Triggers For Referral Research Articles

Enhanced supportive care in cancer centres: national cross-sectional survey

Objectives‘Early’ specialist palliative care (SPC) has been shown to improve outcomes for patients with advanced cancer, yet patients are often referred late. ‘Enhanced supportive care’ (ESC) aims to facilitate earlier...

Using an electronic capture geriatric assessment to guide rehabilitation triage for adults with cancer during systemic therapy.

474 Background: Frailty is associated with poor treatment and survival outcomes but is modifiable if identified and intervened upon early on. ASCO recommends using a geriatric assessment (GA) to identify frailty and guide referrals to interventions to optimize patient outcomes, including rehabilitation (physical and occupational therapy (PT/OT). Yet, using a GA to guide PT/OT referrals is rare, especially in community-based oncology settings. To address this gap, we conducted a pilot feasibility study of a GA-based electronic frailty monitoring and PT/OT triage system. Methods: Adults with cancer starting a new line of systemic therapy at a community-based oncology private practice enrolled in the study. Participants completed a monthly online GA for up to one year. Frailty was identified in real-time from GA responses using a validated 44-item deficit accumulation method [frail (>0.35), pre-frail (>0.2-0.35), or robust (0-0.2)]. Clinicians were notified to place a referral for PT/OT when patients were identified as frail or pre-frail. We evaluated feasibility via participant enrollment and retention rate, oncology compliance to referral triggers, participant conversion to PT/OT, and a 5-item participant experience (PE) survey. For participants who attended rehabilitation, we evaluated changes in health-related quality of life using PROMIS outcomes collected during rehabilitation. PROMIS outcomes included global physical (GPH) and mental (GMH) health, physical function (PF), and the ability to participate in social roles and activities (SRA). Results: Of 537 eligible patients, 26% enrolled (N=141). Participants completed a median of 3 GA (IQR: 1-10). Frailty was identified on 40% of all GA, resulting in 282 referrals to PT/OT (99% compliance) and 110 PT/OT evaluations (40% conversion). Participants attended a median of 6 PT/OT visits (IQR: 2 to 19) and 47% had outcomes available at initial evaluation and discharge (n=52). Significant improvements were observed in GPH (Mean∆=2.82±6.96, p=.003), GMH (Mean∆=3.71±7.76, p<.001), PF (n=48, Mean∆=2.31±7.18, p=.015) and non-significant improvements were observed in SRA (n=48, Mean∆=1.53±6.90, p=.066). Most who completed the PE survey (N=44) agreed the GA was simple to complete (98% agreement), took an appropriate amount of time (93% agreement, median: 10 min), was helpful to monitor for treatment side effects (77% agreement), was an added benefit to their care (72% agreement), and they would recommend to peers (79% agreement). Conclusions: An electronic capture frailty monitoring and PT/OT triage system using patient-reported GA was feasible in a community oncology practice and positively impacted patients’ health-related quality of life and experience during systemic therapy. Community oncology practices using GA should incorporate PT/OT triage into routine care to optimize patient outcomes and experience. Clinical trial information: NCT04852575 .

Early Palliative Care Initiation: Role of the Primary Care Clinician

Palliative care provided to patients with chronic life-limiting illnesses shows improvement in symptom management, quality of life, and caregiver support while reducing cost of care. Early initiation of palliative care faces a multitude of barriers in the primary care setting, including provider confidence, coordination and implementation, education, and family and patient misconceptions. A team-based approach along with additional education, clear referral triggers, and resources for advanced-care planning discussions allows providers to overcome many of these barriers. With the population’s advancing age, it is essential that primary care providers are properly prepared for early initiation of palliative care.

Triggers for Referral to Specialized Palliative Care in Advanced Neurologic and Neurosurgical Conditions: A Systematic Review.

