Abbreviated Outpatient Upper Extremity Fracture Care to Avoid Clinic and Hospital Environmental Encounters During the COVID-19 Pandemic: A New Approach to Fracture Care?

BACKGROUND: To minimize in-person visits during the COVID-19 pandemic, a new fracture care protocol for children with complete and stable, nondisplaced or minimally displaced upper extremity (UE) fractures has been implemented. This protocol involves immobilization with a bivalved cast, which allows for home cast removal during a telemedicine visit, and no follow-up radiographs, thus eliminating the requirement for a return to clinic. The purpose of this study is to evaluate the outcomes and parent satisfaction of this new abbreviated fracture care protocol. METHODS: Between May 2020 and April 2021, during the COVID-19 pandemic, children with complete and stable, nondisplaced or minimally displaced UE fractures were treated with a bivalved cast and 1 follow-up telemedicine visit for home cast removal. A prospective longitudinal study of these patients was performed. The PROMIS Upper Extremity questionnaire was administered at enrollment and 3 months follow-up. Parents completed a satisfaction survey after home cast removal. Demographic data and information regarding complications were collected. A historical cohort of controls treated with standard cast in 2019 was used for comparison. RESULTS: A total of 56 patients with a mean age of 8±3 years (range 2 to 15) were prospectively enrolled in this study. Parent-reported PROMIS Upper Extremity scores showed a significant increase from 24.9 (95% confidence interval=20.8-29.1) at enrollment to 51.6 (95% confidence interval=50.8-52.5) at 3 months follow-up (P<0.001). Results of the satisfaction survey (n=39) showed all parents were either very satisfied (85%) or satisfied (15%). In addition, 10% of parents would have initially preferred to come into clinic for cast removal and 90% of parents would prefer this new treatment plan in the future. Patients in the abbreviated care cohort returned to clinic for a median 1 in-person visits, compared with 2 for historical controls (n=183, P<0.001). Abbreviated care patients received fewer (1.0) radiographs than controls (2.0, P<0.001). Complication rate did not differ between the groups (P=0.77). CONCLUSIONS: Complete and stable, nonminimally or minimally displaced UE fractures can be cared for safely and effectively in a single in-person visit, with a telemedicine cast removal visit. Parents are satisfied with this abbreviated protocol and prefer it to additional in-person visits. LEVEL OF EVIDENCE: Level III.

The pediatric "Spine at Risk" program: 9-year review of a novel safety screening tool.

PURPOSE: We implemented an EMR-based "Spine at Risk" (SAR) alert program in 2011 to identify pediatric patients at risk for intraoperative spinal cord injury (SCI) and prompt an evaluation for peri-operative recommendations prior to anesthetic. SAR alerts were activated upon documentation of a qualifying ICD-9/10 diagnosis or manually entered by providers. We aimed to determine the frequency of recommended precautions for those auto-flagged by diagnosis versus by provider, the frequency of precautions, and whether the program prevented SCIs during non-spinal surgery. METHODS: We performed a retrospective chart review of patients from 2011 to 19 with an SAR alert. We recorded how the chart was flagged, recommended precautions, and reviewed data for SCIs at our institution during non-spinal operations. RESULTS: Of the 3453 patients with an SAR alert over the 9-year study period, 1963 were auto-flagged by diagnosis and 1490 by manual entry. Only 38.7% and 24.3% of the patients in these respective groups were assigned precaution recommendations, making the auto-flag 62.8% better than providers at identifying patients needing precautions. Cervical spine positioning precautions were needed most frequently (86.7% of diagnosis-flagged; 30.0% of provider-flagged), followed by intraoperative neuromonitoring (IONM) (25.2%; 6.1%), thoracolumbar positioning restrictions (16.1%; 7.9%), and fiberoptic intubation (13.9%; 5.7%). There were no SCIs in non-spinal procedures during the study. CONCLUSION: EMR-based alerts requiring evaluation by a Neurosurgeon or Orthopaedic surgeon prior to anesthesia can prevent SCIs during non-spinal procedures. The majority of identified patients are not found to be at risk, and will not require special precautions. LEVEL OF EVIDENCE: III.

Heuristic Evaluation of a Top-Rated Diabetes Self-Management App.

OBJECTIVE: The purpose of this study was to evaluate the usability of a top-rated diabetes app. Such apps are intended to markedly support the achievement of optimal health and financial outcomes by providing patients with substantive and continual support for self-management of their disease between periodic clinician visits. Poor usability can deter use which is especially concerning in patients with diabetes due to prevalence of the disease and impact of self-management on long-term prognosis. METHODS: A diabetes app was selected due to the prevalence and seriousness of the disease. A heuristic evaluation was then performed to collect and analyze data on the usability of the app based on Nielsen's heuristics. Pareto analysis was used to illustrate the contribution of each type of heuristic violation, augmented by a stacked bar chart illuminating associated severity. RESULTS: There were 51 heuristic violations on the opening screen, violating 6 of Nielsen's 10 heuristics. Pareto analysis revealed 29 (57%) of the heuristic violations involved a match between system and real world and 8 (16%) aesthetic and minimalist design. Severity ratings ranged from 1.0 to 4.0 (mean: 3.01) with 80% comprising a major usability problem and 6% a usability catastrophe. CONCLUSION: Studies show that people with diabetes are more likely to receive greater benefit from a diabetes app if they are easy to use. The number and severity of heuristic violations in this study suggest that the commercialization of mobile health apps may play a factor in bypassing experts in clinical informatics during the design phase of development. Usability and associated benefits received from mobile health apps can be enhanced by debugging the user interface of identified heuristic violations during design. Waiting to correct ongoing usability issues while apps are in production can result in patients disengaging from use of digital health tools engendering poorer outcomes.

