Perioperative consultative hematology: can you clear my patient for a procedure?

Periprocedural management of antithrombotics is a common but challenging clinical scenario that renders patients vulnerable to potential adverse events such as bleeding and thrombosis. Over the past decade, periprocedural antithrombotic approaches have changed considerably with the advent of direct oral anticoagulants (DOACs), as well as a paradigm shift away from bridging in many warfarin patients. Successfully navigating this high-risk period relies on a number of individualized patient assessments conducted within a framework of standardized, systematic approaches. It also requires a thorough understanding of antithrombotic pharmacokinetics, multidisciplinary coordination of care, and comprehensive patient education and empowerment. In this article, we provide clinicians with a practical, stepwise approach to periprocedural management of antithrombotic agents through case-based examples of relevant clinical scenarios.

How to use thionamide anti-thyroid drug in the young– what’s new?

The excess thyroid hormone secretion that characterises Graves’ disease (GD) is generated when stimulatory antibodies bind to the thyroid stimulating hormone receptor on the follicular cell of the thyroid gland.This underlying mechanism cannot easily be abolished and the mainstay of Graves’ disease (GD) management in the young remains thionamide anti-thyroid drug (ATD). Unfortunately, GD will usually recur after a 2 or 3 year course of ATD, even when the stimulatory antibody titres have fallen. The diagnosis of GD therefore usually signals the start of a lengthy period of out-patient assessments and associated venepuncture. Careful, more protracted administration of ATD may increase the likelihood of longer-term remission and reduce the likelihood of the patient developing ATD side-effects. An understanding of how best to use ATD and an awareness of the less well-known consequences of GD and its’ treatment - such as excessive weight-gain and long-term hypothyroidism – are also of fundamental importance.Recent clinical studies have shed light on how best to manage the young patient with GD and the associated new information will help to answer some of the questions posed by the young person and their family at diagnosis. This new knowledge is the focus of this article about ATD therapy in the young.

Clinical Efficiency and Safety Outcomes of Virtual Care for Oncology Patients During the COVID-19 Pandemic

PURPOSE: Telehealth has been an integral response to the COVID-19 pandemic. However, no studies to date have examined the utility and safety of telehealth for oncology patients undergoing systemic treatments. Concerns of the adequacy of virtual patient assessments for oncology patients include the risk and high acuity of illness and complications while on treatment. METHODS: We assessed metrics related to clinical efficiency and treatment safety after propensity matching of newly referred patients starting systemic therapy where care was in large part replaced by telehealth between March and May 2020, and 206 newly referred patients from a similar time period in 2019 where all encounters were in-person visits. RESULTS: Patient-initiated telephone encounters that capture care or effort outside of visits, time to staging imaging, and time to therapy initiation were not significantly different between cohorts. Similarly, 3 month all-cause or cancer-specific emergency department presentations and hospitalizations, and treatment delays were not significantly different between cohorts. There were substantial savings in travel time with virtual care, with an average of 211.4 minutes saved per patient over a 3-month interval. CONCLUSION: Our results indicate that replacement of in-person care with virtual care in oncology does not lead to worse efficiency or outcomes. Given the increased barriers to patients seeking oncology care during the pandemic, our study indicates that telehealth efforts may be safely intensified. These findings also have implications for the continual use of virtual care in oncology beyond the pandemic.

Prospective Evaluation of Health Care Provider and Patient Assessments in Chemotherapy Induced Peripheral Neurotoxicity

OBJECTIVEThere is not agreement on the “gold standard” for detection and grading of Chemotherapy Induced Peripheral Neurotoxicity (CIPN) in clinical trials. We performed an observational prospective study to assess and compare both patient-based and physician-based methods.METHODSConsecutive patients, aged 18 years or older, candidates for neurotoxic chemotherapy were enrolled in US/EU/Australia. A trained investigator performed physician-based scales (Total Neuropathy Score clinical [©Johns Hopkins University; TNSc], then used to calculate TNS nurse [TNSn]) and supervised the patient-completed questionnaire (FACT/GOG-NTX©). Evaluations were performed before and at the end of chemotherapy. On participants without neuropathy at baseline we assessed the association between TNSc, TNSn and FACT/GOG-NTX. Considering a previously established Minimal Clinically Important Difference (MCID) for FACT/GOG-NTX, we identified participants with and without a clinically important deterioration according to this scale. Then, we calculated the MCID for TNSc and TNSn as the difference in the mean change score of these scales between the two groups.RESULTSData from 254 participants were available, 180 (71%) had normal neurological status at baseline. At the end of the study, 88% of participants developed any grade of neuropathy. TNSc, TNSn and FACT/GOG-NTX showed good responsiveness (standardized mean change from baseline to end of chemotherapy >1 for all scales). On the 153 participants without neuropathy at baseline and treated with a known neurotoxic chemotherapy regimen we verified a moderate correlation in both TNSc and TNSn scores with FACT/GOG-NTX (Spearman correlation index r=0.6). On the same sample, considering as clinically important a change in the FACT/GOG-NTX score of at least 3.3 points, the MCID was 3.7 for TNSc and 2.8 for the TNSn.CONCLUSIONSMCID for TNSc and TNSn have been calculated, and the TNSn can be considered a reliable alternative objective clinical assessment if a more extended neurological examination is not possible. Moreover, the FACT/GOG-NTX score can be reduced to 7 items and these items correlate well with the TNSc and TNSn.CLASSIFICATION OF EVIDENCEThis study provides Class III evidence that a patient-completed questionnaire and nurse-assessed scale correlate with a physician-assessed scale.

