Team Of Physicians Research Articles

Family Doctors Calling in Transcarpathian Region in the Wartime

After the russian invasion, 60,000 refugees from the eastern and southern parts of Ukraine, who had many problems with physical and mental health, arrived in Uzhgorod. A team of family doctors, residents and students with the support of volunteers and various medical, educational, charity and religious organizations started a volunteer project, which later grew into the “InterFamily” clinic. Starting as a charity center where internally displaced persons could receive free and high quality primary care and medicines purchased through donations from international partners, today it has become a licensed clinic that provides many different medical services (some of which are unique in our region), and as well as primary (i.e. psychological) and secondary care not only to refugees, but also to city residents. The “InterFamily” clinic is a training center for students and residents who gain hands-on skills and experience, and have the opportunity to become staff members as clinic assistants, providing greater autonomy and the opportunity to gain clinical and management skills. Thanks to the European-Ukrainian Support In Teaching (later EUSIT-Exchange) project, the European experts have been conducting practical lectures for Ukrainian doctors and nurses and students since the beginning of the war. The clinic’s innovative medical and educational experience is valuable not only for Ukrainian, but also for foreign specialists. The international recognition of the “InterFamily” clinic was confirmed by the WONCA Europe 5 Star Doctor Award to the director of the “InterFamily” clinic Pavlo Kolesnyk.

Клінічна характеристика жінок із жіночою сексуальною дисфункцією та ендометріозом

Endometriosis is a disease characterized by the presence of endometrial tissue outside the uterine cavity. Endometriosis refers to estrogen-dependent diseases, clinically manifested by dysmenorrhea, dyspareunia, dyschezia. Decreased fertility in women with endometriosis is associated with the presence of chronic inflammation that leads to pelvic pain and infertility. It is believed that endometriosis is associated with mood disorders such as anxiety or depression, which can create a pathological background for sexual dysfunction. Purpose - to establish the relationship between female sexual dysfunction (FSD) and external genital endometriosis in order to optimize women's pregravid preparation. Materials and methods. 100 women of reproductive age were examined. The main group (the Group I) consisted of 70 women who had external genital endometriosis (diagnosed by ultrasound examination of the pelvic organs, ovarian endometrioma size up to 5 cm). The main group was divided into 2 subgroups: IA - 40 women with FSD and endometriosis; IB - 30 women with FSD without endometriosis. The control group (the Group II) included 30 healthy reproductively active women in the pre-gravid stage. In the course of the study, the nosological unit approved by the World Health Organization (1999) was taken into account and taken as a basis - FSD, which include disorders of desire, arousal and reaching orgasm, dyspareunia and vaginismus. The results of clinical and biochemical studies were processed using a specialized package of statistical programs Statistica 8.0 (StatSoft Inc., USA). The following criteria were used for statistical processing of the obtained data: Kruskal-Wallis test, Mann-Whitney U test, Pearson chi-squared (χ2) test, Wilcoxon test. Results. The analysis of the definition of FSD in women with endometriosis clearly indicates the presence of signs of FSD in all areas and is statistically significantly different from the indicator of healthy women. Conclusions. There is a relationship between endometriosis and FSD that can be determined using the FSFI Questionnaire Calculator. Since FSD and endometriosis have a polymorbid background, treatment should be carried out by a multidisciplinary team of doctors and be personalized. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the author.

Deprescribing in Older Poly-Treated Patients Affected with Dementia.