To systematically review the literature for the most suitable trigger criteria for referral to specialist palliative care services in life-limiting and life-threatening neurologic and neurosurgical conditions. Literature searches were conducted in Ovid MEDLINE and EMBASE (1990-December 2020). To be included, studies must have trigger/referral criteria clearly outlined, a ≥75% nononcology neurosciences population, and consensus or guidelines documents regarding palliative neurosciences or trigger/referral criteria. We excluded studies that had an oncologic or non-neurosciences population as the main focus of study, trigger and referral criteria not clearly outlined, and no primary or duplicative data. The protocol was registered with PROSPERO (CRD4202013579), and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The American Academy of Neurology Clinical Practice Guidelines Process Manual was used to assess for risk of bias. Our search identified 1,748 publications, of which 22 articles met the eligibility criteria. Studies were considered in 2 main groups: (A) studies designed specifically to identify trigger criteria for referral to specialized neuropalliative care services (n = 9) and (B) studies that retrospectively reported the reason for referral to specialized palliative care or reflected a consensus statement among people with advanced neurologic illness (n = 13). Overall, the results suggest that several published referral triggers for specialized neuropalliative care are based on expert consensus. However, there is a growing body of literature providing evidence-based condition-specific triggers for multiple sclerosis, parkinsonism, amyotrophic lateral sclerosis, and dementia. There is a growing body of research that outlines evidence-based referral triggers for neuropalliative care. The ambiguity of nomenclature surrounding referral triggers in the current literature and field of neuropalliative care was a limitation to this study. We suggest that condition-specific triggers are likely to be the most effective for identifying the appropriate patients and timing for referral to specialist palliative care. (PROSPERO registration number: CRD42020135791, crd.york.ac.uk/prospero).

Pediatric Cardiology Teams interact with Pediatric Palliative Care (PPC) Teams for children's and family's best interest: Results from a multicentric study in France

Specialized Pediatric Palliative Care (PPC) teams address unmet needs and improve quality of life in patients with Life Limiting Conditions across pediatric subspecialties. However little is known about frequency, timing and trigger for PPC referral in non-malignant diseases. We hereby describe how, when and why french cardiologists interact with PPC teams. We conducted a retrospective nationwide survey among PPC teams in France. All patients referred to PPC team for a cardiologic disease in 2019 were studied. Among 6 respondent PPC teams, 18 patients and families met PPC teams in 2019 for an advanced heart disease. 12 had Congenital Heart Defect (CHD) and 6 had cardiomyopathy. No other diagnosis was represented. Median age at referral was 0.9 months for CHD and 72 months for cardiomyopathy. 61% of the patients were less than 1 years old. Antenatal diagnosis concerned 6 families with CHD and 2 of them were referred to PPC before birth allowing prenatal palliative care project. Main trigger for referral was ethical consideration (50%) followed by organization for home based palliative care (28%). PPC teams did participate to ethical discussion when asked to but also provided home-based PPC (9/18), family support (12/18), coordination of care (5/18), support of referring team (4/18) and symptoms management (3/18) Trigger for referral to PPC team is mainly for help in decision making in palliative care context and life threatening complications but PPC teams interventions tend to develop a holistic model of care. Pediatric cardiologist and PPC teams already interact in children's best interest in France, outcomes measurement and partnerships are ready to be developed.

Evaluating the Need for Integrated Pediatric Palliative Care Services in a Pediatric Oncology Setting: A Retrospective Audit.

Objectives:Early integrated palliative care has shown to improve the quality of life in patients with cancer. During the past decade, pediatric palliative care has become an established area of medical expertise, however due to scant information available regarding the triggers for referral and referral practice very few children receive a formal palliative care consult.Materials and Methods:A retrospective audit of medical case records of pediatric oncology patients over a period of 1 year from September 30, 2019, to September 30, 2020, was conducted. Demographic details, diagnosis, staging, clinical parameters, reason for referral, and palliative care plan were captured in a predesigned pro forma.Results:Among 126 children with cancer, 27 (21.4%) patients were referred to palliative care. Majority 21 (77%) referrals were inpatient consults. Symptom management 17 (44.7%) was the most common trigger for referral followed by referrals for psychosocial support 12 (14.4%). Children with solid tumors 16 (59%) were more often referred than hematological malignancies. Among those needing end of life care, 8 (88.8%) out of 9 families preferred home than hospital.Conclusion:Low incidence of palliative care referral and presence of symptoms as a trigger for palliative care referral suggests gaps in the integrated approach. The study findings prompt a review of palliative care referral criteria and referral practice in a pediatric oncology setting.

