the scope of this study.

One-stop clinic for patients with suspected ovarian cancer: results from a retrospective outcome study\xa0of the referral pathway

BackgroundWomen with abdominal pain and bloating frequently have their Ca-125 levels investigated for suspected ovarian cancer and this has led to a significant increase in referrals to the ovarian cancer service. We have conducted this study to help improve the efficiency in which these patients are investigated and to improve future pathways within the referral service.MethodsThis was a retrospective observational outcome study. Data were collected from electronic documents of patients’ referrals, assessments, and clinical correspondences over 48 months. The study was conducted in a secondary gynaecology cancer centre with direct referrals from primary care. The pelvic mass clinic was set up to include a consultation and an ultrasound scan with support available for patients if required. All patients included were referred directly from primary care for suspected ovarian cancer with Ca-125 result over a period of 2 years.Results286 were referred from primary care according to the NICE guidelines of ‘2-week wait for ovarian cancer’. Only 223 patients who had a Ca-125 result reported at the time of their referral were included in the analysis. Out of the 223 patients, 126 patients were discharged with or without a repeat Ca-125 after the initial assessment. 18 patients were diagnosed with cancer following the referral, but only 12 of them had a primary ovarian malignancy. The malignancy rate in women under 50 years of age was 22% (4/18) and 78% (14/18) in women aged 50 or above.ConclusionOne-stop focused gynaecology ultrasound clinics where clinicians may assess patients and perform ultrasound scans for suspected cancer, may be better for managing this patient population due to improved efficiencies in waiting times, same day diagnosis and a reduction in waiting times to first appointment. Secondly, the majority of the patients with Ca-125 of more than 35 U/mL, who were referred through this pathway, did not have cancer. This review queries the future value of using Ca-125 as the basis for referrals from primary care for suspected ovarian malignancy. Further studies are required to assess whether a higher Ca-125 cut off may be used as the basis of referrals for premenopausal women.

S246 Colorectal Cancer Screening: Quality Improvement and Education at a Resident-Led Clinic

Introduction: Colorectal cancer (CRC) is a leading cause of cancer-related death, yet only ∼65% of age-eligible adults receive appropriate screening. In a resident-led primary care clinic, lack of provider recommendation presents a barrier to screening. This quality improvement project aimed to improve resident confidence in recommending various CRC screening modalities and increase the number of age-appropriate screening referrals made. Methods: A CRC educational module and decision algorithm were designed and presented to internal medicine residents at a single primary care clinic. Each resident was provided a list of patients due for CRC screening. Resident knowledge of and confidence in recommending various CRC screening modalities were assessed on a 5-point Likert scale and with questionnaires via pre- and post-intervention surveys. CRC screening referral rates from 30 months before and 6 months after the intervention were evaluated. Statistical process control (SPC) charts were created to determine if CRC screening referrals significantly increased following the intervention. Results: Of the 60 residents, 59 participated in the pre-survey and 41 in the post-survey. After the educational intervention, residents reported significantly increased confidence in obtaining a list of patients on their panel not up to date on screening (P < 0.05), identifying screening options available at their practice (P < 0.001), and discussing options for CRC screening with patients (P < 0.05). Confidence in recommending guideline-based screening, follow-up, and assisting patients in overcoming barriers for Cologuard (P < 0.001) and FOBT (P < 0.05) also increased. Residents identified inadequate provider training, lower prioritization, and financial limitations as major barriers to successful screening. There was a significant increase in Cologuard referrals and decrease in FOBT (P < 0.01), but there was no significant change in total CRC screening or colonoscopy referrals after the intervention. Conclusion: This study demonstrates that a resident-led curriculum on CRC screening can improve provider confidence in counseling patients on CRC screening modalities and follow-up. Our intervention resulted in a statistically significant increase in referral rates for Cologuard, but did not show an increase in the number of total CRC screening or colonoscopy referrals. Ongoing data collection will evaluate for trends that may suggest a delayed improvement in CRC screening referrals with additional educational interventions.Figure 1.: Monthly CRC Screening Referrals by Modality Legend: Screening Method Blue - Colonoscopy Orange - Cologuard Yellow - Fecal Occult Blood Test Dashed - Intervention Start DateTable 1.: Pre- and Post-Intervention Survey Responses *Significance calculated using the Mann-Whitney U test

Cervical lymphadenopathy following coronavirus disease 2019 vaccine: clinical characteristics and implications for head and neck cancer services.