Polypharmacy is an important issue in older patients affected by dementia because they are very vulnerable to the side effects of drugs'. Between October 2021 and September 2022, we randomly assessed 205 old-aged outpatients. The study was carried out in a Center for Dementia in collaboration with a university center. The primary outcomes were: (1) deprescribing inappropriate drugs through the Beers and STOPP&START criteria; (2) assessing duplicate drugs and the risk of iatrogenic damage due to drug-drug and drug-disease interactions. Overall, 69 men and 136 women (mean age 82.7 ± 7.4 years) were assessed. Of these, 91 patients were home care patients and 114 were outpatient. The average number of the drugs used in the sample was 9.4 drugs per patient; after the first visit and the consequent deprescribing process, the average dropped to 8.7 drugs per patient (p = 0.04). Overall, 74 potentially inappropriate drugs were used (36.1%). Of these, long half-life benzodiazepines (8.8%), non-steroidal anti-inflammatory drugs (3.4%), tricyclic antidepressants (3.4%), first-generation antihistamines (1.4%), anticholinergics (11.7%), antiplatelet drugs (i.e., ticlopidine) (1.4%), prokinetics in chronic use (1.4%), digoxin (>0.125 mg/day) (1.4%), antiarrhythmics (i.e., amiodarone) (0.97%), and α-blockers (1.9%) were included. The so-called "duplicate" drugs were overall 26 (12.7%). In total, ten potentially dangerous prescriptions were found for possible interactions (4.8%). We underline the importance of checking all the drugs taken periodically and discontinuing drugs with the lowest benefit-to-harm ratio and the lowest probability of adverse reactions due to withdrawal. Computer tools and adequately trained teams (doctors, nurses, and pharmacists) could identify, treat, and prevent possible drug interactions.

Management of "De Novo" Carpal Tunnel Syndrome in Pregnancy: A Narrative Review.

Carpal tunnel syndrome is a common entrapment neuropathy that can occur in the upper limbs during pregnancy. However, it is often undervalued and underdiagnosed because the symptoms can be mistaken for regular changes during pregnancy. Delay or absence of diagnosis and treatment can lead to permanent nerve damage, which can affect a woman's quality of life during and after pregnancy. Although the treatment protocols are well established for carpal tunnel syndrome in patients from the general population, there is a different situation among pregnant and postpartum women that requires a preventive and personalized approach to manage this pathology. Unfortunately, the range of available treatment options is limited due to the pregnant woman's physiological status and influenced by the high possibility of the complete resolution of this pathology in the postpartum period without any treatment. To limit the possibility of unfavorable evolution of this syndrome during pregnancy, an early diagnosis and personalized approach are mandatory in each case involving a multidisciplinary team of general practitioners, obstetricians, hand surgeons, rehabilitation physicians, physiotherapists, and occupational therapists.

Orthopedic Team Surgeons in Major Professional Sports: An Analysis of Affiliation With the Top 10 Sports Medicine Fellowship Programs and Implications for Leadership and Diversity.

This paper examines the correlation between orthopedic team surgeons in major professional sports and their affiliation with the top 10 sports medicine fellowship programs. With a growing trend in post-residency fellowship training, particularly in sports medicine, the study focuses on the implications of fellowship program choice for aspiring major professional sports team physicians. By analyzing data from Major League Baseball (MLB), the National Basketball Association (NBA), the National Football League (NFL), and the National Hockey League (NHL), the research reveals that 61 of 124 (49.19%) team surgeons graduated from the top 10 sports medicine fellowship programs. The results identify a noticeable pipeline effect in professional sports, where teams often hire graduates from a select number of esteemed fellowship programs. The study suggests that choosing a fellowship program from the top 10 list may enhance the prospects of becoming a major league team surgeon. Additionally, our results found a significant gender disparity among team surgeons, with only two (1.6%) of all major professional team physicians being women. Thisemphasizes the imperative for diversity improvement in orthopedic sports medicine. In conclusion, the research underscores the impact of top-tier fellowship programs on professional team surgeons, with implications for aspiring sports medicine physicians and a call for addressing gender disparities.

Mapping the Silent Threat: A Comprehensive Analysis of Chagas Disease Occurrence in Riverside Communities in the Western Amazon.

Chagas disease (CD) is a typical tropical illness caused by Trypanosoma cruzi. The objective of this study was to assess the prevalence of Chagas disease in communities in two states of the Brazilian Amazon. Data collection occurred in July in the Alto Juruá region of Acre and in December in the communities of Humaitá, Amazonas, in 2019. A total of 477 participants were included in the study. In the communities of Alto Juruá, triatomine collections and analyses of T. cruzi infection were also carried out. All confirmed cases were found in the state of Acre, resulting in a total prevalence of 1.67. Of these eight cases, seven underwent ECG, all of which were concluded as normal by the physician team's cardiologists. Seventeen triatomine bugs, all belonging to the Rhodnius genus, were captured. The natural infection rate by T. cruzi was 25% in the Nova Cintra community and 66.67% in the Boca do Moa community (Alto Juruá). This research found that more than 1% of the studied population exhibited positive serological results for Chagas disease in the riverine communities during the study period, representing a small portion of cases among those who have not yet been diagnosed.