Pediatric cardiology teams interact with pediatric palliative care (PPC) Teams for children's and family's best interest: Results from a multicentric study in France

Specialized Pediatric Palliative Care (PPC) teams address unmet needs and improve quality of life in patients with Life Limiting Conditions across pediatric subspecialties. However little is known about frequency, timing and trigger for PPC referral in non-malignant diseases. We hereby describe how, when and why french cardiologists interact with PPC teams. We conducted a retrospective nationwide survey among PPC teams in France. All patients referred to PPC team for a cardiologic disease in 2019 were studied. Among 6 respondent PPC teams, 18 patients and families met PPC teams in 2019 for an advanced heart disease. 12 had Congenital Heart Defect (CHD) and 6 had cardiomyopathy. No other diagnosis was represented. Median age at referral was 0.9 months for CHD and 72 months for cardiomyopathy. 61% of the patients were less than 1 years old. Antenatal diagnosis concerned 6 families with CHD and 2 of them were referred to PPC before birth allowing prenatal palliative care project. Main trigger for referral was ethical consideration (50%) followed by organization for home based palliative care (28%). PPC teams did participate to ethical discussion when asked to but also provided home-based PPC (9/18), family support (12/18), coordination of care (5/18), support of referring team (4/18) and symptoms management (3/18) Trigger for referral to PPC team is mainly for help in decision making in palliative care context and life threatening complications but PPC teams interventions tend to develop a holistic model of care. Pediatric cardiologist and PPC teams already interact in children's best interest in France, outcomes measurement and partnerships are ready to be developed.

Nurse Practitioner’s Clinical Triggers for Referral to Other 3D Team Members

This presentation features how 3D Team nurse practitioners (NP) use results of clinical assessments to determine whether older adults and caregivers enrolled in the study are referred to other Team members; these assessment results are called “clinical triggers”. Other team members who receive referrals based on NP-generated clinical triggers include: Licensed Clinical Social Workers, who deliver Problem Solving Therapy to older adults with significant depressive symptoms; Occupational Therapists, who deliver an evidence-based dementia care intervention; Physical Therapists, who deliver an adapted Otago exercise program; Registered Dietician, who provides nutrition and dietary instruction; and Community Health Educator, who provides community resource information to address social determinants of health. All clinical triggers will be detailed in this presentation, along with a description of each intervention delivered by other team members except the Community Health Educator. Case studies will be presented to illustrate how study participants receive multiple interventions from the 3D Team.

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.

When to Integrate Palliative Care in the Trajectory of Cancer Care.

Palliative care provides an extra layer of support to patients and families facing a serious illness. To date, several studies support the use of early, integrated palliative care for patients with cancer, based upon documented improvements in quality of life, symptoms, mood, satisfaction, utilization, and even overall survival. Despite this, patients with cancer continue to have unmet palliative care needs, and palliative care services are often engaged late in their care, if at all. Amid this under-utilization, questions remain about the optimal timing and nature of palliative care integration. To answer this question, we briefly review the evidence based for palliative care in oncology, and discuss three approaches to optimizing the timing of palliative care integration: (1) prognosis-based, (2) needs-based, and (3) trigger-based models. Prognosis-based models most closely mirror the approach of randomized trials to date, but are overly dependent on prognostication, and may miss patients with unmet needs who do not meet standard definitions of poor-prognosis disease. Needs-based models may better capture patients in a personalized manner, based on actual needs, but require sophisticated screening systems to be integrated into routine care processes, along with clinician buy-in. This may lead to excessive referrals, which strain the already limited palliative care workforce. As such, a blended, trigger-based approach may be best, allowing one to utilize certain disease-based and prognosis-based triggers for referral, plus screening of unmet needs, to identify those patients most likely to benefit from integrated palliative care when they need it most.

