170 Social and Environmental Benefits of Virtual Fracture Clinics in Trauma and Orthopaedic Surgery: Reduced Patient Travel Time, Patient Cost and Air Pollutant Emissions

Aim Several papers have analysed the clinical benefits and safety of Virtual Fracture Clinics (VFCs). A significant increase in the use of Trauma and Orthopaedic (T&O) VFCs was seen during the COVID-19 pandemic. This study aims to investigate the social impact of VFCs on the travel burden and travel costs of T&O patients, as well as the potential environmental benefits in relation to fuel consumption and travel-related pollutant emissions. Method All patients referred for T&O VFC review from March 2020 to June 2020 were retrospectively analysed. The travel burden and environmental impacts of hypothetical face-to-face consultations were compared with these VFC reviews. The primary outcomes measured were patient travel time saved, patient travel distance saved, patient cost savings and reduction in air-pollutant emissions. Results Over a four-month period, 1359 VFC consultations were conducted. The average travel distance saved by VFC review was 88.6 kilometres (range 3.3-615), with an average of 73 minutes (range 9-390) of travel-time saved. Patients consumed, on average, 8.2 litres (range 0.3-57.8) less fuel and saved an average of €11.02 (range 0.41-76.59). The average reduction in air-pollutant vehicle emissions, including carbon dioxide, carbon monoxide, nitric oxides and volatile organic compounds was 20.3 kilograms (range 0.8-140.8), 517.3 grams (g) (range 19.3-3592.3), 38.1g (range 1.4-264.8) and 56.9g (range 2.1-395.2), respectively. Conclusions VFCs reduce patient travel distance, travel time and travel costs. In addition, VFCs confer significant environmental benefits through reduced fuel consumption and reduction of harmful environmental emissions.

Analyzing the Carbon Footprint of an Intravitreal Injection

Purpose: To estimate the carbon footprint of a single intravitreal injection in a hospital-based intravitreal service. Methods: Greenhouse gas emissions attributable to the delivery of an intravitreal injection were calculated using a hybrid lifecycle analysis technique. Data were collected regarding procurement of materials, patient travel, and building energy use. Results: Carbon emissions associated with a single intravitreal injection, excluding the anti-VEGF agent, were 13.68 kg CO2eq. This equates to 82,100 kg CO2eq annually for our service. Patient travel accounted for the majority of emissions at 77%, with procurement accounting 19% for and building energy usage for 4% of total emissions. The omission of items considered dispensable from injection packs would reduce carbon emissions by an estimated 0.56 kg per injection – an annual saving of 3,360 kg CO2eq for our service. Similar savings, if extrapolated to a country the size of the United Kingdom, could yield annual carbon savings of 450,000 kg CO2eq. For context, a single one-way economy transatlantic flight produces 480 kg CO2eq per person. Conclusion: Wasteful practice in healthcare increases greenhouse gas production and drives climate change. The healthcare sector should be a leader in sustainable practice promotion and changes to high volume procedures have the largest impact on emissions. Long-acting agents offer the greatest future potential for meaningful reductions.

Carbon footprint reduction associated with a surgical outreach clinic

Background Healthcare systems generate substantial carbon footprints that may be targeted to decrease greenhouse gas emissions. Outreach clinics may represent tools to assist in this reduction by optimizing patient related travel. Therefore, we sought to estimate the carbon footprint savings associated with a head and neck surgery outreach clinic. Methods This study was a cross-sectional survey of patient travel patterns to a surgical outreach clinic compared to a regional cancer treatment centre from December 2019 to February 2020. Participants completed a self-administered survey of 12 items eliciting travel distance, vehicle details, and ability to combine medical appointments. Canadian datasets of manufacturer provided vehicular efficiency were used to estimate carbon emissions for each participant. Geographic information systems were used for analyses. Results One hundred thirteen patients were included for analysis. The majority of patients (85.8%) used their own personal vehicle to travel to the outreach clinic. The median distance to the clinic and regional centre were 29.0 km (IQR 6.0–51.9) and 327.0 km (IQR 309.0–337.0) respectively. The mean carbon emission reduction per person was therefore 117,495.4 g (SD: 29,040.0) to 143,570.9 g (SD: 40,236.0). This represents up to 2.5% of an average individual’s yearly carbon footprint. Fewer than 10% of patients indicated they were able to carpool or group their appointments. Conclusion Surgical outreach clinics decrease carbon footprints associated with patient travel compared to continued care at a regional centre. Further research is needed to determine possible interventions to further reduce carbon emissions associated with the surgical care of patients. Graphical abstract

Automated Travel History Extraction From Clinical Notes for Informing the Detection of Emergent Infectious Disease Events: Algorithm Development and Validation