The ABC of Immune-Mediated Hepatitis during Immunotherapy in Patients with Cancer: From Pathogenesis to Multidisciplinary Management.

Immune-mediated hepatotoxicity (IMH) is not-so-rare complication during treatment with immune checkpoint inhibitors (ICIs). This narrative review aims to report the current knowledge on hepatic immune-related adverse events (irAEs) during immunotherapy from pathogenesis to multidisciplinary management. The majority of cases of IMH are asymptomatic and only a few patients may have clinical conditions. The severity of IMH is usually stratified according to Common Terminology for Clinical Adverse Events (CTCAE) criteria, but these scores may overestimate the clinical severity of IMH compared to the Drug-Induced Liver Injury Network (DILIN) scale. The differential diagnosis of IMH is challenging because the elevated liver enzymes can be due to a number of etiologies such as viral infection, autoimmune and metabolic diseases, liver metastases, biliary diseases, and other drugs. The cornerstones of IMH management are represented by withholding or delaying ICI administration and starting immunosuppressive therapy. A multidisciplinary team, including oncologists, hepatologists, internists, and emergency medicine physicians, is essential for the management of IMH.

Adverse Effects of Cancer Treatment in Patients With Cervical Cancer.

In lower- to middle-income countries such as India, the literature on the adverse effects (AEs) of cancer treatment in patients with cervical cancer is very limited. This knowledge gap provides an opportunity to investigate and improve the quality of life for women with cervical cancer. The purpose of this study was to assess the AEs of various cancer treatment combinations in patients with cervical cancer. This observational, retrospective study analysed 1,030 women with cervical cancer, with a descriptive cross-sectional design, based on a review of medical records from patients who were followed up during the morbidity consultation conducted by a multidisciplinary team of doctors. The AEs of cancer treatment for women with cervical cancer were recorded in these medical records between October 14, 2019, and November 21, 2022, at 10 major public tertiary hospitals in India. This study analysed 1,030 women with cervical cancer aged between 21 and 80 years (mean age: 48.8 ± 13.9 years; p=0.30). Patients between the ages of 36-50 years reported the most AEs (30.2%; 95% confidence interval (CI): 29.1-32.8) among other age groups. Combined radiation therapy and chemotherapy (CT) was the type of cancer treatment in which there were more AEs, presenting in 56.0% (95% CI: 55-60.1) of patients. Adverse effects associated with the gastrointestinal system were observed in the majority (92.5%, 95% CI: 90.2-96.9) of cervical cancer patients. Exposure to different cancer treatments, particularly combination therapy, induces AEs in patients during and after cervical cancer treatment.

Spanish Translation and Cultural Adaptation of the Intensive Care Unit Delirium Playbook.

A lack of high-quality provider education hinders the delivery of standard-of-care delirium detection and prevention practices in the intensive care unit (ICU). To fill this gap, we developed and validated an e-learning ICU Delirium Playbook consisting of eight videos and a 44-question knowledge assessment quiz. Given the increasing Spanish-speaking population worldwide, we translated and cross-culturally adapted the playbook from English into Spanish. To translate and culturally adapt the ICU Delirium Playbook into Spanish, the second most common native language worldwide. The translation and cross-cultural adaptation process included double forward and back translations and harmonization by a 14-person interdisciplinary team of ICU nurses and physicians, delirium experts, methodologists, medical interpreters, and bilingual professionals representing many Spanish-speaking global regions. After a preeducation quiz, a nurse focus group completed the playbook videos and posteducation quiz, followed by a semistructured interview. The ICU Delirium Playbook: Spanish Version maintained conceptual equivalence to the English version. Focus group participants posted mean (standard deviation) pre- and post-playbook scores of 63% (10%) and 78% (12%), with a 15% (11%) pre-post improvement (P = 0.01). Participants reported improved perceived competency in performing the Confusion Assessment Method for the ICU and provided positive feedback regarding the playbook. After translation and cultural adaptation, the ICU Delirium Playbook: Spanish Version yielded significant knowledge assessment improvements and positive feedback. The Spanish playbook is now available for public dissemination.