Lung transplant referral practice patterns: a survey of cystic fibrosis physicians and general pulmonologists

BackgroundMany individuals with cystic fibrosis (CF) die from respiratory failure without referral for lung transplant. Physician practices that may expedite, delay, or preclude referral, are poorly understood.MethodsTwo parallel, web-based surveys focusing on lung transplant referral triggers and barriers, as well as pre-referral evaluation, were emailed to pulmonologists practicing in the New England region. One questionnaire was sent to CF providers (n = 61), and the second to general pulmonary providers practicing at the same institutions (n = 61).ResultsThere were 43 (70%) responses to the CF provider survey, and 25 (41%) responses to the general pulmonary (‘non-CF’) provider survey. Primary reasons for CF providers to refer their patients included: rapidly declining lung function (91%) and a forced expiratory volume in 1 s (FEV1) below 30% predicted (74%). The greatest barriers to referral for both CF and non-CF providers included active tobacco use (65 and 96%, respectively, would not refer), and active alcohol or other substance use or dependence (63 and 80%). Furthermore, up to 42% of CF providers would potentially delay their referral if triple-combination therapy or other promising new, disease-specific therapy were anticipated. In general, non-CF providers perform a more robust pre-referral medical work-up, while CF providers complete a psychosocial evaluation in higher numbers. Across both groups, communication with lung transplant programs was reported to be inadequate.ConclusionsPhysician-level barriers to timely lung transplant referral exist and need to be addressed. Enhanced communication between lung transplant programs and pulmonary providers may reduce these barriers.

Women and Infants in the Deep South Receiving Perinatal and Neonatal Palliative and Supportive Care Services

While women in the Deep South area of the United States have higher rates of maternal and infant mortality, palliative and supportive care programs are lacking. Additionally, few studies have detailed referral triggers that are specific to the mother, infant, or pregnancy for inclusion in perinatal and neonatal palliative and supportive care programs. The purpose of this retrospective, descriptive study was to examine the sociodemographic factors and referral triggers for perinatal-neonatal palliative and supportive care services for women enrolled in a newly developed perinatal-neonatal palliative and supportive care program. Data were collected from medical records of 135 women enrolled in the program. Triggers for referral to the program were classified as fetal, maternal, or prenatal complications. A diverse sample of women were enrolled in the program. Most infants survived to birth and discharge from the hospital. Two-thirds of referrals were related to infant complications and 34% were for multiple complications (fetal, maternal, and/or prenatal). Triggers for referral to the program were not related to sociodemographic characteristics of women. A comprehensive list of triggers that include maternal and prenatal complications, in addition to infant complications, may ensure at-risk women and infants, are enrolled in perinatal-neonatal palliative and supportive care programs early in pregnancy, regardless of sociodemographic factors. Prospective research on the effectiveness of perinatal-neonatal palliative and supportive care programs in diverse populations of women is needed. This includes the examination of family health outcomes and provider perspectives.

"Triggers" for early palliative care referral in patients with cancer: a review of urgent unplanned admissions and outcomes.

Benefits of early palliative referral in oncology are well documented. Palliative care referral "triggers" may help identify patients for referral. Many triggers have been proposed, but are not commonly used. This study reviewed the timing of palliative care involvement for patients in a tertiary referral oncology hospital, and whether the use of a trigger tool prior to admission would have facilitated earlier referral. This was a retrospective cohort study of cancer patients who died during an unplanned admission between November 2014 and October 2015. A literature review identified seven palliative care referral tools which were included in this analysis, and compared by identifying common themes. Each tool was applied to patients by reviewing electronic patient records. Timing of palliative referral and whether patients met any triggers within 6 months before their terminal admission were assessed. A total of 159 patients were identified. Forty-six percent were referred to palliative care prior to terminal admission. Application of 6 out of 7 trigger tools would have resulted in the majority of patients (up to 91.2%) referred to palliative care prior to admission. Most patients (52.2%) were referred only during their terminal admission. Patients known to palliative care before admission (N = 73) were reviewed quicker than those who were not (N = 86) (median (range) 1 day (0-23 days) versus 5 days (0-59 days), p < 0.00001). In this patient cohort, a palliative referral trigger tool may have proactively identified most patients prior to their terminal admission. Prospective testing of trigger tools in oncology populations is warranted.