An innovative nursing approach to caring for an obstetric patient with rape trauma syndrome.

Rape trauma syndrome (RTS) is a posttraumatic stress disorder that can be triggered by routine procedures experienced during childbirth. An explanation of the signs and symptoms of RTS is provided, including how to avoid retraumatization during intrapartum care. A case report is presented from a provider perspective to illustrate the seriousness of this disorder and the importance of delivering respectful care. A new approach to obstetric routines is warranted to avoid further traumatizing the woman with RTS.

Comparison of the quality and timeliness of vital signs data using three different data-entry devices.

It is important to evaluate the impact of clinical information systems on the quality and timeliness of documentation in the patient's record to ensure the systems are improving clinical care processes and providing value to the organization. An observational study was conducted to measure the accuracy and timeliness of vital signs data during three different stages of clinical documentation system implementation at a large academic medical center: (1) a paper medical record system, (2) a clinical documentation system with "computers on wheels" workstation outside the patient's room, and (3) a clinical documentation system with a Tablet PC affixed to the vital signs monitor. Patient observations (n = 270) were completed as patient care technicians made routine vital sign rounds. Equipping patient care technicians with a Tablet PC affixed to the vital signs monitor significantly improved (P < .05) the accuracy and timeliness of vital signs. In addition, a number of unintended consequences were discovered that proved helpful to the nurse managers and nursing informatics leadership team in providing support of the new system. Findings from this study emphasize the importance of ensuring that staff has the appropriate devices needed to effectively document patient care at the bedside.

Transoral technique for gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass (LRYGBP) can accelerate learning curve and reduce cost.

BACKGROUND: The stapled gastrojejunostomy of the laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be created by linear and circular stapling techniques. In the circular-stapled technique, the anvil of the stapler can be introduced into the gastric pouch transabdominally or pulled down the esophagus (transorally) by attachment to a modified gastric tube. The purpose of this study is to determine if the transoral technique to introduce the anvil will reduce operative time and cost compared with the transabdominal technique, which requires creating a new gastrotomy to insert the anvil and followed by its closure. METHODS: We compared 60 consecutive morbidly obese patients who underwent laparoscopic RYGBP. First 30 cases were performed by transabdominal anvil insertion, followed by 30 cases using transoral anvil insertion. All of the transabdominal cases were assisted by experienced fellows. The first ten transoral cases were assisted by experienced fellows and the remaining 20 by new fellows in order to evaluate if the transoral technique shortens the learning curve. Surgery duration and operative costs were compared. Complications (bleeding, leaks, anastomotic strictures, ulcers, wound infections) and length of stay were also evaluated. Data are expressed as mean +/- SD. RESULTS: Mean operative time was shorter in the transoral group compared with the transabdominal group (162.2 +/- 35.8 vs. 186 +/- 33.6 min respectively, p = 0.01), even though most of the transoral cases (n = 20) were assisted by new fellows and all of the transabdominal cases by experienced fellows. Operative times were not different between new and experienced fellows in the transoral technique. Supply costs per patient were higher in the transabdominal technique compared with the transoral technique (2,983.5 +/- 540.9 vs. 2,658.8 +/- 474.4 USD, respectively, p = 0.03). Perioperative complications and length of stay were not statistically different. CONCLUSION: The transoral introduction of the anvil of the circular stapler into the gastric pouch is a simple, safe, and efficient technique for creating the gastrojejunostomy in laparoscopic RYGBP. In addition, the transoral technique is less expensive and appears to accelerate the learning curve compared with the transabdominal technique.

Using mobility technology to improve pharmacist workflow in the PICU rounding process.

Studies have indicated the clinical pharmacist plays a key role in reducing preventable adverse drug events (ADE), as well as decreasing costs and length of stay. Children are particularly at risk for ADEs, primarily due to incorrect dosages. At Children's Hospital in Omaha, Neb., clinical pharmacists are an integral part of the multidisciplinary Pediatric Intensive Care Unit (PICU) team, requiring efficient access to the electronic medical record and other online resources. Children's determined that fixed workstations were not optimal and decided to conduct a comparative workflow study to determine the impact of a mobility computing solution using the Motion C5 mobile clinical assistant. The findings showed solid improvement, increasing pharmacist time with the PICU rounding team to 98.89 percent. Children's also saw a significant decrease in the number of logins and time required to log in to workstations, and a 17 percent increase in pharmacist satisfaction with the rounding workflow.