FAKTOR YANG MEMENGARUHI MORTALITAS PASIEN RAWAT INAP DI RUMAH SAKIT AKADEMIK UGM

Background: Hospital mortality indicators are an important element of a hospital patient safety monitoring program. In 2022, the record of inpatient performance at Academic Hospital UGM (RSA UGM) shows that the Net Death Rate (NDR) value has not yet reached the ideal standard, namely 34.1‰.
 Objective: Identifying factors that influence the mortality rate of adult patients ≥48 hours in inpatient care and developing a program plan to reduce hospital mortality at RSA UGM.
 Methods: An explanatory sequential design of mixed methods research was used. The medical records of adult patients admitted to RSA UGM from October 2022 to December 2022. Quantitative data analysis used chi-square, Fisher’s exact tests, and multivariate logistic regression. Qualitative data was obtained from focus group discussions with three separate groups, namely the managerial group, the doctor team, and the nurse team., while qualitative data used thematic analysis.
 Results: 388 subjects were obtained with 18 (4.64% or 46.4‰) patients who died during treatment ≥48 hours. Independently, ward type (OR 10,799, CI 95 % 3,990 – 29,233), EWS score (OR 15,644, CI 95 % 5,511 – 44,412), and some comorbidities (OR 8,603, CI 95 % 2,769 – 26,730) associated with ≥48 hours in-hospital mortality (<0.001). Multivariate analysis showed that ward type (p=0.018, aOR 4,122, CI 95 % 1,279 – 13,284) and Early Warning System (EWS) score (p=0.016, aOR 4,531, CI 95 % 1,327 – 15,469) had a strong association with ≥48 hours in-hospital mortality. The proposed program to reduce hospital mortality rates by increasing ICU capacity, improving the competency and skills of ICU nurses, adding intensivists, controlling nosocomial infections in ICU, increasing understanding regarding EWS for ward nurses, improving the EWS monitoring, and improving the competency of ward nurses in emergencies condition.
 Conclusion: The EWS score >5 and intensive care are significantly related to in-hospital mortality ≥48 hours after hospitalization so management needs to improve the quality of services at the RSA UGM by carrying out a strategy to reduce hospital mortality rates to decrease the net mortality rate in accordance with the Ministry of Health’s national standards.

Development and evaluation of a novel knowledge assessment tool for pediatric emergency medicine clerkships.

This study seeks to determine validity evidence for a newly developed multiple-choice examination (MCE) tool to assess retention and application of medical knowledge of students enrolled in a pediatric emergency medicine (PEM) clerkship. A team of PEM physicians created a 110-item MCE covering the range of clinical topics in PEM relevant for medical students. The researchers determined examination content using the report of Clerkship Directors in Emergency Medicine and PEM Interest Group of the Society for Academic Emergency Medicine (SAEM). The authors administered the MCE to fourth-year medical students at the end of their PEM rotation from May 2020 to April 2023 at four institutions and then analyzed the examination using four of Messick's five sources of validity evidence: content, response process, internal structure, and relation to other variables. A total of 158 students took the test. In academic year (AY)20-21, 47 students took the test and scored, on average, 81%. After revision of poor and indeterminate questions, the 111 medical students who took the revised version of the test in AY21-AY23 scored on average 77.3% with a standard deviation of 5.7% with a normal distribution in scores. The revised questions were rated as excellent (10.0%), good (26.4%), fair (34.5%), poor (24.5%), or indeterminate (4.5%) based on test item discrimination. There was a positive correlation between MCE scores and students' clinical evaluations but no correlation between MCE scores and scores that students received on their clinical notes or patient presentations during case conference. This novel PEM clerkship examination is a reliable test of medical knowledge. Future directions involve evaluating consequences of the MCE and offering the test to medical students in a dedicated PEM rotation at the national level.

Management of Sleep-Disordered Breathing in a Spinal Cord Injury Rehabilitation Center: Model of Care Adaptation and Implementation.