Patients with coronavirus disease vaccine associated lymphadenopathy are increasingly being referred to healthcare services. This work is the first to report on the incidence, clinical course and imaging features of coronavirus disease vaccine associated cervical lymphadenopathy, with special emphasis on the implications for head and neck cancer services. This was a retrospective cohort study of all patients referred to our head and neck cancer clinics between 16 December 2020 and 12 March 2021. The main outcomes measured were the proportion of patients with vaccine-associated cervical lymphadenopathy, and the clinical and imaging characteristics. The incidence of vaccine-associated cervical lymphadenopathy referrals was 14.8 per cent (n = 13). Five patients (38.5 per cent) had abnormal-looking enlarged and rounded nodes with increased vascularity. Only seven patients (53.9 per cent) reported full resolution within an average of 3.1 ± 2.3 weeks. Coronavirus disease vaccine associated cervical lymphadenopathy can mimic malignant lymphadenopathy and therefore might prove challenging to diagnose and manage correctly. Healthcare services may encounter a significant increase in referrals.

Hyperbaric oxygen for sudden hearing loss: Influence of international guidelines on practice in Australia and New Zealand.

Idiopathic sudden sensorineural hearing loss (ISSHL) is an otolaryngologic emergency. The Undersea and Hyperbaric Medicine Society (UHMS) revised practice guidelines in 2014 adding ISSHL to approved indications. This study investigated whether the UHMS guidelines influenced referral and practice in Australia and New Zealand. Retrospective review of 319 patient referrals in two time periods (five years prior to addition of ISSHL to indications (T-PRE) and three years post (T-POST)). Seven of eight participating hyperbaric facilities provided data down to the level of the indication for HBOT for analysis. In T-PRE 136 patients were treated with HBOT for ISSHL, representing between 0% and 18% of the total cases to each facility. In the T-POST period 183 patients were treated for ISSHL, representing from 0.35% to 24.8% of the total patients in each facility. Comparison between the two periods shows the proportion of patients treated with ISSHL among all indications increased from 3.2% to 12.1% (P < 0.0009). One facility accounted for 74% (101/136) of ISSHL patients receiving HBOT in T-PRE and 63% (116/183) in T-POST. ISSHL case load at that facility increased from 18% to 24.8% (P = 0.009) after the UHMS guideline publication. Three of the seven units had a significant increase in referrals after the guideline change. There remains equipoise regarding HBOT in the management of ISSHL. Only three out of seven units had a significant increase in ISSHL patients after the UHMS guidelines publication. Without well controlled RCTs to develop guidelines based on good evidence this is unlikely to change and practice variation will continue.

Low Risk of Persistent Pain, Sensory Disturbances, and Complications Following Mastectomy After Gender-Affirming Surgery.

Purpose: In recent years, there has been a significant increase in referrals for gender-affirming surgery to departments of plastic surgery in Denmark. There is currently no literature on postsurgical pain in trans men after mastectomy. We aimed at investigating the prevalence and severity of postsurgical persistent pain, sensory disturbances, and complications in trans men after mastectomy. Methods: The 90 trans men who underwent bilateral mastectomy between September 1, 2013 and August 31, 2018 were included. Patients' files were evaluated for complications, and 84 (response rate 93.3%) patients answered a questionnaire (validated for women undergoing oncologic mastectomy) regarding persistent pain and sensory disturbances. Results: Twenty-three patients (27.4%) reported either unilateral or bilateral persistent pain after mastectomy. Of these, 14 (60.9%) patients categorized the pain as mild. However, 77 (95.2%) of the patients did not use analgesics and nonopioid pain medication was sufficient for the remainder. Sensory disturbances were found in 44 (47.5%) of the patients, and 4 (4.8%) patients reported clear signs of neuropathic pain. Seven (7.8%) patients developed hematomas, and areola necrosis was seen in four (4.4%) patients. Due to infection, seven (7.8%) patients received antibiotics. Conclusion: Mastectomy as a part of gender-affirming surgery is a safe procedure with a few, nonsevere, complications. Although a quarter of the patients experienced persistent pain, the majority of that pain is mild, intermittent and can be treated with nonopioid pain medication.