Favorable Outcome of Lung Transplantation for Severe Pulmonary Graft Versus Host Disease: An Australian Multicenter Case Series.

Severe pulmonary chronic graft versus host disease (GVHD) is a life-threatening complication of allogeneic hematopoietic stem cell transplantation. Few treatments influence outcome, with 5-year overall survival as low as 13%. Lung transplantation (LTx) has been reported in small numbers of patients worldwide. We investigated the outcomes of LTx performed for this indication at 2 large Australian LTx centers. Eighteen patients (aged 10-64 y; median, 29.6 y) received bilateral deceased lung transplants for pulmonary chronic GVHD between 2002 and 2017. LTx was performed at a median of 8.6 years after allogeneic stem cell transplantation (range, 2-23 y) with a median interval of 16 months from the time of transplant unit review to LTx. There were 2 early infective deaths and 3 further deaths from pulmonary infection and lung allograft rejection. There were no primary disease relapses. At a median follow-up of 5 years, the 5-year overall survival post-LTx is 80% and comparable to the Australia and New Zealand registry data of 64% for LTx performed for all indications. From one of the largest series of deceased LTx for this indication, we conclude that it is a feasible option for selected patients with severe pulmonary GVHD. The outcomes appear superior to that of non-LTx-based therapies and similar to the survival of the general LTx population. Establishing guidance on referral triggers, patient eligibility, organ selection, prophylaxis of allograft rejection, and supportive care would assist hematopoietic and lung transplant units in optimizing resource allocation and patient outcomes.

116.2: Electronic hospital donor referrals have arrived.

Background: The Centers for Medicare and Medicaid Services in the United States and additional regulatory organizations require that hospitals refer all potential organ, tissue and/or eye donors to their designated Organ Procurement Organization (OPO). To replace the current time-consuming and error-prone telephonic referral process, one OPO, its software system partner, a Hospital clinical team and their Electronic Medical Record (EMR) team successfully collaborated to implement the first-ever secure direct and automatic electronic donor referral interface between a Hospital EMR system and an OPO donor management system. The goals of the interface include: (1) increase the number and timeliness of referrals (and thus transplantable organs); (2) reduce Hospital and OPO resource costs; and (3) reduce risk of error due to human verbal communication and transcription risk. Methods: The multi-disciplinary team collaboratively created a secure technical interface directly connecting the OPO and Hospital systems. The team designed seamless donor referral triggers within the Hospital EMR which expanded upon existing Best Practice Advisory (BPA) notifications that previously instructed the EMR user to call in the referral, and now automatically deliver electronic donor referrals from the Hospital to the OPO. Immediately upon receipt, the OPO’s electronic donor management system creates a new referral that is auto-populated with actionable patient information and delivers real-time notifications alerting OPO staff of the new referral. The interface automatically returns the associated OPO referral ID number to the patient’s EMR. This interface was successfully launched in the Hospital ICU in October 2018. In April 2019 (six months later), the Hospital successfully rolled out the interface to additional units and facility locations, and numerous additional interface discussions and implementations are currently underway. Results: Immediately, the monthly referral count from the Hospital ICU to the OPO quadrupled (October 2017 = 18; October 2018 = 72). Since the launch, the OPO has been able to convert on a total of 36 organ, tissue, and eye donors across the facility. The use of an existing BPA resulted in minimal change to Standard Operating Procedures and reduced the need for clinical team training. Successfully transmitted referrals contained zero (0) errors in data transmission. Higher levels of awareness of organ donation potential in the units was observed. Conclusions: The current results were successful in the following measures: 1) increased number of referrals; 2) reduction in resource cost; and 3) decreased errors. The interface was established using standard interoperability technology connecting widely-adopted OPO donation software and Hospital EMR Systems to allow for scalable expansion. There is unlimited potential for streamlining the referral process through this electronic interface, ultimately leading to more donors and transplantations.

Managing common mental health disorders in healthcare workers.