Obstructive sleep apnea (OSA) is highly prevalent and poorly managed in spinal cord injury (SCI). Alternative management models are urgently needed to improve access to care. We previously described the unique models of three SCI rehabilitation centers that independently manage uncomplicated OSA. The primary objective was to adapt and implement a similar rehabilitation-led model of managing OSA in an SCI rehabilitation center in Australia. Secondary objectives were to identify the local barriers to implementation and develop and deliver tailored interventions to address them. A clinical advisory group comprised of rehabilitation clinicians, external respiratory clinicians, and researchers adapted and developed the care model. A theory-informed needs analysis was performed to identify local barriers to implementation. Tailored behavior change interventions were developed to address the barriers and prepare the center for implementation. Pathways for ambulatory assessments and treatments were developed, which included referral for specialist respiratory management of complicated cases. Roles were allocated to the team of rehabilitation doctors, physiotherapists, and nurses. The team initially lacked sufficient knowledge, skills, and confidence to deliver the OSA care model. To address this, comprehensive education and training were provided. Diagnostic and treatment equipment were acquired. The OSA care model was implemented in July 2022. This is the first time a rehabilitation-led model of managing OSA has been implemented in an SCI rehabilitation center in Australia. We describe a theory-informed method of adapting the model of care, assessing the barriers, and delivering interventions to overcome them. Results of the mixed-methods evaluation will be reported separately.

The weapons of mass destruction-civil support team PA.

The weapons of mass destruction-civil support team (WMD-CST) physician associate/assistant (PA) is an autonomous PA who balances military and civilian roles to achieve mission success and support the safety of the US public. This article by multiple WMD-CST PAs across the nation describes the WMD-CST PA profession and how traditional PA roles continue to advance.

Abstract WP71: Early Stroke Alert and Telestroke Notification Reduces Door to Needle Time

Background: Door to telestroke request times (DTSR) contribute to door to needle time (DTN) in telestroke networks, however, data is limited on the relationship between DTSR, DTN and other contributing factors. We aimed to evaluate the relationship between processes at the spoke, by EMS and how these contributed to DTN in telestroke spokes. Methods: This is a multi-center retrospective analysis of telestroke patients treated with IV thrombolysis from a hub and spoke telestroke network from June 2018 to March 2023. Patients were excluded from this study due to missing data. The Primary outcome was to examine the relationship between DTSR, DTN and other contributing variables. Multiple regression analyses evaluated which factors contributed to DTSR and DTN. A simple mediation model with covariates NIHSS and average telestroke volume was used to determine if DTSR mediates the relationship between door to stroke alert and DTN. A subgroup analysis examined which variables contributed to DTSR in patients arriving by EMS. A hierarchical multivariable regression analysis entering potential confounding variables as identified in preliminary analyses then variables of interest was used in the subgroup analysis. Results: There were 582 telestroke patients treated with IV thrombolysis and after exclusions, 471 (80.9%) patients were included in the study. The mean age ± SD of the patients was 69.50 ± 15.11 and 238 (50.5%) were female. Door to telestroke request partially mediated the relationship between door to stroke alert and DTN as door to stroke alert was significantly associated with DTN after adjustment for DTSR, B = 0.25 [95% Confidence Interval (CI), 0.10 - 0.41], p < 0.001. In the adjusted model, DTSR explained 29% [95%CI, 22% - 35%] of the variance in DTN. Prehospital stroke alert by EMS reduced DTSR by 6.99 minutes [95%CI, 3.31 - 10.68], p < 0.001, after adjustment of confounding variables. In patients with prehospital stroke alert, earlier ED physician evaluation was associated with quicker DTSR, B = 0.48 [95%CI, 0.01 - 0.95], p = 0.045. Conclusion: Early notification of the local stroke alert team and telestroke physician is associated with quicker DTN. Prehospital stroke alerts by EMS allow for quicker evaluation by ED physician which results in reduced DTSR.