Background Patient travel history can be crucial in evaluating evolving infectious disease events. Such information can be challenging to acquire in electronic health records, as it is often available only in unstructured text. Objective This study aims to assess the feasibility of annotating and automatically extracting travel history mentions from unstructured clinical documents in the Department of Veterans Affairs across disparate health care facilities and among millions of patients. Information about travel exposure augments existing surveillance applications for increased preparedness in responding quickly to public health threats. Methods Clinical documents related to arboviral disease were annotated following selection using a semiautomated bootstrapping process. Using annotated instances as training data, models were developed to extract from unstructured clinical text any mention of affirmed travel locations outside of the continental United States. Automated text processing models were evaluated, involving machine learning and neural language models for extraction accuracy. Results Among 4584 annotated instances, 2659 (58%) contained an affirmed mention of travel history, while 347 (7.6%) were negated. Interannotator agreement resulted in a document-level Cohen kappa of 0.776. Automated text processing accuracy (F1 85.6, 95% CI 82.5-87.9) and computational burden were acceptable such that the system can provide a rapid screen for public health events. Conclusions Automated extraction of patient travel history from clinical documents is feasible for enhanced passive surveillance public health systems. Without such a system, it would usually be necessary to manually review charts to identify recent travel or lack of travel, use an electronic health record that enforces travel history documentation, or ignore this potential source of information altogether. The development of this tool was initially motivated by emergent arboviral diseases. More recently, this system was used in the early phases of response to COVID-19 in the United States, although its utility was limited to a relatively brief window due to the rapid domestic spread of the virus. Such systems may aid future efforts to prevent and contain the spread of infectious diseases.

Case Report: Management of Dengue Fever in the U.S.

A patient diagnosed with dengue fever was recently treated at a hospital in California. This rare case raises the concern that dengue fever may become a larger threat in the future for the contiguous United States, which is not currently considered endemic for the disease. Over the past decade, there has been an increase in the number of cases; therefore, dengue fever must be given greater consideration in the differential diagnosis, especially with a patient travel history to endemic parts of the world. This case report examines the management of a patient presenting with dengue fever and demonstrates that continued vigilance, prompt testing, and patient education can improve patient care and decrease disease prevalence in the future.

Automated Travel History Extraction from Clinical Notes: Development and Application during Emergent Infectious Disease Events (Preprint)

BACKGROUND Patient travel history can be crucial in evaluating evolving infectious disease events. Such information can be challenging to acquire in electronic health records as it is often available only in unstructured text. OBJECTIVE Assess the feasibility of annotating and automatically extracting travel history mentions from unstructured clinical documents in the Department of Veterans Affairs (VA) across disparate healthcare facilities and among millions of patients. Information about travel exposure augments existing surveillance applications for increased preparedness in responding quickly to public health threats. METHODS Clinical documents related to arboviral disease were annotated following selection using a semi-automated bootstrapping process. Using annotated instances as training data, models were developed to extract from unstructured clinical text any mention of affirmed travel locations outside of the continental United States. Automated text processing models were evaluated involving machine learning and neural language models for extraction accuracy. RESULTS Among annotated instances, 2,659 (58%) contained an affirmed mention of travel history while 347 (7.6%) were negated. Inter-annotator agreement resulted in a document-level Cohen’s kappa (Κc) of 0.776. Automated text processing accuracy (F1=85.6) and computational burden were acceptable such that the system can provide a rapid screen for public health events. CONCLUSIONS Automated extraction of patient travel history from clinical documents is feasible for enhanced capabilities to improve public health systems. This evaluation was initially performed on emergent arboviral disease. More recently, this system was utilized in early phases of response to COVID-19 in the United States although its utility was limited to a relatively brief window due to rapid domestic spread of the virus. Such systems may aid future efforts to prevent and contain the spread of infectious diseases.

Telerobotic ultrasound to provide obstetrical ultrasound services remotely during the COVID-19 pandemic

Introduction Obstetrical ultrasound imaging is critical in identifying at-risk pregnancies and informing clinical management. The coronavirus disease 2019 (COVID-19) pandemic has exacerbated challenges in accessing obstetrical ultrasound for patients in underserved rural and remote communities where this service is not available. This prospective descriptive study describes our experience of providing obstetrical ultrasound services remotely using a telerobotic ultrasound system in a northern Canadian community isolated due to a COVID-19 outbreak. Methods A telerobotic ultrasound system was used to perform obstetrical ultrasound exams remotely in La Loche, Canada, a remote community without regular access to obstetrical ultrasound. Using a telerobotic ultrasound system, a sonographer 605 km away remotely controlled an ultrasound probe and ultrasound settings. Twenty-one exams were performed in a five-week period during a COVID-19 outbreak in the community, including limited first-, second- and third-trimester exams ( n = 11) and complete second-trimester exams ( n = 10). Participants were invited to complete a survey at the end of the telerobotic ultrasound exam describing their experiences with telerobotic ultrasound. Radiologists subsequently interpreted all exams and determined the adequacy of the images for diagnosis. Results Of 11 limited obstetrical exams, radiologists indicated images were adequate in nine (81%) cases, adequate with some reservations in one (9%) case and inadequate in one (9%) case. Of 10 second-trimester complete obstetrical exams, radiologists indicated images were adequate in two (20%) cases, adequate with some reservations in three (30%) cases and inadequate in five (50%) cases. Second-trimester complete obstetrical exams were limited due to a combination of body habitus, foetal lie and telerobotic technology. Discussion A telerobotic ultrasound system may be used to answer focused clinical questions such as foetal viability, dating and foetal presentation in a timely manner while minimising patient travel to larger centres and potential exposure to severe acute respiratory virus coronavirus 2 during the COVID-19 pandemic.