Approximately a quarter of sickness absence in the UK National Health Service (NHS) is attributed to common mental health disorders (CMHDs). This is costly to the NHS and impacts on patient care and staff morale. Little is known about the occupational health (OH) management of NHS staff who take sick leave for CMHDs. To explore the current OH management of NHS staff on sick leave for CMHDs. We invited providers of NHS OH services identified from the NHS Health at Work Network and Commercial OH Providers Association to complete a survey on the management of employees off work because of CMHDs. Analysis involved descriptive statistics and content analysis. Forty-nine (39%) of the 126 OH departments approached responded. The majority (98%) had an organizational sickness absence policy that included triggers for referral for staff absent with CMHDs. In 63%, referral occurred 8-28 days after the onset of absence; in 92%, the consultation was completed by an OH nurse or OH physician. Content of the first consultation often included assessment of symptoms and medication for CMHDs. Case management and regular reviews were least commonly used despite evidence on their effectiveness in supporting return to work. All providers offered some support for managers of staff with CMHDs. Variation existed between providers of NHS OH services in the timing of referrals, use of case management and regular reviews for staff with CMHDs. Our findings suggest that current evidence-based guidance on interventions to improve return to work is not being implemented consistently.

Implications of Pediatric Palliative Consultation for Intensive Care Unit Stay.

Background: The impact of specialty pediatric palliative care (PPC) on intensive care unit (ICU) length of stay for children is unclear. Objective: To estimate the impact of PPC consultation by analyzing ICU stay as a dynamic outcome over the course of hospitalization. Patients and Methods: Retrospective cohort study of children hospitalized with diagnoses suggested as referral triggers for PPC at a large academic children's hospital. We assessed ICU stay according to PPC consultation and, using a patient-day analysis, applied multivariable mixed effects logistic regression to predict the odds of being in the ICU on a given day. Results: The analytic sample included 777 admissions (11,954 hospital days), of which 100 admissions (13%) included PPC consultation. Principal patient demographics were age 8 ± 6 years, 55% male sex, 71% white race, and 52% commercial insurance. Cardiac diagnoses were most frequent (29%) followed by gastrointestinal (22%) and malignant (20%) conditions. Although total ICU stay was longer for admissions, including PPC consultation (compared to admissions where PPC was not consulted), the odds of being in the ICU on a given day were reduced by 79% after PPC consultation (odds ratio [OR] = 0.21; 95% confidence interval [CI]: 0.13-0.34; p < 0.001) for children with cancer and 85% (OR = 0.15; 95% CI: 0.08-0.26; p < 0.001) for children with nononcologic conditions. Conclusions: Among children hospitalized with a diagnosis deemed eligible for specialty PPC, the likelihood of being in the ICU on a given day was strongly reduced after PPC consultation, supporting the value of PPC.

Physician awareness of decompressive hemicraniectomy for malignant middle cerebral artery infarction in Saudi Arabia and the Gulf countries.

Objectives:To explore the perspective on Decompressive craniectomy (DH) of each of these specialties to establish common grounds for improved clinical practice.Method:An electronic survey was distributed via email and social media groups to members of these specialties in Kingdom of Saudi Arabia and the Gulf countries. Local practices, common triggers for referral for DH, perceived outcomes of these procedures, individual impression of what constitutes good clinical outcomes were explored.Results:There are 89 physicians participated: 41 (46.1%) neurologists, 34 (38.2%) neurosurgeons, and 14 (15.7%) intensivests. Participants are mostly practicing in intermediate volume centers or high volume centers. Half of the neurosurgeons preferred to be consulted immediately on candidates with large middle cerebral artery (MCA) strokes. The most important referral trigger for DH was clinical changes. The modified Rankin Scale (mRS) cutoff for good clinical outcome was 3 for 73.6% of respondents. There was agreement that DH only improves survival (64.4%). A third of the neurologists considered it to improve functional outcome compared to 15.4% of intensivests and 14.8% of neurosurgeons. There was agreement (66.7%) that patients older than 60 years with involvement of more than one territory should be excluded from DH. Only 7.7% of neurosurgeons excluded patients with dominant hemispheric strokes.Conclusion:Our physicians’ views are variable in what’s called acceptable outcome, and further studies are needed to to test the characteristics that helps in decision making such as hemisphere dominancy, time onset of stroke and vital radiological signs. This is seen despite the literature being full of data that supports the DC over medical management in malignant MCA infarction. Better multidisciplinary education initiatives are needed to unify the understanding and help improve the practices in this challenging subset of patients.