Improving the quality of GP referrals to the Croydon Assessment & Liaison Team

AimsTo increase the percentage of GP referrals to the Croydon Assessment & Liaison (A&L) Team deemed to be of ‘good quality’. The A&L Team receives a large number of referrals daily from GPs, and it was identified that many of these referrals did not include important and relevant information, leading to delays in patient assessments.MethodA questionnaire was distributed to A&L MDT members to collect information about what information they consider important in a GP referral. The project team reviewed the results of the questionnaire, along with current policies and guidelines, to create a set of criteria by which to assess the quality of GP referrals, as there was no pre-existing gold standard available. A random sample of 6 GP referrals per week stratified by locality was collected and assessed against these criteria.Using Plan-Do-Study-Act (PDSA) methodology change ideas were generated, and a GP referral form was identified as an important intervention to adopt. A previously-developed draft form was updated after a round of consultations with various stakeholders including Assessment & Liaison staff, GPs and the CCG. The new GP referral form was uploaded to the GP DSX electronic referrals platform and GP practices were also emailed directly to encourage them to use the new form.The proportion of GP referrals deemed to be of good quality was compared pre and post-intervention. Uptake of the new GP referral form was recorded as a process measure, and the length of time taken to discuss referrals at A&L daily referrals meetings as a counterbalance measure.ResultAt baseline 33% of GP referrals were deemed to be of good quality using the developed criteria. This improved to 58% after implementation of the new referral form in January 2021. There was poor overall uptake of the form, with only 32.5% of GP referrals utilising the new form so far, however of the referrals received on the new form 69% fulfilled the criteria for good quality. Comparison of length of discussion required for referrals with and without the new form showed no significant difference (7.7 and 7.6 minutes respectively).ConclusionImplementation of a standardised GP referral form was effective at increasing the proportion of referrals deemed to be of good quality. However, further PDSA cycles focused on improving uptake of the form will be required.

The role of telephone consultations in psychiatry

AimsTelephone consultations have been in clinical use since the early 1960s and are increasing in frequency and importance in many areas of medicine. With the advent of the COVID-19 pandemic in 2020, the use of telemedicine consultations increased dramatically alongside utilization of other digital technologies. Despite promise and potential advantages for clinicians (including remote working, improved time management and safety) there are known drawbacks to telephone consultations for psychiatrists. This includes limitations to assessments of mental state and risk, with loss of non-verbal communication often cited as a point in favour of more sophisticated technologies such as video calling. By adopting telephone consultations to a greater extent during the initial months of the COVID-19 pandemic in the Coventry Crisis Resolution and Home Treatment Team (CRHTT), we aimed to assess the patient experience in telehealth, through a patient survey.MethodAfter an initial assessment or follow-up consultation with a medical practitioner from the crisis team, patients were invited to take part in a short questionnaire with a member of the administration staff. This consisted of eight questions on a Likert scale and three open questions for comments. Results were collated and analyzed via Microsoft Excel.ResultMost patients found the telephone consultations satisfactory, with more than 90% returning positive scores in understanding, convenience and overall satisfaction. All patients felt listened to and that their confidentiality was maintained; with all but one respondent willing to engage in further consultations via the telephone. Negative scores were typically returned for practical telephonic problems including poor signal, interference and background noise. In their comments patients expressed largely positive views about their experience with their clinician; analysis revealed key insights into the patient experience, demonstrating the convenience, comfort and flexibility possible with ‘telepsychiatry’.ConclusionPatient experience of telemedicine in a UK psychiatric crisis team is mostly positive, with clear advantages for both patients and clinicians. Our results show telephone consultations can be expanded to new patient assessments alongside follow-ups, enabling the team to reach a greater number of service users. This includes service users who are housebound due to infirmity, required to shield or have significant anxiety about the pandemic.