AUTOMATED ELECTRONIC REFERRALS ARE CHANGING DONATION

Introduction: It is broadly understood and supported by previous studies that disruptive inefficiencies exist in the hospital to Organ Procurement Organization (OPO) donor referral process, including failure to notify the OPO and delayed referrals. Without a reliable and timely donor referral, life-saving organs cannot be procured and transplanted. A secure direct and automatic electronic donor referral interface was collaboratively developed and implemented to confront the issue of inefficient donor referrals by 1) eliminating the need for nurses to step away from patient care and place the phone call; and 2) automating the donor referral trigger with the goals of increasing referrals and donations while also reducing critical time spent by the hospital and OPO. Materials and Methods: The multi-disciplinary team collaborated to create a secure technical interface directly connecting the OPO and Hospital systems, as well as design seamless donor referral triggers within the Hospital EMR. These triggers automatically deliver electronic donor referrals from the Hospital to the OPO upon staff entry of pre-determined clinical data into the EMR, greatly reducing the need for donation knowledge and decision making by the hospital staff. The interface includes an additional manual trigger for staff to utilize in cases such as early family mention of donation and other exceptional situations. Upon receipt of the initial electronic referral, the OPO can quickly retrieve critical details for donation screening without pulling the hospital staff away from their critical duties of care. The above described interface has been successfully implemented in all 4 facilities in the hospital system. Results and Discussion: The interface has led to a significant increase in referrals and donations. Comparing the data from previous (2018) and following years (2019), during which time the only major process change at the hospital was the implementation of the electronic interface, there was a 49% increase in donor referrals (389 to 579) and a 333% increase in organ donors (3 to 13). Over the same period, over 190 hours of staff time were saved by the hospital and the OPO, regardless of the increase in referrals. There are several case studies of the OPO receiving an automatically triggered donor referral when the nurse was unable to connect on a phone call due to duties in a busy ICU. OPO staff were then able to retrieve the appropriate data directly from the EMR, allowing them to mobilize and ultimately recover organs and tissue which likely would have otherwise timed out. Conclusion: The results demonstrate increased efficiency in the donation referral process and project goals fulfillment by significant increase in referrals and donations as well as reduced burdens on both the Hospital and OPO through time savings. The initiative has been successful due to both the electronic interface and automating the donor referral trigger, leading to more donation and transplantation.

Improving Access for Patients Undergoing Gonadotoxic Therapy: Creation of a Formal Fertility Preservation Program [25A

INTRODUCTION: Prior to 2016, patients undergoing gonadotoxic therapies were not routinely directed towards educational resources regarding fertility preservation options. In 2016, a formalized fertility preservation program was initiated to increase education, referrals, and provide treatment options to this uniquely vulnerable patient population. METHODS: A database was created following initiation of the fertility preservation program (FPP) to track patient demographics such as diagnosis, treatment plan, referring department, consultation turn-around time, uptake of fertility preservation services, and outcomes (post treatment and post fertility preservation, if applicable). For patients undergoing sperm/oocyte/embryo cryopreservation for fertility preservation needs prior to program initiation (2006–2015), a chart review was performed to obtain the same data. We assessed the overall impact of implementation of FPP as compared to other published data from institutions providing formal fertility preservation services. RESULTS: Each year following implementation of FPP, noted statistically significant increase in referrals, consultations, and uptake of fertility preservation services. Similarly, the referring departments and diagnoses on referral expanded beyond oncologic providers and oncologic diagnoses, respectively. We also noted a trend of increased uptake for female patients for fertility preservation as compared to male patients, which is dissimilar from previously published data. CONCLUSION: A formalized program for fertility preservation improves access and uptake of services for patients undergoing gonadotoxic therapies. Our program demonstrated significant beneficial impact on multiple parameters of interest, even within the first two years following implementation. Subsequently, fertility preservation for oncology patients is now considered a covered benefit within this health maintenance organization.

Improving the healthcare response to domestic violence and abuse in UK primary care: interrupted time series evaluation of a system-level training and support programme

BackgroundIt is unknown whether interventions known to improve the healthcare response to domestic violence and abuse (DVA)—a global health concern—are effective outside of a trial.MethodsAn observational interrupted time series study in general practice. All registered women aged 16 and above were eligible for inclusion. In four implementation boroughs’ general practices, there was face-to-face, practice-based, clinically relevant DVA training, a prompt in the electronic medical record, reminding clinicians to consider DVA, a simple referral pathway to a named advocate, ensuring direct access for women to specialist services, overseen by a national, health-focused DVA organisation, fostering best practice. The fifth comparator borough had only a session delivered by a local DVA specialist agency at community venues conveying information to clinicians. The primary outcome was the daily number of referrals received by DVA workers per 1000 women registered in a general practice, from 205 general practices, in all five northeast London boroughs. The secondary outcome was recorded new DVA cases in the electronic medical record in two boroughs. Data was analysed using an interrupted time series with a mixed effects Poisson regression model.ResultsIn the 144 general practices in the four implementation boroughs, there was a significant increase in referrals received by DVA workers—global incidence rate ratio of 30.24 (95% CI 20.55 to 44.77, p < 0.001). There was no increase in the 61 general practices in the other comparator borough (incidence rate ratio of 0.95, 95% CI 0.13 to 6.84, p = 0.959). New DVA cases recorded significantly increased with an incident rate ratio of 1.27 (95% CI 1.09 to 1.48, p < 0.002) in the implementation borough but not in the comparator borough (incidence rate ratio of 1.05, 95% CI 0.82 to 1.34, p = 0.699).ConclusionsImplementing integrated referral routes, training and system-level support, guided by a national health-focused DVA organisation, outside of a trial setting, was effective and sustainable at scale, over four years (2012 to 2017) increasing referrals to DVA workers and new DVA cases recorded in electronic medical records.