Abstract TP46: Improving Efficiency of Interfacility Transfer for Mechanical Thrombectomy: Delaware Stroke System Experience

Introduction: Delaware (DE) created a stroke system with a primary objective to improve the interfacility transfer process between DE PSCs and its only CSC to improve efficiency and outcomes for mechanical thrombectomy (MT) transfer patients. Methods: The DE stroke system, including stroke coordinators/medical directors and EMS, defined criteria for MT eligibility, identified barriers to transfer, and implemented the interventions listed below. Data on transfer volumes, thrombectomy rates, and outcomes were collected. Objectives were to improve early detection of MT eligible patients, improve rate of thrombectomy on MT transfers, and track patient outcomes (mRS 0-2 at 90 days). • MT eligibility defined as any patient with a significant/disabling deficit with target lesion identified on CTA. • Implementation of “EZ” button in PSC EDs for early activation of flight team for suspected MT candidates upon initial clinical evaluation. • Time goal of 30 min for PSC arrival to call out to CSC for MT candidates. • Implementation of RAPID.AI platform at PSCs to allow CSC immediate access to imaging. • Revision of CSC transfer process: conference call with transfer center, PSC physician, and CSC stroke team physicians to discuss case. • Transport expedited for MT eligible patients; ineligible patients stay at PSC. • CSC provides outcome feedback and time goals to PSC on each transfer. • Variant cases reviewed by CSC and DE Stroke System Quality & Data committee as needed. Results: From FY22 to FY23, there was a 39% increase in MT transfers, 20% increase from 52% to 72% in rate of thrombectomy, and 15% increase in # patients in mRS 0-2 category at 90d (figure 1). Conclusion: By implementing collaborative and focused interventions, the DE stroke system increased rates of MT in transferred patients while reducing unnecessary transfers and improving patient outcomes.

Unrecognized Superficial Venous Thrombosis in a Female Division-1 Athlete: A Case Report

BACKGROUND: Superficial venous thrombosis (SVT) is a blood clot that forms in superficial veins and may occur after surgery. Treatment typically consists of anticoagulation medication and palliative care. CASE PRESENTATION: A 20-year-old female basketball athlete presented to physical therapy (PT) after posterior labral repair. Examination revealed tenderness along the medial forearm, venous distension of the hand, and discomfort with wrist extension overpressure and resisted wrist flexion. The patient was referred by the physical therapist to the team physician, who ordered ultrasonography, which demonstrated SVT of the right basilic vein. The patient was placed on anticoagulation medication for 4 months. OUTCOME AND FOLLOW-UP: At 4 months after initial diagnosis, a computed tomography venogram revealed resolution of SVT. The patient continued with physical therapy throughout this period, with no adverse effects reported. DISCUSSION: Physical therapists play an important role in medical screening and referral of patients who present with potential vascular complications postsurgery. Physical therapists may also safely implement a plan of care in patients who develop medical complications after surgery. JOSPT Cases 2024;4(1):34-38. Epub 26 January 2024. doi:10.2519/josptcases.2024.12174

Острое повреждение почек у полиморбидных пациентов

The presented clinical observation shows the role of a multidisciplinary team of doctors in the treatment of acute kidney injury (AKI) in a patient suffering from bronchial asthma and metabolic syndrome (morbid obesity, arterial hypertension, type 2 diabetes mellitus). The importance of correcting metabolic disorders (diet, self-monitoring of glycemia, urate- and glucose-lowering therapy) has been demonstrated both as part of the complex therapy of AKI and for the prevention/slowing of further kidney damage.

P646 Clinical decision support in the prevention of adverse effects associated with immunosuppressive drugs in patients with Inflammatory Bowel Disease