Occupational medicine specialist referral triggers: Mixed-methods analysis of teleconsult cases.

Qualitative analyses can yield critical lessons for learning organizations in healthcare. Few studies have applied these techniques in the field of occupational and environmental medicine (OEM). To describe the characteristics of complex cases referred for OEM subspecialty evaluation and variation by referring provider's training. Using a mixed methods approach, we conducted a content analysis of clinical cases submitted to a national OEM teleconsult service. Consecutive cases entered between April 2014 and July 2015 were screened, coded and analysed. 108 cases were available for analysis. Local Veterans Health Administration (VHA) non-specialist providers entered a primary medical diagnosis in 96% of cases at the time of intake. OEM speciality physicians coded significant medical conditions based on free text comments. Coder inter-rater reliability was 84%. The most frequent medical diagnosis types associated with tertiary OEM referral by non-specialists were endocrine (19%), cardiovascular (18%) and mental health (16%). Concern for usage of controlled and/or sedating medications was cited in 1% of cases. Compared to referring non-specialists, OEM physicians were more likely to attribute case complexity to musculoskeletal (OR: 2.3, 1.68-3.14) or neurological (OR: 1.69, 1.28-2.24) conditions. Medication usage (OR: 2.2, 1.49-2.26) was more likely to be a source of clinical concern among referring providers. The findings highlight the range of triggers for OEM physician subspecialty referral in clinical practice with employee patients. The results of this study can be used to inform development of provider education, standardized clinical practice pathways, and quality review activities for occupational medicine practitioners.

Predictors of referral to outpatient specialty palliative care (SPC) in gynecologic cancer (GC) patients.

159 Background: Prior studies in GC patients have described predictors of inpatient palliative care (PC) consultation, but predictors of outpatient SPC consultation have not been elucidated. We sought to identify factors predictive of referral and associated care outcomes. Methods: We performed a cross-sectional study of GC patients seen in the gynecologic oncology clinic at a comprehensive cancer center over a three month period. As a part of routine care, patients completed a symptom questionnaire. Patients previously seen at the outpatient PC clinic were compared to those who had not with respect to demographics, disease characteristics, symptom scores, and provider factors using univariate statistics. A multivariate model was created to identify independent predictors of referral. Results: 913 patients completed the symptom survey. 76 patients (8%) had been seen in the outpatient PC clinic. Disease factors associated with referral included site (p &lt; 0.01), stage (p &lt; 0.01), evidence of disease (p &lt; 0.01), active treatment (p &lt; 0.01), and time point in the disease trajectory (p &lt; 0.01). Women with moderate to severe pain (p &lt; 0.01), sadness (p = 0.03), distress (p &lt; 0.01), fatigue (p &lt; 0.01), neuropathy (p = 0.03), and sexual dysfunction (p &lt; 0.01) were more likely to have seen PC. Marital status, number of symptoms, and patient provider were also predictive of referral (all p &lt; 0.01). In a multivariate model, site, stage, number of symptoms, moderate to severe sexual dysfunction, and provider were independently associated with referral. Compared to women who had not been referred, patients seen in the PC clinic were more likely to have a health care proxy documented in the electronic medical record (p &lt; 0.01). Among patients with related symptoms, patients referred to PC more often had an opioid prescribed for pain (p &lt; 0.01) and medications prescribed for depression (p &lt; 0.01), anxiety (p = 0.04), insomnia (p &lt; 0.01), and fatigue (p &lt; 0.01). Conclusions: Women with depression, anxiety, insomnia, and fatigue were more likely to receive pharmacologic treatment for these symptoms from a SPC provider. Future research should identify referral triggers for those patients most likely to benefit from outpatient SPC consultation.