PLAN standards and writing to patients: quality improvement by audit

AimsThis quality improvement project aimed to assess the adherence of a hospital psychiatric liaison team's documentation of assessments to the Psychiatric Liaison Accreditation Network (PLAN) standards framework; to identify areas of improvement; to identify barriers to and improve adherence.MethodData were extracted from 27 randomly selected patient assessments from 01/07/2020 to 31/08/2020 and then 27 assessments from 01/10/2020 to 30/11/2020 for re-audit.Quantitative data was collected by calculating the percentage of assessments which documented each specific aspect of PLAN standards.Qualitative data including attitudes specifically towards writing to patients was gathered from 1:1 discussions with members of staff.Interventions between rounds of audit:Presentation of results of 1st data collection to team in November 2020 followed by discussionEmailed instructions to create a template based on PLAN standards for assessments to staffLobbied for Cerner access at liaison team office to facilitate use of aboveResultQuantitative – overall improvements were seen in adherence to all aspects of documentation of assessments including collateral history (from 23% to 67%) past medical history (30% to 70%) and acknowledging the patient/carer perspective (46% to 74%). Some improvement was seen in offering written correspondence to patients (0% to 20%).Qualitative – the majority of comments regarding writing to patients were positive, with no staff members opposing the standard (“it is best practice”, “should become a habit”). However, some barriers were identified including increased workload (“requires more editing”, “could take a lot more time”).ConclusionTeam adherence to PLAN standards for documentation of assessments was improved through low intensity interventions. Overall adherence was high, however certain areas leave space for improvement. The audit facilitated conversations around writing to patients on discharge, both in the form of formal gathering of qualitative data and informal discussions between staff. Attitudes towards writing these letters were positive and some improvement was seen between audits. Ongoing audit activity aims to further improve adherence and monitor improvements.

Redesign of a Transfusion Issue Form Using Human Factors Science

Blood transfusions are common procedures but are high risk for patient safety. Verification of the correct blood unit for the patient, assessments of the patient for symptoms of transfusion reactions, and quick responses to suspected reactions are the main interventions to ensure this process are safe. Each of these steps is aided by the transfusion issue form. We identified opportunities to use human factors principles to redesign and evaluate the form. We provide a discussion of the specific design changes and methods to facilitate use in other contexts.

Point-of-care ultrasound in a multiplace hyperbaric chamber

Historically, electronic devices have been generally prohibited during hyperbaric oxygen (HBO2) therapy due to risk of fire in a pressurized, oxygen-rich environment. Point-of-care ultrasound (POCUS), however, has emerged as a useful imaging modality in diverse clinical settings. Hyperbaric chambers treating critically ill patients would benefit from the application of POCUS at pressure to make real-time patient assessments. Thus far, POCUS during HBO2 therapy has been limited due to required equipment modifications to meet safety standards. Here we demonstrate proof of concept, safety, and successful performance of an off-the-shelf handheld POCUS system (SonoSite iViz) in a clinical hyperbaric environment without need for modification.

Patient Satisfaction in Postanesthesia Unit: Matched Study Participant Methodology

ObjectivesThe aim of this study is to determine patient satisfaction compared to nurse perception of patient satisfaction in Peri-anesthesia unit.BackgroundIn 2014 American Society of Anesthesiology published guidelines stating standards for care for hypervigilance during perioperative patient assessments. Other policy publications focus on equipment and practices in this clinical setting. However, none of these sources provide an account of patient experience.MethodsThis is a Prospective, convenience paired matched sampling study using Three multichoice questionnaires were distributed to patients and nurses in this unit. Both nurse and patient questionnaires were distributed simultaneously and paired.Results200 patients and total staff 30 nurses, 26 participated in the study-response rate 87%. Patients' perception showed highest level of satisfaction in nurses' listening. The nurses rated patients' satisfaction with communication and environmental conditions highest compared to other categories. The only significant difference between the nurses and patients' perceptions was in specific symptom communication, patients rated this lower satisfaction compared to nurses ranking this domain.ConclusionIn conclusion, similarity was found between nurses' and patients' ratings. This knowledge is relevant in raising awareness that nurses should be more vigilant evaluating and inquiring about peri-operative patients' symptoms.