Abstract Background With the goal of effective and early prevention and detection of medication-related adverse effects, an explosion of technological advances is taking place. However, none of these systems are currently intelligent enough to ensure safe prescribing of treatments on their own. Purpose To design and integrate clinical decision rules (CDR) to increase the safety of immunosuppressive treatments in patients with inflammatory bowel disease (IBD) into an electronic prescribing assistance software (HIGEA). Methods This is a descriptive study conducted in a tertiary university hospital in Madrid (Spain). 1. We reviewed the technical product information sheet of the immunomodulatory drugs used in the treatment of patients with IBD and the current recommendations and clinical practice guidelines on the management of IBD. 2. The CDR were developed within a multidisciplinary team of physicians and pharmacists by integrating data from pharmacogenetics, microbiology, biochemistry, immunology and haematology laboratories, the electronic medical record and the electronic prescribing programme. 3. Integration was performed using a standard language (HL7). Results The technical product information sheet of 33 immunomodulatory drugs (19 biological therapies, 6 small molecules and 8 traditional disease-modifying drugs) and the clinical practice guidelines for the treatment of IBD of the European Crohn's and Colitis organisation (ECCO) and the Spanish working group on Crohn's disease and ulcerative colitis (GETECCU) were reviewed. A total of 169 CDR were developed: 2 related to pharmacogenetics laboratory values, 26 to microbiology, 38 to biochemistry, 24 to immunology, 42 to haematology, 28 to clinical history and 9 related to concomitant use of other drugs. Of the 169 CDR, 50 (29.58 %) were related to screening prior to initiation of immunosuppressive treatment, 10 (5.92%) to drug interactions and 109 (64.5%) related to clinical conditions requiring adjustment or discontinuation of immunosuppressive treatment. Conclusion The incorporation of personalised clinical rules into the medical prescription and pharmaceutical validation process will allow the selection of patients in whom there could be a safety problem with immunosuppressive treatment, increasing the percentage of early detected and avoided adverse events. Future steps will be to evaluate the impact of the implementation of the CDR tool on increasing safety, reducing healthcare costs and improving patient health outcomes.

Massive transfusion protocol reactivation as a novel marker of physician team under-triage after injury.

Large trauma centers have protocols for the assessment of injury and triaging of care with attempts to over-triage to ensure adequate care for all patients. We noted that a significant number of patients undergo a second massive transfusion protocol (MTP) activation in the first 24 h of care and conducted a retrospective cohort study of patients involved over a 3-year period. Transfusion service records of MTP activations 2019-2021 were linked to Trauma Registry records and divided into cohorts receiving a single versus a reactivation of the MTP. Time of activation and amounts of blood products issued were linked to demographic, injury severity, and outcome data. Categorical and continuous data were compared between cohorts with chi-squared, Fisher's, and Wilcoxan tests as appropriate, and multivariable regression models were used to seek interactions (p < .05). MTP activation was recorded for 1884 acute trauma patients over our 3-year study period, 142 of whom (7.5%) had reactivation. Factors associated with reactivation included older age (46 vs. 40 years), higher injury severity score (ISS, 27 vs. 22), leg injuries, and presentation during morning shift change (5-7 a.m., 3.3% vs. 7.7%). Patients undergoing MTP reactivation used more RBCs (5 U vs. 2 U) and had more ICU days (3 vs. 2). Older patients and those presenting during shift change are at risk for failure to recognize their complex injury patterns and under-triage for trauma care. The fidelity and granularity of transfusion service records can provide unique opportunities for quality assessment and improvement in trauma care.

1756 Improvement in the number of discharges prior to 3 p.m. using quality improvement methodology

Abstract Introduction Under current nationwide clinical pressures, hospitals are running at full capacity. Late discharges can lead to poor flow throughout the hospital, overcrowding in the emergency department and out of hours transfers, leading to a poor patient experience and impacts on patient safety. Early morning and afternoon discharges create better flow and improve patient satisfaction, by being home in time for tea. The discharge collaborative within Leeds Teaching Hospitals NHS Trust is a multidisciplinary team (MDT) of junior doctors, pharmacists, nurses and discharge co-ordinators. The aim of the team is to improve discharges in the trust prior to 3 p.m. to 70%. Discharging patients earlier in the day is a complex multifactorial issue which requires an MDT approach. Method To understand this further a retrospective case note review was conducted to look at avoidable and unavoidable causes of delayed discharges. Each team also received a questionnaire, to discover their perceived barriers to early discharges. This was communicated to teams to empower them to develop their own solutions which were shared within the trust. Run charts of discharges before 3 p.m. are published for each ward in the hospital every two weeks, which is available to wards, but also monitored by the discharge collaborative. Changes to practice include; education of the medical team regarding importance of timely discharge, use of discharge boards, the increase use of discharge lounge, identifying ‘golden patients’ for early morning discharges, prioritisation of community discharges the previous day and achievement recognition for wards with the most improvement. Results/Conclusions Within the trust, several departments have improved their discharges prior to 3 p.m. through the improvements implemented from the discharge collaborative, including speciality and integrated medicine (SIM), oncology, and trauma services. This project resulted in two step improvements within the Trust with 40% of patients being discharged before 3 p.m.